Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic...

Chapter 6Chapter 6

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Serum bilirubin test• Liver enzyme tests• Serum protein test• Oral cholecystography (gallbladder series)• Intravenous cholangiography (IV cholangiogram)• Operative cholangiography• T-tube cholangiogram• Ultrasound of the liver, gallbladder, and biliary

system• Gallbladder scanning• Liver biopsy• Liver scanning


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

(continued)

• Blood ammonia

• Hepatitis virus studies

• Serum amylase test

• Urine amylase test

• Ultrasound of pancreas

• Computerized tomography of the abdomen

• Endoscopic retrograde cholangiopancreatography of the pancreatic duct (ERCP)


Disorders of the Liver, Biliary Tract, Gallbladder, and PancreasDisorders of the Liver, Biliary Tract, Gallbladder, and Pancreas

• Cirrhosis Etiology/pathophysiology

• Chronic, degenerative disease of the liver

• Scar tissue restricts the flow of blood to the liver

• Types of cirrhosis Laennec’s cirrhosis Postnecrotic cirrhosis Primary biliary cirrhosis Secondary biliary cirrhosis



• Cirrhosis (continued) Etiology/pathophysiology (continued)

• Alteration of liver function Reduced ability to construct albumin Obstruction of portal vein Increased pressure in veins that drain GI tract

• Complications Portal hypertension due to vein obstruction by cirrhosis Ascites – excessive fluid and albumin in peritoneal cavity Esophageal varices due to portal hypertension Hepatic encephalopathy – ammonia intoxication causing

brain damage – check for flapping hands



• Cirrhosis (continued) Clinical manifestations/assessment

• Early stages Abdominal pain’ anorexia, N/V, Liver is firm and easy to palpate

• Late stages Dyspepsia;Changes in bowel habits Nausea and vomiting Jaundice and ecchymoses Gradual weight loss



• Cirrhosis (continued) Clinical manifestations/assessment (continued)

• Late stages (continued) Ascites Enlarged spleen Spider angiomas Anemia Bleeding tendencies –

o Epistaxis; Hematuria; Purpura; bleeding gums Disorientation


Figure 6-2Figure 6-2

Systemic clinical manifestations of liver cirrhosis.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)



• Cirrhosis (continued) Medical management/nursing interventions

• Pharmacological management Antiemetics

o Benadryl and Dramamineo Contraindicated: Vistaril, Compazine, and Atarax

• Eliminate the cause! Alcohol Hepatotoxins Environmental exposure to harmful chemicals




(continued)• Diet

Well-balanced High in calories -2500-3000 cal Moderate in protein 75G Low in fat Low in sodium 1-2 G Supplemental vitamins (especially B group) and folic acid




(continued)• Treatment of complications

Asciteso Bed resto Strict I&Oo Restrict fluids and sodiumo Diuretics: Aldactone, Lasix, HCTZo Vitamins K, C, and folic acid supplementso LeVeen peritoneal-jugular shunto Paracentesis


Figure 6-3 Decreases ascitesFigure 6-3 Decreases ascites

LeVeen continuous peritoneal jugular shunt.

(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)




(continued)• Treatment of complications (continued)

Ruptured esophageal variceso Maintain airway; establish IVo Vasopressin drip to control bleedingo Sengstaken-Blakemore tubeo Endoscopic sclerotherapyo Portacaval shunto Blood transfusions




(continued)• Treatment of complications (continued)

Hepatic encephalopathyo Decrease protein in dieto Avoid drugs that are detoxified by the livero *Lactulose – pulls ammonia from blood into bowel

and causes osmotic laxative effect *http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682338.html

o Neomycin – “causes a reduction in mucosal glutaminase activity and thereby decreases the ability of the mucosa to consume glutamine and produce ammonia”.http://www.ncbi.nlm.nih.gov/pubmed/7741004


Normal labsNormal labs

• Total bilirubin: 0.3 to 1mg/dL

• AST: 0-35 units/dL

• ALT: 4-36 units/dL

• Alkaline Phosphatase; 30-120 units/ dL

• Albumin: 3.5 – 5 /dL

• Total protein: 6.4 – 8.4 g/dL

• Lipase: 10- 140 units/ L



• Liver cancer Etiology and pathology

• Hepatocellular carcinoma most commonly seen

• Cirrhosis of the liver and hepatitis C and B are also elevated risk factors

• In the United States liver cancer is seen more in people over age 40

• Metastatic carcinoma of the liver is seen more than primary liver cancer due to high vascularity and blood flow



• Liver cancer Clinical manifestations

• Hepatomegaly*

• Weight loss*

• Peripheral edema*

• Ascites*

• Portal hypertension* *also seen in cirrhosis

• Dull epigastric pain

• Jaundice (visible with bili level over 2.5mg/dL)

• Anorexia, N/V

• Extreme weakness



• Liver cancer Diagnostic tests

• Liver scan

• Ultrasound

• CT scan

• Magnetic resonance imaging

• ERCP

• Liver biopsy – needle aspirate How do you position the patient to recover from a liver

biopsy?



• Liver cancer Medical management/nursing interventions

• Palliative care

• Surgery – excision or removal with transplant

• Chemotherapy - 5FU via hepatic artery or portal vein



• Hepatitis Etiology/pathophysiology

• Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances

• Hepatitis A Most common Oral-fecal transmission “A” for awfully dirty hands



• Hepatitis (continued) Etiology/pathophysiology (continued)

• Hepatitis B Transmission by contaminated serum; blood transfusion,

contaminated needles, dialysis, or direct contact with infected body fluids

It “B” in the blood and body fluids

• Hepatitis C Transmitted through contaminated needles and blood

transfusions “C” the needles with the blood on them



• Hepatitis (continued) Etiology/pathophysiology (continued)

• Hepatitis D Co-infection with hepatitis B “D’sex ain’t worth it”

• Hepatitis E Fecal contamination of water Rare in the United States; usually in developing countries “EWW” the water looks brown

• Hepatitis G “Gee” I don’t want transfusions from over there

****Reportable to CDC****



• Hepatitis (continued) Clinical manifestations/assessment

• May be asymptomatic

• General malaise

• Aching muscles

• Photophobia

• Headaches

• Chills

• Abdominal pain

• Dyspepsia

• Nausea



• Hepatitis (continued) Clinical manifestations/assessment (continued)

• Diarrhea/constipation

• Pruritus

• Hepatomegaly

• Enlarged lymph nodes

• Weight loss

• Jaundice

• Dark amber urine

• Clay-colored stools



Severe jaundice.

(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book—Europe.)



• Hepatitis (continued) Medical management/nursing interventions

• Hospitalization for bilirubin > 10mg/dl or inc. PT, INR

• Treat symptoms

• Bed rest

• Small, frequent meals Low-fat, low protein and high-carbohydrate NO ETOH

• IV fluids for dehydration

• Vitamin C, vitamin B–complex, vitamin K

• Avoid unnecessary medications, especially sedatives



• Hepatitis (continued) Medical management/nursing interventions

(continued)• Gamma globulin or immune serum globulin

• Hepatitis B immune globulin (HBIG) Should be given to anyone exposed to hepatitis B

• Hepatitis B vaccine Should be given to people identified as high risk for

developing hepatitis B



• Liver abscesses Etiology/pathophysiology

• May be single or multiple

• Abscess forms in the liver due to invading bacteria



• Liver abscesses (continued) Clinical manifestations/assessment

• Fever

• Chills

• Abdominal pain and tenderness in the right upper quadrant

• Hepatomegaly

• Jaundice

• Anemia



• Liver abscesses (continued) Diagnostic tests

• Radiograph

• Ultrasound

• CT scan

• Liver scan Medical management/nursing interventions

• IV antibiotic therapy specific to organism

• Percutaneous drainage of liver abscess

• Open surgical drainage if abscess ruptures

• Treatment is deemed proper if symptoms decrease



• Cholecystitis & cholelithiasis

• Etiology/pathophysiologyAn obstruction, gallstone, or

tumor keeps bile from leaving the gallbladder, and the trapped bile acts as an irritant, causing edema

• Risk factors: Female; American Indian or white; obesity; pregnancy; diabetes; multiparous women; use of birth control



• Cholecystitis and cholelithiasis (continued) Clinical manifestations/assessment

• Indigestion after eating foods high in fat

• Severe, colicky pain in the right upper quadrant

• Anorexia

• Nausea and vomiting

• Flatulence

• Increased heart and respiratory rates

• Diaphoresis



• Cholecystitis and cholelithiasis (continued) Clinical manifestations/assessment (continued)

• Low-grade fever

• Elevated WBC

• Mild jaundice

• Steatorrhea (fatty stool)

• Clay colored stool – bile duct is blocked

• Dark amber urine



• Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions

• Mild attacks Pharmacological management

o Antispasmodic and analgesic medicationso Demerol (meperidine)o Antibiotics

Bed rest NG tube to suction NPO IV fluids Dietary recommendations: Avoid spicy foods when

allowed PO intake; low fat



• Cholecystitis and cholelithiasis (continued) Medical management/nursing interventions

(continued)• Lithotripsy – shock waves through water or a cushion to

pulverize the stone(s) to sizes that can be excreted

• Cholecystectomy Laparoscopic removal Open – may need T-tubes if common bile duct is

edematous May need to aspirate bile from gallbladder before it can

be removed



• Pancreatitis Etiology/pathophysiology

• Inflammation of the pancreas Acute or chronic

• Predisposing factors Damage to the tract Alcohol overuse Trauma Infectious disease Certain drugs



• Pancreatitis (continued) Clinical manifestations/assessment

• Elevated lipase level (5-40 x normal)

• Abdominal pain – LUQ Relieved by fetal or forward leaning positions

• Anorexia; nausea and vomiting

• Malaise

• Low-grade fever

• Jaundice

• Weight loss

• Steatorrhea

• Tachycardia



• Pancreatitis (continued) Medical management/nursing interventions

• Pharmacological management Antiemetics Analgesics Anticholinergics Antacids

• NPO – WHY?

• IV fluids

• NG tube

• Hyperalimentation



• Cancer of the pancreas Etiology/pathophysiology

• Unknown

• Risk factors Risk increases with age Cigarette smoking; exposure to chemical carcinogens;

diabetes mellitus; pancreatitis; diet high in meat, fat, and coffee; obesity

• May be metastasis from the lung, stomach, duodenum, or common bile duct (CBD)

• May live only 4 to 8 months after diagnosis



• Cancer of the pancreas (continued) Clinical manifestations/assessment

• Abdominal pain in 85% of patients – worse at night Steady, dull, aching pain in the epigastric area

• Anorexia

• Fatigue

• Nausea and flatulence

• Change in stools

• Weight loss

• Jaundice and pruritis

• Onset of diabetes mellitus – 50%



• Cancer of the pancreas (continued) Medical management/nursing interventions

• Surgery Whipple procedure

o Like Billroth 2 but pancreas is attached to middle of jejunum and bile ducts are attached to end of jejunum

Total pancreatectomy with resection of parts of the GI tract

• Chemotherapy

• Radiation

• Nerve block to celiac plexus nerve

Prognosis is poor. 5 year survival is <10%



Whipple’s procedure, or radical pancreaticoduodenectomy.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)

Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic...

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