1. Chapter 35
Nursing Care of Patients with Liver, Pancreatic, and Gallbladder Disorders

2. The Liver The largest internal organ in the body
Located under the diaphragm in the upper right abdomen
The word hepatic refers to the liver

3. Anatomy and Physiology of the Liver
Divided into four lobes made up of many lobules
Blood from aorta delivered to liver via the hepatic artery
Portal vein delivers blood from intestines to liver
Portal blood circulates through liver; transported to the inferior vena cava by the hepatic veins
Specialized hepatic cells allow the liver to carry out many critical functions

4. Hepatitis Pathophysiology
Locally, inflammatory process causes the liver to swell
Bile channels compressed; damage the cells that produce bile
Then blood flow through the liver is impaired, causing pressure to rise in the portal circulation
Systemic effects related to altered metabolic functions performed by the liver and to the infectious response in viral hepatitis
Signs and symptoms: rash, angioedema, arthritis, fever, malaise

5. Hepatitis Types of Hepatitis - page 781 HAV HBV HCV HDV HEV HGV
Noninfectious: caused by exposure to toxic chemicals; drugs

6. Prevention of Hepatitis
Hand Hygiene
Vaccines
HAV
HBV
Standard Precautions
Immune Globulin
Prevention
Vaccines; immune globulin (IG); hepatitis B immune globulin (HBIG)

7. Signs and Symptoms Prodromal Stage: 1 Week Icteric Stage: 2 to 6 Weeks
Flu-like Symptoms, RUQ Pain
Icteric Stage: 2 to 6 Weeks
Jaundice, Worsening Symptoms
Convalescent: 2 to 6 Weeks
Returning to Normal Liver Function
Signs and symptoms
Preicteric phase
Malaise, severe headache, right upper quadrant abdominal pain, anorexia, nausea, vomiting, fever, arthralgia (joint pain), rash, enlarged lymph nodes, urticaria, liver enlargement and tenderness
Icteric phase
Jaundice, light or clay-colored stools, dark urine
Posticteric phase
Fatigue, malaise, and liver enlargement

8. Hepatitis
Assessment
General health state, drug and alcohol use, chemical exposure, dietary habits, blood transfusions, recent travel, gastrointestinal disturbances, and changes in skin, urine, or stools
Vital signs, skin, weight changes, and mental status

9. Complications Liver Failure Acute Chronic
Fuliament Hepatitis- sudden severe liver failure when Hep B & D co-exists this can develop
Chronic Infection- Can occur with HBV & HCV
Carrier- spread the disease be asymptomatic
Risk of Liver Cancer
Complications
Chronic persistent hepatitis, chronic active hepatitis, and fulminant hepatitis

10. Diagnostic Tests Liver Enzymes Serum Bilirubin Prothrombin
Serologic Tests
Liver Biopsy
Medical diagnosis
Detection of the virus or its antibodies in the blood
Elevated levels of serum enzymes (AST, ALT, GGT), serum and urinary bilirubin, and urinary urobilinogen

11. Therapeutic Interventions
Rest
Nutrition
Interferon Therapy
Antivirals
Avoidance of Alcohol and Liver-toxic Drugs
Medical treatment
No cure: treat to promote healing and manage symptoms
Antipyretics, corticosteroids, and antiemetics
Diet: high calorie, high carbohydrate, moderate to high protein, and moderate to low fat with supplementary vitamins
Interventions
Activity Intolerance and Impaired Physical Mobility
Imbalanced Nutrition: Less Than Body Requirements
Deficient Fluid Volume
Risk for Impaired Skin Integrity
Disturbed Body Image
Anxiety
Deficient Knowledge
Staff Protection

12. Nursing Diagnoses Pain Imbalanced Nutrition
Risk for Impaired Skin Integrity
Risk for Ineffective Self-Health Management

13. Acute Liver Failure Pathophysiology Etiology
Sudden Massive Loss of Liver Tissue
Etiology
Drug Toxicity
Hepatitis

14. Signs and Symptoms
Jaundice
Encephalopathy
Confusion
Coma
Bleeding

15. Jaundice of the Sclera

16. Diagnostic Tests
ALT
AST
Serum Bilirubin PT
Potassium
Blood Glucose

17. Therapeutic Interventions
Bedrest
Eliminate all Drugs
Possible Dialysis
High-calorie, Low-sodium, and Protein Diet
Lactulose, Neomycin, Magnesium Citrate, Sorbitol
Transplant

18. Cirrhosis
Progressive, Irreversible Replacement of Healthy Liver Tissue with Scar Tissue
12th Leading Cause of Death
Pathophysiology
Chronic, progressive disease
Degeneration and destruction of liver cells
Fibrotic bands of connective tissue impair the flow of blood and lymph and distort the normal liver structure
Incidence
Fifth leading cause of death in ages 40 to 60 in the United States
More common in men than in women
Related to alcoholic liver disease or chronic viral infection

19. Cirrhosis (cont’d) Etiology Chronic Alcohol Use – Most Common
Hepatotoxins
Hepatitis
Gallbladder Obstruction
Heart Failure
Types
Alcoholic
Postnecrotic
Biliary
Cardiac

20. Pathophysiology Inflammation of Liver Cells
Infiltration with Fat and WBC
Fibrotic Scar Tissue Replaces Liver Tissue
Abnormal Regeneration
Impaired Liver Blood Flow
Impaired Liver Function

21. Signs and Symptoms Signs and symptoms
Early: slight weight loss, unexplained fever, fatigue, and dull heaviness in the right upper abdomen
Progresses: anorexia, nausea, vomiting, diarrhea or constipation, flatulence, dyspepsia, esophageal varices, infections, and epistaxis
Later: jaundice; testicular atrophy, impotence, and gynecomastia, amenorrhea; palmar erythema and spider angiomas; confusion and decreasing consciousness; ascites; peripheral neuropathy

22. Complications of Cirrhosis
Clotting Defects
Portal Hypertension
Varices
Ascites
Encephalopathy
Hepatorenal Syndrome
Complications
Portal hypertension, esophageal varices, ascites, hepatic encephalopathy, and hepatorenal syndrome
Medical diagnosis
History and physical examination
Liver function tests, CBC, prothrombin time, protein, electrolytes, albumin, bilirubin, urine bilirubin, urobilinogen, liver biopsy, liver scan, ultrasonography, angiography, CT, and MRI
Liver biopsy

23. Cirrhosis: Medical Treatment
Bed rest
Diet high in carbohydrates and vitamins with moderate to high protein unless blood ammonia level is elevated
Intravenous fluids
Anemia may require blood transfusions
Water and sodium likely to be restricted
Cathartics and antibiotics for hepatic encephalopathy

24. Cirrhosis: Medical Treatment
Ascites
Various types of diuretics
Salt-poor albumin may be given intravenously
Paracentesis
Peritoneal-venous shunt of the transjugular intrahepatic portosystemic shunt
Bleeding esophageal varices
Drug therapy, sclerotherapy, surgical ligation, and placement of an esophageal-gastric balloon tube

25. Portal Hypertension

26. Diagnostic Tests Liver Enzymes Bilirubin Serum Ammonia Prothrombin
Abdominal X-Ray
Ultrasound
Esophagastroscopy
Liver Biopsy

27. Therapeutic Interventions
Ascites
Diuretics
Sodium Restriction
Paracentesis
Albumin Infusion
TIPS- Transjugular intrahepatic portosystemic shunt

28. Therapeutic Interventions (cont’d)
Esophageal Varices Vasoconstrictors
Banding
Sclerotherapy
Vitamin K
Antibiotics

29. Therapeutic Interventions (cont’d)
Encephalopathy
Lactulose
Neomycin
Restrict Dietary Protein
Dialysis

30. Nursing Diagnoses: Acute and Cirrhosis
Excess Fluid Volume
Imbalanced Nutrition
Pain
Risk for Disturbed Thought Processes
Risk for Ineffective Breathing Pattern
Risk for Deficient Fluid Volume
Risk for Infection

31. Patient Education Disease Process Signs and Symptoms to Report
Adequate Rest
Diet
Avoid Narcotics, Sedatives, Tranquilizers, Alcohol
Follow-up Care

32. Liver Transplant Candidates Liver Failure No Cancer No Complications
Otherwise Stable
Only cure for end-stage liver disease
Transplantation for cancer confined to the liver; for patients with congenital disorders
Ranked by acuity and need and entered into a national computer network
When a liver becomes available by donation, the best recipient can be identified

33. Liver Transplantation
Patient often has a T-tube, wound drainage devices, a nasogastric tube, and a central line for total parenteral nutrition (TPN); mechanical ventilation used initially
Assessments focus on neurologic status, vital signs, central venous pressure, respiratory status, and indicators of bleeding
Lifelong drug therapy needed to prevent rejection
Recipient must be monitored for signs of rejection
Fever, anorexia, depression, vague abdominal pain, muscle aches, and joint pain

34. Anti-Rejection Meds Cyclosporine (Cyclosporin A) Tacrolimus (Protopic)
Azathioprine (Imuran)
Prednisone (Deltasone)
Mycophenolate mofetil (Cellcept)

35. Signs of Rejection Pulse >100 bpm Temperature >101°F RUQ Pain
Increase in Jaundice
Decrease in Bile from T-tube
Elevated Liver Enzymes

36. Cancer of the Liver Usually Metastasized from Another Site
Risk Factors
Chronic Hepatitis B/C
Nutritional Deficiencies
Exposure to Hepatotoxins
Heavy alcohol use or smoking
Rarely begins in the liver but frequent site of metastasis
Cirrhosis is a predisposing factor
Signs/symptoms: liver enlargement, weight loss, anorexia, nausea, vomiting, dull pain in upper right quadrant of abdomen
As disease progresses, signs and symptoms are essentially the same as those of cirrhosis
Because early signs and symptoms of liver cancer are vague, the condition often not diagnosed until advanced
Tests: liver scan and biopsy, hepatic arteriography, endoscopy, and measurement of alpha-fetoprotein levels
If the cancer is confined to one area, a lobectomy may be done; otherwise chemotherapy is the primary treatment

37. Signs and Symptoms
Encephalopathy
Bleeding
Jaundice
Ascites

38. Diagnosis Serum Alkaline Phosphatase Abdominal X-Ray Liver Scan
Ultrasound
Biopsy

39. Therapeutic Interventions
Surgery- However rarely can the tumor from the liver be removed if it is localized or in a removable lobe
Chemotherapy

40. Anatomy and Physiology of the Pancreas
A fish-shaped organ located in the upper left quadrant of the abdomen behind the stomach
Head of the pancreas lies against the duodenum, and the tail lies next to the spleen
Ducts connect the pancreas to the duodenum
One duct goes directly to the duodenum, and the other merges with the common bile duct

41. Acute Pancreatitis Pathophysiology Complications Inflammation
Autodigestion
Elevated Enzymes
Fluid Loss
Complications
Shock
DIC
Chronic Pancreatitis
Carried out by acinar tissue
Pancreatic fluid contains enzymes needed to digest proteins, fats, and carbohydrates
Trypsin, amylase, and lipase
Islets of Langerhans
Alpha cells produce and secrete glucagon
Beta cells produce and secrete insulin
Delta cells produce somatostatin, which inhibits the release of glucagon and insulin

42. Etiology
Alcohol
Biliary Disease
Trauma
Certain Drugs

43. Signs and Symptoms Abdominal Pain Guarding Rigid Abdomen
Hypotension or Shock
Respiratory Distress
Low-grade Fever
Nausea and Vomiting
Jaundice
Signs and symptoms
Abdominal pain
Severe, with a sudden onset; centered in the upper left quadrant or the epigastric region and radiates to the back
Severe vomiting, flushing, cyanosis, and dyspnea often accompany the pain
Low-grade fever, tachypnea, tachycardia, hypotension
Abdomen may be tender and distended
Bowel sounds may be absent
Bleeding and shifting of fluid may lead to shock

44. Complications Cardiovascular Failure
Acute Respiratory Distress Syndrome
Acute Renal Injury
Hemorrhage
Infection
Complications
Pseudocyst, abscess, hypocalcemia, and pulmonary, cardiac, and renal complications
Medical diagnosis
Elevated serum amylase, serum lipase, and urinary amylase levels
Elevated WBC count, elevated serum lipid and glucose level, and decreased serum calcium level
Ultrasonography and ERCP
Secretin stimulation test and fecal studies

45. Diagnostic Tests Serum Amylase Serum Lipase X-Ray CT Scan Ultrasound
Imaging studies
CT scan, endoscopic ultrasonography, MRI, PET, and ERCP
Serum amylase, lipase, glucose, calcium, triglycerides
Urine amylase and renal amylase clearance
Stool specimens may be analyzed for fat content
Secretin stimulation test
If cancer is suspected, blood levels of CA 19-9, carcinoembryonic antigen, pancreatic oncofetal antigen, and others that are considered “markers” for cancer may be measured

46. Therapeutic Interventions
NPO
IV Fluids/TPN, Nutrition
NG Suction
Analgesics, Anti-anxiety Agents
Oxygen
Blood Products PRN
Medical treatment
Nothing by mouth
Nasogastric tube
Intravenous fluids
Blood or plasma expanders
Urine output should be at least 40 mL/hour
Jejunal feeding tube or total parenteral nutrition
Once food permitted, usually bland, low-fat, high-carbohydrate diet divided into frequent, small meals
Prophylactic antibiotics

47. Chronic Pancreatitis Pathophysiology Etiology Progressive Fibrosis
Obstructed Ducts
Ulceration
Etiology
Alcohol
Biliary Disease

48. Prevention Alcohol Abstinence Biliary Disease Treatment
Nutritional Intake Monitoring

49. Signs and Symptoms Remissions and Exacerbations LUQ Pain
Anorexia and Weight Loss
Malabsorption
Diabetes Mellitus

50. Diagnosis Pancreatic Enzymes Normal High Fecal Fat Level
Changes on CT Scan

51. Therapeutic Interventions
Analgesics
Pancreatic Enzyme Replacement
Surgery

52. Nursing Diagnoses: Acute and Chronic Pancreatitis
Pain
Imbalanced Nutrition
Risk for Ineffective Breathing Pattern
Risk for Injury

53. Cancer of the Pancreas Ductal Adenocarcinoma of Exocrine Pancreas
Risk Factors
High-fat Diet
Smoking
Diabetes Mellitus
Alcohol
Chronic Pancreatitis
Quickly spreads to the duodenum, stomach, spleen, and left adrenal gland
Risk factors: chronic pancreatitis and smoking
Also high-fat diet, exposure to toxic chemicals
Signs and symptoms
Pain, jaundice with or without liver enlargement, weight loss, and glucose intolerance
Other signs and symptoms may be weight loss, upper abdominal pain, anorexia, vomiting, weakness, and diarrhea

54. Signs and Symptoms Weight Loss Abdominal Pain Radiates to Back
Anorexia
Nausea and Vomiting
Weakness
Jaundice

55. Diagnostic Tests Serum Amylase/Lipase Alkaline Phosphatase Bilirubin
Coagulation Studies
CEA
CT, ERCP
Biopsy

56. Therapeutic Interventions
Surgery
Pancreatectomy
Whipple Procedure
Stent to Relieve Biliary Obstruction
Chemotherapy
Radiation
Medical diagnosis
Transabdominal ultrasound, computed tomography, ERCP, and endoscopic ultrasonography
Serum amylase, lipase, bilirubin, and enzyme levels; carcinoembryonic antigen and CA 19-9 titers
Medical and surgical treatment
If tumor confined to head of pancreas, surgery an option
Postoperative radiation therapy and chemotherapy

57. Whipple Procedure

58. Nursing Diagnoses Pain Imbalanced Nutrition
Risk for Deficient Fluid Volume
Risk for Impaired Skin Integrity

59. Patient Education Management of Hyperglycemia
Pancreatic Enzyme Replacement
Dressing/Drain Care
Complications to Report
Hospice Referral

60. Cancer of the Pancreas Assessment
Assess gastrointestinal function, pain, and emotional state
If surgery planned, determine the patient’s knowledge about pre- and postoperative care
Extremely serious, spreads quickly to the duodenum, stomach, and spleen.
Only 24 % of patients will survive a year
4 % will be alive after 5 years
Early diagnosis 17% will be alive after 5 years

61. Gallbladder Disorders
Cholecystitis: Inflammation
Cholelithiasis: Stones
Choledocholithiasis: Stones in Common Bile Duct

62. Etiology Bile Stasis High Cholesterol Intake Fasting
Sedentary Lifestyle
Family History, Female
Risk Increases with Age

63. Signs and Symptoms Increased Vital Signs Vomiting Jaundice
Epigastric Pain
RUQ Tenderness
Nausea
Indigestion
Positive Murphy’s Sign
Biliary Colic

64. Complications Cholangitis- Inflammation of the bile ducts
Necrosis/Perforation of Gallbladder
Empyema- Purulent drainage in gallbladder
Fistulas
Adenocarcinoma of Gallbladder
Pancreatitis

65. Diagnostic Tests Ultrasound ERCP Radionuclide Scan WBC Bilirubin
Serum Amylase

66. Therapeutic Interventions
Analgesics
Bile Acid Sequestrants
Anti-Emetics
Diet

67. Cholelithiasis Treatment
Cholecystectomy
Laparoscopic
Traditional
ESWL- Lithotripsy
Medication to Dissolve
Ursodiol
Chenix

68. T-Tube

69. Nursing Diagnoses
Acute Pain
Risk for Deficient Fluid Volume

70. Postoperative Nursing Diagnoses
Risk for Impaired Skin Integrity
Risk for Ineffective Breathing Pattern