hepatobiliary disorders 1

8/9/2019 Hepatobiliary Disorders 1

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DISCUSSION OUTLINE

DAY 1I. Review of the Anatomy and Physiology of the

Biliary system-(Liver)

II. AssessmentA. chief complaints

B. Past Medical History

C. Physical Examination

III. Laboratories/ Diagnostic Procedures/ Studies

IV. Common Disorders

A. Liver Cirrhosis

B. Hepatitis


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DISCUSSION OUTLINE

DAY 2I. Review of the Anatomy and Physiology of

the Pancreas and Gallbladder

II. Assessment

III. Common disorders

A. Cholelithiasis

B. Cholecystitis

C. Acute and Chronic Pancreatitis


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I. REVIEW ON THE ANATOMY AND

PHYSIOLOGY (BILIARY SYSTEM)


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MAJOR FUNCTIONS OF THE

LIVER1. Metabolism

2. Production of bile salts

3. Bilirubin metabolism

4. Detoxification of endogenous and exogenous

substances

5. Storage of minerals and vitamins

6. Blood reservoir

7. Excretion of the adrenal cortex hormones

8. Phagocytosis


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ASSESSMENT

PAST MEDICAL HISTORY

Recent skin/mucous membrane

disruption

Major illness/hospitalization

Medications

Family historyPsychosocial History and lifestyle

Habits


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ASSESSMENT

PHYSICAL EXAMINATIONINSPECTION

Skin color

Abdominal size and contour

symmetry

Skin characteristics

Jugular vein

AUSCULTATION

Bowel sounds

PERCUSSION

Liver dullness

Spleen Dullness


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ASSESSMENT

PHYSICAL EXAMINATIONSpider Angioma PALMAR ERYTHEMA


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ASSESSMENT

PHYSICAL EXAMINATIONPALPATION

Light palpation

Deep palpation

Palpate specific organs

SPECIAL PROCEDURES:

Fluid wave test

Shifting Dulllness

Abdominal assment.movie


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ASSESSMENT

CHIEF COMPLAINTSAbdominal pain

Anorexia

Nausea and vomiting

Weight loss

Stool changes

Food intolerance

Altered level of

consciousness

Urine changes

Jaundice, pruritus

Bleeding tendencies

Ascites

Edema of the limbs

Fatigue


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LABORATORY AND

DIAGNOSTIC TESTSFat Metabolism

indicators

Increase: biliary obstruction

Decrease: hepatocellular

damage

Examples:

Serum Total Cholesterol &

Cholesterol Esters

Normal value: 140-200 mg/dl

Serum phospholipids

Normal value: 150-250 mg/dl

Protein Metabolism

Indicators

Total Serum Protein- dec

Immunoglobulins

IgA- inc in Liver cirrhosis

IgG- inc in chronic active

hepatits

IgM- inc in Hepatitis A

BUN- inc in hepatocelluar dse

Protime, PTT, PT- inc

Blood Ammonia Levels- Inc


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LABORATORY AND

DIAGNOSTIC TESTBilirubin Metabolism

Indicators Total Serum Bilirubin

inc- hepatocellualr damage

nv: 0.1- 1 mg/dl

Unconjugated/ Indirect

Bilirubin

inc- hepatocellular damage

nv: 0.1- 1 mg/dl

Conjugated bilirubin

Inc- bilirary obstruction

Urine Bilirubin/ Foam Test

inc- hepatocelluar

damage

Fecal Urobilinogen

(stercobilin)

- alcohol stool (pale or

gray colored stool)


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LABORATORY AND

DIAGNOSTIC TESTInc Serum Enzymes

Alanine transaminase (ALT), also called Serum Glutamic PyruvateTransaminase

Normal value:

Aspartate transaminase (AST) also called Serum Glutamic OxaloaceticTransaminase (SGOT)

Normal value:

Alkaline phosphatase (ALP)

Normal value

Gamma glutamyl transpeptidase (GGT)

Normal value:

LDH (Lactic Dehydrogenase)

Normal Value


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LABORATORY AND

DIAGNOSTIC PROCEDURESLIVER BIOPSY

Nsg intervention before andDuring the procedure:

1. consent

2. NPO: 2-4 hrs

3. Pre-op meds: Vitamin K ifprolonged Prothromin Time

4.

Monitor Pro-time : BLEEDI

NG most commoncomplication

5. Position: LEFT LATERAL

6. HOLD breath 5-10 secondsduring the needle insertion


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LABORATORY AND

DIAGNOSTIC PROCEDURESLIVER BIOPSY

Nsg intervention after the

procedure:

1. POSITION: RIGHT SIDE

for the four hours

2. BED REST for 24 hours

3.Monitor

V

/s: changes mayindicate internal

hemorrhage

4. Observe for signs of

Peritonitis


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LABORATORY AND

DIAGNOSTIC PROCEDURESPARACENTESIS

Nsg intervention BEFORE ANDDURING the procedure:

1. Consent

2. V/S prior

3. Empty the bladder

4. Check serumproteins

5. POSITION: sitting/upright


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LABORATORY AND

DIAGNOSTIC PROCEDURESPARACENTESIS

Nsg intervention after theprocedure:

1. V/s monitoring

2. Urine output

3. Rigidity of the

abdomen

4. Sx and symptoms ofhypovolemic shockand peritonitis


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LABORATORY AND

DIAGNOSTIC PROCEDURESPeritoneoscopy

Nsg intervention before the

procedure:

1. Consent

2. Clotting fx

3. Hypersensitive tolocal anesthesia

4. NPO


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LABORATORY AND

DIAGNOSTIC PROCEDURESPeritoneoscopy

Nsg intervention after the

procedure:

1. V/s and site

monitoring

2. Watch out for

complications:

Bile peritonitis


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HEPATITIS


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HEPATITIS

Inflammation of the liver

Causes: virus, exposure tomedications, hepatotoxins

3 subtypes:

1. Viral Hepatitis

2. Toxic Hepatitis

3. Alcoholic Hepatitis


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A. VIRAL HEPATITIS

Virus HEP A HEP B HEP C HEP D HEP E HEP F HEP G

MOT Fecal-

oral

Blood and

body

fluids,perinatal

Blood

and body

fluids,intranasa

l

Blood and

body

fluids,perinatal

Fecal- oral Fecal- oral Blood and

body

fluids

INCUBATION 2-6 wks 6-24 wks 5-12 wks 3-13 wks 3-6 wks asympto

ONSET abrupt slow Slow Abrupt abrupt

COMP rare Cirrhosis,

Liver CA,

Chronic

Hepatitis

Cirrhosis,

Liver CA,

Chronic

Hepatitis

Liver CA,

Chronic

Hepatitis

Fulminant

H.

No

evidence

on

chronicity


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A. VIRAL HEPATITIS

TREATMENTS AND PREVENTION

Hepatitis A

formerly called Infectious hepatitis, Epidemichepatitis, Epidemic jaundice, Catarrhaljaundice,

Type A hepatitis,

1. Self limiting with only few long termconsequences

2. Txtment of H20 supplies and proper sanitation

3. Hepatitis Vaccine A (Havrix)- 2 doses

4. Immunoglobulin (Gammar) before and afterexposure


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A. VIRAL HEPATITIS


Hepatitis B

1. Strict handwashing

2. Screening blood donors

3. Testing pregnant women (HBsAg)

4. Hepatitis b Vaccine ( Engerix- B, Recombivax

HB)- 3 dose

5. Immunoglobulin : for post exposure


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A. VIRAL HEPATITIS


Hepatitis C

1. Major cause of POST TRANSFUSION

HEPATITIS

2. Treatment: Interferon and Oral Ribavirin

Hepatitis D

1. Co-infection of Hepa B

Hepatitis E, F, G

1. General hygiene precautions


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A. VIRAL HEPATITIS

MANIFESTATIONS Preicteric phase

1. Flulike symptoms: malaise, fever, fatigue

2. GI: anorexia, N/V, diarrhea & constipation

3. Muscle aches, polyarthritis

4. Mild RU abdominal pain and tenderness


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A. VIRAL HEPATITIS

MANIFESTATIONSIcteric phase

1. Jaundice

2. Pruritus

3. Clay colored stools

4. Brown urine

5. Decrease in

preicteric phase

symptons


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A. VIRAL HEPATITIS

MANIFESTATIONSNsg. Diagnosis and Intervention for

JAUNDICE

1. Impaired Skin Integrity

NPI: Loose fitting clothes

Tepid Sponge bath

Cool room and clean linens

Pharma: Oral Cholestyramine bind with bile

salts for excretion

antihistamines, and phenobarbitals


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A. VIRAL HEPATITIS

MANIFESTATIONSNsg. Diagnosis and Intervention for

JAUNDICE

1. Disturbed Body Self image

- verbalize concerns or feelings toward condition


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A. VIRAL HEPATITIS

MANIFESTATIONSPost icteric phase

1. Serum bilirubin and

enzymes return tonormal levels

2. Energy level

increases

3. Pain subsides


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A. VIRAL HEPATITIS

COMPLICATIONSFulminant Hepatitis

Massive hepatic

necrosis

Seen primarily in HEP

A, B, D and E

Progression of:

Jaundice

Hepatic

encepalopathy

ascites

Chronic Hepatitis

Liver inflammation

beyond 3-6 months


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HEPATITIS

MANAGEMENTSMedical Management

Glucose water/

dextrose

Bile Acid Sequestrants

(Cholestyramine (

Questran) or Colestipol

( colestid)

Interferon Treatment

Milk thistle

Licorice roots

Nursing Management

Imbalanced Nutrition,

Less thanRisk for infection

(Transmission)

Fatigue


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LIVER CIRRHOSIS


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LIVER CIRRHOSIS

End stage of chronic liver disease

progressive, irreversible

TYPES OF LIVER CIRRHOSIS

1. Laennec s Cirrhosis / Alcoholic Cirrhosis

2. Postnecrotic cirrhosis

3. Primary biliary cirrhosis

4. Secondary biliary cirrhosis

5. Cardiac Cirrhosis


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LIVER CIRRHOSIS

PORTAL HYPERTENSION

increase in the blood

pressure within a system

of veins called the portal

venous systemBlood backs up and find

other ways to the heart

Esophagus

Skin on the abdomen

Veins in the rectum

spleen


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LIVER CIRRHOSIS

BLEEDING ESOPHAGEAL

VARICES Fragile, thin walled, distended

esophageal veins that may

become irritated and ruptured

Note for this sx:

Blod pressure less than or

equal 90/60mmhg

Heart rate: more than 100

beats/min

Cool, clammy skin

Slow capillary refill

restlessness


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LIVER CIRRHOSIS

BLEEDING ESOPHAGEAL

VARICESSENGSTAKEN BLAKEMORE

TUBE

-oro- or nasogastric tube used

occasionally in the management

of upper gastrointestinal

hemorrhage due to bleeding

from esophageal varices

HOW TO PREVENT :

Avoid screaming, shouting

straining at stool

coughing and sneezing

REMEMBER---SCI

SSORS @ bedside


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LIVER CIRRHOSIS

HEPATIC ENCEPALOPATHY

Results from the accumulation

of ammonia in the blood and

other neurotoxins

ASTERIXIS- earliest sign

Other manifestations:

1. Confusion/disorientation

2. Delirium/hallucination

3. FETOR HEPATICUS

4. HEPATIC COMA


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LIVER CIRRHOSIS

MANAGEMENTS

A. Medications

1. Diuretics- Spironolacotone ( Aldactone)

2. Lactulose and neomycin

3. Nadolol (Cogard) & Isosorbide mononitrate (Imdur)

4. Oxazepam (Serax)

5. Ferrous sulfate


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LIVER CIRRHOSIS

MANAGEMENTS

B. DIETARY AND FLUID MANAGEMENT

1. Fluids : 1500 ml/ day with Sodium restriction

2. Diet:

Low protein ( 60- 80 g/ day if with hepatic

encepalopathy)

Adequate protein (75- 100 g/ day if wihout)

3. Vitamin and Mineral Supplements


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LIVER CIRRHOSIS

MANAGEMENTS

C. COMPLICATION MANAGEMENT

1. PARACENTESIS

2. TI

PS ( TRANSJUGULARI

NTRAHEPATI

CPORTOSYSTEMIC SHUNT)

Insertion of expandable stent to allow the

blood flow the portal vein to drain direclty

into the hepatic vein and bypassing the

cirrhotic liver

- Common complication: stenosis and

occlusion of the stent

3. SCLEROTHERAPY (Morrhuate sodium)


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LIVER CIRRHOSIS

MANAGEMENTS

D. NURSING DIAGNOSIS AND INTERVENTIONS

1. Ineffective perfusion

2. Excess Fluid volume

3. Disturbed thought process

4. Imbalanced Nutrition: Less than Body requirements

5. Ineffective protection

hepatobiliary disorders 1

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