DISORDERS OF THE LIVER,

PANCREAS AND
GALLBLADDER

Prepared by:
Dr. PA Maroma
 Cholelithiasis
⦿ “gallstones”
⦿ FAT, FEMALE,
FORTY, FERTILE
• More common in
women after age 40
(estrogen therapy),
women taking oral
contraceptives, and
in the obese
Cholecystitis
• acute or chronic
inflammation of the
gallbladder
 Cholelithiasis
Theory of Stone formation:
Metabolic factors (obesity, pregnancy, DM,
hypothyroidism,stasis) MAY all lead to stagnation of
bile in the gallbladder

excessive absorption of water

precipitation of salts (stones)

⦿ Gallstones are composed primarily of cholesterol

(80%), bile salts, Ca++, bilirubin & CHONs
Cholelithiasis
 Cholelithiasis

Assessment findings
• Most patients are asymptomatic.
• When symptomatic; PAIN in RUQ and
epigastric pain lasting approximately 30
min.
• Fever & leukocytosis (⭡WBC)
• Charcot triad
●fever, jaundice, pain in RUQ pain
(ascending cholangitis)
 Cholelithiasis

Assessment findings
• Intolerance for fatty foods (steatorrhea,
N&V, sensation of fullness)
• Pruritus, easy bruising, dark amber urine

Diagnostic tests
• Direct bilirubin transaminase, alkaline
phosphatase, WBC, amylase, lipase: all
increased
• Oral cholecystogram (gallbladder series):
positive for gallstone
 Cholelithiasis
Nursing interventions
• Administer pain medications as
ordered and monitor for effects.
• Administer IV fluids as
ordered.
• Provide small, frequent meals
of modified diet, low fat (if oral
intake allowed)
• Provide care to relieve pruritus
• Provide care for the client with
a cholecystectomy or
 Cholelithiasis

Medical management
⦿ Supportive treatment: NPO with
NG intubation and IV fluids
⦿ Diet modification with
administration of fat- soluble
vitamins
⦿ Drug therapy
• Narcotic analgesics (Demerol is
the drug of choice) for pain
• Morphine sulfate is contraindicated
because it causes spasms of the
sphincter of Oddi
 Cholelithiasis

Medical management
⦿ cont… Drug therapy
• Anticholinergics (atropine) may be used
for pain
• Antiemetics
⦿ Surgery
• Cholecystectomy
• Choledochostomy
• Choledochotomy
 Cholelithiasis

⦿ Cholecystectomy
• removal of the gallbladder with insertion of a T-tube
into the common bile duct if common bile duct
exploration is performed
⦿ Choledochotomy
• opening of common duct, removal of stone, and
insertion of a T-tube
⦿ Laparoscopic Cholecystectomy
• performed via laparoscopy for uncomplicated cases
when client has not had previous abdominal surgery
⦿ Cholecystostomy
• opening of the gallbladder to remove stones
Cholelithiasis
 Cholelithiasis
Nursing interventions:
⦿ Provide routine pre-op care
⦿ Provide routine post-op care
⦿ Position client in semi-Fowler’s or side-lying
positions; reposition frequently.
⦿ Splint incision when turning, coughing, and
deep breathing
⦿ Maintain/monitor functioning of T-tube
• Ensure that T-tube is connected to closed
gravity drainage.
• Avoid kinks, clamping, or pulling of the
tube.
 Cholelithiasis
Nursing interventions
⦿ cont… Maintain/monitor functioning of T-tube
• Measure and record drainage every shift
• Expect 300 – 500 ml bile-colored drainage for the
1st 24° then 200 ml/24° for 3 - 4 days
• Assess for signs of peritonitis
• Monitor color of urine and stools (stools will be
light colored if bile is flowing through T tube but
normal color should reappear as drainage
diminishes)
• Assess skin around T-tube; cleanse frequently and
keep dry
Cholelithiasis
 Cholelithiasis

⦿ Provide client teaching and discharge

planning concerning
• Adherence to dietary restrictions
• Resumption of ADL
●avoid heavy lifting for at least 6 weeks
●resume sexual activity as desired unless ordered
otherwise by physician
●clients having laparoscopy cholecystectomy
usually resume normal activity within two weeks
• Recognition and reporting of signs of complications
(fever, jaundice, pain, dark urine, pale stools, pruritus)
Pancreatitis
 Pancreatitis

• An inflammatory process with varying

degrees of pancreatic edema, fat necrosis,
or hemorrhage
• Proteolytic and lipolytic pancreatic
enzymes are activated in the pancreas
rather than in the duodenum, resulting in
tissue damage and autodigestion of the
pancreas
• Occurs most often in the middle aged
 Pancreatitis
Causes:
• Alcoholism/ alcohol abuse
• Biliary tract disease/ biliary obstruction
• Trauma, viral infection, penetrating
duodenal ulcer, abscesses
• Drugs (antihypertensives, steroids, thiazide
diuretics, antimicrobials,
immunosuppressives, oral contraceptives)
• Metabolic disorders (hyperparathyroidism,
hyperlipidemia)
• Unknown/ autoimmune
 Pancreatitis
Assessment findings
• Pain (LUQ radiating to back, flank, or
substernal area) accompanied by DOB
(shallow respiration with pain), aggravated
by eating
• N&V, decreased/absent bowel sounds,
• Abdominal tenderness w/ muscle-guarding
• (+) Grey Turner’s spots (ecchymoses on
flanks)
• (+) Cullen’s sign (ecchymoses of periumbilical
area)
• Tachycardia
Pancreatitis
 Pancreatitis
Diagnostic tests
• ↑Serum amylase
(>300 somogyi units) &
lipase
• ↑urinary amylase
• ↑blood sugar
• ↑lipid levels
• ↓Serum calcium
• CT scan: enlargement
of the pancreas
 Pancreatitis
Nursing interventions:
• Administer analgesics, antacids, and anticholinergics
as ordered, monitor effects
• Withhold food/fluid and eliminate odor and sight of
food from environment to decrease pancreatic
stimulations
• Maintain NGT and assess for drainage.
• Institute Non-pharmacologic measures to decrease
pain.
●Assist client to positions of comfort (knee chest,
fetal position)
●Teach relaxation techniques and provide a quiet,
restful environment.
 Pancreatitis
⦿ Provide client teaching and discharge
planning concerning
• Dietary regimen when oral intake
permitted
●High CHO, high CHON, low-fat diet
●Eating small, frequent meals instead of
three large ones
●Avoiding caffeine products
●Eliminating alcohol consumption
●Maintaining relaxed atmosphere after
meals
 Pancreatitis
⦿ cont… Provide client teaching & discharge
planning concerning
• Recognition/reporting of signs of complications
●Continued N&V
●Abdominal distension with increasing fullness
●Persistent weight loss
●Severe epigastric or back pain
●Frothy/foul-smelling bowel movements
●Irritability, confusion, persistent elevation of
temperature (2 days)
 Pancreatitis
Medical management:
⦿ Drug therapy
• Analgesics (Demerol) to relieve pain.
MORPHINE is avoided because it can cause
spasm of the sphincter aggravating pain
• Smooth-muscle relaxants to relieve pain
● papaverine, nitroglycerin
• Anticholinergics to decrease pancreatic
stimulation
●atropine, propantheline bromide
 Pancreatitis
Medical management:
• cont… Drug therapy
●Antacids to decrease pancreatic
stimulation
●H2-antagonists, vasodilators, calcium
gluconate

• Diet modification
• NPO usually for a few days to promote GIT
rest
• Peritoneal lavage
• Dialysis if the condition is severe
Hepatitis
 Hepatitis A B C D E
⦿ Infectious inflammation of the liver
parenchyma caused by bacteria, viruses and
other microorganisms.
• widespread inflammation of the liver tissue
• liver cell damage due to hepatic cell
degeneration and necrosis
• proliferation and enlargement of the Kupffer cells
• inflammation of the periportal areas causing
interruption of bile flow
 Viral Hepatitis A

⦿ ssRNA virus
transmitted via
fecal-oral route.
⦿ Poor hygiene or
contaminated food
and shellfish
increase risk of
transmission
⦿ Incubation period:
15 – 45 days
 Viral Hepatitis B
⦿ DNA virus, identified in all body fluids: blood,
saliva, synovial fluid, breast milk, ascites, cerebral
spinal fluid, etc.
⦿ Transmitted by blood and body fluids (saliva,
semen, vaginal secretions): often from contaminated
needles among IV drug abusers; intimate/sexual
contact
⦿ accounts for 50% of cases of fulminant hepatitis
⦿ In an adult who develops acute hepatitis B, there is
approximately 10% chance that it will progress into
chronic hepatitis; in the neonate the chance is 90%
for chronic hepatitis.
⦿ Incubation period is very long: 1 - 6 months
Viral Hepatitis B
Viral Hepatitis B
 Viral Hepatitis C
⦿ ssRNA virus generally transmitted
predominantly by blood products
⦿ Currently the most common hepatitis among IV
drug abusers and in prisons
⦿ Before 1990 it accounted for 90% of transfusion
hepatitis
⦿ Incubation: 2 weeks - 6 months
⦿ high risk of progression to chronic form (70 –
80%)
⦿ associated with extrahepatic manifestations
commonly: mixed cryoglobulinemia and
polyarteritis nodosa
 Viral Hepatitis D
⦿ RNA virus that infects either simultaneously with
hepatitis B or as a super-infection in a person with
chronic hepatitis B
⦿ Hepatitis D infection cannot occur unless there is
current and ongoing replication of the hepatitis B
virus
⦿ Overall, this infection carries the highest risk among
acute viral hepatitis for fulminant disease; the risk is
even greater in super-infection
⦿ Predominantly seen in patients exposed to blood
products (drug addicts and hemophiliacs). If anti-HBs
antibodies are present, then that person is immune to
hepatitis B and D
Viral Hepatitis D
 Viral Hepatitis E

⦿ Similar to Hepatitis
A with fecal or
oral transmission,
there is no chronic
form
⦿ The risk of
fulminant disease
has been
described mainly
in pregnant
patients
 Viral Hepatitis
Assessment findings
⦿ Preicteric stage (prodromal phase) = 1 week
• Anorexia (major manifestation), N&V, fatigue,
constipation or diarrhea, weight loss
• RUQ discomfort, hepatomegaly, splenomegaly,
lymphadenopathy
⦿ Icteric stage
• Fatigue, weight loss, light-colored stools, dark urine
• Continued hepatomegaly with tenderness,
lymphadenopathy, splenomegaly
• Jaundice, pruritus
⦿ Posticteric stage
• Fatigue, but an increased sense of well-being,
hepatomegaly gradually decreasing
 Viral Hepatitis
Collaborative Management
• Promotion of rest to relieve fatigue
• Maintenance of food and fluid intake
• 3,000 ml/day of fluids for fever and
vomiting; monitor I and O, weight
• Well – balanced diet; encourage fruit juices
and carbonated beverages
• Fats may need to be restricted
• Alcoholic beverages should be avoided
• Prevention of injury
 Viral Hepatitis

cont… Collaborative Management

• Monitor PT (bleeding tendencies): plan so
that all blood samples are collected at one
time to avoid several punctures
●avoid parenteral injections, if possible
●apply pressure to injection sites and
venipuncture sites for 5 minutes
• Monitor Hgb/Hct, urine and stools for fresh
or old blood; the skin for petechiae
 Viral Hepatitis
cont… Collaborative Management
• advise client to use soft toothbrush or swabs
• administer Vitamin K as ordered
• Provision of comfort measures
• Relaxing baths, backrubs, fresh linens and
quiet dark environment
 Viral Hepatitis
cont… Collaborative Management
⦿ Relieve pruritus through the following measures:
• Use of cool, light, non-restrictive clothing
• Use of soft, dry, clean bedding, use of warm
baths
• Application of emollient creams and lotions to
dry skin.
• Maintenance of a cool environment
• Administration of antihistamines as ordered
• Use of diversional activities, e.g. reading, TV
and radio
 Liver Cirrhosis
⦿ Chronic, progressive disease characterized
by inflammation, fibrosis, and degeneration of
the liver parenchymal cells
 Liver Cirrhosis
⦿ Destroyed liver cells are replaced by scar
tissue, resulting in architectural changes &
malfunction of the liver
 Liver Cirrhosis

Types
• Laênnec’s cirrhosis
●associated with alcohol abuse and
malnutrition; characterized by an
accumulation of fat in the liver cells,
progressing to widespread scar formation.
• Postnecrotic cirrhosis
●results in severe inflammation with massive
necrosis as a complication of viral hepatitis.
 Liver Cirrhosis

cont… Types
• Cardiac cirrhosis
●occurs as a consequence of RSHF;
manifested by hepatomegaly with some
fibrosis.
• Biliary cirrhosis
●associated with biliary obstruction, usually
in the common bile duct; results in chronic
impairment of bile excretion
Liver Cirrhosis

Fatty
Normal Liver Liver cirrhosis
Liver caused
by alcoholism
 Liver Cirrhosis

Assessment:
• Anorexia, weakness, weight loss (liver is unable to
metabolize nutrients and store fat-soluble vitamins)
• Fever (in response to tissue injury)
• Jaundice, pruritus, tea colored urine (due to
⭡bilirubin in the blood)
●remember!!! bilirubin is conjugated initially
before excretion
• Increased Bleeding tendencies. (liver is unable to
store Vit. K. There is also impaired production of
clotting factors)
• Portal HPN
 Liver Cirrhosis
Pathology:
⦿ In portal hypertension
• plasma shift into interstitial spaces within the liver due
to the increase pressure. The collection of fluids shifts
out of the Glisson’s capsule and accumulate in the
peritoneal cavity
⦿ The liver is unable to metabolize protein,
thereby hypoalbuminemia occurs
• result to decreased oncotic pressure, fluids shift out of
the IVC, and accumulate in the peritoneal cavity.
 Liver Cirrhosis

Pathology:
⦿ The liver is unable to excrete adrenal cortex
hormone, one of which is aldosterone
• Hyperaldosteronism leads to retention of sodium and
water
⦿ Esophageal varices = 2° to backpressure
⦿ Internal hemorrhoids, leg varicosities, and
dependent edema
• due to venous stasis, increasing hydrostatic pressure.
This leads to shifting of plasma into interstitial space
 Liver Cirrhosis

⦿ Consequences of Portal HPN:

• Hepatomegaly= initially, then the liver shrinks in size
as fibrosis replaces the liver parenchyma
• Splenomegaly= due to increased backpressure of the
blood
• Caput medusae (dilated veins over the abdomen)
• Spider angioma (telangiectasia / dilated capillaries
over the face and anterior trunk)= due to increased
estrogen
• Palmar erythema. This is also due to elevated
estrogen level in males.
• Ascites
Liver Cirrhosis
Liver Cirrhosis
 Liver Cirrhosis
⦿ Males (⭡estrogen) will result to:
• Decreased libido, Impotence, Fall of body hair,
Atrophy of testicles, gynecomastia
 Liver Cirrhosis

⦿ Females
(⭡androgen)
• Hirsutism
• acne
• deepening of voice
• Virilism
(development or
premature
development of male
secondary sexual
characteristics)
 Liver Cirrhosis
HEPATIC ENCEPHALOPATHY
⦿ Accumulation of AMMONIA because the liver
cannot convert ammonia into urea that can lead to
hepatic coma (Ammonia is by product of CHON
metabolism)
⦿ initial manifestations: BEHAVIORAL changes and
MENTAL changes
⦿ Other findings in advanced stages are:
• asterixis – flapping tremors of the hands
• confusion / disorientation
• delirium / hallucination
• fetor hepaticus - disagreeable odor from the mouth
• coma
 Liver Cirrhosis

Diagnostic tests
• SGOT or AST, SGPT, LDH, alkaline
phosphatase increased
• Serum bilirubin increased
• PT prolonged
• Serum albumin decreased
• Hgb/Hct decreased
• BSP increased
 Liver Cirrhosis

Nursing interventions
⦿ Provide sufficient rest and comfort
• Provide bed rest with bathroom privileges.
• Encourage gradual, progressive, increasing activity
with planned rest periods.
• Institute measures to relieve pruritus.
●Do not use soaps and detergents
●Bathe in tepid water followed by application of an
emollient lotion.
●Provide cool, light, nonrestrictive clothing.
●Keep nails short to avoid skin excoriation from
scratching.
●Apply cool, moist compresses to pruritic areas.
 Liver Cirrhosis
cont… Nursing interventions
⦿ Promote nutritional intake
• Encourage small frequent feedings.
• Promote a high-calorie, low- to moderate- protein,
high CHO, low-fat diet, with supplemental vitamin
therapy (vitamins A, B- complex, C, D, K, and folic
acid)
⦿ Prevent infection
• Prevent skin breakdown by frequent turning and
skin care.
• Provide reverse isolation for clients with severe
leukopenia; pay special attention to hand-washing
technique.
• Monitor WBC.
⦿ Monitor/prevent bleeding.
 Liver Cirrhosis
cont… Nursing interventions
⦿ Administer diuretics as ordered
⦿ Provide client teaching & D/C planning concerning:
• Avoidance of agents that may be hepatotoxic (sedatives, opiates,
or OTC drugs detoxified by the liver)
• How to assess for weight gain and increased abdominal girth
• Avoidance of persons with upper respiratory infections
• Recognition and reporting of signs of recurring illness (liver
tenderness, increased jaundice, increased fatigue, anorexia)
• Avoidance of all alcohol
• Avoidance of straining at stool, vigorous blowing of nose and
coughing, to decrease the incidence of bleeding
Peritonitis
⦿ Local or generalized inflammation of part or all
of the parietal and visceral surfaces of the
abdominal cavity
 Peritonitis
Pathology:
• Initial response
●edema, vascular congestion, hypermotility of the
bowel and outpouring of plasma-like fluid from
the extracellular, vascular, and interstitial
compartments into the peritoneal space
• Later response
●abdominal distension leading to respiratory
compromise, hypovolemia results in decreased
urinary output
• Intestinal motility gradually decreases and progresses
to paralytic ileus
 Peritonitis
Causes
• Caused by trauma (blunt or penetrating)
• Inflammatory conditions
●ulcerative colitis, diverticulitis, pelvic
inflammatory disease
• Ischemia
• Ruptured appendix
• Perforated peptic ulcer
• UTI
• Bowel obstruction (volvulus, intestinal obstruction)
• Bacteria invasion
 Peritonitis
Assessment findings
⦿ Severe abdominal PAIN, rebound tenderness,
muscle rigidity, absent bowel sounds, abdominal
distension
⦿ Anorexia, N&V
⦿ Shallow respirations; decreased urinary output;
weak, rapid pulse; fever
⦿ Signs of shock
• Tachycardia, Tachypnea, Oliguria, Restlessness,
Weakness, Pallor, Diaphoresis
⦿ Diagnostic tests
• WBC elevated WBC (20,000/cu. mm. or higher)
• Hct elevated (if hemoconcentration)
 Peritonitis
Management
• NPO with fluid replacement
• Drug therapy: antibiotics to combat
infection, analgesics for pain
• NGT is inserted to relieve abdominal
distention
• Peritoneal lavage with warm saline
• Insertion of drainage tubes
• Fluid, electrolyte and colloid
replacement, TPN solutions
 Peritonitis
⦿ Surgery
• Laparotomy: opening made through the abdominal wall
into the peritoneal cavity to determine the cause of
peritonitis
• Depending on cause, bowel resection may be necessary
 Peritonitis
Nursing interventions
⦿ Assess respiratory status for possible distress.
⦿ Assess characteristics of abdominal pain and
changes over time.
⦿ Administer medications as ordered.
⦿ Perform frequent abdominal assessment
⦿ Monitor and maintain F&E balance; monitor for
signs of septic shock.
⦿ Maintain patency of NG or intestinal tubes
⦿ Encourage deep breathing exercises
⦿ Place client in Fowler’s position to localize
peritoneal contents
⦿ Provide routine pre- and post-op care if surgery
ordered