Fast Facts About GI and Liver Diseases for Nurses: What...

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FAST FACTS ABOUT GI AND LIVER DISEASES

FOR NURSES

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Amanda Chaney, MSN, ARNP, FNP-BC, is a liver transplant nurse practitioner, nurse practitioner advocate, and nurse leader in the nurse practitioner and transplant nursing areas. She holds an academic appoint-ment as an assistant professor of medicine. Ms. Chaney is the author of several book chapters and articles for peer-reviewed journals and she is an avid researcher. She was chosen as one of 19 nurse practitioners from across the United States to be a part of the inaugural American Associa-tion of Nurse Practitioners (AANP) Leadership Program in 2014. To help the professional development and leadership of other nurses and nurse practitioners, she founded a group for the professional development of aspiring leaders that encourages mentorship and guides members in fine-tuning their publishing and presenting skills, while offering support and guidance for successful careers.

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FAST FACTS ABOUT

GI AND LIVER DISEASES

FOR NURSES

What APRNs Need

to Know in a Nutshell

Amanda Chaney, MSN, ARNP, FNP-BC

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Library of Congress Cataloging-in-Publication DataNames: Chaney, Amanda, author.Title: Fast facts about GI and liver diseases for nurses : what APRNs need to know in a nutshell / Amanda Chaney.Other titles: Fast facts about gastrointestinal and liver diseases for nurses | Fast facts (Springer Publishing Company)Description: New York : Springer, [2017] | Series: Fast facts | Includes bibliographical references and index.Identifiers: LCCN 2016018940| ISBN 9780826117243 | ISBN 9780826117496 (e-book)Subjects: | MESH: Gastrointestinal Diseases | Liver Diseases | Nurses’ InstructionClassification: LCC RC801 | NLM WI 140 | DDC 616.3/3--dc23 LC record available at https://lccn.loc.gov/2016018940

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This is dedicated to my best friend, my biggest fan, and my guy, Chris. Thank you for supporting

me always, no matter what.

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ix

Preface xi

Part I: Assessment of Common Gastrointestinal Symptoms

1. Abdominal Assessment, Labs, Imaging, and Differential Diagnosis 3

2. Nausea and Vomiting 9

3. Abdominal Pain 15

4. Constipation 23

5. Diarrhea 29

Part II: Common GI Disorders

6. Celiac Disease 39

7. Irritable Bowel Syndrome 45

8. Food Intolerances or Allergies 51

9. Inflammatory Bowel Disease 55

10. Gastroesophageal Reflux Disease 61

11. Peptic Ulcer Disease 65

12. Diverticular Disease 71

Contents

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13. Gallstones 77

14. Gastrointestinal Cancers 83

Part III: Liver Disease

15. Assessment of Liver Function and Abnormal Liver Function Tests 91

16. Causes of Liver Disease 99

17. Viral Hepatitis 107

18. Fatty Liver Disease 117

19. Autoimmune Liver Disease 123

20. Acute Liver Failure 127

Part IV: Cirrhosis and Its Complications

21. Cirrhosis 135

22. Ascites/Fluid Retention 143

23. Spontaneous Bacterial Peritonitis 149

24. Gastrointestinal Bleeding 155

25. Hepatic Encephalopathy 159

26. Hepatorenal Syndrome 165

27. Hepatopulmonary Syndrome 169

28. Hepatocellular Carcinoma 173

29. Malnutrition/Vitamin Deficiencies 177

Part V: Liver Transplantation

30. Transplant Recipient Considerations 185

31. Transplant Donor Considerations 191

32. Posttransplant Care 195

Index 203

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xi

The purpose of this book is to offer insight into the diagnosis, management, and treatment of patients with gastrointestinal (GI) and liver disease. There is not much scholarly work de-voted to this topic for this select group of professionals, yet we provide a great deal of care to these patients. GI disorders and liver disease are becoming common problems in the United States, with nausea, vomiting, and abdominal pain being some of the most common complaints in the offices of primary care providers.

Each chapter provides the reader with an overview and introduction, followed by significant laboratory or imaging findings, treatment options, expected outcomes, and several “Fast Facts in a Nutshell” that will highlight key take-away points. I hope that this book will review much-needed informa-tion for those at the bedside caring for these patients, allowing more time with patients rather than fumbling through pages to find an answer on how to manage these illnesses. There is no other book in the literature that is like this one. This book offers concise information you can use to provide your patient with the best care.

Amanda Chaney

Preface

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39

Celiac Disease

At the end of this chapter, the reader will be able to:

1. Name the gold standard laboratory test to diagnose celiac disease

2. State three risk factors for celiac disease

3. Describe the treatment for celiac disease

INCIDENCE AND RISK FACTORS

In the United States and worldwide, 1% of the population has celiac disease (AGA, 2006; Leffler & Vanga, 2015). There are several risk factors for the development of celiac disease

6

According to the American Gastroenterological Associa-tion (AGA), celiac disease is an intolerance to gluten that causes inflammation of the small bowel that can create malabsorption and poor digestion (AGA, 2006). Wheat, barley, and rye have gluten-containing products. Celiac disease is considered an autoimmune disorder with a genetic component. It is quickly becoming a common disorder that is gaining public recognition.

The food industry is taking notice, and there are many offerings now for gluten-free foods.

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TABLE 6.1 Risk Factors for Celiac Disease

Cereal in infant’s diet prior to 3 months of age

History of type 1 diabetes

First-degree relative with celiac disease

History of liver disease (elevated transaminases, primary biliary cirrhosis, autoimmune hepatitis)

History of iron-deficiency anemia

History of Down syndrome or Turner’s syndrome

History of osteoporosis History of autoimmune thyroid disease

History of other autoimmune disorders

History of fertility problems

Advanced age North American or European ancestry

Immunoglobulin A deficiency Eosinophilic esophagitis (children)

Adapted from AGA (2006), Leffler and Vanga (2015), and Schuppan et al. (2009).

(Table 6.1; AGA, 2006). If left untreated, patients with celiac disease have an increased risk of developing gastrointestinal cancers and enteropathy-associated T-cell lymphoma (Schuppan, Junker, & Barisani, 2009). In 40% to 50% of untreated patients with celiac disease, asymptomatic elevated aminotransferase levels develop (Leffler & Vanga, 2015).

ASSESSMENT FINDINGS

There is a wide range of symptoms for the patient with celiac disease. Some are asymptomatic, whereas some have severe malabsorption issues with skin manifestations. Celiac disease is frequently found in patients who have other autoimmune disorders (Schuppan et al., 2009).

Answers are needed regarding the patient’s diet, paying particular attention to symptoms that develop following con-sumption of foods containing wheat, rye, or barley. Patients may complain of abdominal bloating, chronic or frequent episodes of diarrhea, and weight loss (Kelly, 2015).

Patients with severe gluten intolerance may develop a severely itchy rash (dermatitis herpetiformis; AGA, 2006).







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*Villous atrophy is a hallmark finding in patients with celiac disease.

Other issues include anemia, chronic fatigue, constipation, neurological/psychiatric issues (anxiety, migraines, peripheral neuropathy, ataxia), and infertility (Leffler & Vanga, 2015). All of these issues should be included in the review of systems when interviewing the patient with possible celiac disease.

On examination, providers evaluate for rash, abdominal distention, and evidence of weight loss (e.g., loose skin or temporal wasting; Kelly, 2015).

PERTINENT LABORATORY/DIAGNOSTIC

FINDINGS

A serologic test called immunoglobulin A (IgA) anti-tissue transglutaminase (tTGA) is performed to detect possible celiac disease in patients over 2 years old (Kelly, 2015). The gold standard for diagnosing celiac disease is duodenal biopsy performed by endoscopy.

Characteristic histological changes of celiac disease are villous atrophy,* crypt hyperplasia, intraepithelial lymphocy-tosis, and mucosal inflammation. Biopsy is recommended in patients with a positive serologic test (AGA, 2006; Kelly, 2015; Schuppan et al., 2009).

DIFFERENTIAL DIAGNOSIS

Other possibilities for gastrointestinal symptoms that present with celiac disease include irritable bowel syndrome and lactose intolerance (Kelly, 2015).

MANAGEMENT

The only curative treatment for celiac disease is strict adherence to a gluten-free diet (GFD). As this disease has







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gained public awareness, there are many patient education pamphlets and even support groups available that patients can be a part of to help with diet adherence. It is important to recognize other vitamin deficiencies in patients with celiac disease, including B 12 , D, iron, and folate. A screening for osteoporosis is also recommended by bone mineral density scan (AGA, 2006). Future treatments are being explored, including medications that could make it possible for these patients to tolerate gluten (Schuppan et al., 2009). Patients should consult with a registered dietician for a thorough dietary education on necessary lifestyle changes. With essential dietary changes, some patients may have undesired weight gain. Counseling on ideal food choices is important for patient success (Leffler & Vanga, 2015).

ICD-10 CODE

Celiac disease: K90.0

1. Celiac disease is a common gastrointestinal disorder that results from gluten intolerance.

2. If left untreated, patients with celiac disease can de-velop cancer or have further serious complications.

3. The gold standard for diagnosing celiac disease is duodenal biopsy by endoscopy.

4. The only cure for celiac disease is strict adherence to a gluten-free diet.

FAST FACTS in a NUTSHELL

REFERENCES

American Gastroenterological Association. (2006). AGA institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology, 131 , 1977–1980.







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Kelly, C. P. (2015). Diagnosis of celiac disease in adults. In S. Grover (Ed.). Waltham, MA: UpToDate. Retrieved from www.uptodate.com/contents/diagnosis-of-celiac-disease-in-adults?source=search_result&search=celiac&selectedTitle=1%7E150.html

Leffler, D. A., & Vanga, R. R. (2015). Celiac disease. In P. R. McNally (Ed.), GI/liver secrets plus (5th ed., pp. 308–312) McNally, P. R. (Ed.). Philadelphia, PA: Elsevier Saunders.

Schuppan, D., Junker, Y., & Barisani, D. (2009). Reviews in basic and clinical gastroenterology: Celiac disease: From pathogenesis to novel therapies. Gastroenterology, 137 , 1912–1933.


http://www.uptodate.com/contents/diagnosis-of-celiac-disease-in-adults?source=search_result&search=celiac&selectedTitle=1%7E150.html








51

At the end of this chapter, the reader will be able to:

1. Identify the most common food allergen (causing an immune response)

2. Name two other differential diagnoses to consider in the patient

with a possible food allergy

3. State two possible treatment options for the patient with

food-induced anaphylaxis

Food intolerances, or food allergies, are becoming increasingly common and recognized more frequently as a cause of gastrointestinal distress. Both immunological and nonimmunological reactions to food exist, with nonimmunological reactions occurring much more often. Reactions usually occur as the body’s response to a food protein (Burks, 2015).

Nonimmunological reactions to food typically occur in the skin and gastrointestinal tract, and are usually not as severe.

Food intolerance is defined as an adverse reaction to a specific food. Celiac disease (see Chapter 6) and lactose intolerance are examples of food intolerances and are the most commonly diagnosed food intolerances (Rindfleisch, 2012).

Food Intolerances or Allergies

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INCIDENCE AND RISK FACTORS

Food-induced anaphylaxis, particularly in the pediatric population, has increased over the past 50 years. It has been estimated that over 125,000 emergency room visits per year in the United States are related to a food-related reaction or allergy. Most common reactions occur from peanuts and tree nuts, followed by fish and shellfish allergies. Patients at risk are those who have asthma and/or a history of allergic reactions to food (Sampson, 2014). Food allergy reactions are increasing in our population, with 4% to 8% occurring in children and 1% to 4% occurring in adults (Rindfleisch, 2012).

ASSESSMENT FINDINGS

Symptoms can range from mild to severe anaphylactic-type reactions. Patients should be questioned regarding skin lesions, rash, difficulty breathing, palpitations, chest pain, nausea, vomiting, or diarrhea.

Patients with an immunological reaction to food develop symptoms acutely, usually within minutes to 2 hours after consumption of the offending food. Symptoms that may develop include an itchy rash (urticaria) and swelling (an-gioedema), asthma and allergic rhinitis, nausea, vomiting, abdominal pain and/or cramping, and diarrhea. The most severe reaction that can occur is an anaphylaxis reaction, which occurs quickly and can cause death if not treated rapidly (Burks, 2015).

PERTINENT LABORATORY FINDINGS

Immunologic testing—allergic reaction: enzyme-linked im-munosorbent assay testing performed to determine presence of IgG and IgE immunoglobulins (Rindfleisch, 2012).

Antigen leukocyte cellular antibody test (ALCAT)—measures body’s response to food antigens (Rindfleisch, 2012).







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These tests should be ordered by an allergy specialist who can review findings in detail with patient and determine best treatment.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis in patients with food intolerances is largely dependent on the type of reaction that is occurring. Some considerations include:

• Lactose intolerance • Anatomic abnormalities • Neurologic disorders • Gastroesophageal reflux disease (GERD) • Infectious processes, gastroenteritis • Pancreatic insufficiency • Peptic ulcer disease (Burks, 2015)

MANAGEMENT

The key to managing the patient with a food intolerance or allergy is to identify the trigger. An accurate dietary history (preferably a food diary) is important in identifying the possible allergen. Expert consultation to a specially trained allergist is recommended for uncertain or moderate to severe cases to accurately identify the food culprit causing the patient to become ill. Once the allergen or trigger is identified, the patient must avoid the allergen to prevent future episodes. For those patients with severe reactions, providers should prescribe an epinephrine injection for emergen-cies and provide patient and family education on proper usage. Patients should be told when to seek urgent medical attention.

For patients with food intolerance, an elimination diet may be recommended. A careful history should be reviewed with the patient and a plan of which foods to eliminate can be recommended based on symptoms. These foods should be avoided for a few weeks. Individual foods can be reintroduced gradually and, if symptoms recur, those foods should be avoided (Rindfleisch, 2012).







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ICD-10 Code

Food allergy: Z91.02Lactose intolerance, unspecified: E73.9Hereditary fructose intolerance: E74.12Malabsorption due to intolerance (to protein, fat, starch, carbohydrate, or not classified elsewhere): K90.4

1. A careful dietary history is important when trying to determine a food allergy or intolerance. A food diarycan be used and may provide a clue as to the offend-ing allergen.

2. For patients with a severe food allergy history, a medical-alert bracelet is recommended for daily wearin combination with constant access to epinephrineinjection in case of food allergen exposure.

3. An elimination diet may be recommended to retrain the body to avoid the offending food and to rid the body of its exposure.

4. Consultation with an allergist is recommended for moderate to severe cases or if symptoms have beenprolonged or reoccur.

FAST FACTS in a NUTSHELL

REFERENCES

Burks, W. (2015). Clinical manifestations of food allergy: An overview. Retrieved from www.uptodate.com/contents/clinical-manifestations-of-food-allergy-an-overview?source=search_result&search=Clinical+manifestations+of+food+allergy&selectedTitle=1%7E150.html

Rindfleisch, J. A. (2012). Food intolerance and elimination diet. In D. Rakel (Ed.), Integrative medicine (3rd ed., pp. 776–788). Philadelphia, PA: Saunders.

Sampson, H. A. (2014). Food-induced anaphylaxis. Retrieved from www.uptodate.com/contents/food-induced-anaphylaxis?source=search_result&search=food+induced+anaphylaxis&selectedTitle=1%7E40.html


http://www.uptodate.com/contents/clinical-manifestationsof-food-allergy-an-overview?source=search_result&search=Clinical+manifestations+of+food+allergy&selectedTitle=1%7E150.html


http://www.uptodate.com/contents/food-induced-anaphylaxis?source=search_result&search=food+induced+anaphylaxis&selectedTitle=1%7E40.html





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