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Management of Patients with Liver/Biliary Dysfunction

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Title: Management of Patients with Liver/Biliary Dysfunction


1
Management of Patients with Liver/Biliary
Dysfunction
  • Hepatitis
  • Cirrhosis
  • Gall Bladder Disease

2
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3
Functions of the Liver
  • Metabolizes CHO, proteins, fat
  • Synthesizes plasma proteins
  • Stores vitamins and minerals
  • Forms blood clotting factors
  • Detoxifies drugs toxins
  • Produces excretes bile
  • Regulates hormone function
  • Phagocytic activities
  • Acts as reservoir for blood volume

4
Circulation of the liver Dual Blood Supply
  • Portal system
  • Hepatic veins drain liver empty into IVC
    1000-1200 ml/min
  • (rich in nutrients)
  • Hepatic artery
  • 400-500 ml/min blood flow
  • Oxygenated blood

5
Portal Vein
  • Receives 1050 mL/min from
  • Spleen
  • Intestines
  • Pancreas
  • Stomach
  • Stores 450 mL blood

6
Overview of liver pathophysiology
  • Inflammation
  • Edema
  • ? pressure
  • Obstruction
  • ? internal pressure
  • ? external pressure
  • Hepatocellular damage
  • ? breakdown of urea ? ? NH3 ? encephalopathy
  • ? absorption of fat soluble vitamins (Vit. K) ?
    ? synthesis of clotting factors ? bleeding
  • ? synthesis of plasma proteins (albumin) ?
    malnutrition edema

7
Diagnostic Tests non-invasive
  • Non invasive LFTs
  • Enzymes
  • Proteins
  • Prothrombin time
  • CBC
  • ? ALP, LDH, GGT, AST, ALT
  • ? serum urinary bilirubin
  • ? serum albumin proteins
  • ? Prothrombin time
  • ? platelet count

8
Diagnostic Tests - Invasive
  • Nursing role
  • Liver Bx

9
Hepatitis
10
Pathophysiology of Hepatitis
  • Liver damage
  • Inflammation
  • Cellular degeneration
  • Cellular necrosis
  • Interruption of bile flow

Impaired function
11
Clinical manifestations-similar
  • RUQ pain
  • Anemia
  • Bruising/bleeding
  • Icterus Altered bilirubin excretion
  • Fatigue
  • Jaundice

12
Diagnosis of Hepatitis
  • Viral specific serological markers (Surface
    antigens)
  • Current infection
  • Carrier state
  • Antibodies
  • Current or recent infection
  • Carrier state
  • IgM acute infection
  • IgG past exposure
  • probable immunity

13
Diagnosis of Hepatitis lab findings
  • Laboratory tests
  • ? ALP, GGT, AST, ALT
  • ? serum urinary bilirubin
  • ? serum albumin proteins
  • ? Prothrombin time
  • ? platelet count
  • liver damage or
  • altered function

14
Prevention
Strict handwashing!
  • Eliminate exposure
  • Fecal/oral routes
  • Contact with infected blood or body fluids
  • Safer sexual contact
  • Mother/newborn exposure
  • Vaccines
  • A
  • B
  • C (unavailable)
  • D (protected by Hep B vaccine)

15
Nursing Diagnoses
  • Physical emotional rest
  • ? fat w/ vitamin. Supp.
  • Protein may be restricted
  • ? exposure
  • ? invasive procedures
  • Patient family education
  • Activity Intolerance
  • Fatigue
  • Altered Nutrition
  • Risk for infection r/t
  • ? immune function
  • Ineffective health maintenance

16
Complications of Hepatitis
  • Chronic active (mild/mod./severe) hepatitis may
    progress to cirrhosis
  • Fulminant hepatitis is a complication of HBV that
    leads to liver failure ( Severe liver damage )
  • HAV HBV
  • Most acute cases resolve without complications

17
Cirrhosis
Diffuse fibrotic bands of connective tissue in
response to inflammation
18
Cirrhosis of the Liver Pathophysiology
  • Degeneration
  • Destruction
  • Necrosis
  • Regeneration attempts
  • Nodule (scar) formation
  • Compression of vascular system lymphatic bile
    duct channels
  • Fibrous tissue proliferation in a disorganized
    pattern

Poor cellular nutrition Hepatocellular hypoxia
Altered flow
19
Cirrhosis - 4 Types
  • Alcoholic
  • Long term alcohol abuse
  • Post necrotic - Massive hepatic cell necrosis
  • Post viral hepatitis
  • Toxic exposure
  • Autoimmune process
  • Biliary
  • Chronic biliary obstruction
  • Bile stasis
  • Inflammation
  • Cardiac
  • Severe RHF
  • Constrictive pericarditis
  • Tricuspid insufficiency

20
Clinical Manifestations Early
  • GI disturbances
  • anorexia
  • Dyspepsia
  • Flatulence
  • Nausea vomiting
  • ? bowel habits
  • Altered metabolism of
  • fats, CHO, proteins
  • Abdominal pain
  • Dull, heavy
  • RUQ or epigastrium
  • Swelling/stretching of liver capsule
  • Spasm of biliary ducts
  • Intermittent vascular spasm

21
Additional CMs - Early
  • Fever
  • Slight weight loss
  • Hepatosplenomegaly
  • Palpable liver

22
Clinical Manifestations Later
  • Skin Lesions
  • Jaundice
  • Hematologic Problems
  • Endocrine Disturbances

Peripheral Neuropathy
23
Diagnosis
  • Invasive studies
  • liver biopsy
  • angiograms
  • Liver function studies
  • enzymes
  • proteins
  • cholesterol
  • prothrombin time
  • Liver may be contracted or enlarged

24
Normal Bilirubin Excretion
  • Lab tests
  • Indirect unconjugated, BU or pre-hepatic
  • Direct conjugated, or post-hepatic
  • Urobilinogen is the breakdown of conjugated
    bilirubin that is excreted in the urine (small
    amount) and feces (most).
  • Breakdown of hgb bilirubin (non
    water-soluble).
  • Carried by albumin to the liver for conjugation
    where it is made water-soluble.

25
Bilirubin
  • Congugated
  • direct bilirubin-impaired excretion of
    bilirubin from liver d/t hepatocellular disease
  • Drugs
  • Sepsis
  • Hereditary disorders
  • Extra-hepatic biliary obstruction
  • Unconjugated
  • indirect bilirubin
  • Overproduction d/t Hemolysis
  • Impaired hepatic intake d/t certain drugs
  • Impaired conjugation by glucoronide

26
RBC
bilirubin
Unconjugated
Break down
Joins with albumin
In blood stream to liver
To intestine in bile
Liver - bilirubin releases from albumin, combines
with glucuronic acid (conjugation)
Intestine - bilirubin converted to urobilinogen
Excreted in stool
Small amount Conjugated enters circulation
Excreted via kidneys
27
Lab Test Abnormalities Cirrhosis
  • ? ALP, LDH, GGT, AST, ALT indicate liver damage
    or altered function
  • ? serum bilirubin
  • urinary bilirubin
  • ? PT
  • ? platelet count
  • ? serum albumin proteins

28
Jaundice
  • Inability of liver to conjugate bilirubin
  • Bilirubin- bile pigment from breakdown of Hb from
    RBCs by macrophages
  • Skin sclera jaundice
  • Excreted in urine tea colored urine
  • Blocked from flow into intestines clay colored
    stools

Hyperbilirubinemia gt1.2mg/dl
29
What changes do you see and why?
  • Skin Sclera
  • Jaundice
  • Urine
  • Tea colored
  • Stool
  • Clay colored

30
Skin Lesions
  • Spider angiomas
  • Small, dilated blood vessels with red center and
    spider like branches
  • Palmar erythema
  • Reddened palms that blanch with pressure
  • ? In circulating estrogen d/t ? ability of liver
    to metabolize steroids

31
Hematologic Problems
  • Thrombocytopenia
  • Leukopenia
  • Anemia
  • Coagulation defects
  • d/t splenomegaly
  • back up of blood from portal vein into spleen
  • Overactivity of enlarged spleen - ? removal of
    blood cells from circulation
  • d/t livers inability to produce Prothrombin and
    other clotting factors
  • d/t ? synthesis of bile fats ? ?
    absorption of fat soluble vits
  • Without Vit. K, clotting factor production ?

32
Endocrine Problems
  • Gynecomastia
  • Loss of axillary/pubic hair
  • Testicular atrophy
  • ? libido/impotence
  • hyperaldosteronism
  • ? Na
  • ? H20
  • ? K

33
Peripheral Neuropathy
  • Mixed form
  • Sensory predominant
  • Dietary ? of
  • Thiamine
  • Folic acid
  • Cobalamin Vit. B 12

34
Complications of Cirrhosis
  • Portal Hypertension
  • Esophageal Varices
  • Hepatic Encephalopathy
  • Ascites
  • Peripheral Edema
  • Hepatorenal Syndrome

35
Portal Hypertension Esophageal Varices
  • Compression destruction
  • Portal veins
  • Hepatic veins
  • Obstruction of normal flow through portal system
    ? portal hypertension
  • Collateral circulation develops to ?
  • Portal pressure
  • Plasma volume
  • Lymphatic flow
  • Collateral circulation develops primarily in
  • Lower esophagus
  • Anterior abdominal wall
  • Rectum
  • Parietal peritoneum

36
Esophageal Varices ? risk for bleeding
  • Chemical irritants
  • Alcohol
  • Medications
  • Refluxed gastric acid
  • Fragile, inelastic, thin-walled, large esophageal
    veins become distended or irritated leading to
    rupture
  • Mechanical trauma
  • Poorly chewed, coarse food
  • Vomiting
  • N/G insertion
  • ? esophageal pressure
  • Vigorous exercise, heavy lifting
  • Coughing, sneezing
  • Retching/vomiting
  • Straining at stool

37
Esophageal Varices Medical Management
  • Prevent
  • initial
  • hemorrhage
  • Manage
  • acute
  • hemorrhage
  • Prevent
  • recurrent
  • hemorrhage

38
Prevent initial hemorrhage
  • Pharmacological Mgt.
  • ?-blockers
  • ? portal pressure by
  • ? splanchic blood flow ??
  • ? flow in collateral channels
  • Stool softeners
  • H-2 blockers, PPIs
  • Dietary Modifications
  • ? alcohol
  • ? caffeine
  • ? spicy foods
  • ? coarse foods

39
Manage acute hemorrhage
  • Pharmacological Mgt.
  • Vasopressin
  • 65-75 of cirrhotic
  • patients develop
  • esophageal varices.
  • Ruptured varices have
  • a 30-60 mortality rate
  • Endoscopic injection
  • Supportive Tx
  • FFP, RBCs
  • Vit. K
  • H2 blockers
  • Neomycin

40
Nursing Management
  • Impaired Gas Exchange r/t ? O2 exchange
  • Aspiration pneumonitis
  • Aspiration Pneumonia
  • Assure suction port
  • Suction frequently
  • Nares Erosion
  • Clean, lubricate external nares
  • Pad if necessary
  • Airway Obstruction

41
Prevent recurrent hemorrhage
  • Shunts
  • ? portal pressure
  • divert flow away from collateral channels
  • send portal venous blood directly to IVC
    bypassing liver
  • Complications
  • Hepatic encephalopathy
  • Heart Failure
  • Bacteremia
  • Shunt Clotting

42
Ascites Pathophysiology/Interventions
  • Protein leaks through liver capsule to peritoneal
    cavity ? oncotic pressure of PRO pulls more fluid
  • ? albuminemia d/t livers inability to synthesize
    PRO ? ? colloidal osmotic pressure
  • ? aldosteronism d/t livers inability to
    metabolize aldosterone ? ? Na reabsorption ? ?
    serum osmolarity ?
  • ? ADH secretion ? ? water retention
  • ? Fowlers Position
  • ? Pro, ? Na diet
  • mouth care/ dehydration
  • K-sparing diuretics
  • Paracentesis
  • Salt Poor Albumin

43
Ascites and Peripheral Edema
  • Portal hypertension
  • protein plasma leak into the peritoneum
  • osmotic pressure pulls more fluid in
  • Hypoalbuminemia
  • Hyperaldosteronism

44
Therapeutic Goals Outcomes
  • ? metabolic demand on the liver
  • Treat complications
  • Balanced fluid volume
  • Absence of breathing problems
  • Corrected coagulation defects
  • Absence of infection
  • Adequate nutritional intake

45
Portal Systemic Encephalopathy Hepatic
Encephalopathy
  • Build up of NH3 in serum and CSF ? neurotoxicity
  • Altered LOC
  • Impaired thinking
  • Neuromuscular disturbance
  • Early Sign Change in hand writing
  • Neomycin
  • Lactulose

46
Hepatorenal Syndrome CMs Pathophysiology
  • Azotemia (? BUN, creatinine)
  • Sudden oliguria
  • Intractable ascites
  • Redistribution of blood flow from kidneys to
    peripheral splachnic
  • Hypovolemia d/t ascites
  • Intrarenal imbalance of vasoconstriction
    vasodilating mechanisms d/t Liver disease

47
Hepatorenal Syndrome Risks management
  • Precipitants
  • Overly vigorous Diuretics
  • GI/Vericeal hemorrhage
  • Paracentesis
  • Hepatic encephalopathy
  • NSAIDs
  • Sepsis
  • Salt Poor Albumin
  • Na H20 restriction
  • Diuretic therapy

48
Alcohol Withdrawal Syndrome (48-72 Hours after
last Drink)
  • Facts
  • Hidden disease
  • Potent CNS depressant
  • Withdrawal awakens SNS
  • Untreated or undertreated ETOH withdrawal ?
    ? mortality and morbidity
  • Delirium-Tremens (DTs) can be a life-threatening
    medical condition
  • Clinical Manifestations
  • Tremor/shakiness
  • ? VS
  • Diaphoresis
  • Agitation, Anxiety
  • GI
  • Confusion
  • Sleep disturbance
  • Hallucinations
  • Seizures

49
Alcohol Withdrawl - Goals
  • ? patient discomfort
  • ? dangerous cms
  • Prevent complications
  • Prepare patient for rehabilitation

Consider primary diagnosis
  • Admission assessment
  • Frequent monitoring
  • Prompt adequate treatment
  • Benzodiazepines

50
Hepatocellular Carcinoma
Hep B Hep C Cirrhosis Metastatic
51
Liver CA treatment survival
  • Surgical resection
  • Lobectomy
  • Hepatectomy
  • Chemotherapy
  • Portal Vein or Hepatic Artery perfusion
  • 5-FU, Adriamycin
  • Palliative Care
  • Same as for cirrhosis
  • Transplantation
  • Cirrhosis d/t hepatitis viruses
  • Hepatic malignancy confined to liver
  • Congenital diseases

52
The Biliary Tract
Gallbladder
Hepatic Duct
Common bile duct
Cystic duct
53
Function of the Gallbladder
  • Concentration and storage of bile produced by the
    liver
  • Bile release stimulated by presence of food in GI
    tract

54
Disorders of the Gallbladder
  • Cholelithiasis
  • cholesterol, bile and calcium stone formation
  • Cholecystitis
  • inflammation and/or obstruction
  • stones
  • bacterial

55
Clinical Manifestations
  • Indigestion fat intolerance
  • steatorrhea (fatty stools)
  • Moderate to severe pain
  • referred to right shoulder and scapula
  • biliary colic, RUQ tenderness
  • Nausea and vomiting
  • ? temperature, ? WBCs
  • jaundice
  • dark urine
  • clay-colored stools
  • pruritis
  • bleeding tendencies

56
Diagnosis
  • History
  • Ultrasound
  • Oral cholecystograms
  • Percutaneous transhepatic cholangiography
  • Endoscopic retrograde cholangiopancreatography
    (ERCP)
  • Lab studies
  • elevated direct and indirect bilirubin
  • elevated AST (aspartate aminotransferase) (SGOT)

57
Normal Bilirubin Excretion
Breakdown of hgb bilirubin (non
water-soluble). Carried by albumin to the liver
for conjugation where it is made water-soluble.
Lab tests Indirect unconjugated, BU or
pre-hepatic Direct conjugated, BC or
post-hepatic Urobilinogen is the breakdown of
conjugated bilirubin that is excreted in the
urine (small amount) and feces (most).
58
Treatment
  • Cholecystitis (conservative)
  • pain control
  • anti-nausea meds
  • antibiotics
  • NG tube
  • Diet restrictions/ NPO
  • anticholinergics
  • Fat soluble vitamins (A, D, E, K)
  • Cholelithiasis
  • dissolve stones
  • endoscopic intervention
  • Extracorporeal shockwave lithotripsy (ESWL)

59
Surgical Intervention
  • Laparoscopic Surgery
  • preferred treatment
  • Open or incisional cholecystectomy
  • for more complicated cases

60
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63
Post-Operative Care
  • Laparoscopic
  • pain management
  • meds
  • Sims position
  • mobility
  • CDB
  • DC teaching
  • activity diet
  • Open or incisional
  • pain management
  • mobility
  • CDB
  • wound care
  • T- tube monitoring
  • DC teaching
  • activity diet

64
Care Teaching T-tube
  • Keep bag level w/abd
  • Prevent tension
  • Monitor output
  • Skin site care
  • Clamp 1-2 hr ac and unclamp 1-2 hr pc
  • Unclamp if distress
  • Time Approx. 10 days

65
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