Liver, Biliary Tract,

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Liver, Biliary Tract, Pancreas Problems

• Nur 302
• Unit I

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Liver, Biliary Tract Pancreas Problems

• Jaundice
• Hemolytic jaundice
• Hepatocellular Jaundice
• Obstructive jaundice

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Viral Hepatitis

• Inflammation of the liver.
• Types A,B,C,D,E,G
• Epstein-Barr, herpes, cytomegalovirus,
  coxsackievirus, rubella
• Presence of antigens antibodies
• Outbreaks of hepatitis type A,
• 50 type B, 20 type C, 30 type A

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Hepatitis A

• Fecal-oral route, outbreaks caused by fecal
  contaminated food or drinking water.
• Crowded conditions, poor sanitation hygiene,
  undeveloped countries, shellfish from
  contaminated water
• Most infectious 2 wks before s/s 1wk after s/s
  start.
• No chronic carrier

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Hepatitis B

• Percutaneous, permucosal, or perinatal exposure,
  sexually transmitted disease.
• 100X more infectious than HIV can live on dry
  surface for 7 days
• Carrier state - antigen HBsAg for 6-12 mo.
• Immunity antigen anti-HBs-Ag

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Hepatitis C

• Transmission- pericutaneous
• At risk IV drugs, bld transfusion, hemodialysis,
  tattooing, hi risk sexual behavior, organ
  transplants, health care workers

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Hepatitis D

• Delta virus
• Transmission - percutaneous
• Can turn mild or chronic hepB into severe,
  chronic, progressive, active hepatitis
  cirrhosis
• Can occur as coinfection with hepB or as
  superinfection

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Hepatitis E

• Transmission fecal-oral route, esp contaminated
  drinking water.
• Enteric non-A, non-B hepatitis
• Occurs in developing countries, epidemics in
  India, Asia, Mexico, Africa. In US rarely, only
  after a person traveled.

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Hepatitis G

• Recently discovered.
• Found in blood donors transmitted by
  transfusion.
• Co-exists with other hepatitis viruses.
• Not associated with chronic hepatitis or
  cirrhosis.

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Pathophysiology

• Inflammation of liver -gt Cell degeneration
  necrosis
• Proliferation enlargement of Kupffer cells
• Interrupted flow of bile cholestasis
• If no complications, liver cells regenerate,
  resume normal appearance function.
• Rash, angioedema, arthritis, fever, malaise

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Collaborative Care

• Rest, well balanced diet
• Antiemetics, Benadryl, NO phenothiazines
• Immunoglobulin for hepB or hepA
• Alpha inferon
• wks after exposure, hepA vaccine pre-exposure
  prophylaxis
• HepB vaccine prophylaxis, post exposure-
  hepatitis B immune globulin

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Nursing Care Hepatitis

• Health Promotion
• Assessment of jaundice
• Adequate nutrition
• Rest
• Home Care

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Toxic, Drug-induced Idiopathic Hepatitis

• Ingestion, inhalation, parenteral injection of
  chemicals
• Systemic poisons- carbon tetrachloride, gold
  compounds, converted toxic metabolites
  (acetaminophen)
• Drugs Halothane, INH, Diuril, Aldomet
• Elderly, previous liver diseased
• Idiopathic - autoimmune

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Cirrhosis of the Liver

• Degeneration destruction of liver cells
• Abnormal bld vessel bile duct relationships
  from fibrosis
• Lobules of irreg size shape impeded bld flow
  from overgrowth of new fibrous tissue
• Insidious, progressive, chronic disease

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Types of Cirrhosis

• Alcoholic, portal or nutritional cirrhosis fat
  accumulation in liver cells, scar formation.
• Post necrotic- re hepatitis, broad bands scar
  tissue.
• Biliary due to chronic biliary obstruction or
  infection. Jaundice, diffuse fibrosis.
• Cardiac R heart failure, constrictive
  pericarditis, tricuspid insufficiency
• Cell necrosis, scar tissue, nodules, decr
  cellular nutrition, hypoxia-gt decreased
  functioning of liver

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Clinical Manifestations

• Insidious- anorexia, dyspepsia, n/v, flatulence,
  diarrhea or constipation, dull, heavy feeling in
  RUQ, enl liver spleen
• Jaundice
• Skin lesions spider angiomas, palmer erythema
• Hematologic thrombocytopenia, anemia,
  leukopenia, coagulation disorders
• Endocrine disturbances hormone inactivation
• Peripheral neuropathy deficiency in folic acid,
  thiamine, B-12.

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Diagnostic Studies

• Liver enzymes elevated, PT prolonged
• Cholesterol Protein levels decreased
• Serum urine bilirubin increased, stool
  decreased
• Liver scan,biopsy, analysis of ascitic fluid
• Esophagogastroduodenoscopy, angiogram
• Lytes, CBC, ammonia level

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Peripheral Edema Ascites

• Peripheral edema _at_ ankle presacral area - decr.
  albumin -gt decr colloidal osmotic pressure.
  Increased portalcaval pressure from portal
  hypertension.
• Ascites- hypertension in liver-gtproteins move bld
  via capillaries to lymph-gtleak into peritoneal
  cavity-gt osmotic pres pulls water. Lo albumin
  hyperaldosteronism adds to ascites formation.
• S/S- abd distention, wt gain, distended abd wall
  veins, dehydration, decr output, hypokalemia.
  

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Collaborative Care

• Na restriction 250-500mg Na/day
• Salt poor albumin
• Diuretics Aldactone, Dyrenium, Midamor, Lasix
• Fluid removal via paracentesis or retroperitoneal
  shunt
• Monitor lytes and fluid balance

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Portal Hypertension Esophageal Varices

• Compression, destruction of hepatic portal
  veins sinusoids-gt obstruction portal bld flow-gt
  portal hypertension.
• Collateral circulation lower esophagus,
  parietal peritoneum, rectum-gt varices where
  collateral systemic circulation meet.
• Esophageal varices, fragile, tolerate hi pressure
  poorly, tortuous, bleed easily. Life threatening
  complication.

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Hepatic Encephalopathy

• Ammonia in systemic circulation without liver
  detoxification.
• Ammonia from metabolism of P shunted past liver
  or liver unable to convert ammonia to urea-gt lg
  amt ammonia-gt crosses blood-brain barrier-gtneuro
  s/s
• S/S LOC changes from lethargy to coma,
  disorientation, asterixis, writing impairments,
  hyperventilation, hypothermia, grimacing,
  grasping, fetor hepaticus

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Collaborative Care

• Protein restriction
• Neomycin po or enemas
• Lactulose (Cephalac)
• Control GI blding, remove bld from intestinal
  tract, treat lyte acid/base imbalance
• Liver transplant

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Nursing Care Encephalopathy

• Neuro assessment q2h - LOC, reflexes, pupils,
  sensory motor
• Check lytes, acid/base balance, ammonia
• Decrease ammonia with lactulose, enemas
• Possible tube feeding- lo-no protein, hi CHO
  flds

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Hepatorenal Syndrome

• Renal failure- possibly due to redistribution of
  blood flow from kidneys or hypovolemia
• Follows diuretic therapy, GI hemorrhage or
  paracentesis
• Tx salt poor albumin, salt water restrictions,
  diuretic therapy

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Nursing Care Cirrhosis

• Health Promotion
• Bed rest prevent complications
• Nutrition- oral hygiene, supplements
• Assess jaundice, edema, ascites, bleeding, LOC,
  dyspnea
• Skin care
• Altered body image
• Monitor lytes, liver coag studies, ammonia, CBC

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Home Care

• Written instructions- fluid diet restrictions
• Teach pt family- s/s complications, meds side
  effects, observe for bleeding, skin care,
  protection from infection
• Counseling referral to community health nurse

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Liver Cancer

• Metastasis, h/o cirrhosis, chronic hepB or C
• Malignant cells enlarge mis-shape liver
• Hemorrhage or necrosis common
• Dx hard to differentiate bet cirrhosis Ca
• Rx palliative, lobectomy, chemo, poor prognosis,
  death in 4-7 months
• Nsg care same as advanced liver disease

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Endoscopic Retrograde Cholangiopancreatography

• ERCP
• The scope is brought in through the esophagus,
  the stomach and into the bile ducts. A contrast
  fluid is injected. The gallbladder does not
  become visible. The hepatopancreatic duct does
  not show signs of obstruction.Conclusion No
  signs of obstruction of the hepatopancreatic
  duct, obstruction in the gallbladder or the
  cystic duct cannot be excluded.
• Nursing Care???

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ERCP Nursing Care

• Explain procedure get consent
• NPO 8 hours before ERCP
• Sedation before during ERCP
• Antibiotics if ordered
• Post ERCP check perforation, infection, s/s
  pancreatitis, VS, check gag reflex

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Cholecystitis Cholelithiasis

• S/S cholecystitis indigestion, moderate-gt severe
  pain, URQ tenderness, referred to R shoulder
  scapula, n/v, restless, diaphoretic
• S/S cholelithiasis none, s/s depend if stones
  are moving or not, spasms can be severe,
  tachycardia, diaphoresis, 3-6 hr after meal, when
  lie down, s/s bile blockage
• Dx ultrasound, cholangiogram, cholecystogram

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Collaborative Care

• Cholecystitis control pain, antibiotics, flds
• Cholelithiasis cholesterol solvents,
  lithotripsy, endoscopic sphincterotomy, surgery
• Surgery cholecystectomy, laparoscopic
  cholecystectomy
• Transhepatic biliary catheter
• Meds anticholinergics, analgesics, fat soluble
  vitamins, bile salts, Demerol, Questran, diet

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Nursing Care GB Disease

• Health promotion
• Acute GB attack relieve pain, n/v, assessment of
  progression of s/s s/s obstruction bile duct,
  observe s/s bleeding at mucous membranes, assess
  for infection
• Post endoscopy assess s/s pancreatitis,
  perforation, bleeding
• Post-op referred pain to shoulder, place in
  Simms position, prevent resp complications, care
  of T-tube

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Cancer of the Gallbladder

• Uncommon
• Relationship bet Ca GB chronic cholelithiasis
  or cholecystitis
• S/S insidious, same as GB disease, later s/s
  biliary obstruction
• Rx surgery, symptomatic, supportive
• Nursing care supportive, pain relief, skin care,
  hydration, comfort

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Chronic Pancreatitis

• Progressive destruction fibrotic replacement of
  tissue
• Chronic obstructive pancreatitis
• Chronic calcifying pancreatitis
• S/S pain, malabsorption with wt loss, jaundice,
  dark urine, steatorrhea, DM
• Dx secretin stimulation test

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Collaborative Care

• Diet, pancreatic enzyme replacement, control of
  diabetes
• Antacids, anticholinergic meds, H2 blockers, bile
  salts, insulin
• Surgery if obstruction
• Nursing Care health promotion diet, pancreatic
  enzymes, diabetic teaching, avoid alcohol,
  referrals for narcotic or alcohol dependence

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Pancreatic Cancer

• Over 50 tumors _at_ head of pancreas-gt obstruction
  of common bile duct-gtjaundice
• S/S pain, rapid wt loss, anorexia, nausea,
  jaundice
• Dx CEA, CA19-9, ultrasound, CT, ERCP-gt samples
  for cytology biopsy
• Rx Whipples procedure, radiation, chemo
• Nursing Care supportive, comfort, help pt
  family grieve