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Review of the Pancreatobiliary System What Every GI Nurse Needs to Know

Review of the Pancreatobiliary System What Every GI Nurse Needs to Know. Joyce Flueckiger, APRN, BC, CGRN. Liver. The liver is the largest organ in the body Weighs 3-4 pounds Extends from the fifth intercostal space in the midclavicular line to the right costal margin

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Review of the Pancreatobiliary System What Every GI Nurse Needs to Know

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  1. Review of the Pancreatobiliary SystemWhat Every GI Nurse Needs to Know Joyce Flueckiger, APRN, BC, CGRN

  2. Liver • The liver is the largest organ in the body • Weighs 3-4 pounds • Extends from the fifth intercostal space in the midclavicular line to the right costal margin • Glisson’s capsule covers the liver – contains blood vessels and lymphatics • Serosa covers the Glisson’s capsule

  3. Liver • Two lobes – right - 6 times larger than the left • One million hepatic lobules – functioning unit of the liver • Each lobule • Hepatocytes → secrete bile • Each portal triad → hepatic artery, hepatic vein, bile duct • Sinusoids → lie between each row of cells • Kupffer cells → phagocytosis

  4. Blood Supply to Liver • 1500 ml of blood flow into the liver every minute • Portal vein supplies 75% • Hepatic artery supplies 25% • Cells can regenerate within 3 weeks • Can function with 90% damage for short time

  5. Functions of Liver • Bile production – up to 1000 ml per day • Storage of vitamins, minerals • A, D, B12 and iron in form of ferritin • Coagulation – production of clotting factors → fibrinogen and prothrombin • Detoxification and excretion of many drugs and hormones

  6. Primary Sclerosing Cholangitis • More common in males • 50-75% associated with ulcerative colitis • Monitor progression of disease with liver function tests, cholangiography

  7. Portal Hypertension • Portal vein resistance is increased → collateral circulation • Splenomegaly, varices, hemorrhoids, dilated cutaneous umbilical veins • Jaundice, bleeding, edema, palmar erythema, fetor hepatics, spider nevus

  8. Complications of Liver Disease • Varices • Ascites • Hepatorenal syndrome • Hepatic encephalopathy • Mild → severe

  9. Hepatitis A • HAV – RNA virus, fecal – oral, contaminated food • Symptoms – low-grade fever, fatigue, nausea, anorexia, myalgias, dark urine, light stools, right upper quadrant pain or discomfort • Self-limiting

  10. Hepatitis B • HBV – DNA virus, bloods, saliva, semen • Incubation period up to 6 months • HBsAg is positive, ALT and AST 5-20 above upper limits normal • HBsAb – when disease clears • Hepatitis vaccine

  11. Hepatitis C • HCV – IV drug use, blood transfusions, most common • Interferon therapy • Now close to being treated with medications, will soon be treated by PCP

  12. Other Diseases of the Liver • NASH • Wilson’s disease – autosomal recessive – excess copper stores • Porphyria – hereditary disorder affects synthesis of heme • Hemochromatosis – autosomal recessive – excess iron stores • Gilbert’s syndrome

  13. Gallbladder • Size – 3” x 1” • Capacity – 50 ml of bile • Alkaline greenish-yellow fluid • Bile • Bile salts • Fatty acids • Lipids (cholesterol & lecithin) • Inorganic substances • Conjugated bilirubin • 90% of water is removed from bile from the liver → cystic duct → gallbladder

  14. Anatomical Divisions of Gallbladder • Cystic duct • Hepatic duct • Common bile duct • Sphincter of Oddi • Arrangement of smooth muscles

  15. Gallbladder has Three Layers • Outer serosa derived from peritoneum • Middle layer which contains longitudinal & spiral smooth muscle and fibrous tissue • Inner mucosa which is simple columnar epithelium arranged in folds similar to rugae in the stomach

  16. Diseases of the Gallbladder • Cholelithiasis – the presence of stones or calculi in the gallbladder • Two types of stones • Cholesterol – contain pure cholesterol • Mixed – cholesterol, bile acids, calcium salts, fatty acids, protein, phospholipids • Pigment • Black contain bilirubin polymers, inorganic calcium salts • Brown contain primarily calcium bilirubinate and organic fatty acid salts of calcium

  17. Symptoms of Cholelithiasis • 50% of gallstones do not cause symptoms • Biliary colic – usually within 30 minutes of meal, lasting up to or greater than one hour • Location of pain – right upper quadrant, right subscapular, back • May be associated with nausea and vomiting

  18. Diagnosis of Cholelithiasis • Ultrasound – may miss very small stones • MRI/MRCP • EUS • ERCP – want to be sure stones are present before doing this procedure

  19. Choledocholithiasis • Stones in the common bile duct • Patients may be asymptomatic • Symptoms associated with choledocholithiasis • Biliary colic with constant right upper quadrant pain, epigastric pain • Obstructive jaundice and pruritus • Cholangitis – urgent or emergent situation manifested with fever, right upper quadrant pain, jaundice (Charcot triad), +/- rigors • Gallstone pancreatitis

  20. Acalculous Cholecystitis • May occur in hospitalized patients not receiving oral intake resulting in gallbladder stasis • Right upper quadrant pain, guarding, nausea and vomiting

  21. Cholangitis • Bacterial infection of the bile duct • Associated with choledocholithiasis, strictures, neoplasms, cysts, fistulas • Symptoms – acute fever, chills, rigors, dark urine, often abdominal pain • Acute, emergent situation – ERCP

  22. Acute Calculous Cholecystitis • 90% associated with a stone impacted in the cystic duct • Symptoms include midepigastric or right upper quadrant pain, radiation of pain to shoulders and back • Nausea, vomiting, fever, leukocytosis

  23. Gallbladder Cancer • More common in older women • 80% have gallstones • Gallbladder polyps >1 cm in size raise the risk of gallbladder cancer • Vague symptoms of pain, anorexia, weight loss, nausea, vomiting • 80% of tumors are adenocarcinoma – rarely are gallbladder tumors benign

  24. Bile Duct Cancers • 30% associated with gallstones • Maybe associated with long-standing UC, Crohn’s, PSC, choledochal cysts

  25. Pancreas • The pancreas is 6-8 inches long • Lies posterior to the stomach • Segments • Head, body and tail

  26. Exocrine Cells – Approximately 99% • Acinar cells – majority of pancreatic tissue • Groups of acinar cells form lobules (acinus) • Pancreatic juice with enzymes drains into the main pancreatic duct

  27. Endocrine Cells – Remaining 1% • Loculated in islets of Langerhaus – in the connective tissue between the lobules, mostly in the tail

  28. Endocrine Cells • Alpha → glucagon • Beta → insulin • Delta → somatostatin

  29. Exocrine Acinar Cells • 500-1000 ml daily (pancreatic juice) • pH 8.5 • Contains water, enzymes, electrolytes, bicarbonate

  30. Exocrine Acinar Cells • 500-1000 ml daily (pancreatic juice) • pH 8.5 • Contains water, enzymes, electrolytes, bicarbonate

  31. Exocrine Acinar Cells • 500-1000 ml daily (pancreatic juice) • pH 8.5 • Contains water, enzymes, electrolytes, bicarbonate

  32. Pancreatic Enzymes • Amylase → CHO3 into glucose and maltose • Lipase → pancreatic lipase and phospholipase A, important in early fat digestion • Proteases → trypsinogen, then trypsin which break amino acids into active forms

  33. Secretin and Cholecystokinin-Pancreozymin • Hormones which stimulate pancreatic secretions • Rest → bicarbonate 2% of maximum; enzymes 15% of maximum • Cephalic phase → sight and smell of food stimulate the flow of digestive enzymes • Gastric phase → increasing amounts of enzymes secreted still low in bicarbonate • Intestinal phase → food entering the duodenum stimulates pancreatic enzyme secretion at 70% of maximal rate • Bicarbonate output increases as the pH of meal decreases and acid increases

  34. Diseases/Conditions of the Pancreas • Cystic fibrosis • Pancreatic exocrine insufficiency • Associated with chronic pancreatitis • Malabsorption of fat, protein, and carbohydrates → quantitative • 72 hour fecal fat test (>7%) • Treat with pancreatic enzymes and acid suppression • Pancreatic rest • Pancreatic divisum – in 7-10% of general population • Annular pancreas

  35. Tumors of the Pancreas • Cystic – fluid filled, most often in head of pancreas • Serous cystadenoma • Cyst adenocarcinoma • Mucinous cystadenoma • Cyst adenocarcinoma • IPMN – intraductal papillary mucinous neoplasm • Carcinoma • Endocrine tumors

  36. Acute Pancreatitis • Inflammation of enzymatic digestion • Etiology – alcohol, gallstones, trauma, family history, genetic abnormalities, medications, tumors, anatomic variants, hypercalcemia

  37. Symptoms of Pancreatitis • Epigastric pain radiating to back, left blank • Nausea and vomiting • Low-grade fever • Abdominal distention, ileus

  38. Treatment of Acute Pancreatitis • Aggressive hydration • Analgesics and antiemetics • Antiobiotics - ? • Nasojejunal feedings • ERCP - ?

  39. Chronic Pancreatitis • Not defined only by chronic pain • Criteria on endoscopic ultrasound • Criteria on pancreatography • Intraductal secretin test • HCO3 < 105, volume < 3 ml/min

  40. Manifestations of Chronic Pancreatitis • Chronic abdominal pain • Weight loss • Steatorrhea • Nausea and/or vomiting • Obstructive jaundice

  41. Treatment of Chronic Pancreatitis • Analgesics • Enteral feeding tube • Octreotide/sandostatin • Pancreatic enzymes • Celiac plexus block • Intrathecal pain pump

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