Stressors of the Gallbladder, Pancreas And Liver

GI Stressors II

McKevney 4/08, rev Borrero 11/09

Topics
Choleycystitis Pancreatitis & Pancreatic Cancer Cirrhosis Hepatitis Liver Cancer Liver Transplantation NCLEX Time
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Gallbladder
Function- storage depot for bile Cholecystitis- inflammation of the gallbladder wall, acute infection Cholelithiasis- presence of gallstones

Cholecystitis:Pathophysiology
The most common cause is cholelithiasis; obstructing the cystic and or common bile ducts. Can be acute or chronic Bile is used for digestion of fats. Its produced in the liver and stored in the gallbladder. Acute- gallstones partially/completely obstruct CBD Chronic Cholecystitis- results from inefficient emptying of bile by gallbladder and gallbladder muscle wall disease persists. Chronic- may be caused by or lead to formation of gallstones (cholelithiasis)
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Gallbladder
Pancreatitis and Cholangitis (inflammation of common bile duct) can occur as complications of cholecystitis. Pancreatitis and cholangitis result from backup of bile throughout biliary tract. Bile obstruction leads to jaundice. Nonsurgical management- diet and drug therapy.

Risk Factors
More common in females (Remember 4Fs) High-fat diets Obesity (impaired fat metabolism, high cholesterol) Genetic predisposition Older than 60 years Type 1 diabetes (high triglycerides) Low-calorie, liquid protein diets Rapid weight loss (increases cholesterol) Trauma, Surgery, Immobilty Pregnancy HRT
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Diagnostic Procedures
RUQ ultrasound Abdominal x-ray- calcified gallstones ERCP- Endoscopic Retrograde Cholangiopancreatography Hepatobiliary scan (assesses patency of biliary duct system Elevated WBC Increase serum bilirubin levels Increased LFTS; AST, ALT, Alkphos, LDH Serum cholesterol elevated above 200 mg/dL
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Nursing Assessment S/S of Acute Cholecystitis

Patient complains of sharp RUQ pain radiating to right shoulder Intense pain after eating a high fat meal Increased HR, pallor, diaphoresis Rebound tenderness
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Nausea, vomiting, anorexia Dyspepsia, eructation, and flatulence Fever, chills Steatorrhea, light colored stools Light colored bowel movements

Fat soluble vitamin deficiency

Nursing Diagnoses Acute Cholecystitis

Acute pain Impaired gas exchange Risk for infection Knowledge deficit

Cholecystitis
Diet therapy: NPO or modify diet by avoiding high fat or high volume meals. These measures decrease stimulation of gallbladder. IV Hydration Drug therapy: Acute pain: opioids: meperidine HCL (Demerol), not Morphine Sulfate Antispasmodics or anticholinergics: Atropine or dicyclomine (Bentyl) Anti-emetics

Surgical Interventions
Open Choleycystectomy Laproscopic Cholecystectomy

http://www.youtube.com/watch?v=7tTGfYCq H5w http://www.youtube.com/watch?v=Pr3Md9Xl Lvw

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Nursing Interventions S/P Cholecystectomy

Lap vs.Open Cholecystecomy
LOC Vital signs Pulmonary Hygiene (cough deep breath, ambulate, turn and postion incentive spirometer) Splinting to reduce pain Pain management Monitor wound incision /S/S of infection Monitor T-tube drainage (initially bloody, then green-brown bile) T-tube initially may drain >400ml/day then should gradually decrease
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Care of the T-tube

Report sudden increases in drainage or amounts exceeding 1000ml/day Keep drainage bag below level of GB Inspect surrounding skin Maintain flow by gravity Never irrigate, clamp or aspirate without MD order Clamp 1 to 2 hours ac and pc Monitor and document the clients response to food

Nursing Interventions: Patient Education

Dietary counseling: Low fat diet Weight reduction Fat-soluble vitamins and bile salts to enhance absorptions and aid digestion Avoid gas-forming foods Smaller more frequent meals Activity precautions 4-6 weeks Care of T-tube
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Pancreatitis and Pancreatic Cancer

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Function of Pancreas
Pancreas has both exocrine and endocrine functions Exocrine: secretes pancreatic enzymes to break down starch, proteins, and fats Endocrine function: Islet of Langerhans: B cells secrete insulin and A cells secrete glucagon

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Pathophysiology
Pancreatitis is an autodigestion of the pancreas Can result in inflammation, necrosis, and hemorrhage Acute pancreatitis is an inflammation of the pancreas resulting from activated pancreatic enzymes autodigesting the pancreas Severity varies but the overall mortality rate is 10% to 20% r/t hypotension, fluid/electrolyte imbalance, and shock Chronic pancreatitis progressive destruction of the pancreas. Mortality rate up to 50%
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What would you expect to see if the pancreas isnt functioning properly??
Exocrine function: Digestive enzymes for starch, protein, and fat

Endocrine function: Insulin and glucagon

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Diagnostic Testing for Pancreatitis

Elevated serum amylase, lipase, elastase Elevated trypsin Elevated urine amylase Elevated serum glucose Serum calcium and magnesium levels are decreased Serum liver enzymes and bilirubin levels are elevated- hepatobiliary involvement WBC elevated CT scan with contrast
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Nursing Assessment
Monitor mental status Monitor VS- Elevated T, P. R, decreased BP. Dyspnea, or resp. complications Sudden onset of severe pain Epigastric pain radiating to back, left flank, or shoulder Not relieved with vomiting Some relief in fetal position Abdominal tenderness, guarding, rigidity. Palpable mass if cyst is present Possible changes in behavior r/t ETOH withdrawal.

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Nursing Assessment
Nausea and vomiting Weight loss Signs and symptoms of inflammation or peritonitis Ecchymosis on the flanks (Turners sign) Bluish periumbilical discoloration (Cullens sign) Generalized jaundice Paralytic ilieus Hyperglycemia

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Nursing Diagnoses
Pain r/t Fluid volume deficit r/t Altered nutrition r/t Ineffective breathing pattern r/t

Pancreatitis Nursing Interventions P- Pain: Morphine or Dilaudid A- Antispasmodic drugs- motility N- NPO/NGT suction- pancreas to rest, TPN C- Calcium, hypocalcemia, replace Ca R- Replace F/E- NG losses and fluid shift E- Endocrine & Enzymes A- Antibiotics- with fever S- Steroids- corticosteroids during acute attacks
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Pancreatitis Nursing Interventions

Monitor for hypocalcemia: Tetany Trousseaus sign (hand spasm when BP cuff is inflated) Chvosteks sign (facial twitching when facial nerve is tapped)

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Complications of Pancreatitis
Pancreatic Infection: Pseudocyst or Abscess Type 1 diabetes Left lung effusion and atelectasis DIC- Monitor bleeding times Acute Renal Failure ARDS- Shock Paralytic Ileus ** Pulmonary failure accounts for more than 50% of the deaths that occur within the first 7 days of the disease

Chronic Pancreatitis
Types: 1.Chronic Calcifying Pancreatitis (CCP) 2.Chronic Obstructive Pancreatitis- develops from inflammation, spasm and obstruction of sphincter of Oddi. The primary cause of chronic pancreatitis in the older adult is chronic alcoholism Age related changes reduce the older persons ability to process alcohol
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Pancreatic Cancer
Vague symptoms Usually diagnosed in late stages after liver or gallbladder problems Cause is unknown Occurs 60-80 years of age Risk factors

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Diagnostic Procedures
Serum amylase and lipase elevated Serum alkaline phosphate and bilirubin levels elevated CEA (Carcinoembryonic antigen elevated) CT ERCP: Most definitive test, analysis of aspirate, placement of a drain or stent for biliary drainage Abdominal paracentesis: Test for malignant cells Nursing interventions for paracentesis; consent, specimen to lab, assess/monitor insertion site
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Nursing Assessment Pancreatic Cancer

Monitor vital signs Monitor for signs of biliary obstruction (Jaundice-late sign, clay colored stools and dark urine-earlier sign) Nursing Diagnoses.. Chemotherapy: Monitor for myelosuppression and pancytopenia Radiation: Monitor fatigue and diarrhea Anorexia and weight loss Prep for possible surgery
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Surgical Procedures
Whipple procedure: Removal of the head of the pancreas, duodenum, parts of the jejunum and stomach, gallbladder, and possibly the spleen The pancreatic duct is connected to the common bile duct and the stomach is connected to the jejunum Post-op care

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Postoperative Care Whipple Surgery

LOC Vital signs Respiratory status: Incentive spirometer, O2 IVF Pain Management : PCA Opioids Monitor NG -tube Surgical drainage: Protect the surgical sites Semi-fowlers: facilitate lung expansion and to decrease stress on the suture line Monitor glucose levels and administer insulin prn Provide nutritional support Standard post-op care for GI surgery
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Complications Whipple Procedure

1.Fistulas
Due to breakdown of a site of anastomosis

2.Peritonitis
Internal leakage of corrosive pancreatic fluid Elevated WBCs, fever, abdominal pain, rebound tenderness, alteration in bowel sounds, shoulder pain Administer antibiotics 3. Venous thromboembolism: most common complication of pancreatic cancer
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LIVER DISORDERS

HEPATITIS CIRRHOSIS OF THE LIVER LIVER CANCER TRANSPLANTATION

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Functions of the Liver

1.Bile production: essential for fat metabolism 2.Protein metabolism: Breaks down amino acids ammonia urea excreted via kidneys 3.Phagocyte system: removes toxins and breaks down old RBCs

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Functions of the Liver

4.Synthesizes albumin 5.CHO Metabolism: storage of glycogen 6.Storage of fat soluble vitamins A,D,E,K 7.Steroid and drug metabolism 8.Clotting: prothrombin and fibrinogen

Lab Findings in Liver Disease

Elevated AST(aspartase aminotransferase) Elevated ALT (alanine aminotransferase) Elevated LDH (lactate dehydrogenase) and ALP (alkaline phosphatase) Elevated serum bilirubin Increased total serum protein-acute Decreased total serum protein- chronic Decreased serum albumin (normal 3-5 g/dl) Prolonged PT/INR Elevated serum ammonia

Liver Lab Results

LAB TESTS AST ALT LDH Alkaline Phosphatase Bilirubin Total Protein Ammonia PT INR Albumin NORMAL RESULTS 5-40 u/L 8-20 u/L 100-190 units/L 42-128 u/L 0.3 -1.0 mg/dl 6.4-8.3 g/dl 15-45 mg/dl 11.0-12.5 seconds 0.8-1.1 3-5 g/dl LIVER DISEASE Normal Prolonged Prolonged

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Viral Hepatitis-Facts
Acute (short- term)-inflammation of the liver Chronic (long- term) debilitating with increasing severity of symptoms Each year 250,000 in US become infected Persons with hepatitis are carriers and can spread disease without showing any symptoms of the disease Never donate blood, body organs or tissues Hepatitis B vaccine for all health care workers Mandated that all cases of hepatitis are reported to the health department Hepatitis A vaccine for high risk population
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Failure to follow Universal/Standard Precautions Dirty needles, sharp instruments, body piercing, tattooing, sharing drug paraphernalia and personal hygiene tools Unprotected sex, multiple sex partners and/or anal sex Unscreened blood transfusions (before 1992) Hemodialysis Poor hand hygiene with food preparation by a person infected with hepatitis Traveling in underdeveloped countries and using tap water Living in crowded environments: prisons, dormatories, universities, long-term care facilities, military housing

High Risk Behaviors HBV, HCV

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Type
HAV

Route of Transmission
Oral-fecal route

Risk Factors
Ingestion of contaminated food (shellfish) or water Drug abuse Sexual contact Healthcare work Drug abuse Sexual contact Drug abuse Contaminated water

HBV

Blood

HCV HDV HEV

Blood Co-infection with HBV Oral-fecal route

Diagnostic testing
Serological markers: Identify presence of virus. +HBsAg for longer than six months indicates chronic hepatitis and/or hepatitis carrier status Clotting factors Hepatitis antibody serum test: Indicates immunity and effectiveness of vaccine ( + HBsAb) X-rays : hepatomegaly, ascites, spleen enlargement Liver biopsy: Most definitive test that identifies the degree of liver damage Nursing: consent, explain procedure, have patient lie on affected surgical side for short period of time after biopsy)

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Nursing Assessment Hepatitis

Monitor for signs and symptoms: Flu-like symptoms and RUQ abdominal pain, N&V HBV presents with hepatomegaly and possible obstruction Signs of obstruction: light colored stools, dark urine, jaundice, elevated bilirubin and liver enzymes
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Nursing Assessment Hepatitis

Assess skin color and sclera Pain in muscles joints and abdomen Fever, malaise, increased fatigue, nausea and vomiting Clay colored stools Dark urine Rashes, pruritis
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Hepatitis A
Mild course, spread fecal-oral route Sources: Contaminated water Shellfish from contaminated water Infected food handlers Oral/anal sex Incubation: 15-60 days Symptoms:
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Hepatitis B
HBV spread by percutaneous/permucosal route by contamination with blood or serous fluid. Incubation 60-90 days Sources: sexual contact,sharing needles, tattooing, body piercing, accupuncture, perinatal Symptoms:
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Hepatitis- Other Causes

Direct toxic hepatitis- alcohol abuse, tylenol toxicity, industrial toxins Idiosyncratic toxic hepatitis- may occur during or shortly after exposure to drug Eg. Halothane, Methyldopa, Isoniazid

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Nursing Interventions
Medications: Used sparingly to promote hepatic rest Antivirals- Lamivudine (Epivir HBV) Interferon for HBV and HCV Assess for side effects of interferon: Flu-like symptoms Alopecia Bone marrow suppression Monitor CBC Administer antiemetics Provide comfort measures
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Nursing Interventions
Contact Precautions Hepatitis A,E Universal/Standard Precautions for HBV,HCV ,HDV Limit activity: bedrest, initially to promote hepatic healing Patient Education Dietary Education: High carbohydrate, high calorie, low-moderate fat, low-moderate protein WHY?
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Complications
Chronic hepatitis B, C, D: increases risk for liver cancer Fulminating Hepatitis: Fatal. Liver cells cannot regenerate and progressive liver necrosis occurs. Hepatic encephalopathy and death occur Cirrhosis of the liver: Scarring causes injury to the liver Liver failure Liver Cancer

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Cirrhosis of the Liver

Extensive scarring of the liver caused by necrotic injury or a chronic reaction to inflammation over a prolonged period of time Risk Factors 4 Types- Laennecs, Postnecrotic, Biliary, Cardiac

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Diagnostic Procedures
Liver biopsy
EGD: Esphagastroduodenoscopy: detect esophageal varices

LABS to be monitored??
WHY??
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Nursing Assessment Cirrhosis of the Liver

Monitor vital signs LOC-Neuro Pulmonary GI Integumentary GU Coagulation defects Fetor hepaticus-liver breath-end stage

Nursing Assessment
Petechiae red pinpoint and red-purple lesions, Ecchymosis, nose bleeds, hematemesis

Spider angiomas red spider -like lesions of face, upper thorax, and shoulders Dependent peripheral edema of extremities and sacrum

Asterixis- tremors liver flapping tremor of the wrist and fingers

Complications of portal hypertension
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Management of Cirrhosis
Non-surgical Diet- low Na, low protein, moderate fat restriction, high carb, high calories, vitamins TPN often necessary Meds-Aldactone, Lactulose, Neomycin, antacids Paracentesis Esophagogastric balloon tamponade Injection sclerotherapy STOP alcohol Surgical Peritovenous shunt or LaVeen shunt Endoscopic band ligation
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Complications of Cirrhosis
Portal Hypertension Ascites Bleeding esophageal varices Coagulation defect Jaundice Hepatic encephalopathy Hepatorenal syndrome
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Bleeding esophageal varices

Hematemesis and melena Dx: endoscopy, CT, ultrasound, barium swallow, LFTs Tx: O2, IVF, Blood transfusions, I&O, Balloon tamponade, saline lavage, endoscopic tamponade, vasopressin (Pitressin)

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Nursing Diagnoses
Altered mental status Ineffective breathing pattern Excess fluid volume Risk for impaired skin integrity Risk for infection Chronic pain Risk for imbalanced nutrition
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Portal Hypertension
Portal hypertension results from the abnormal blood flow pattern in liver created by cirrhosis. The increased pressure is transmitted to collateral venous channels. Sometimes these venous collaterals are dilated. Seen here is "caput medusae" which consists of dilated veins seen on the abdomen of a patient with cirrhosis of the liver.
library.med.utah.edu/WebPath/LIVEHTML/LIVER061.html

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Treatment for Cirrhosis of Liver

Injection sclerotherapy: varices are sclerosed TIPS: Transjugular intrahepatic portosystemic shunt placement of a portal shunt for esophageal varices Surgical bypass shunting procedures: Last resort: Ascites is shunted from the abdominal cavity to the superior vena cava Liver Transplantation

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Hepatic Encephalopathy and Coma

Early symptoms- minor mental changes and motor disturbances Progression to changes in LOC, difficult to arouse, asterixis Hyperactive reflexes then flaccid Progression to seizures and coma

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Hepatic Coma
Jaundice Profound anorexia Coagulation defects Renal failure Electrolyte disturbances Hypoglycemia Infection Encephalopathy
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Concept Map: Impaired Liver Function

Ineffective breathing pattern Impaired Skin Integrity Body Image Disturbance

Risk for injury

Impaired Liver Function

Activity Intolerance

Imbalanced Nutrition, Less than Body Requirements

Excess fluid volume

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Liver Cancer
HCC- hepatocellular carcinoma most common of liver cancer Most liver tumors are unresectable 5 year survival rate is less than 9%. Clinical manifestations

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Risk Factors
Cirrhosis Metastasis from another site Dx AFP: Alpha-fetoprotein tumor marker Liver enzymes ALP elevated Liver biospy: definitive diagnosis

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Treatment For Liver Cancer

Chemotherapy via an surgically implanted infusion pump Liver transplantation Portions of a liver are transplanted and will regenerate Transplantation surgery- 12 hours Immunosuppressant drugs Steroids Monitor for infection and organ rejection
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Indications for Liver Transplant

Primary or secondary biliary cirrhosis Chronic active hepatitis with cirrhosis Liver abscesses Fatty liver infiltrates Liver Ca

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Liver Transplant Complications

1. Graft rejection Manifestations of graft rejection are: Fever Tachycardia RUQ or flank pain Dimished bile flow through t-tube or change in bile color Increased bilirubin Increased jaundice