Transcript Cirrhosis of the liver

Stressors of the
Gallbladder, Pancreas
And Liver
GI Stressors II
McKevney 4/08, rev Borrero 11/09
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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. It’s 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
• Nausea, vomiting, anorexia
• Intense pain after eating a
high fat meal
• Fever, chills
• Increased HR, pallor,
diaphoresis
• Light colored bowel movements
• Dyspepsia, eructation, and
flatulence
• Steatorrhea, light colored stools
• Fat soluble vitamin deficiency
• Rebound tenderness
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Nursing Diagnoses
Acute Cholecystitis
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Acute pain
Impaired gas exchange
Risk for infection
Knowledge deficit
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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
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• http://www.youtube.com/watch?v=Pr3Md9Xl
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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 client’s response to food
Nursing Interventions:
Patient Education
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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
isn’t 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
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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
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Nausea and vomiting
Weight loss
Signs and symptoms of inflammation or peritonitis
Ecchymosis on the flanks (Turner’s sign)
Bluish periumbilical discoloration (Cullen’s
sign)
• Generalized jaundice
• Paralytic ilieus
• Hyperglycemia
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Nursing Diagnoses
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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
Trousseau’s sign (hand spasm when BP cuff
is inflated)
Chvostek’s sign (facial twitching when facial
nerve is tapped)
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Complications of Pancreatitis
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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 person’s
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
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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
NORMAL RESULTS
LIVER DISEASE
AST
5-40 u/L
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ALT
8-20 u/L
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LDH
100-190 units/L
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Alkaline Phosphatase
42-128 u/L
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Bilirubin
0.3 -1.0 mg/dl
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Total Protein
6.4-8.3 g/dl
Normal
Ammonia
15-45 mg/dl
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PT
11.0-12.5 seconds
Prolonged
INR
0.8-1.1
Prolonged
Albumin
3-5 g/dl
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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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High Risk Behaviors
HBV, HCV
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
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Type
Route of
Transmission
Risk Factors
HAV
Oral-fecal route
Ingestion of
contaminated food
(shellfish) or water
HBV
Blood
Drug abuse
Sexual contact
Healthcare work
HCV
Blood
HDV
Co-infection with
HBV
Drug abuse
Sexual contact
Drug abuse
HEV
Oral-fecal route
Contaminated water
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- Laennec’s, 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
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Nursing Assessment
• Petechiae red pinpoint and red-purple lesions,
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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
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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
Risk for injury
Body Image
Disturbance
Impaired
Liver
Function
Imbalanced
Nutrition,
Less than
Body
Requirements
Activity
Intolerance
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