GIT part 2

Accessory Organs

Ruby Ruth T. Roces, R.N., M.D.

Anatomy and
Physiology
Accessory Organs
 Pancreas

 Liver

 Gall bladder
Pancreatic secretions

1. Bicarbonate
2. Pancreatic amylase
3. Pancreatic lipase
4. Trypsin and
chymotrypsin
 Liver physiology and Pathophysiology
Normal Function Abnormality in function

1. Stores glycogen = Hypoglycemia

2. Synthesizes proteins = Hypo-proteinemia

3. Synthesizes globulins =Decreased Antibody formation

 risk for INFECTION
4. Synthesizes Clotting = Bleeding tendencies
factors
5. Secreting bile = Jaundice and pruritus

6. Converts ammonia to =Hyper-ammonemia

urea
7. Stores Vitamims and =Deficiencies of Vit and min
minerals
8. Metabolizes estrogen = Gynecomastia, testes atrophy
Disorders
CONDITION OF THE
LIVER
Liver Cirrhosis
 A chronic, progressive
disease characterized by a
diffuse damage to the
hepatic cells
CONDITION OF THE
LIVER
Liver Cirrhosis
ETIOLOGY:
Post-infection, Alcohol
(Laennac’s cirrhosis),
Cardiac diseases,
Schisostoma, Biliary
obstruction
Pathogenesis:

 repeated destruction of hepatic

cell

→ scar tissue formation (fibrotic)

→ regeneration of liver cell
follows → another destruction will
occur → cycle (scarring and
regeneration) will be repeated
until hepatocytes becomes
fibrotic and liver function is
CONDITION OF THE
LIVER
ASSESSMENT
FINDINGS
 1. Anorexia and
weight loss
 2. Jaundice

 3. Fatigue
 CONDITION OF THE
LIVER
ASSESSMENT FINDINGS
 4. Early morning nausea
and vomiting
 5. RUQ abdominal pain

 6. Ascites

 7. Signs of Portal
hypertension
 Liver function test:
 Elevated AST aspartate
aminotransferase
formerly SGOT 4.8 - 19 U/L
 Elevated ALT alanine
aminotransferase
formerly SGPT 2.4 - 7 U/L
highly specific
 Elevated Alkaline Phosphatase-30-
115 IU
 Elevated Bilirubin -0.1-1.0 mg/dL
COMMON
LABORATORY
PROCEDURES
Liver biopsy
 Intratest
– Position: Semi fowler’s LEFT
lateral to expose right side of
abdomen
Post-test: position on RIGHT
lateral with pillow underneath,
monitor VS and complications
like bleeding, perforation.
Instruct to avoid lifting objects
for 1 week
CONDITION OF THE
LIVER
NURSING INTERVENTIONS
 1. Monitor VS, I and O,
Abdominal girth, weight,
LOC and Bleeding
 2. Promote rest.
Elevated the head of
the bed to minimize
dyspnea
CONDITION OF THE
LIVER
NURSING INTERVENTIONS
 3. Provide Moderate to LOW-
protein (1 g/kg/day) and LOW-
sodium diet
 4. Provide supplemental vitamins
(especially K) and minerals
 Administer prescribed
Diuretics= to reduce ascites and
edema
Lactulose= to reduce NH4 in the
bowel
Antacids and Neomycin= to kill
 CONDITION OF THE
LIVER
NURSING INTERVENTIONS
6. Avoid hepatotoxic drugs
– Paracetamol
– Anti-tubercular drugs
7. Reduce the risk of injury
– Side rails reorientation
– Assistance in ambulation
– Use of electric razor and soft-
bristled toothbrush
CONDITION OF THE
LIVER
NURSING
INTERVENTIONS
 8. Keep equipments ready
including Sengstaken-
Blakemore tube, IV fluids,
Medications to treat
hemorrhage
Wilson’s disease

 Rare autosomal-recessive
disorder
 Excessive deposition of
copper in the liver & brain
 < 30 y.o.

 Defect in chromosome 13-

copper transporting
protein
Assessment

Liver abnormalities
 Jaundice

Neurologic
 Loss of coordination

 Tremor

 Dysphagia
Psychiatric abnormalities
 Psychosis
 Mania
 depression
 Anxiety

 Kayser-Fleischer rings in the

cornea
Diagnostics

 Decreased serum
ceruloplasmin
 Elevated urinary copper
excretion
 Elevated hepatic copper
Management
 Dietary copper restriction
(shellfish,liver,legumes)
 Penicillamine (copper chelator),
administered w/ pyridoxine
 Oral zinc ( inc fecal excretion)
Gall bladder
Cholelithiasis

 Formation of
GALLSTONES in the
biliary apparatus
Predisposing FACTORS

“ 5 F’s”
 Female

 Fat

 Forty

 Fertile

 Fair
Assessment findings

 Asymptomatic in 80%
PE:
 RUQ tenderness

 Palpable gallbladder
Diagnostics
 Ultrasound may show the
gallstones (95%)
Management
 Cholecystectomy- definitive &
curative
 Dietary modification

 Pharmacologic dissolution( w/ bile

salts)
w/ or w/o lithotripsy
CONDITION OF THE
GALLBLADDER
Cholecystitis
 Inflammation of the
gallbladder
 Can be acute or chronic
 Can be calculous or
acalculous
Pathophysiology

Supersaturated bile, Biliary

stasis

Stone formation

Blockage of Gallbladder

Inflammation, Mucosal Damage and

WBC infiltration
CONDITION OF THE
GALLBLADDER
ASSESSMENT findings
for cholecystitis
1. Charcot’s triad
2. Indigestion, belching
and flatulence
3. Fatty food intolerance
CONDITION OF THE
GALLBLADDER
ASSESSMENT findings
for cholecystitis
4. Mass at the RUQ
5. Murphy’s sign
CONDITION OF THE
GALLBLADDER
 DIAGNOSTIC PROCEDURES
 1. Ultrasonography-
can detect the stones
 2. Abdominal X-ray

 3. Cholecystography
CONDITION OF THE
GALLBLADDER
 DIAGNOSTIC PROCEDURES
 4. WBC count increased
 5. HIDA scan- cannot
visualize the gallbladder-
+
 6. ERCP: revels inflamed
gallbladder with
gallstone
ERCP
 CONDITION OF THE
GALLBLADDER
NURSING INTERVENTIONS
 1. NPO in the active phase

 2. Maintain NGT
decompression
 3. give pain med- Demerol
(MEPERIDINE)
 CONDITION OF THE
GALLBLADDER
 4. AVOID HIGH- fat diet and GAS-
forming foods
 5. Assist in surgical and non-
surgical measures
 6. Surgical procedures-
Cholecystectomy,
Choledochotomy, laparoscopy
 CONDITION OF THE
GALLBLADDER
 PHARMACOLOGIC
THERAPY
2. Analgesic- Meperidine
3. Chenodeoxycholic acid=
to dissolve the gallstones
4. Antacids
5. Anti-emetics
 CONDITION OF THE
GALLBLADDER
Post-operative nursing interventions
 1. MONITOR
 2. Post-operative position- LOW
FOWLER’s
 3. Encourage early ambulation
 4. Administer medication before
coughing and deep breathing
exercises.Advise client to splint
during exercise.
 CONDITION OF THE
GALLBLADDER
5. Administer analgesics,
antiemetics, antacids
 6. Care of the biliary drainage
or T-tube drainage ( 200-
300ml)
 7. Fat restriction is only limited
to 4-6 weeks. Normal diet is
resumed
Cholangitis

 Infection/inflammation
of biliary tree 2 to
obstruction (stone or
malignancy)
Assessment

 Charcot’s triad
 Reynold’s pentad
( charcot’s plus shock
& altered mental
status)
Diagnostics

 WBC

 Bilirubin,alk
phosphate- inc
 Blood cultures- ( gm –
enterics)
 ERCP- diagnostic gold
standard
 Management
 Life threatening- ICU
 Iv antibiotics

 Bile duct decompression-

endoscopic sphicterotomy,
pecutaneous hepatic
drainage or operative
decompression
 ERCP- stone removal, stent
Pancreas
CONDITION OF THE
PANCREAS
Pancreatitis
Inflammation of
the pancreas
Can be acute or
chronic
 Etiology & Risk Factors

– Alcoholism
– gallstones
– Hypercalcemia
– Trauma
– Viral infections
– Post ERCP
– Hyperlipidemia
– Drugs(thiazide)
CONDITION OF THE
PANCREAS
PATHOPHYSIOLOGY of
acute pancreatitis
 Spasm, edema or block in the
Ampulla of Vater reflux of
proteolytic enzymes auto
digestion of the pancreas
inflammation
 PATHOPHYSIOLOGY
Autodigestion of pancreatic tissue

Hemorrhage, Necrosis and

Inflammation

KININ ACTIVATION will result to

increased permeability

Loss of Protein-rich fluid into the

peritoneum
HYPOVOLEMIA
CONDITION OF THE
PANCREAS
ASSESSMENT findings
 1. Abdominal pain-
acute onset,
occurring after a
heavy meal or
alcohol intake
CONDITION OF THE
PANCREAS
ASSESSMENT findings
 3. Bruising on the
flanks and umbilicus
Grey turner’s sign-purplish
discoloration of the flank
(ecchymoses)
 Cullen’s sign-periumbilical
discoloration
 5. Hypotension and
hypovolemia
 6. Signs of shock
 7. Client assumes fetal
position to relieve
pressure (celiac plexus
nerve)
CONDITION OF THE
PANCREAS
DIAGNOSTIC TESTS
 1. Serum amylase and serum
lipase- inc 3x
 2. Ultrasound
 3. WBC- inc
 4. Serum calcium-dec.- binds
w/ area of necrosis
 5. CT scan
CONDITION OF THE
PANCREAS
NURSING INTERVENTIONS
 Demerol is given. Morphine is
AVOIDED
 correction of Fluid and Blood
loss
 Place patient on NPO to
inhibit pancreatic stimulation
 NGT insertion to decompress
distention and remove gastric
CONDITION OF THE
PANCREAS
NURSING
INTERVENTIONS
 Position patient in SEMI-
FOWLER’s to decrease
pressure on the diaphragm
 Deep breathing and coughing
exercises
 Provide parenteral nutrition
CONDITION OF THE
PANCREAS
NURSING INTERVENTIONS
 Introduce oral feedings
gradually- HIGH carbo, LOW
FAT
 Maintain skin integrity
 Manage shock and other
complications
Pancreatic Cancer

 Usually an
adenocarcinoma
 Usually involves the Head

Risk factors:
 Smoking

 High fat diet

 Men
Assessment

 Abdominal pain radiating

to the back
 Anorexia

 N/V

 Weight loss

 Weakness, fatigue

 Indigestion
 Jaundice (obstructs the
bile duct)
 Trousseau’s sign-
migratory
thrombophlebitis d/t
ectopic production of
procoagulatants
 Courvoisier’s sign-
palpable nontender
Diagnostics

 CT scan
 ERCP

 Transcutaneous
pancreatic biopsy- risk
of spreading tumor
Management

 Surgery- whipples
procedure
(pancreaticoduodenecto
my)
 Radio/chemo