Transcript Hepatobiliary - usnnursing / School of Nursing FrontPage

Adult Health Nursing II
Block 7.0
The
Hepatobiliary
System
Diagnostic Tests
I. Cholecystitis
--Acute & Chronic
--Cholecystectomy
--T-Tubes
II. Cancer of Gallbladder
III. Pancreatitis
--Acute & Chronic
Nursing
Assessment
IV. Pancreatic Cancer
V. Liver Disease
--Cirrhosis
--Liver Cancer
Nursing Care
Planning
& Evaluation
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Learning Outcomes
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Discuss anatomy and physiology of the
hepatobiliary system
Distinguish pathophysiology of hepatobiliary
disorders
Discuss clinical manifestations in clients with
hepatobiliary disorders
Interpret laboratory findings and diagnostic
testing for clients with hepatobiliary disorders
Differentiate interventions and treatment
options for clients with hepatobiliary disorders
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Learning Outcomes
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Discuss medication management of clients
with hepatobiliary disorders
Discuss complications associated with
hepatobiliary disorders
Prioritize nursing care for clients with
hepatobiliary disorders
Explore teaching plans for clients with
hepatobiliary disorders
Differentiate hepatobiliary disorders in the
older adult
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Quick A & P Overview
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Quick A & P Overview
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The Biliary System
 Comprised
Pancreas
of Liver, Gallbladder, and
 Primary
Functions:
Secrete enzymes and other substances to
promote food digestion
 Failure
of these organs results in impaired
digestion which may result in inadequate
nutrition
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Gallbladder Disorders
 Function
of the Gallbladder:
--Collects, concentrates, and stores bile
--Releases bile into duodenum when fat is
present
 Cholecystitis- Acute and Chronic
 Cancer of the Gallbladder
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Gallbladder
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Cholecystitis
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Inflammation of the Gallbladder
May be acute or chronic
Acute Cholecystitis
* 2 Types (Calculous & Acalculous)
A.
Calculous-
Chemical Irritation and inflammation resulting from
gallstones (cholelithiasis) that obstruct the cystic duct,
gallbladder neck, or common bile duct. Exact
pathophysiology of gallstones is unknown but
cholesterol, bilirubin, calcium, and bile salts play a role
in their formation
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Cholecystitis
 Acute
Cholecytitis
Acalculous- Inflammation occurring
without gallstones.
 B.
Biliary stasis due to any condition that
affects filling or emptying of the gallbladder
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Cholecystitis
 Chronic
Cholecysitis
 Repeated episodes of cystic obstruction
 Calculi are most always present
 Gallbladder becomes fibrotic and
contracted resulting in decrease motility
and deficient absorption
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Cholelithiasis (Gallstones)
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Clinical Manifestations
Acute
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Sharp pain in right upper quad
Pain with deep inspiration
during right subcostal palpation
(Murphy’s Sign)
Rebound Tenderness
(Blumberg’s Sign)
Nausea, vomiting
Loss of appetite
Fever
Eructation, Flatulence
Chronic
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Jaundice- Yellow
discoloration of the skin and
mucous membranes due to
increased bilirubin in the
blood
Icterus-Yellow discoloration of
the sclera
Pruritis- Accumulation of bile
salts due to blockage of bile
to the duodenum
Clay colored stools
Steatorrhea- (Fatty Stools)
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Jaundice
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Diagnostics
 RUQ
Ultrasound- Most diagnostic test
 Abdominal X-Rays
 Hepatobiliary Scans
 Labs: Check your ATI Book 
 Elevated
WBC
 Elevated Direct, Indirect, and Total Bilirubin
 Elevated AST (with liver dysfunction)
 Elevated LDH (with liver dysfunction)
 Elevated Serum Cholesterol
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Nursing Interventions
and Care
 History
 Dietary
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Counseling
- Low fat diet
- Promote weight reduction
- Avoid gas-forming foods
- Small , frequent meals
 Pain
Management – Meperidine (Demerol)
 Antispasmodics
 Antiemetics
 Prepare for Pre and Post-Op Care
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Cholecystectomy

Removal of the Gallbladder
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Nursing Care:
Pain Management
Encourage Splinting to reduce pain
Fundamentals- turn, cough, deep breathe
Monitor incision site
Monitor and record T-Tube drainage-initially
bloody then turns to green/brown bile
Assess appetite and response to food
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Cholecystectomy
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T-Tube
 Ensures
patency of common bile duct
 Limits fluid accumulation allowing duct
to heal
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Surgically placed
Remains up to 6 weeks post-op
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Nursing Care of a T-Tube- Iggy pg. 1370, Chart 62-2
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The Older Adult
 May
have Diabetes and have atypical
presentation of symptoms (absence of
pain or fever)
 Post Op period is of greater risk
 May have difficulty managing care of TTube at home
 May have difficulty modifying lifelong
dietary patterns
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Cancer of the
Gallbladder
 Rare,
more common in women than men
 More common in American Indians (etiology
unknown)
 Most
cancers are adenocarcinoma and
squamous cell
 Begin in inner layer of gallbladder (mucosa)
and metastasize to outer organs: Liver, small
intestine, and pancreas
 Prognosis is poor due to late diagnosis
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Cancer of the Gallbladder
Clinical
Manifestations
 Similar
to cholecystitis
 Anorexia, wt loss
 Nausea, vomiting
 Abdominal Bloating
 Fever
 Malaise
 Jaundice- Advanced
 Enlarged liver and
spleen
 Severe abdominal
pain-advanced
Treatment
 Surgery
 Radiation
 Chemotherapy
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Pancreas
 Functions:
 Exocrine:
secrete enzymes for digestion
 Endocrine:
Islets of Langerhans cells
producing glucagon (Alpha cell) and
insulin (beta cell)
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Pancreatitis
 Acute-
Inflammation of the pancreas resulting from
activated pancreatic enzymes autodigesting the
pancreas
 Mortality
can be as high as 20%
 Chronic
– Progressive destruction of the pancreas
with development of calcification and necrosis,
possible resulting in hemorrahagic pancreatitis.
 Mortality
can be as high as 50%
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Acute Pancreatitis
 Life
threatening inflammatory process
 Patho:
Premature activation of pancreatic enzymes
that destroy ductal tissue and pancreatic cells
 Etiology-
Mostly unknown however most common
causes are:
Excessive alcohol intake
Biliary tract disease with gallstones
Trauma-From surgical procedures
Trauma-From diagnostic procedure-ERCP
Familial
Drug Use
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Clinical Manifestations
Acute Pancreatitis
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Jaundice
Ascites
Severe, usually sudden
onset
abdominal/epigastric
pain that radiates to
back, left flank. Feels
“boring” (a feeling like it is
going thru the body)
Nausea, Vomiting, Wt.
loss
Cullen and Turner signs
Diagnostics
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Serum Amylase (30-110u/L)
Rises within 12-24 hrs, last 4
days
Serum Lipase (3-73u/L)
Rises slower but last up to 2
weeks
Lipase is usually more
specific because the
pancreas is the only organ
that secretes lipase
Urine amylase
Decrease in serum calcium
and magnesium
Elevated WBCs
Ultrasound and CT
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Acute Pancreatitis
Cullen’s Sign
Turner’s Sign
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Acute PancreatitisComplications
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Pancreatic infection (most common cause of
death)
Hypocalcemia
Hypovolemia
Type I diabetes-Total destruction of the pancreas
Hemorrhage
Septic Shock
Paralytic ileus
ARF
Pneumonia, Atelectasis, Pleural Effusion, ARDS
Coagulation defects- DIC
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Nursing Care
 Priority
is provide supportive care by relieving
symptoms and decreasing inflammation
 Always ABCs
 Pain Management-Opioids, Dilaudid and MS
 IV Fluids, I & O
 Rest GI Tract- NPO
 Nutrition- TPN
 NG Tube
 No Smoking
 No Alcohol
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Medication Management
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Spasmolytics- Pavabid, Cerespan
Anticholinergics- Bentyl- Relieves spasms of muscles in
the stomach and intestines , reduces spasms of
Sphincter of Oddi (contraindicated in paralytic ileus)
Histamine Receptor Antagonists (HCAs)-Suppress
secretion of gastric acid by selectively blocking H2
receptors (Zantac)
Protein Pump Inhibitors (PPIs)- Prilosec
Pancreatic Enzymes- Increases digestion of fats,
carbohydrates, and proteins in the GI tract Take
immediately before meals with water Viokase,
Donnazyme
Antibiotics
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Chronic Pancreatitis
 Progressive
disease with exacerbations
and remissions
 Usually develops after repeated episodes
of alcohol induced acute pancreatitis
 Also caused by chronic obstructive
disorders of the common bile duct
 Loss of exocrine function-Digestive
Enzymes
 Loss of endocrine function- Diabetes
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Chronic Pancreatitis
Clinical
Manifestations
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Intense abdominal
pain that is
continuous, burning
or gnawing
LUQ pain- ?
Pseudocyst
Steatorrehea or Clay
color stools
Weight loss
Exacerbations
Nursing Care
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Prevent exacerbation
Pain Management
Pancreatic enzymes
Monitor I&O, IV fluids
Education: pancreatic
enzymes, diet, avoid
smoking, caffeine,
avoid alcohol, alcohol
support groups
Comfort measures
Insulin therapy
Monitor calcium levels
Iggy pg. 1378 chart
62-3
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Pancreatic Cancer
 Etiology-Unknown
 High
incidence in age group 60-80 years
 High incidence in smokers
 4th leading cause of cancer death in the U.S.
 Spreads rapidly through lymphatic and venous
systems to other organs
 Vague symptoms usually diagnosed after there
is already liver and gallbladder involvement
 High mortality rate- Less than 20% live longer
than 1 year after diagnosis
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Clinical Manifestations
 Jaundice-May
be first sign but signifies late stage of
disease
 Fatigue
 Clay colored stools
 Dark urine
 Abdominal pain-vague
 Weight loss, nausea, vomiting
 GI bleeding
 Anorexia
 Splenomegaly- if spleen involved
 Hepatomegaly-if liver is involved
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Pancreatic CancerDiagnostics
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CT scan- visualization of the tumor
Elevated serum amylase and lipase
Elevated carcinoembryonic antigen (CEA)
Elevated alkaline phosphatase and bilirubin
ERCP- Most definitive- Allows for placement of
a drain or stent for biliary drainage
Abdominal Paracentesis- Drains fluid and tests
for malignant cells
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Endoscopic Retrograde
Cholangiopancreatography (ERCP)
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ERCP
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Pancreatic Cancer
- Treatments
 Management
is geared toward preventing tumor
spread and decreasing pain. It is palliative not
curative
 Surgery- 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. The stomach is
connected to he jejunum
 High
Risk
 Follow with chemotherapy and radiation
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Nursing Care
 Post
op care- Usually ICU with Whipple Procedure
 Pain management
 In addition to routine post op care:
Assess glucose
Assess bowel sounds and stools
Assess for infections
NPO- NG Tube
TPN- Usually started pre-op
*Assess for S+S of peritonitis- Board like abdomen
*Assess fluids and electrolytes and other labs????
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Liver Diseases
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Function of the Liver is to:
Store
Protect
Metabolize
Cirrhosis
Liver Cancer
Liver Transplants
Hepatitis
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Liver (“Hepato-”) Disorders
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Cirrhosis
 Extensive
irreversible scarring of the liver
caused by a chronic reaction to hepatic
inflammation and necrosis
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Cirrhosis
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Etiology
Cirrhosis
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Alcohol (Laennec’s
cirrhosis)
Hepatitis B,C, and D
(Post necrotic cirrhosis)
Autoimmune hepatitis
Steatohepatitis-(Fatty
Liver Disease)
Drugs and toxins
Biliary disease
Cardiac cirrhosis(Caused by Heart
Failure)
Clinical Manifestations
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Fatigue
Significant change in wt
Confusion or difficult thinking
GI symptoms and GI Bleeding
ABD and liver pain
Pruritus
Ascites
Jaundice and Icterus
Petechiae
Palmar Erythema
Spider Angiomas
Fector hepaticus
Dependent edema of
extremities and sacrum
Asterixis
READ YOUR ATI BOOK 
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Ascites
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Diagnostics
Check Your ATI Book 
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Serum Liver Enzymes- ALT, AST,ALP- All Increase
Serum Bilirubin- Direct, Indirect, and Total- All Increase
Serum Protein and Serum Albumin- Decrease
CBC- Values Decrease (anemia)
PT/INR- Increase
Serum Ammonia- Increase
Abdominal X-Rays, Ultrasound, CT, MRI
EGD- Detect bleeding or esophageal varices
Liver Biopsy- Most definitive-Measures progression and
extent of cirrhosis
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Cirrhosis Secondary
to Hepatitis
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Acute hepatitis A and acute hepatitis E do not lead
to chronic hepatitis.
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Acute hepatitis B leads to chronic hepatitis infection
in approximately 5% of adult patients. In a few of
these patients, the chronic hepatitis B progresses to
cirrhosis.
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Acute hepatitis D infects individuals already infected
by hepatitis B.
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Acute hepatitis C becomes chronic in approximately
80% of adults. A minority of these patients (20-30%)
will progress to cirrhosis, typically over many years.
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Nursing Care
 Comfort
Measures
 Assess for Bleeding Complications- Blood
Transfusions as ordered: Usually RBCs and FFP
 Diet and Dietary Teaching
High Calorie, Moderate Fat
Low-Sodium
Low-Protein if encephalopathy and ^
ammonia levels
Small-frequent feedings
Vitamin Supplements
Teach to Avoid Alcohol, MayBlock
need
Referrals
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Non-Surgical Management
 Paracentesis-
Remove and drain ascitic
fluid from the peritoneal cavity. Will relieve
symptoms of fullness and respiratory
distress
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Nursing Implications for
Paracentesis
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Explain procedure and answer questions
Obtain consent
Monitor vital signs
Monitor color and amount of drainage
Send fluid to lab for analysis
Abdominal girth measurements before and
after
Monitor puncture site for bleeding and serous
fluid oozing
Monitor respiratory status before and after
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Non-surgical Management
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TIPS- Transjugular Intrahepatic Portosystemic Shunt
Used to control ascites and variceal bleeding
Clients are discharged 2-4 days post procedure
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Medications
 Careful!!!!-
Many medications metabolized in the
liver. Caution with Opioids, Sedatives, Barbituates.
 Diuretics H2
Monitor for hypokalemia and hypotension
receptor Antagonists- For Stress Ulcers
 Lactulose-
stool
Promotes excretion of ammonia via the
 Neomycin
and Flagyl- Removes intestinal bacteria
which produces ammonia
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Complications of Cirrhosis
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Portal Systemic Encephalopathy- Inability to remove ammonia
causes increased toxins to the brain. Clients develop
neurological symptoms
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Portal Hypertension
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Splenomegaly
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Esophageal Varices- Esophageal veins become distended due
to increased pressure. Most often occur in the esophagus but
can be present in stomach and rectum
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Bleeding Esophageal Varices is a life-threatening medical
emergency. Client may vomit large amounts of blood
(hematemesis) or possess large amounts of black tarry stools
(melena)
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Esophageal
Varices
 Treatment
is endoscopic scleral
therapy
 Use of a Blakemore Tube
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Portal Hypertension
 Hepatic
encephalopathy
 Esophageal varices
 Peritonitis
 Metabolic and respiratory acid-base
imbalance
 Systemic infections
 Malnutrition
 Death
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Portal Hypertension
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Hepatic Encephalopathy
 Clinical
disorder seen in liver failure
patients
 Results from shunting of portal venous
blood and build up of toxic substances
 Ammonia crosses the blood brain barrier
 Stimulated by active GI bleeding
 Stages of Encephalopathy-Iggy- Pg. 1346
Table 61-2
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Liver Cancer
 Most
common Tumor is Hepatocellular
Carcinoma (HCC)
 Most tumors are unresectable
 5-year survival rate is less than 90%
 Risk Factors- Cirrhosis, Alcohol, HBV and
HCV infections
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Diagnostics
 Alpha-fetoprotein
(AFT) is elevated
 Serum Liver Enzymes-Elevated
 Ultrasound
 CT
 Liver Biopsy-Most definitive, High risk due
to potential for bleeding
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Liver Cancer-Clinical
Manifestations
 Abdominal
Discomfort
 Weight Loss, Anorexia
 Jaundice
 S+S of Cirrhosis
 Enlarged liver
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Liver Transplant
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Most common reason for liver transplant is Hepatitis C
Clients Not Considered Candidates:
-Metastatic Tumors
-Active alcohol/substance abuse
-Severe cardiac & respiratory disease
Can use a “lobe” of a liver for donation as the liver
will regenerate itself
12 hour surgery
Goal: Prevent rejection
Rejection occurs 4-10 days post-op (liver failure),
tachycardia, right upper flank pain, fever
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Liver Transplant
 Nursing
Care Post Transplant:
Monitor for S + S of rejection
Cyclosporine
Vaccinations and Antibiotics
Post-Op Care- Infection, Pain, Fluid
Management,
Monitor for
bleeding
problems
Psychosocial Support
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Hepatitis
 Hepatitis
is inflammation of the liver
 Types: HAV, HBV, HCV, HDV, HEV, HFV, HGV- Iggy
pgs 1356-1357
 Viral Hepatitis can be acute or chronic
 Clients
can NEVER donate blood, body organs, or
tissue
 MUST report ALL cases of hepatitis to health
department
 All healthcare workers should have Hep B
vaccination series
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Risk Factors
 Ingestion
of Contaminated Food or
Water- A,E
 Drug Abuse-B,C,D
 Sexual Contact-B,C
 Transmission by Infected Healthcare
Worker-B
 See ATI Chart- Pg 737
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High Risk Behaviors
 Failure
to Follow Universal Precautions
 Percutaneous Exposure- Sharps, Tattoos,
Body-Piercing, Contaminated needles
 Unprotected Sex
 Unscreened Blood Transfusions (prior to
1992)
 Travel in underdeveloped countries
without taking precautions (water)
 Crowded unsanitary environments
 TEACH!!!!!!!!!!!!!!!
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Diagnostics
Lab Tests
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Serum liver enzymes-Elevated
Serum bilirubin-Elevated
Serologic markers-Presence
of virus
Hepatitis antibody serumIdentifies exposure
Positive HBsAb indicates
immunity to Hep B either
following recovery or from
successful vaccination
Diagnostics
 Abdominal
Films
 Liver biopsies-Most
definitive
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Complications
 Chronic
Hepatitis
 Fulminating hepatitis
 Cirrhosis of the liver
 Liver cancer
 Liver failure
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Hepatitis
Nursing Interventions and Care
Clinical Manifestations
 Influenza
symptoms
 RUQ pain
 HBV:
hepatomegaly,
light color stools,
dark urine,
jaundice
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Assessment-Skin, eyes, pain
History-Contacts, Travel
Contact isolation
Limit Activity
Diet-High calorie
Education to prevent
transmission
Drug therapy: Interferon(
HBC,HCV)
Monitor these clients for:
-flu like symptoms
-alopecia
-bone marrow suppression
-N&V
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End of Hepatobiliary
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