Liver and Pancreas
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Transcript Liver and Pancreas
LIVER and PANCREAS
DYSFUNCTION
Valerie Gumangan, RN, ACNP
PANCREAS
Exocrine
Secretes digestive
enzymes into the
small intestines
Breakdown of CHO,
protein, and fats
Endocrine
Produces hormones
Insulin
Glucagon
EXOCRINE FUNCTION
CCK: Cholecystokinin
Secretin
Stimulus for enzyme
secretion
Secretion of bicarb and
water
Lipase: Fats
Amylase: Carbohydrates
Trypsin: Proteins
EXOCRINE FUNCTION
90% of pancreatic
digestive enzymes are
proteolytic
Trypsin
Chymotrypsin
splits proteins into
peptones
Elastase
Breakdown elastic
tissue
EXOCRINE FUNCTION
Amylolytic
Breakdown of
carbohydrates
Amylase
Lipolytic
Breakdown of fats
Lipase
Phospholipase A
ENDOCRINE FUNCTION
Islet of Langerhans
Alpha cells
Beta cells
Glucagon: ↑ blood
glucose
Insulin: ↓ blood
glucose
Delta cells
Somatostatin
PANCREATITIS
Inflammation of the
pancreas
Autodigestion of the
pancreas by
pancreatic enzymes
Cellular destruction
and organ damage
ACUTE PANCREATITS
Acute
Mild or Nonhemorrhagic
Severe or
Hemorrhagic
Fulminant
EPIDEMIOLOGY
185,000 cases each
year
150,000 cholelithiasis
or sustained alcohol
abuse
African-Americans
are at ↑ risk
CAUSES
Alcohol consumption
Gallstones
Pancreatic
obstruction
Drugs and toxins
Hyperlipidemia
Family history
Trauma and
iatrogenic factors
SIGNS and SYMPTOMS
Severe abdominal pain
Epigastrium radiating to
midback
Not relieved by vomiting
Fever, malaise
Nausea, vomiting
Rigid and distended
Rebound tenderness
Absent or diminished
bowel sounds
SIGNS and SYMPTOMS
Dyspnea and
Tachypnea
Grey Turner’s sign
Large ecchymosis
appearing in the
flanks
Cullen’s sign
Pulmonary infiltrates
Ecchymosis in
umbilical area
Hypovolemic Shock
DIAGNOSTIC FINDINGS
Serum Amylase
Serum Lipase
Normal (23-85 u/L)
Normal (0-160 u/L)
Serum trypsinogen:
elevated
Urinary amylase:
elevated
DIAGNOSTIC FINDINGS
Hematocrit: initially
elevated then later
decreased
WBC: elevated
C-reactive protein:
elevated
Liver function tests:
elevated
DIAGNOSTIC FINDINGS
Sodium and
Potassium: decreased
Blood glucose:
elevated
Serum Calcium:
decreased
Albumin and
Magnesium:
decreased
DIAGNOSTIC FINDINGS
Abdominal and Chest X-ray
CT scan, Ultrasound, MRI
Endoscopic Retrograde
Cholangiopancreatography
(ERCP)
Aspiration biopsy
Stool studies: steatorrhea
COMPLICATIONS
Hypovolemic shock
3rd spacing
Hemorrhage
Vomiting
Decreased protein
intake
COMPLICATIONS
Pulmonary
complications
Atelectasis
Acute lung injury
Pleural effusion
ARDS
COMPLICATIONS
Cardiovascular
Release of myocardial
depressant factor
Pancreatic
pseudocyst
Cavity next to
pancreas
Filled with necrotic
products
COMPLICATIONS
Pancreatic abscess
2-4 weeks after
episode
Necrosis of tissue
Relocation of bacteria
Hypocalcaemia can
occur with severe
disease
COMPLICATIONS
Fluid and electrolytes
Vomiting
NG suction
Redistribution of fluids
TREATMENT
Pain Management
IV opioid analgesics
Dilaudid IV PCA
Demerol and
Morphine IV
GI rest
Decrease stimulation
of pancreas
Nasogastric tube
insertion
TREATMENT
Fluid and Electrolyte
replacement
Cessation of alcohol
consumption
Nutrition: enteral
versus parenteral
Surgery if there is
biliary obstruction
TREATMENT
Respiratory
Oxygen
Monitor oxygen
saturation
Arterial blood gas
Ventilator support
TREATMENT
Fluid volume deficit
IV fluids
Plasma expanders
Vasopressors
Blood replacement
Strict intake and output
TREATMENT
Fluid and electrolyte
imbalance
LR or IV maintenance
fluid containing K+
Calcium gluconate
Hypocalcemia
Chvostek’s sign
Trousseau’s sign
TREATMENT
Pseudocyst, abscess
or fistula
Monitor for signs and
symptoms of shock
Prepare patient for
surgery
Watch for infections
post-operatively
TREATMENT
Biliary drainage tube
Surgical debridement
ERCP
Sphinceterotomy
Gallstone removal
Stent placement
Balloon dilatation
Laparoscopic
cholecystectomy with
CBDE
MEDICATIONS
Viokase
Pancrease
Replace pancreatic
enzymes
Replace pancreatic
enzymes
Glucagon
Treat hypoglycemia
NURSING IMPLICATIONS
Vital signs
Laboratory values
Hypovolemic shock
Sepsis
Amylase, Lipase
BMP
Fluid and electrolytes
NPO
NGT
Nutrition
NURSING IMPLICATIONS
Administer pain
medication
Monitor blood
glucose
Monitor intake and
output
Daily weight
CHRONIC PANCREATITIS
Persistent
inflammation of the
pancreas
Scarring and
calcification of the
pancreatic ducts
CAUSES
70% is caused by
alcohol abuse
20% is caused by
obstruction, trauma,
metabolic
disturbances
SIGNS & SYMPTOMS
80% of pancreatic
destruction causes
Malabsorption
resulting in nutritional
deficits
Diarrhea and
steatorrhea
Impaired glucose
regulation
DIAGNOSTIC FINDINGS
LFT, CMP, CBC, ESR
Stool studies
Abdominal CT scan
Abdominal US
Images organ, detect
inflammation
Detect inflammation and
calcifications
ERCP
looks for stones
TREATMENT
GI rest
Pain control
No Alcohol
Daily weight
TREATMENT
Low fat, protein, and
high carbohydrate
diet
Oral pancreatic
enzymes
Monitor blood
glucose
TREATMENT
Replacement of fat
soluble vitamins
Octreotide
(Sandostatin)
Celiac plexus block
LIVER FUNCTION
Glucose metabolism
Ammonia conversion
Glycogenolysis
Gluconeogenesis
Ammonia to urea
Urea excreted in the
urine
Protein metabolism
Synthesis of plasma
proteins
LIVER FUNCTION
Fat metabolism
Vitamin and iron
storage
Fatty acids broken
down for energy
Vitamin A,B,D, and Bcomplex vitamins
Bile formation
Bilirubin excretion
Drug metabolism
LIVER FUNCTION TESTS
ALT: Alanine
aminotransferase
ALP: Alkaline
phosphotase
AST: Aspartate
aminotransferase
Bilirubin
Albumin
LIVER PANEL
Total Protein
GGT: Gammaglutamyl transferase
LDH: Lactic acid
dehydrogenase
Prothrombin time
HEPATIC DYSFUNCTION
Primary liver disease
Obstruction of bile
flow
Altered hepatic
circulation
Acute or chronic
CAUSES
Toxicities:
Chemicals, Plants,
Drugs
Bacterial invasion
Nutritional deficiency
Autoimmune
Hepatitis
Viruses
Hepatitis A,B,C,D,E
CHRONIC LIVER DISEASE
12th leading cause of
death in the United
states among young
and middle-aged
adults
40% associated with
alcohol use
Cirrhosis
SIGNS & SYMPTOMS
Jaundice
Portal hypertension
Ascites and varices
Nutritional
deficiencies
Hepatic
encephalopathy
Coma
JAUNDICE
Bilirubin level >2.5
mg/dL
All body tissue
become tinged yellow
Hepatocellular
jaundice
Obstructive jaundice
PORTAL HYPERTENSION
Increased pressure
through portal
venous system
Obstructed blood
flow through
damaged liver
Commonly
associated with liver
cirrhosis
PORTAL HYPERTENSION
GI bleeding
Black tarry stool
Hematemesis
Encephalopathy
Coagulopathy
Ascites
ASCITES
Backup of venous
blood flow from portal
HTN
Failure to metabolize
aldosterone
Movement of fluid
from vessels to
peritoneal space
Accumulation of
albumin-rich fluid
HEPATIC ENCEPHALOPATHY
Life-threatening
complication of liver
disease
Liver unable to
detoxify toxic
byproducts of
metabolism
Ammonia is the
major etiologic factor
of encephalopathy
HEPATIC ENCEPHALOPATHY
Mental changes
Motor disturbances
Altered mood and
sleep patterns
Asterixis “liver flap”
Flapping tremor of
the hands
Constructional
apraxia
VIRAL HEPATITIS
Systemic, viral
infection
Necrosis and
inflammation of liver
cells
Altered liver function
5 definitive types of
viral hepatitis
Hepatitis A, B, C, D, E
HEPATITIS A
Hepatitis A Virus
Fecal-oral
transmission
Poor sanitation
Person-person
contact
Water and food borne
Incubation
15-50 days
SIGNS and SYMPTOMS
Hepatitis A Phases
Preicteric
Flu-like symptoms
Fatigue
Loss of appetite
Nausea
Cough
Joint pain
SIGNS and SYMPTOMS
Icteric
Jaundice
Dark colored urine
RUQ pain
Itchy skin
Clay-colored stools
Poor appetite
Some preicteric
symptoms subside
SIGNS and SYMPTOMS
Post icteric phase
Things start to return
to normal
Fatigue can remain
HEPATITIS A
Mild with recovery
No carrier state
Doesn’t usually lead
to chronic state
HEPATITIS A
Prevention
Hand washing
Safe water supplies
Proper sanitation
Sewage disposal
HAV vaccination
Medical Management
Bed rest during acute
stage
Small frequent meals
Supplemental IV with
glucose
Gradual progressive
ambulation
HEPATITIS B
Hepatitis B Virus
Parenteral
transmission
Intimate contact with
carriers
Perinatal: mother to
baby
Occupational hazard
to health care
workers
HEPATITIS B
Incubation: 28-160
days
Symptoms: rash and
arthralgias
Outcome: may be
severe
Carrier state possible
Increased risk of
chronic hepatitis
HEPATITIS B
Prevention
Hand washing
Wear gloves when
handling body fluids
safe sex
HBV vaccination
Hepatitis B
Immunoglobulin
Medical management
Alpha-interferon
Lamivudine (Epivir)
and adefovir
(Hepsera)
Bed rest until s/s
subside
Restrict activities
Adequate nutrition
HEPATITIS B PANEL
HBsAg: Hepatitis B
surface antigen
HBsAb or Anti-HBs:
Hepatitis B surface
antibody
HBcAb: Hepatitis B
core antibody
HEPATITIS C
Hepatitis C Virus
Blood transfusion
transmission
Exposure to
contaminated blood
Intimate contact with
infected partner
Increased risk for
STDs
HEPATITIS C
Incubation: 15-160
days
Symptoms: similar to
HBV. Less severe
and anicteric
Chronic carrier state
Can lead to chronic
liver disease
Increased risk for
cancer
HEPATITIS C
No benefit from rest,
diet, or vitamin
supplements
Antiviral agents
Interferon (Intron-A)
Ribavirin (Rebetol)
Side effect: hemolytic
anemia
HEPATITIS D
Delta agent
HBV surface antigen
required for replication
Incubation: 21-140
days
Symptoms: similar to
HBV
Can lead to carrier
state, chronic active
hepatitis, and cirrhosis
HEPATITIS E
Hepatitis E Virus
Fecal-oral
transmission
Low risk for person to
person contact
Incubation: 15-65
days
Symptoms: Similar to
HAV
Severe in pregnant
women
HEPATITIS G and GB VIRUS C
Non A-E virus
Incubation: 14-145
days
2 isolates of same
virus
Autoantibodies are
absent
Still too many
unknowns
Persistent infection
TOXIC HEPATITIS
Resembles viral
hepatitis
Exposure to toxic
chemicals
Medications
Botanicals
Remove causative
agent
TOXIC HEPATITIS
Anorexia, nausea,
vomiting
Jaundice
Hepatomegaly
No effective antidotes
Delay in treatment
can result in
increased severity
DRUG INDUCED HEPATITIS
Most common cause
of acute liver failure
50% of all cases in
the U.S.
Acetaminophen has
been identified as the
leading cause of
acute liver failure
DRUG INDUCED HEPATITIS
Onset is abrupt
Early symptoms
Late symptoms
Fever, chills, rash,
arthralgia, pruritus,
anorexia
Jaundice, dark urine,
enlarged and tender liver
Treatment
Short course of highdose corticosteroids
TREATMENT
Rest
Small, frequent
meals
Low protein, fat, and
high carbohydrate
IV fluid containing
dextrose as needed
Monitor labs