Liver, Biliary Tract, Pancreas Problems Module 1

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Liver, Biliary Tract, Pancreas ProblemsModule 1

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Jaundice

• Yellowish discoloration of body tissue
• Results from an alteration in normal bilirubin
  metabolism of flow of bile into hepatic or
  biliary duct system
• Symptom rather than disease
• Bilirubin is usually three times norm (2-3 mg/dl)
  for jaundice to occur

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Three Types of Jaundice

• Hemolytic
• Hepatocellular
• Obstructive

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Hemolytic Jaundice

• Increased breakdown of RBCs
• Increased amount of unconjugated bilirubin in
  blood
• Etiology
• Blood transfusion
• Sickle cell crisis
• Hemolytic anemia

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Hepatocellular Jaundice

• Livers altered ability to
• Take up bilirubin from blood
• Conjugate bilirubin
• Excrete bilirubin
• Hepatocytes are damaged and leak bilirubin
• Elevated Conjugated bilirubin
• Severe disease-both conjugated and unconjugated
  are elevated
• Etiology
• Hepatitis
• Cirrhosis
• Hepatic Carcinoma

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Obstructive Jaundice

• Impede or obstructed flow of bile through liver
  or biliary duct system
• Intrahepatic
• Due to swelling or fibrosis of livers canaliculi
  and bile ducts i.e. Liver tumors, hepatitis,
  cirrhosis
• Extrahepatic from
• Bile stones
• Carcinoma of head of pancreas

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Obstructive Jaundice

• Elevation of both conjugated and unconjugated
  bilirubin
• Bilirubin does not enter intestine
• Little to no fecal or urinary urobilinogen
• Stools can be clay colored i.e. cholecysitis

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Disorders of the Liver

• Hepatitis
• Toxic and Drug Induced Hepatitis
• Autoimmune Hepatitis
• Cirrhosis of the Liver
• Fulmant Hepatic Failure
• Liver Cancer
• Liver Transplant

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Hepatitis

• Inflammation of the liver
• Etiology
• Acute viral-most common cause
• Drugs, IV drug use, piercings, ETOH
• Chemicals
• Autoimmune
• Bacterial

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Types of Hepatitis

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E
• Hepatitis G

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Hepatitis A

• Incubation 15-50 days
• Transmission fecal-oral
• Sources of infection contaminated food,
  shellfish, infected food handlers, sexual contact
• Infectivity Most contagious 2 weeks before
  symptoms (Virus present in feces)

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Hepatitis B

• Incubation 45-180 days
• Transmission parenteral, blood contact,
  perinatal
• Sources of infection contaminated needles,
  syringes, blood products, sexual contact, tattoo,
  body piercing
• Infectivity Most contagious before and after
  symptoms, infectious for 4-6 months, can become
  carrier for life
• HBs ag-chronic carrier-positive times two six
  months apart

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Hepatitis C

• Incubation 14-180 days
• Transmission parenteral, blood contact
• Sources of infection contaminated needles,
  syringes, blood products, sexual contact
• Infectivity Most contagious 1-2 weeks before
  symptoms, can get chronic Hepatitis

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Hepatitis D-Delta virus

• Incubation 2-26 weeks must have HBV first
• Transmission Same as HBV
• Sources of infection Same as HBV
• Infectivity All stages of Hepatitis D

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Hepatitis E

• Incubation 15-64 days
• Transmission Fecal-oral, contaminated water in
  developing countries
• Sources of infection Contaminated water
• Infectivity Not known

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Hepatitis G

• Not a lot known about HGV
• Transmission Parenterally, Sexual transmission
• Coexists with HCV

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Hepatitis-Pathophysiology

• Widespread inflammation of the liver
• Acute infection
• Cytotoxic cytokines
• Natural killer cells
• Lysis of infected hepatocytes
• Hepatic cell necrosis
• Enlargement of Kupffer cells
• Systemic effects
• Antibody-antigen reaction

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Hepatitis-Clinical Manifestations

• Preicteric
• Icteric
• Posticteric

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Hepatitis-PreictericClinical Manifestations

• Precedes jaundice
• Lasts 1-21 days
• Anorexia, N/V
• RUQ discomfort
• Constipation/diarrhea
• Malaise, H/A, Fever, arthralgias
• Urticaria
• Hepatomegaly/Splenomegaly
• Weight Loss

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Hepatitis-IctericClinical Manifestations

• Lasts 2-4 weeks
• Jaundice-if no jaundice called anicteric
  hepatitis
• Pruritis
• Dark urine, Bilirubinuria
• Light stools
• Fatigue
• Hepatomegaly with tenderness
• Weight loss

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Hepatitis-PostictericClinical Manifestations

• Malaise
• Fatigue
• Hepatomegaly

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Hepatitis-Complications

• Most have no complications
• Fulmant hepatic failure
• Chronic hepatitis
• Cirrhosis
• Hepatocellular carcinoma

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Hepatitis-Diagnostics

• Refer to textbook
• Of interest
• HBsAG (surface antigen)-Current infection (not
  necessarily acute), positive in carriers
• Anti-HBs-Marker to vaccination

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Hepatitis-Treatment

• Rest/bedrest may be warranted
• Well balanced diet
• Antiemetics for nausea, but not Phenothiazines
• Chronic Hep B
• Decrease viral load-Epivir, 3TC for 1 year
• Interferon
• Hepsera-slows progression of chronic HBV
  (interferes with viral replication)

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Hepatitis-Treatment

• Chronic Hep C
• Decrease viral load-Ribavirin
• Interferon

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Hepatitis-Treatment

• Best treatment is prevention
• Hep A-
• Immunization preexposure-Twinrix for HAV and HCV
• Immune globin post exposure
• Avoid food exposure

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Hepatitis-Treatment

• Best treatment is prevention
• Hep B-
• Immunization preexposure-95 Effective
• Three immunizations IM in deltoid
• Second dose within 1 month after first
• Third dose within 6 months of the first
• Post exposure-immune globins (HBIG)

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Hepatitis-Treatment

• Best treatment is prevention
• Hep C
• No treatment available
• Interferon post exposure

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Hepatitis-Nursing Care

• No isolation needed
• Watch blood contact for HBV,HCV
• HCV-screen blood products
• Education-prevention
• Monitor jaundice

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Toxic and Induced Hepatitis--Etiology

• Toxic
• Systemic poisons carbon tetrachlorine
• Induced
• Idiosyncratic drug reactions
• INH, chlorothiazides, Aldomet
• Clinical manifestations are same as for viral
  Hepatitis

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Autoimmune Hepatitis

• Etiology Idiopathic
• Symptoms same as for Viral hepatitis
• Lab tests Elevated liver enzymes, liver
  inflammation without viral antigens
• Treatment Corticosteroids, Immunosuppressive
  agents, immuran

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Cirrhosis of the Liver

• Chronic, Progressive
• Extensive degeneration and destruction of
  parenchymal cells
• Overgrowth of fibrous tissue
• Lobules of irregular size/shape
• Etiology Most common- Excessive ETOH

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Types of Cirrhosis of the Liver

• Alcoholic (Laennecs)/Portal/Nutritional
• Alcohol abuse
• Accumulation of fat in liver, later scar
  formation
• Postnecrotic
• Complication of viral, toxic, or autoimmune
• Scar tissue

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Types of Cirrhosis of the Liver

• Biliary
• Associated with chronic biliary
  obstruction/infection
• Fibrosis of liver with jaundice
• Cardiac
• From long standing right sided heart failure

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Pathophysiology of Cirrhosis

• Cell necrosis, liver cell replaced by scar tissue
• Irregular regeneration
• Hypoxia of liver cells
• Fibrosis occurs

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Early Clinical Manifestations of Cirrhosis

• Anorexia
• Dyspepsia
• Flatulence
• N/V
• Change in Bowel habits
• Dull pain
• Hepatomegaly/Splenomegaly

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Late Clinical Manifestations of Cirrhosis

• Jaundice/Pruritis
• Peripheral edema
• Peripheral neuropathies
• Spider angiomas
• Palmer erythema
• Thrombocytopenia
• Leukopenia
• Anemia

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Late Clinical Manifestations of Cirrhosis

• Coagulation problems
• Pettechiae
• Easy bruising
• Epistaxis
• Heavy menstrual
• Hypoaldosteronism
• Gynecomastia

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Complications of Cirrhosis

• Portal Hypertension
• Esophageal varicies
• Peripheral Edema
• Ascities
• Hepatic Encephalopathy
• Hepatorenal syndrome

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Portal Hypertension

• Increased venous pressure in the portal
  circulation
• Collateral circulation develops
• Varicosities develop

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Esophageal Varicies

• Tortuous veins at the lower end of the esophagus
• Very fragile
• Can rupture, resulting in death

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Peripheral Edema

• Results from decreased oncotic pressure from
  decreased albumin production by the liver
• Seen in ankles, sacral other areas

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Ascities

• Accumulation of serous fluid in peritoneal cavity
  fluid wave
• BP elevated, proteins move from blood vessels
  into lymph space
• Hypoalbuminemia also contributes
• Abdominal striae
• Client has signs of dehydration
• Hypokalemia

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Hepatic Encephalopathy

• Neuropsychiatric
• Terminal complication
• Ammonia enters system without detoxification
• LOC ranges from lethargy to deep coma
• Change can be sudden or gradual

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Hepatic Encephalopathy

• Asterixis-flapping tremor (liver flap)-clinical
  sign
• Client holds arms and hands out, rapid rhythmic
  flexion and extension occurs
• Rapid rhythmic flexion and extension can also
  occur with legs
• Apraxia (inability to construct simple figures)
• Fetor Hepaticus-sweet breath

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Hepatorenal Syndrome

• Complication of hepatic encephalopathy
• Renal Failure can occur
• Azotemia
• Oliguria
• Ascities
• Portal hypertension
• Can be reversed with liver transplantation

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Diagnostic Studies for Cirrhosis

• Elevated liver enzymes/liver cells are damaged
• AST
• SGOT
• ALT
• SGPT
• GGT
• PT time is prolonged
• Increased
• Unconjugated serum bilirubin
• Urine bilirubin

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Diagnostic Studies for Cirrhosis

• Decreased
• Albumin
• Total Protein
• Cholesterol

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Care for the Client with Cirrhosis

• Rest
• Control Ascities
• Na restriction
• Restricted fluids only with severe ascities
• Diuretic therapy
• Paracentesis-temporary
• Peritoneovenous shunt

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Care for the Client with Cirrhosis

• Prevent esophageal varicies from bleeding
• No ETOH
• Control coughing
• Beta blockers
• Endoscopic ligation/sclerotherapy of varicies
• Balloon tamponade-Sengstaken-Blakemore tube
• Aquamephyton (Vitamin K)
• Transjugular intrahepatic portosystemic shunt

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Care for the Client with Cirrhosis

• Prevent Hepatic encephalopathy
• Lactulose to reduce Ammonia level-creates loose
  stools
• Protein restriction
• Prevent constipation
• Nutrition
• High calorie, high carb, low fat,
• Low protein if risk of encephalopathy
• Protein if client is malnourished
• Low sodium if ascities/edema

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Fulmant Hepatic Failure

• Clinical syndrome characterized by severe
  impairment of liver function associated with
  hepatic encephalopathy
• Encephalopathy occurs within 8 weeks of first
  symptom

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Fulmant Hepatic Failure--Etiology

• Viral hepatitis (usually HBV)-most common
• Acetaminophen or ETOH
• INH
• Fluorothane
• Sulfa drugs
• NSAIDs

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Fulmant Hepatic Failure-Clinical Manifestations

• Jaundice
• S/S of encephalopathy
• Elevated liver enzymes
• Increased PT
• Increased bilirubin
• Treatment
• Possible liver transplant

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Liver Cancer

• Rare carcinoma
• Primary
• Hepatocellularmost common primary type, clients
  usually have cirrhosis, hepatitis
• Primary usually metastasizes to lung
• Secondary
• Metastatic cancer of liver more common

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Liver CancerClinical Manifestations

• Difficult to differentiate from cirrhosis
• Since symptoms are same
• Hepatomegaly
• Weight loss
• Edema
• Ascities
• Portal Hypertension
• Dull abdominal pain
• Jaundice
• Anorexia
• N/V

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Liver Cancer - Diagnostic Studies

• CT
• MRI
• ERCP
• Liver biopsy
• Tumor markers
• Alpha feto Protein-helps to distinguish primary
  vs. secondary carcinoma

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Liver Cancer - Treatment

• Mostly palliative
• Surgical excision of tumor if possible
• Radiofrequency-electrical energy creates heat,
  destroys cancerous cells
• Cryosurgery
• Percutaneous ethanol injection-Injection of
  ethanol

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Liver Cancer - Treatment

• Chemotherapy
• Chemoembolism-embolitic agent with chemo injected
• Liver transplant

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Liver Transplant

• Used for irreversible liver disease
• Chronic viral hepatitis-most common indication
• Not for metastatic processes
• Major post op complication
• Rejection
• Infection-fever may be only sign
• Reinfection with hepatitis/cirrhosis
• Immunosuppressant administration
• Cyclosporine
• Imuran
• Simulect
• Zenapax