The Hepatic & Biliary System: Liver, Gall Bladder, & Pancreas

4/11/08

Accessory organs of Digestion CHD2 VN 235 Edited by: Cynthia Bartlau, MSN, RN, PHN

DISORDERS
Disorders of the liver (hepat/o)
Cirrhosis Liver failure Portal hypertension Hepatitis

Disorders of the gallbladder (chole- is bile; cyst- is bladder or sac) (biliary is bile or gall bladder)
Cholecystitis Cholelithiasis Choledocholithiasis

Disorders of the pancreas

Pancreatitis Pancreatic CA

Liver
Liver:
largest organ/gland located URQ under the ribs divided into 4 lobes most vascular organs

Liver Functions

Liver:
Portal circulation: blood supply to the liver is very different from other organs.
25% oxygenated blood via Hepatic artery. 75% via Portal vein-deoxygenated blood

Hepatic portal circulation allows liver to:

Regulate blood levels of nutrients Remove potential toxins

 Draw portal circulation

Liver Failure
C = clotting disorders H = hepatorenal syndrome E = encephalopathy A = ascites P = portal hypertension

Liver Failure
Chronic liver disease Common cause of death in US Causes:
Malnutrition *Chronic alcoholism Drug/toxin ingestion Bile duct disease

Alcohol & Cirrhosis of the Liver

Toxins (ETOH) cause inflammation Cells infiltrated with fat & WBCs Replaced by fibrotic tissue More fat & more scar tissue Liver shrinks - with gray connective tissue

Hepatic Encephalopathy
Accumulation of noxious substances
#1 is ammonia a by-product of protein metabolism

S/S
Asterixis Fetor hepaticus Behavior changes Progresses to coma death

Liver: Lets examine?

Consider:
Both Bile & Bilirubin is formed in the liver.
Bilirubin is carried away in the bile (to the intestines or stored in small amounts in the gallbladder). If an obstruction occurs
*Jaundice = yellowing of the sclera of the eye & skin *Itchy-skin (impaired breakdown of bilirubin) *Clay colored or pale looking stools (fatty frombile production) Darker looking urine.

Lets examine More!

Protein Synthesis:
As liver disorders set in, see a decrease in protein synthesis: therefore; *decrease albumin level As a result, changes in oncotic or water pressure are shifted and water leaks into the abdominal (peritoneal) cavity causing abdominal distention

 Ascites - edema
Respiratory distress from pressure on the diaphragm!
Do you want to check abdominal girth? Yes! use the umbilicus as your guide mark for measurement.

Fluid & Na restriction, Titrate protein levels per serum albumin levels, Potent diuretics, rest periods, Daily weights - best way to determine fluid loss!

 ** Double edge sword!

The byproduct of protein metabolism (breakdown of protein) = ammonia. An increase in ammonia level causes changes in the CNS or Hepatic encephalopathy* *confusion, asterixis, *fetor hepaticus, and ultimately coma if not treated properly

Lets examine more

*Portal Hypertension
Blockage of blood flow through the portal vein. Dilation of abdominal veins around the umbilicus, rectal hemorrhoids, enlarged spleen, and esophagus = esophageal varices. Portal hypertension places pressure on the varices .
Sudden excessive pressure or increase intra-abdominal pressure, may cause varices to rupture = severe bleeding! Possibly Death.

Lets examine more!

Nutritional deficiencies:
Proteins - serum albumin levels. No production of Vitamin A, D, E, K, and Fe storage In early stages of liver dz proteins in diet. At end-stage liver dz, low protein diet because of rising ammonia levels *Bleeding tendency: lack of vitamin K for synthesis of pro-thrombin & other clotting factors n/v/anorexia common in clients w/liver disorders

Esophageal Varices
*Veins are dilated & may tear from coughing, straining, vomiting Use esophageal balloon (balloon tamponade) using a *Sengstaken-Blakemore tube which compresses bleeding varices Use: Drug Vasopressin: strong vasoconstrictor constriction of the splenic arterial bed thus portal pressure Sclerotherapy

Lab and other Diagnostics

Physical exam: tenderness, enlargement (deep palpation by M.D. or nurse practitioner) Labs: Liver function tests: serum enzyme activity:
Is there increase *AST & ALT? (reflects a death to tissue or organs) 70% of the parenchyma may be damaged before LFT become abnormal! Flat plate X-ray abd, liver scan, MRI, CT, or Liver Biopsy*

 *Percutaneous Liver Bx: signed consent,

check labs, clotting, NPO x 6-8 hrs, VS, position on back or left side, exhale then hold breath when needle inserted, Afterwards: *bedrest x 24 hrs, lay on right side x 2hrs, pillow or towel underneath (*pressure) to prevent *hemorrhage. Avoid coughing, straining, inc. intra-abd. pressure

Possible Nursing Diagnoses

Activity intolerance R/T fatigue & lethargy Altered Nutrition R/T abdominal distention, discomfort, and/or anorexia Altered Skin Integrity R/T jaundice, edema or itching High Risk for Injury Altered Body Image disturbance R/T ascites

General Nursing Actions: Tx is supportive

*Low protein diet in the end-stage liver dz. High CHO, actually a vegetarian type diet *Low sodium Fluid restriction & strict I & O, weigh daily, potent diuretics Vitamin replacements Lotions to *dry, itchy pruritic skin Measure abd. girth Check for *asterixis flapping of hands which is an early s/s of hepatic encephalopathy. Give lactulose (Cephulac) to decrease ammonia levels * monitor stools to see if working! Always check see how drugs are excreted? In liver or kidney? Be careful giving sedatives, barbiturates, Tylenol!

More Nursing interventions!

Check for bleeding tendencies, lab work, bruising, frank blood from gums, stool, urine, hematoemesis Use electric shaver only, soft toothbrush Frequent rest periods Possibly assist physician with a paracentesis Lots of support No ETOH - ever!

LIVER TRANSPLANT
Patients with liver disease not responding to medical or surgical treatment Chronic liver failure from hepatitis Not cancer patients Normally not for alcoholics National list for potential liver recipients Medication for life

Discussions
Think, Pair, Share Discuss opinions on organ (esp. liver) transplantation for drug and alcohol abusers.
Mickey Mantle David Crosby

Hepatitis: inflammation of cells of the liver: virus, drugs, bacteria

Alphabet soup of viral Hepatitis ex. HAV, HBV, HCV, NANB, HEV, HGV Attacks liver cells, and may affect bile channels (jaundice): May have complete remission or progress into liver failure Mode of transmission varies for each of the different virus *Prevention: Use standard precautions Cleanliness & good health practices *Now have vaccines for:
HAV- 2- injections HBV-3-injections

Hepatitis A Risk Factors

HAV: spread via oral-fecal route Risk factors
*shellfish, sharing eating utensils, not washing your hands after using the toilet-then touching food * food handlers at restaurants

Hepatitis A (HAV)
Mode of transmission*: Incubation period: *Oral: fecal route 3-7 weeks early (prodromal) fatigue, anorexia, n/v Icteric: jaundice, *pale stools, amber/dk. urine (tea-colored), RUQ pain Elevated liver enzymes (ALT,AST), bilirubin, HAV antigen Immune globulin (IG) or a *Hepatitis A vaccine

S/S

Diagnostic test:

Preventive vaccine:

Hepatitis B: Risk factors HBV

Have a job that may exposes you to human blood! Healthcare worker Live in the same house with someone who has lifelong HBV infection (carrier-state) IV drug user Unprotected sex, and have more than 1 partner Hemophilia, transplant and/or hemodialysis pt. Work at or is a /client at a developmentally disabled institution Are a child whose parents were born in SE Asia, Africa, Central or So. America, Pacific Islands, or Middle East Sharing needles &/or dye from tattoos At childbirth-Baby- can get infected if mother has the virus Daycare center, military units, crowded living situations Homosexuals/ > 1 partner

Hepatitis B (HBV)
Mode of transmission:

Incubation period:
S/S

Diagnostic Tests: Preventive vaccine:

Blood/ body fluids, saliva, semen, breast milk, equipment contaminated by blood (*never donate blood) 2- 5months, may have no early symptoms, Prodromal: 1-2 months fatigue, malaise, anorexia, low grade fever, n/v/h/a, abd pain or tenderness, muscle aches Icteric: jaundice, rashes elevated liver enzymes/serum bilirubin, presence of Hep B antigen Immune globulin (IG) and now Hepatitis B vaccine* 1st shot, 2nd, 1 month later, 3rd- @6mos later

General Nursing management

Rest (bed rest with BRP) No special drugs or medical therapies. Anti-viral drugs may be used for HBV & HCV Nutrition
No alcohol or drugs that are toxic to liver High protein, high calorie diet, low fat

TX: s/s, ex. vomiting give anti-emetics, pruritis * use lotion, dont scratch skin, anti-histamines, analgesics for pain (no Tylenol)
Teach: proper hand-washing, home cleanliness, use soap & hot water for eating utensils, food preparation surfaces, cookware (hospital - use disposable trays) Family avoid using the same toilet/towels/linen, etc.

Discussions
Discuss methods you might use to control the spread of the three types of hepatitis discussed in the hospital and in the community.

Pancreatitis: inflammation of pancreas (mild-severe)

Self-limiting disorder: autodigestions*** pancreatic enzyme go hay-wire and begin to digest the pancreascauses severe pain! Think !!! Pain: Pancreatitis Acute vs. chronic pancreatitis *Often associated with ETOH abuse, and often clients have biliary disease (gallbladder) Pancreas produces pancreatic juices

Continued: pancreatitis
Clinical manifestations: PAIN!!! Severe abdominal pain & sometimes back pain Nausea/vomiting, sometimes jaundice if biliary obstruction is present Diagnosis: *increase serum amylase & lipase, see increase in urinary amylase Increase in WBCs, glycosuria?, Bilirubin? Stools: greasy, bulky, fatty (steatorrhea), foul smelling, pale colored stools (no bile)

Continued: pancreatitis
Treatment: symptomatic & prevent complications (diabetes) **** Keep NPO- to prevent the stimulation of pancreatic juices, prevent the pain!
May be given IVs and TPN or PPN Give the GI tract a rest! Adequate pain relief: Demerol works best on biliary system (morphine may cause spasms of the sphincter of Oddi) hurt worse! Might have a biliary drain/stent inside the duct

Continued: pancreatitis
May need to give pancreatic enzymes to aid in digestions: give with meals Pancreatin or pancrelipase (Viokase, Pancrease) Raise the HOB, semi-fowlers position Avoid ETOH! NGT: relieve abdominal distention & N/V Pepcid/Zantac/Axid, etc., to decrease the production of HCL acid

Complications: acute hemorrhage, malabsorption/malnutrition, and diabetes

Pancreatic Cancer
4th leading cancer cause of death Spreads quickly Chemical carcinogens or metastasis Even with surgery ~ 5 year survival rate

Disorders of the Gallbladder: Cholecystitis, Cholelithiasis

Cholecystitis: inflammation of the gallbladder Cholelithiasis: gall stones in the gall bladder Choledocholithiasis: gall stones in the common bile duct Cause? Several theories.
bile is thick and sluggish/stasis and forms stones some stones are calcium based stones some more cholesterol based stones

Gall- bladder disease:

Clinical manifestations:
under 40 yrs. of age, fat, (fertile), (forty), female, flatulence over 50 yrs. of age found in both male/females

Elevated temp Increase in epigastric pain

AKA: biliary colic, pain that radiates to right shoulder/scapula, starts after a fatty meal & may last 1-2 hrs. or longer

RUQ tenderness N/V Jaundice may be present Color of stools? pale or clay colored?

Gall-bladder disease
Diagnosis: increase in WBCs
Abdominal flat plate x-ray, sonogram,oral *cholecystography (with contrast medium) ERCP: best to visualize pancreatic and bile ducts & to visualize any gall stones & remove the stones. (*caution: this test may cause pancreatitis too !)

Medical/Nursing management: pain control primarily with Demerol, prevent F& E imbalance, prevent infection, anti-spasmodics such as Probanthine or Bentyl, Compazine for n/v, low fat, high protein diet when not nauseated

ERCP

ERCP

Continued:
Surgical procedures:
Laparoscopic Cholecystectomy (make 4 puncture wound incision w/knife/scope)
Often goes home next day: risk for hemorrhage after surgery!

Open cholecystectomy: old fashioned route, used primarily if lap-chole doesnt work! Often signs an OR consent for both!

Cholecystectomy:
Long- transverse 6 right sub-costal incision (Hurts to TCDB due to location of incision to diaphragm). Often a T tube or drain left in for a few days to drain bile (greenish yellow or brown in color). Plus, remember general post-op instructions and monitor for complications, ex. nausea/vomiting, DVT, hypostatic pneumonia, infection, etc. (NGTs rarely used now)

Continued:
Other procedures: extracorporeal shockwave lithotripsy, may use oral drugs to dissolve the stones along with this

Concept Mapping
Newly admitted 46 yo patient with rt. lower leg cellulitis. Homeless & unmarried. Teenage children live with ex-wife in another state. Hx of ETOH abuse (drinks two or more pints of whiskey per day x 20 yrs). Has not seen a doctor x 25 yrs. MDO: Regular diet, BRP with assist, Librium 20mg BID, Multivitamin tab 1 daily, Zinc 220 mg tab 1 daily, Levaquin x mg IVPB q12 hrs, IV D5W c MVI, thiamine, & folic acid.

Questions???