Transcript 2010 Univ of Rochester, Clinical challenges, managing

Review of the Pancreatobiliary System
What Every GI Nurse Needs to Know
Joyce Flueckiger, APRN, BC, CGRN
Liver
• The liver is the largest organ in the body
– Weighs 3-4 pounds
– Extends from the fifth intercostal space in the
midclavicular line to the right costal margin
– Glisson’s capsule covers the liver – contains blood
vessels and lymphatics
– Serosa covers the Glisson’s capsule
Liver
• Two lobes – right - 6 times larger than the left
• One million hepatic lobules – functioning unit of
the liver
• Each lobule
– Hepatocytes → secrete bile
• Each portal triad → hepatic artery, hepatic vein,
bile duct
• Sinusoids → lie between each row of cells
• Kupffer cells → phagocytosis
Blood Supply to Liver
• 1500 ml of blood flow into the liver every
minute
• Portal vein supplies 75%
• Hepatic artery supplies 25%
• Cells can regenerate within 3 weeks
• Can function with 90% damage for short time
Functions of Liver
• Bile production – up to 1000 ml per day
• Storage of vitamins, minerals
– A, D, B12 and iron in form of ferritin
• Coagulation – production of clotting factors →
fibrinogen and prothrombin
• Detoxification and excretion of many drugs
and hormones
Primary Sclerosing Cholangitis
• More common in males
• 50-75% associated with ulcerative colitis
• Monitor progression of disease with liver
function tests, cholangiography
Portal Hypertension
• Portal vein resistance is increased → collateral
circulation
• Splenomegaly, varices, hemorrhoids, dilated
cutaneous umbilical veins
• Jaundice, bleeding, edema, palmar erythema,
fetor hepatics, spider nevus
Complications of Liver Disease
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Varices
Ascites
Hepatorenal syndrome
Hepatic encephalopathy
– Mild → severe
Hepatitis A
• HAV – RNA virus, fecal – oral, contaminated
food
• Symptoms – low-grade fever, fatigue, nausea,
anorexia, myalgias, dark urine, light stools,
right upper quadrant pain or discomfort
• Self-limiting
Hepatitis B
• HBV – DNA virus, bloods, saliva, semen
• Incubation period up to 6 months
• HBsAg is positive, ALT and AST 5-20 above
upper limits normal
• HBsAb – when disease clears
• Hepatitis vaccine
Hepatitis C
• HCV – IV drug use, blood transfusions, most
common
• Interferon therapy
• Now close to being treated with medications,
will soon be treated by PCP
Other Diseases of the Liver
• NASH
• Wilson’s disease – autosomal recessive –
excess copper stores
• Porphyria – hereditary disorder affects
synthesis of heme
• Hemochromatosis – autosomal recessive –
excess iron stores
• Gilbert’s syndrome
Gallbladder
• Size – 3” x 1”
• Capacity – 50 ml of bile
• Alkaline greenish-yellow fluid
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Bile
Bile salts
Fatty acids
Lipids (cholesterol & lecithin)
Inorganic substances
Conjugated bilirubin
90% of water is removed from bile from the liver →
cystic duct → gallbladder
Anatomical Divisions of Gallbladder
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Cystic duct
Hepatic duct
Common bile duct
Sphincter of Oddi
– Arrangement of smooth muscles
Gallbladder has Three Layers
• Outer serosa derived from peritoneum
• Middle layer which contains longitudinal &
spiral smooth muscle and fibrous tissue
• Inner mucosa which is simple columnar
epithelium arranged in folds similar to rugae
in the stomach
Diseases of the Gallbladder
• Cholelithiasis – the presence of stones or calculi
in the gallbladder
• Two types of stones
– Cholesterol – contain pure cholesterol
– Mixed – cholesterol, bile acids, calcium salts, fatty
acids, protein, phospholipids
• Pigment
– Black contain bilirubin polymers, inorganic calcium
salts
– Brown contain primarily calcium bilirubinate and
organic fatty acid salts of calcium
Symptoms of Cholelithiasis
• 50% of gallstones do not cause symptoms
• Biliary colic – usually within 30 minutes of
meal, lasting up to or greater than one hour
• Location of pain – right upper quadrant, right
subscapular, back
• May be associated with nausea and vomiting
Diagnosis of Cholelithiasis
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Ultrasound – may miss very small stones
MRI/MRCP
EUS
ERCP – want to be sure stones are present
before doing this procedure
Choledocholithiasis
• Stones in the common bile duct
• Patients may be asymptomatic
• Symptoms associated with choledocholithiasis
– Biliary colic with constant right upper quadrant pain,
epigastric pain
– Obstructive jaundice and pruritus
– Cholangitis – urgent or emergent situation manifested
with fever, right upper quadrant pain, jaundice
(Charcot triad), +/- rigors
– Gallstone pancreatitis
Acalculous Cholecystitis
• May occur in hospitalized patients not
receiving oral intake resulting in gallbladder
stasis
• Right upper quadrant pain, guarding, nausea
and vomiting
Cholangitis
• Bacterial infection of the bile duct
• Associated with choledocholithiasis, strictures,
neoplasms, cysts, fistulas
• Symptoms – acute fever, chills, rigors, dark
urine, often abdominal pain
• Acute, emergent situation – ERCP
Acute Calculous Cholecystitis
• 90% associated with a stone impacted in the
cystic duct
• Symptoms include midepigastric or right
upper quadrant pain, radiation of pain to
shoulders and back
• Nausea, vomiting, fever, leukocytosis
Gallbladder Cancer
• More common in older women
• 80% have gallstones
• Gallbladder polyps >1 cm in size raise the risk
of gallbladder cancer
• Vague symptoms of pain, anorexia, weight
loss, nausea, vomiting
• 80% of tumors are adenocarcinoma – rarely
are gallbladder tumors benign
Bile Duct Cancers
• 30% associated with gallstones
• Maybe associated with long-standing UC,
Crohn’s, PSC, choledochal cysts
Pancreas
• The pancreas is 6-8 inches long
• Lies posterior to the stomach
• Segments
– Head, body and tail
Exocrine Cells – Approximately 99%
• Acinar cells – majority of pancreatic tissue
• Groups of acinar cells form lobules (acinus)
• Pancreatic juice with enzymes drains into the
main pancreatic duct
Endocrine Cells – Remaining 1%
• Loculated in islets of Langerhaus – in the
connective tissue between the lobules, mostly
in the tail
Endocrine Cells
• Alpha → glucagon
• Beta → insulin
• Delta → somatostatin
Exocrine Acinar Cells
• 500-1000 ml daily (pancreatic juice)
• pH 8.5
• Contains water, enzymes, electrolytes,
bicarbonate
Exocrine Acinar Cells
• 500-1000 ml daily (pancreatic juice)
• pH 8.5
• Contains water, enzymes, electrolytes,
bicarbonate
Exocrine Acinar Cells
• 500-1000 ml daily (pancreatic juice)
• pH 8.5
• Contains water, enzymes, electrolytes,
bicarbonate
Pancreatic Enzymes
• Amylase → CHO3 into glucose and maltose
• Lipase → pancreatic lipase and phospholipase
A, important in early fat digestion
• Proteases → trypsinogen, then trypsin which
break amino acids into active forms
Secretin and
Cholecystokinin-Pancreozymin
• Hormones which stimulate pancreatic secretions
• Rest → bicarbonate 2% of maximum; enzymes 15% of
maximum
• Cephalic phase → sight and smell of food stimulate the
flow of digestive enzymes
• Gastric phase → increasing amounts of enzymes
secreted still low in bicarbonate
• Intestinal phase → food entering the duodenum
stimulates pancreatic enzyme secretion at 70% of
maximal rate
• Bicarbonate output increases as the pH of meal
decreases and acid increases
Diseases/Conditions of the Pancreas
• Cystic fibrosis
• Pancreatic exocrine insufficiency
– Associated with chronic pancreatitis
– Malabsorption of fat, protein, and carbohydrates →
quantitative
– 72 hour fecal fat test (>7%)
– Treat with pancreatic enzymes and acid suppression
• Pancreatic rest
• Pancreatic divisum – in 7-10% of general population
• Annular pancreas
Tumors of the Pancreas
• Cystic – fluid filled, most often in head of
pancreas
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Serous cystadenoma
Cyst adenocarcinoma
Mucinous cystadenoma
Cyst adenocarcinoma
• IPMN – intraductal papillary mucinous neoplasm
• Carcinoma
• Endocrine tumors
Acute Pancreatitis
• Inflammation of enzymatic digestion
• Etiology – alcohol, gallstones, trauma, family
history, genetic abnormalities, medications,
tumors, anatomic variants, hypercalcemia
Symptoms of Pancreatitis
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Epigastric pain radiating to back, left blank
Nausea and vomiting
Low-grade fever
Abdominal distention, ileus
Treatment of Acute Pancreatitis
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Aggressive hydration
Analgesics and antiemetics
Antiobiotics - ?
Nasojejunal feedings
ERCP - ?
Chronic Pancreatitis
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Not defined only by chronic pain
Criteria on endoscopic ultrasound
Criteria on pancreatography
Intraductal secretin test
– HCO3 < 105, volume < 3 ml/min
Manifestations of Chronic Pancreatitis
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Chronic abdominal pain
Weight loss
Steatorrhea
Nausea and/or vomiting
Obstructive jaundice
Treatment of Chronic Pancreatitis
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Analgesics
Enteral feeding tube
Octreotide/sandostatin
Pancreatic enzymes
Celiac plexus block
Intrathecal pain pump