Nursing Care of Patients with Hepatobiliary Disorders

1. Nursing Care of Patients with Hepatobiliary Disorders C. Cummings RN, EdD.

2. Anatomy Diaphragm Liver Hepatic Duct Cystic Duct Pancreas Gall Bladder Sphincter of Oddi Common Bile Duct Duodenum

3. Pancreas • Exocrine- 80% of organ, acinar cells with digestive enzymes: • What are they? • Endocrine- islets of langerhans • Alpha cells- ? • Beta cells- ?

4. Acute Pancreatitis • Cause: • Pancreatic enzymes destroy ductal tissue and cancreatic cells autodigestion and fibrosis • Can be life threatening • NHP- necrotizing hemorrhagic pancreatitis • 20%, diffuse bleeding • Enzymes are activated before they reach the duodenum • Toxic injury to pancreatic cells

5. Four major physiologic processes • Lipolysis • Caused by lipase, release fatty acids and combine with I Ca  causes? • Proteolysis • Caused by trypsin, splits proteins into smaller polypeptides  what??

6. Four major physiologic processes • Necrosis of the Blood Vessels • Caused by elastase, elastic fibers of the blood vessels and ducts dissolve  what? • Kallikrein releases vasoactive peptides, bradykinin and kinin what? and increased ? • Inflammation • Leukocytes form around hemorrhagic and necrotic areas  pus, abcess formation and if walled off pancreatic what??

7. Why does enzyme activation occur? • Bile Reflux- obstruction of CBD • Hypersecretion-obstruction theory- pancreatic duct ruptures • Alcohol induced changes- stimulates hydrochloric acid and secretin production exocrine functions, also causes edema of the duodenum and ampulla of Vater, this obstructs flow, may also decrease tone at sphincter of Oddi and cause duodenal reflux

8. Other causes • Besides alcohol ingestion and biliary disorders, can also be caused by: • Trauma- blunt or surgical (whipple/ ERCP) • Pancreatic obstruction- such as? • Metabolic disturbances- hyperlipidemia, hyperparathyroid • Renal failure or transplant • Ulcers that lead to peritonitis • Coxsackievirus B infections • Drug toxicities- such as?

9. Complications • Pancreatic infection • Peritonitis • Hypovolemia • Hemorrhage • ARF • Paralytic ileus • Septic Shock • What are other complications??

10. Symptoms of Acute Pancreatitis • What is predominant symptom? • Where is it? • When is it worse? • Jaundice • Cullen’s sign- what is that? • Turner’s sign- and that? • Bowel sounds may be decreased or absent • Abdominal tenderness • Watch for signs of shock • Respiratory effusions/ SOB • Assess for excessive alcohol intake

11. Turner’s sign

12. Laboratory Diagnoses • Elevated Serum • What are major enzymes? • Trypsin • Elastase • Also, increased serum • Glucose • Bilirubin • Alanine aminotransferase • Leukocyte count • Decreased • Calcium and magnesium

13. Diagnoses for Acute Pancreatitis • What are two primary nursing diagnoses? • Nausea • Risk for fluid volume deficit • Risk for infection • Risk for ineffective breathing pattern • Risk for activity and sleep disturbances

14. Collaborative Diagnoses • What are two potential nursing diagnoses? • Potential for Hypovolemic or Septic Shock • Potential for ARDS • Potential for Paralytic Ileus • Potential for MOSF

15. Nursing Interventions • Acute Pain • What is primary method to relieve pain, other than medication? • IV fluids for hydration • Replacement of Ca and Mg • NG drainage and suction • Assess for return of bowel sounds and pain control

16. Pain Control • Opiods, IV and PCA • Demerol for relief of spasms at the sphincter of Oddi, but it has problems with breakdown and is rarely used now • Fentanyl patch • Epidural morphine with bipivacaine • Pain may last how long?

17. Other management of pain • Anticholinergics, atropine, glucagon, calcitonin, histamine receptor antagonists (Zantac), protease inhibitors are used for what? • Antibiotics • Ceftazidime, cefuroxime, imipenem (Primaxin)

18. Other Management of Pain Surgery ERCP (endoscopic retrograde cholangiopancreatography) - used to open sphincter Pseudocystojejunostomy or Pseudocystogastrotomy to drain abcess or pseudocyst JP drains or sump tubes may be used for excessive drainage

19. ERCP

20. ERCP

21. Imbalanced nutrition: less than body requirements • Maintain on NPO, may have NGT • May not eat for 7-10 days • Receive nutritional support through what? • Begin back on what kind of diet? What should they not take in? • Diet teaching and teaching on signs of chronic progression should be stressed with the patient

22. Chronic Pancreatitis • Usually develops after repeated episodes of acute pancreatitis • What is the most common cause? • Types: • Chronic Calcifying Pancreatitis- alcohol induced, proteins plug the ducts  • lead to atrophy and dilation  • ulceration and inflammation  • fibrosis, intraductal calification and cystic sacs develop • Hard, firm organ with pancreatic insufficiency

23. Chronic Pancreatitis • Type • Chronic Obstructive Pancreatitis • Inflammation, spasm and obstruction of the sphincter of Oddi • Inflammation and sclerotic lesions occur at the head of the pancreas obstruction and backflow of secretion

24. Chronic Pancreatitis with pseudocysts

25. Results • Loss of exocrine function: • Aqueous bicarbonate- neutralizes duodenal contents • Pancreatic enzymes- what do they do? • Enzyme secretion is reduced by 80%  steatorrhea, what do the stools look like? • Fat malabsorption  wt loss and muscle wasting and edema r/t loss of albumin

26. Results • Pancreatic endocrine dysfunction causes what disease? • May also have pulmonary complications from edema and pancreatic ascites • ARDS may develop • Chronic pancreatitis is a major risk factor for pancreatic cancer

27. Symptoms of Chronic Pancreatitis • Intense abdominal pain and tenderness • Ascites • What type of stools? • Respiratory compromise • Wt loss or gain? • Jaundice • What does the urine look like? Why? • Signs of diabetes • Elevated lipase and amylase • Elevated bilirubin, alkaline phosphatase and glucose • Definitive dx- by biopsy to look for calcification

28. Nursing Management • Manage pain- how? • Enzyme replacement- dietary supplements, pancrease, viokase, cotazyme, donnazyme- take before or during meals, take according to number of stools/day and wipe lips after • Insulin therapy • NPO or TPN for days, then what kind of diet? • Histamine receptor blockers to decrease acid • Octreotide (Sandostatin) like somatostatin may be used for diarrhea to slow motility

29. Health teaching • Surgery is not an option, unless there is a cyst, obstruction or possible transplant for diabetes • Diet and alcohol avoidance is stressed • Medication compliance with insulin, pancreatic enzymes • Skin care for irritation r/t steatorrhea • What should the patient monitor?

30. Case Study • 44 year old female admitted with abdominal pain, nausea and vomiting. She states that she has a lot of gas pain that wakes her up in the night. • What do you suspect?

31. Case Study • What are the symptoms of GB disease? • What can precipitate it? • What is the treatment? • How can you prepare her for surgery? How do you decide between laparoscopic and open? • What needs to be done postop?

32. Case Study • What structures are located in the RUQ of the abdomen? • Which of the above organs are palpable in the RUQ? • Given the patient’s diagnosis, what lab values would be important to evaluate? • List 4 preop preparations that to be done.

33. Case Study • The patient undergoes a laproscopic cholecystectomy, why is a T-tube inserted? • What type of postoperative care would be required? • The patient is sent home with the T-tube, what care would be appropriate? • What type of diet should they be on?

34. Case Study • The patient is medicated with Morphine and the pain has decreased from 10-4 in 1 hour, what else could be done for his pain? • What data charted in the assessment is consistent with common bile duct obstruction? • The patient spikes a temp of 38.6, a CXR is ordered and the patient is started on an antibiotic, imipenem. What should be done before the antibiotic is started?

35. Case Study • She is ready for discharge • What type of teaching is needed? • What should be avoided, what about care of the T-tube?

36. Cholecystectomy • Removal of the Gallbladder • Can be done open or laproscopic • Signs are nausea, vomiting, abdominal pain • Risk Factors: • Fat, Female, Forty and Fertile • lap cholecystectomy

37. Lap Cholecystectomy

38. T-tube

39. Post-operative Care • Pain control- demerol or PCA • NPO until bowel sounds return, then clear liquids to DAT • Diet depends on what patient can tolerate • T-tube may remain in for 1-6 weeks • Monitor drainage, should be bile colored • Less than 1000ml/day • Never irrigate, aspirate or clamp a T-tube without an MD order

40. Disorders of the Liver • Largest organ in the body and is located in the RUQ • Large right lobe and smaller left lobe • Made up of lobules • Bile is made in hepatocytes, secreted into bile canaliculi • Receives 1500 ml of blood/min

41. Liver Functions • 400 functions • Storage: • What types of vitamins and minerals? • Protective: • Kupfer cells, phagocytic, destroy bacteria, anemic RBC’s • Detoxifies what? • Metabolism: • Makes proteins, for what? • Breaks down amino acids to remove ammonia, converted to what? • Synthesizes plasma proteins, albumin, prothrombin and fibrinogen • Stores and releases glycogen • Breaks down and stores fatty acids and triglycerides • Forms and secretes what substance?

42. Liver Disorders • Cirrhosis/ Liver Failure • Hepatitis

43. Case Study 53 year old male admitted to the ED with abdominal pain, nausea and vomiting, weight loss. His abdomen is large and tender. His skin is light yellow. He has a fruity odor to his breath. What do you suspect?

44. Case Study • What lab work should be done? • What interventions would you perform and why? • Your patient becomes belligerent after a few hours and wants to leave, what would you do? • What radiology studies may be done?

45. Case Study • His liver enzymes are extremely elevated and he is becoming confused. He is admitted to the floor. • What symptoms are you likely to see in this patient? • He starts to vomit blood, what does this mean and what may be done? • What medications may be given to this patient?

46. Case Study • He has improved and is now ready for discharge. • What kind of teaching would this patient need? • What should be done about rehab?

47. Cirrhosis • Scarring of the liver, caused by a chronic, irreversible reaction to hepatic inflammation and necrosis • Causes: • #1 cause? • #2 cause? • Destruction of hepatocytes, tissue becomes nodular, block bile ducts and blood flow from fibrous connective tissue • Liver begins enlarged and then shrinks

48. Cirrhosis

49. Complications • Compensated and Decompensated Cirrhosis • Liver failure  • Portal hypertension, what is this? • Ascites, why? • Bleeding esophageal varices • Coagulation defects, why? • Jaundice, what causes this? • Portal systemic encephalopathy and coma • Hepatorenal syndrome • Bacterial peritonitis

50. Liver Dysfunction PSE Esophageal Varices Jaundice Bleeding Hepatorenal Syndrome Bacterial Peritonitis Ascites