Transcript Liver, Biliary Tract, & Pancreas Problems

Liver, Biliary Tract, &
Pancreas Problems
Nur 302
Unit I
Liver, Biliary Tract &
Pancreas Problems
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Jaundice
Hemolytic jaundice
Hepatocellular Jaundice
Obstructive jaundice
Viral Hepatitis
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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
Hepatitis A
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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
Hepatitis B
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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
Hepatitis C
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Transmission- pericutaneous
At risk: IV drugs, bld transfusion,
hemodialysis, tattooing, hi risk sexual
behavior, organ transplants, health
care workers
Hepatitis D
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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
Hepatitis E
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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.
Hepatitis G
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Recently discovered.
Found in blood donors & transmitted
by transfusion.
Co-exists with other hepatitis viruses.
Not associated with chronic hepatitis
or cirrhosis.
Pathophysiology
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Inflammation of liver -> 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
Collaborative Care
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Rest, well balanced diet
Antiemetics, Benadryl, NO phenothiazines
Immunoglobulin for hepB or hepA
Alpha inferon
wks after exposure, hepA vaccine –preexposure prophylaxis
HepB vaccine prophylaxis, post exposurehepatitis B immune globulin
Nursing Care: Hepatitis
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Health Promotion
Assessment of
jaundice
Adequate nutrition
Rest
Home Care
Toxic, Drug-induced &
Idiopathic Hepatitis
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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
Cirrhosis of the Liver
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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
Types of Cirrhosis
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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-> decreased
functioning of liver
Clinical Manifestations
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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
Diagnostic Studies
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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
Peripheral Edema &
Ascites
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Peripheral edema @ ankle & presacral area decr. albumin -> decr colloidal osmotic
pressure. Increased portalcaval pressure
from portal hypertension.
Ascites- hypertension in liver->proteins
move bld via capillaries to lymph->leak into
peritoneal cavity-> 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.
Collaborative Care
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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
Portal Hypertension &
Esophageal Varices
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Compression, destruction of hepatic & portal
veins & sinusoids-> obstruction portal bld
flow-> portal hypertension.
Collateral circulation – lower esophagus,
parietal peritoneum, rectum-> varices
where collateral & systemic circulation meet.
Esophageal varices, fragile, tolerate hi
pressure poorly, tortuous, bleed easily. Life
threatening complication.
Hepatic Encephalopathy
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Ammonia in systemic circulation without
liver detoxification.
Ammonia from metabolism of P shunted
past liver or liver unable to convert
ammonia to urea-> lg amt ammonia->
crosses blood-brain barrier->neuro s/s
S/S: LOC changes from lethargy to coma,
disorientation, asterixis, writing
impairments, hyperventilation, hypothermia,
grimacing, grasping, fetor hepaticus
Collaborative Care
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Protein restriction
Neomycin po or enemas
Lactulose (Cephalac)
Control GI blding, remove bld from
intestinal tract, treat lyte & acid/base
imbalance
Liver transplant
Nursing Care:
Encephalopathy
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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
Hepatorenal Syndrome
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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
Nursing Care: Cirrhosis
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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
Home Care
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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
Liver Cancer
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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
Endoscopic Retrograde
Cholangiopancreatography
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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???
ERCP Nursing Care
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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
Cholecystitis &
Cholelithiasis
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S/S cholecystitis: indigestion, moderate->
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
Collaborative Care
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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
Nursing Care: GB Disease
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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
Simm’s position, prevent resp complications,
care of T-tube
Cancer of the Gallbladder
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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
Chronic Pancreatitis
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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
Collaborative Care
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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
Pancreatic Cancer
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Over 50% tumors @ head of pancreas->
obstruction of common bile duct->jaundice
S/S: pain, rapid wt loss, anorexia, nausea,
jaundice
Dx: CEA, CA19-9, ultrasound, CT, ERCP->
samples for cytology & biopsy
Rx: Whipple’s procedure, radiation, chemo
Nursing Care: supportive, comfort, help pt &
family grieve