Chapter 48 Liver, Biliary Tract, and Pancreas Problems Hepatitis Hepatitis Inflammation of the liver Causes Viral (most common) Alcohol Medications Chemicals Autoimmune diseases Metabolic problems 3 Viral Hepatitis Types of viral hepatitis A B C D E 4 Hepatitis A Virus (HAV) Ranges from mild to acute liver failure Not chronic Incidence decreased with vaccination RNA virus transmitted via fecal-oral route Contaminated food or drinking water 5 Serologic Events in HAV Infection Fig. 48.2 6 Hepatitis B Virus (HBV) (1 of 2) Blood-borne pathogen Acute or chronic disease Incidence decreased with vaccination DNA virus transmitted Perinatally Percutaneously Via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids Detected in almost every body fluid 7 Hepatitis B Virus (HBV) (2 of 2) At-risk persons Men who have sex with men Household contact of chronically infected Patients on hemodialysis Health care and public safety workers Prisoners, veterans, and homeless Persons who inject drugs Recipients of blood products 8 Serologic Events in HBV Infection Fig. 48.3 9 Hepatitis C Virus (HCV) Acute: asymptomatic or mild symptoms Chronic: cirrhosis, liver failure RNA virus transmitted percutaneously • • • • • IV drug use High-risk sexual behaviors Occupational exposure Perinatal exposure Blood transfusions before 1992 10 Hepatitis D Virus (HDV) Also called delta virus Defective single-stranded RNA virus Cannot survive on its own Requires HBV to replicate Transmitted percutaneously No vaccine 11 Hepatitis E Virus (HEV) RNA virus Transmitted via fecal-oral route Most common mode of transmission: drinking contaminated water Occurs primarily in developing countries Acute and self- resolving Few cases in United States 12 Pathophysiology (1 of 2) Acute infection Large numbers of hepatocytes are destroyed Liver cells can regenerate in normal form after resolution of infection Chronic infection can cause fibrosis and progress to cirrhosis 13 Pathophysiology (2 of 2) Antigen-antibody complexes activate complement system Systemic manifestations: • Rash, angioedema, arthritis, fever, malaise, cryoglobulinemia, glomerulonephritis, vasculitis 14 Case Study (1 of 10) A.M. is a 30-year-old man admitted to the hospital with general fatigue, lack of appetite, headaches, and jaundice. Symptoms became progressive during the past few days. 15 Case Study (2 of 10) One month ago, he was in Mexico He says he ate a lot of seafood and local food. A.M. tells you that he had sex with a prostitute while in Mexico. 16 Case Study (3 of 10) The health care provider suspects A.M. may have acute hepatitis. What other manifestations would you assess for in A.M.? 17 Clinical Manifestations (1 of 4) Classified as acute and chronic Many patients with acute hepatitis are asymptomatic Symptoms intermittent or ongoing Anorexia, nausea and vomiting Malaise, fatigue, lethargy Muscle and joint pain Right upper quadrant tenderness 18 Clinical Manifestations (2 of 4) Acute phase Maximal infectivity; lasts 1 to 6 months Symptoms during incubation • Decreased sense of smell • Find food repugnant • Distaste for cigarettes 19 Clinical Manifestations (3 of 4) Acute phase Assessment findings • Hepatomegaly • Lymphadenopathy • Splenomegaly Icteric (jaundice) or anicteric If icteric, patient can also have • Dark urine • Light or clay-colored stools • Pruritus 20 Clinical Manifestations (4 of 4) Convalescent phase Begins as jaundice is disappearing Lasts weeks to months Major problems • Malaise • Easy fatigability Hepatomegaly persists Splenomegaly subsides 21 Recovery Most patients recover completely with no complications Almost all cases of acute hepatitis A resolve Some HBV and most HCV result in chronic hepatitis 22 Complications (1 of 6) Acute liver failure Chronic hepatitis Some HBV and majority of HCV infections Cirrhosis Portal hypertension Liver cancer 23 Complications (2 of 6) Acute liver failure Fulminant hepatic failure Manifestations include • • • • Encephalopathy GI bleeding Disseminated intravascular coagulation Fever with leukocytosis • Renal manifestations Liver transplant is usually the cure 24 Complications (3 of 6) Chronic hepatitis Chronic HBV is more likely to develop if person acquired infection at birth or during childhood Chronic HBV can remain asymptomatic for years. Complications such as liver cirrhosis, liver failure and liver cancer develop in 15-40% of people with HBV. HCV infection is more likely than HBV to become chronic 25 Complications (4 of 6) Skin manifestations Spider angiomas Palmar erythema Gynecomastia Spleen, liver, and cervical lymph node enlargement 26 Complications (5 of 6) Hepatic encephalopathy Potentially life-threatening spectrum of neurologic, psychiatric, and motor disturbances Results from liver’s inability to remove toxins • Especially ammonia 27 Complications (6 of 6) Ascites Accumulation of excess fluid in peritoneal cavity Due to reduced protein levels in blood, which reduces the plasma oncotic pressure 28 Case Study (4 of 10) Physical assessment of A.M. reveals hepatomegaly and splenomegaly. His urine is also dark-colored (icteric) What diagnostic tests would you expect the health care provider to order? 29 Diagnostic Studies Specific antigen and/or antibody for each type of viral hepatitis Viral load in the blood Liver function tests Viral genotype testing Liver biopsy FibroScan Magnetic resonance imaging elastography (MRE) FibroSure (FibroTest) 30 Case Study (5 of 10) Laboratory results show Hemoglobin 12 g/dL Bilirubin (direct) 5.6 mg/dL Bilirubin (indirect) 3.4 mg/dL Alkaline phosphatase 600 U/mL AST 1200 U/mL ALT 1510 U/mL Urine positive for bilirubin 31 Case Study (6 of 10) Additional laboratory results show Anti-HAV IgM positive Anti-HAV IgG negative HBsAg negative Anti-HBs negative Anti-HCV negative Anti-HDV negative 32 Case Study (7 of 10) What type of hepatitis does A.M. have? How did he get infected? 33 Case Study (8 of 10) What interventions would you expect the health care provider to order? 34 Interprofessional Care Acute and chronic Adequate nutrition • Well balanced diet • Vitamin supplements Rest (degree depends on severity of symptoms) Avoid alcohol intake and drugs detoxified by liver Notification of possible contacts 35 Interprofessional Care: Drug Therapy Acute HAV infection: no specific Acute HBV infection: only if severe Acute HCV infection Direct-acting antivirals (DAAs) Supportive drug therapy Antihistamines Antiemetics 36 Interprofessional Care Chronic Hepatitis B Drug therapy focuses on ↓ viral load , liver enzyme levels, and rate of disease progression Prevent cirrhosis, portal hypertension, liver failure, and cancer First –line therapies include nucleoside and nucleotide analogs Inhibit viral DNA replication Substantially lower viral load Lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), tenofovir (Viread). 37 Drug Therapy Chronic Hepatitis B Interferon Naturally occurring immune protein Antiviral, antiproliferative, and immune-modulating effects Pegylated interferon (PegIntron, Pegasys) given subcutaneously Side effects - Flu-like symptoms, depression 38 Drug Therapy Chronic Hepatitis C Based on genotype of HCV, severity of liver disease, presence of other health problems Treatment includes DAAs Many patients with HIV also have HCV HCV treatment to irradicate HCV equally effective for HCV/HIV coinfected and HCV mono-infected patients 39 Nutrition Therapy No special diet needed Emphasize a well-balanced diet that patient can tolerate Adequate calories are important during acute phase Fat content may need to be reduced Vitamins B-complex and K IV glucose or enteral nutrition 40 Nursing Assessment (1 of 3) Subjective data Health history • • • • • • Hemophilia Exposure to infected persons Ingestion of contaminated food or water Ingestion of toxins Past blood transfusion (before 1992) Other risk factors Medications • Acetaminophen, OTC, or herbal medications 41 Nursing Assessment (2 of 3) Subjective data: Functional health patterns IV drug and alcohol use Distaste for cigarettes (in smokers) High-risk sexual behaviors Weight loss, anorexia, nausea/vomiting RUQ abdominal discomfort Urine and stool color Fatigue/arthralgias/myalgia Exposure to high-risk groups 42 Nursing Assessment (3 of 3) Objective data Low-grade fever Jaundice Rash Hepatomegaly Splenomegaly Abnormal laboratory values 43 Case Study (9 of 10) Identify appropriate clinical problems for A.M. 44 Clinical Problems Nutritionally compromised Activity intolerance Risk for bleeding 45 Planning Patient will Have relief of discomfort Be able to resume normal activities Return to normal liver function without complications 46 Case Study (10 of 10) What is the priority care for A.M.? How would A.M.’s family members and close contacts be treated? 47 Interprofessional Care (1 of 3) Health promotion: Hepatitis A Personal and environmental hygiene Active immunization: HAV vaccine • Children at 1 year of age • Adults at risk Post-exposure prophylaxis with HAV vaccine and immune globulin (IG) Special precautions for health care personnel 48 Interprofessional Care (2 of 3) Health promotion: Hepatitis B General measures Immunization • Recombivax HB, Engerix-B • Series of three IM injections • All children and at-risk adults Postexposure prophylaxis: vaccine and hepatitis B immune globulin (HBIG) 49 Interprofessional Care (3 of 3) Health promotion: Hepatitis C No vaccine to prevent HCV General measures to prevent HCV transmission Screen all persons born between 1945 and 1965 No postexposure prophylaxis; baseline and follow-up testing 50 Nursing Implementation (1 of 4) Acute care Assess for jaundice Comfort measures Adequate nutrition • • • • • Small, frequent meals Measures to stimulate appetite Carbonated beverages Avoid very hot and cold foods Adequate fluid intake 51 Nursing Implementation (2 of 4) Acute care Physical rest Modified activity plan Psychologic and emotional rest Diversion activities 52 Nursing Implementation (3 of 4) Ambulatory care Diet teaching Plan activities after periods of rest Teach how to prevent transmission Symptoms to report Assessment for complications 53 Nursing Implementation (4 of 4) Ambulatory care Regular follow-ups for at least 1 year after diagnosis No alcohol Medication education • How to administer interferon • Side effects No blood donation by HBsAg- or HCV-positive patients 54 Evaluation Expected outcomes Maintain food and fluid intake adequate to meet nutrition needs Avoid alcohol and other hepatotoxic agents Show gradual increase in activity tolerance Perform daily activities with scheduled rest periods 55 Cirrhosis Description End-stage of liver disease Extensive degeneration and destruction of liver cells Results in replacement of liver tissue by fibrous and regenerative nodules Usually happens after decades of chronic liver disease 57 Case Study (1 of 13) D.L. is a 35-year-old woman admitted from the ED with a diagnosis of hepatic encephalopathy. Review of old medical records indicate a diagnosis of fatty liver disease at age 29 and cirrhosis at age 31. She accepts treatment only during crises. 58 Case Study (2 of 13) What else would you look for in D.L.’s medical history that might be a precipitating factor in her liver disease? 59 Etiology and Pathophysiology (1 of 2) Most common causes in United States are chronic HCV, NASH, and alcohol-induced liver disease Other causes Extreme dieting, malabsorption, obesity Environmental factors Genetic predisposition 60 Cirrhosis (Fig. 48.4) 61 Etiology and Pathophysiology (2 of 2) Biliary cirrhosis Primary biliary cirrhosis (PBC) Primary sclerosing cholangitis (PSC) Cardiac cirrhosis Results from long-standing severe right-sided heart failure 62 Case Study (3 of 13) For what late clinical manifestations of cirrhosis would you assess D.L.? 63 Clinical Manifestations (1 of 7) Early manifestations Few symptoms in early-stage disease Fatigue and enlarged liver may be early symptoms Blood tests may be normal liver function (compensated cirrhosis) 64 Clinical Manifestations (2 of 7) Late manifestations Result from liver failure and portal hypertension • Jaundice, peripheral edema, ascites Other • Skin lesions, hematologic problems , endocrine problems , and peripheral neuropathies Liver becomes smaller, nodular 65 Pathophysiology of Cirrhosis (Fig. 48.5) 66 Clinical Manifestations of Cirrhosis (Fig. 48.6) 67 Clinical Manifestations (3 of 7) Jaundice Results from decreased ability to conjugate and excrete bilirubin Overgrowth of connective tissue in liver compresses bile ducts • Leads to obstruction • Increase in bilirubin in vascular system May be minimal or severe 68 Clinical Manifestations (4 of 7) Skin lesions Due to increase in circulating estrogen due to inability of liver to metabolize steroid hormones Spider angiomas (telangiectasia or spider nevi) Palmar erythema 69 Clinical Manifestations (5 of 7) Hematologic disorders Thrombocytopenia Leukopenia Anemia Coagulation disorders 70 Clinical Manifestations (6 of 7) Endocrine disorders Secondary to decreased metabolism of hormones In men—gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido In women—amenorrhea or vaginal bleeding Hyperaldosteronism in both sexes 71 Clinical Manifestations (7 of 7) Peripheral neuropathy Common finding in alcoholic cirrhosis • Diet deficiencies of thiamine, folic acid, and cobalamin Sensory and motor symptoms • Sensory symptoms may predominate 72 Complications (1 of 9) Compensated cirrhosis Decompensated cirrhosis Portal hypertension Esophageal and gastric varices Peripheral edema Abdominal ascites Hepatic encephalopathy Hepatorenal syndrome 73 Complications (2 of 9) Portal hypertension Increased venous pressure in portal circulation Splenomegaly Large collateral veins Ascites Gastric and esophageal varices 74 Complications (3 of 9) Esophageal varices Gastric varices Complex of tortuous, enlarged veins at lower end of esophagus Upper part of stomach Both are very fragile, bleed easily Most life-threatening complication 75 Complications (4 of 9) Peripheral edema Decreased colloidal oncotic pressure from impaired liver synthesis of albumin Increased portacaval pressure from portal hypertension Occurs as lower extremities/presacral edema 76 Complications (5 of 9) Ascites Accumulation of serous fluid in peritoneal or abdominal cavity Several mechanisms • Portal hypertension • Hypoalbuminemia • Hyperaldosteronism Those with severe ascites are at risk for pleural effusion 77 Mechanisms of Ascites (Fig. 48.7) 78 Gross Ascites (Fig. 48.8) 79 Case Study (4 of 13) What might be causing D.L.’s current episode of hepatic encephalopathy? What specific manifestations related to hepatic encephalopathy would you expect D.L. to have? 80 Complications (6 of 9) Hepatic encephalopathy Neurotoxic effects of ammonia Abnormal neurotransmission Astrocyte swelling Inflammatory cytokines Liver unable to convert increased ammonia to urea Ammonia crosses blood-brain barrier 81 Complications (7 of 9) Hepatic encephalopathy Changes in neurologic and mental responsiveness Impaired consciousness Inappropriate behavior Sleep disturbances, trouble concentrating, coma 82 Complications (8 of 9) Hepatic encephalopathy Asterixis • Flapping tremors • Most common in arms and hands Apraxia • Impairment in writing • Difficulty in moving pen left to right Fetor hepaticus • Musty, sweet odor of patient’s breath 83 Complications (9 of 9) Hepatorenal syndrome Renal failure with azotemia, oliguria, and intractable ascites No structural abnormality of kidneys Portal hypertension leads to vasodilation which leads to renal vasoconstriction Treat with liver transplantation 84 Case Study (5 of 13) What diagnostic tests would you expect the health care provider to order for D.L.? 85 Diagnostic Studies Liver enzyme tests Alkaline phosphatase, AST, ALT, GGT Total protein, albumin levels Serum bilirubin, globulin levels Cholesterol levels Prothrombin time Ultrasound elastography (Fibroscan) Liver biopsy- gold standard 86 Case Study (6 of 13) D.L.’s laboratory values are as follows: Total bilirubin 11 mg/dL AST 80 U/mL ALT 70 U/mL LDH 700 U/mL Serum ammonia 220 mg/dL WBC 21,450/μL 87 Case Study (7 of 13) D.L. is thin and malnourished with ascites and marked edema on lower extremities. Both her liver and spleen are palpable. 88 Case Study (8 of 13) Jaundice and spider angiomas are present. There is evidence of bruising throughout her body. 89 Case Study (9 of 13) What would be your priorities of care for D.L.? 90 Interprofessional Care (1 of 11) Rest Administration of B-complex vitamins Avoidance of alcohol Minimization or avoidance of aspirin, acetaminophen, and NSAIDs 91 Case Study (10 of 13) What specific treatment measures might be used to treat D.L.’s ascites? 92 Interprofessional Care (2 of 11) Ascites Sodium restriction Diuretics, fluid removal Albumin Tolvaptan (Samsca) 93 Interprofessional Care (3 of 11) Ascites Paracentesis Transjugular intrahepatic portosystemic shunt (TIPS) Peritoneovenous shunt • Rarely used • High rate of complications 94 Interprofessional Care (4 of 11) Esophageal and gastric varices Prevent bleeding/hemorrhage • Avoid alcohol, aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs) • Screen for presence with endoscopy • Nonselective β-blocker To reduce bleeding risk Decrease high portal pressure 95 Interprofessional Care (5 of 11) If bleeding occurs, stabilize patient, manage airway, start IV therapy and blood products Drug therapy Octreotide (Sandostatin) Vasopressin Endoscopic therapy Endoscopic variceal ligation(EVL, or banding) Sclerotherapy 96 Interprofessional Care (6 of 11) Balloon tamponade Mechanical compression of varices Sengstaken-Blakemore tube Minnesota tube Linton-Nachlas tube 97 Interprofessional Care (7 of 11) Supportive measures for acute bleed Fresh frozen plasma Packed RBCs Vitamin K Proton pump inhibitors Lactulose (Cephulac) and rifaximin (Xifaxan) Antibiotics 98 Interprofessional Care (8 of 11) Long-term management Nonselective β-blockers Repeated band ligation Portosystemic shunts 99 Interprofessional Care (9 of 11) Shunting procedures Done more after second major bleeding episode Nonsurgical: transjugular intrahepatic portosystemic shunt (TIPS) Surgical: portacaval and distal splenorenal shunt 100 Portosystemic Shunts (Fig. 48.9) 101 Case Study (11 of 13) What specific treatment measures would you expect the health care provider to order for D.L.’s encephalopathy? 102 Interprofessional Care (10 of 11) Hepatic encephalopathy Reduce ammonia formation • Lactulose (Cephulac), which traps ammonia in gut • Rifaximin (Xifaxan) antibiotic • Prevent constipation Treatment of precipitating cause • Lower diet protein intake • Control GI bleeding • Remove blood from GI tract 103 Interprofessional Care (11 of 11) Drug therapy Not specific for cirrhosis Several drugs used to treat symptoms and complications of advanced liver disease 104 Nutrition Therapy (1 of 2) Diet for patient without complications High in calories (3000 cal/day) High carbohydrate Moderate to low fat 105 Nutrition Therapy (2 of 2) Protein supplements for protein-calorie malnutrition Low-sodium diet for patient with ascites and edema Seasonings to make food more palatable Collaborate with a dietitian 106 Nursing Management Nursing Assessment (1 of 8) Subjective data Health history • • • • Hepatitis NASH Chronic biliary obstruction and infection Severe right-sided heart failure Medications • Adverse reactions • Anticoagulants, aspirin, NSAIDs, acetaminophen 107 Nursing Management Nursing Assessment (2 of 8) Subjective data: Chronic alcohol use Weakness, fatigue Anorexia, weight loss Dyspepsia Nausea and vomiting Gingival bleeding 108 Nursing Management Nursing Assessment (3 of 8) Subjective data: Dark urine Decreased output Light-colored or black stools Flatulence Change in bowel habits Dry, yellow skin Bruising 109 Nursing Management Nursing Assessment (4 of 8) Subjective data RUQ or epigastric pain Numbness, tingling Pruritus Impotence Amenorrhea 110 Nursing Management Nursing Assessment (5 of 8) Objective data Fever, cachexia, wasting of extremities Icteric sclera, jaundice Petechiae, ecchymoses Spider angiomas, palmar erythema Alopecia, loss of axillary and pubic hair Peripheral edema 111 Nursing Management Nursing Assessment (6 of 8) Objective data Shallow, rapid respirations Epistaxis Abdominal distention, ascites Distended abdominal wall veins Palpable liver and spleen Foul breath Hematemesis; black, tarry stools Hemorrhoids 112 Nursing Management Nursing Assessment (7 of 8) Objective data Altered mentation Asterixis Gynecomastia Testicular atrophy Impotence Loss of libido Amenorrhea, vaginal bleeding 113 Nursing Management Nursing Assessment (8 of 8) Objective data Anemia, thrombocytopenia, leukopenia Decreased serum albumin and potassium levels Abnormal liver function studies Increased INR Increased ammonia and bilirubin levels Abnormal findings on abdominal ultrasonography or MRI 114 Nursing Management Clinical Problems Nutritionally compromised Ineffective tissue perfusion Activity intolerance Fluid imbalance 115 Nursing Management Planning Overall goals Relief of discomfort Minimal to no complications Return to as normal a lifestyle as possible 116 Nursing Management Nursing Implementation (1 of 13) Health promotion Reduce or eliminate risk factors Treat alcoholism Maintain adequate nutrition Identify and treat acute hepatitis Bariatric surgery for morbidly obese 117 Nursing Management Nursing Implementation (2 of 13) Acute care Rest needs • Prevent complications • Modify schedule Nutrition needs • • • • Oral hygiene Between-meal snacks Offer preferred foods Explanation of diet restrictions 118 Nursing Management Nursing Implementation (3 of 13) Acute care Assess for jaundice Measures to relieve pruritus • • • • • • Cholestyramine or hydroxyzine Baking soda or Alpha Keri baths Lotions, soft or old linen Antihistamines Temperature control Short nails; rub with knuckles 119 Nursing Management Nursing Implementation (4 of 13) Acute care Monitor color of urine and stools Accurate I/O recording Daily weights Extremities measurement Abdominal girth measurement 120 Nursing Management Nursing Implementation (5 of 13) Acute care Paracentesis • • • • • Have patient void immediately before High Fowler’s position or sitting on side of bed Monitor for hypovolemia and electrolyte imbalances Monitor BP and heart rate Monitor dressing for bleeding/leakage 121 Nursing Management Nursing Implementation (6 of 13) Acute care Relief of dyspnea • Semi- or high Fowler’s position Skin care • Special mattress • Turning schedule, at least every 2 hours ROM exercises Coughing/deep breathing exercises Elevate lower extremities/scrotum 122 Nursing Management Nursing Implementation (7 of 13) Acute care Monitor for fluid and electrolyte imbalances • Hypokalemia • Water excess (hyponatremia) Observe for bleeding tendencies Assess patient’s response to altered body image • Supportive listening 123 Nursing Management Nursing Implementation (8 of 13) Acute care Bleeding varices • Close observation for signs of bleeding • Balloon tamponade care Explanation of procedure Check for patency Position of balloon verified by x-ray 124 Nursing Management Nursing Implementation (9 of 13) Acute care • Balloon tamponade Monitor for complications (i.e., aspiration pneumonia) Scissors at bedside Semi-Fowler’s position Oral/nasal care 125 Case Study (12 of 13) What nursing measures would you prioritize in caring for D.L. in relation to her encephalopathy? 126 Nursing Management Nursing Implementation (10 of 13) Acute care Hepatic encephalopathy • Maintain safe environment • Assess carefully Level of responsiveness Sensory and motor abnormalities Fluid/electrolyte imbalances Acid-base imbalances Response to treatment measures 127 Nursing Management Nursing Implementation (11 of 13) Acute care Hepatic encephalopathy • Assess neurologic status every 2 hours • • • • Include exact description of behavior Prevent falls and injuries Minimize constipation Encourage fluids Control factors known to precipitate encephalopathy 128 Case Study (13 of 13) D.L. recovers from her hepatic encephalopathy and is ready to be discharged from the hospital. What teaching would you provide for D.L. and her family? How might a social worker help you with D.L.’s discharge planning? 129 Nursing Management Nursing Implementation (12 of 13) Ambulatory care Supportive measures • • • • Proper diet Rest Avoiding potentially hepatotoxic OTC drugs Abstinence from alcohol Caring attitude always 130 Nursing Management Nursing Implementation (13 of 13) Ambulatory care Community support programs Symptoms of complications When to seek medical attention Written instructions with adequate explanations for patient/family Referral to community or home health nurse 131 Nursing Management Evaluation Patient with cirrhosis will: Maintain of food/fluid intake to meet nutrient needs Maintain skin integrity with relief of edema and itching Have normal of fluid and electrolyte balance Acknowledge and get treatment for substance use problem 132 Pancreatic Disorders Acute Pancreatitis Acute inflammation of pancreas Spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion and severe pain Varies from mild edema to severe necrosis 134 Case Study (1 of 6) A.J. is a 48-year-old woman who comes to the ED. She has nausea, vomiting, and epigastric and left upper quadrant pain. 135 Case Study (2 of 6) She describes the pain as severe, sharp, and radiating through to her midback. She states the pain started 24 hours ago. 136 Case Study (3 of 6) A.J. admits to smoking a half-pack of cigarettes/day but denies drinking alcohol or using any IV or other drugs. Her health history is positive for gallstones and hypothyroidism. She is 5 ft 4 in tall and weighs 160 pounds. 137 Case Study (4 of 6) A.J.’s vital signs: BP 100/70 Heart rate 97 Respiratory rate 30 Temperature 100.2° F Health care provider suspects acute pancreatitis and admits A.J. to the medical-surgical unit. 138 Case Study (5 of 6) What are the possible causes of A.J.’s pancreatitis? 139 Acute Pancreatitis Etiology Gallbladder disease (women) Chronic alcohol use (men) Other less common causes Drug reactions Pancreatic cancer Hypertriglyceridemia 140 Case Study (6 of 6) A.J. asks you what pancreatitis is. How would you explain the pathophysiology of this disease process to her? 141 Acute Pancreatitis Pathophysiology (1 of 3) Caused by autodigestion of pancreas Injury to pancreatic cells Activation of pancreatic enzymes Activation of trypsinogen to trypsin within pancreas leads to bleeding 142 Pathogenic Process of Acute Pancreatitis Fig. 48.11 143 Acute Pancreatitis Pathophysiology (2 of 3) Alcohol use is another common cause Exact mechanism unknown Alcohol may increase production of pancreatic enzymes 144 Acute Pancreatitis Pathophysiology (3 of 3) Mild pancreatitis Edematous or interstitial Severe pancreatitis Necrotizing Endocrine and exocrine dysfunction Necrosis, organ failure, sepsis Overall fatality rate 5% 145 Acute Pancreatitis (Fig. 48.12) 146 Acute Pancreatitis Clinical Manifestations (1 of 3) Abdominal pain predominant Left upper quadrant or mid-epigastric Radiates to back Sudden onset Deep, piercing, continuous, or steady Eating worsens pain Starts when recumbent Not relieved with vomiting 147 Case Study (1 of 8) As you admit A.J. to the medical-surgical unit, for what other manifestations of pancreatitis would you assess her? 148 Acute Pancreatitis Clinical Manifestations (2 of 3) Flushing Cyanosis Dyspnea Nausea/vomiting Low-grade fever Leukocytosis Hypotension, tachycardia Jaundice 149 Acute Pancreatitis Clinical Manifestations (3 of 3) Abdominal tenderness with muscle guarding Decreased or absent bowel sounds Crackles in lungs Abdominal skin discoloration Grey Turner’s spots or sign Cullen’s sign Shock 150 Case Study (2 of 8) For what potential complications of acute pancreatitis will you monitor A.J.? (©Fuse/Thinkstock) 151 Acute Pancreatitis Complications (1 of 3) Pseudocyst Fluid, pancreatic enzymes, debris, and exudates surrounded by wall Abdominal pain, palpable mass, nausea/vomiting, anorexia Detected with imaging Resolves spontaneously or may perforate and cause peritonitis Surgical , percutaneous, or endoscopic drainage 152 Acute Pancreatitis Complications (2 of 3) Pancreatic abscess Infected pseudocyst Results from extensive necrosis May rupture or perforate Upper abdominal pain, mass, high fever, leukocytosis Need prompt surgical drainage 153 Acute Pancreatitis Complications (3 of 3) Systemic complications Pleural effusion Atelectasis Pneumonia ARDS Hypotension Thrombi, pulmonary embolism, DIC Hypocalcemia: tetany 154 Case Study (3 of 8) What diagnostic studies would you expect the health care provider to order for A.J.? 155 Acute Pancreatitis Diagnostic Studies (1 of 3) Laboratory tests Serum amylase level Serum lipase level Liver enzymes Triglycerides Glucose level Bilirubin level Serum calcium level 156 Acute Pancreatitis Diagnostic Studies (2 of 3) Abdominal ultrasound X-ray Contrast-enhanced CT scan Endoscopic retrograde cholangiopancreatography (ERCP) 157 Acute Pancreatitis Diagnostic Studies (3 of 3) Endoscopic ultrasonography (EUS) Magnetic resonance cholangiopancreatography (MRCP) Angiography Chest x-ray 158 Acute Pancreatitis Interprofessional Care (1 of 7) Objectives include Relief of pain Prevention or alleviation of shock Decreased pancreatic secretions Correction of fluid/electrolyte imbalances Prevention/treatment of infections Removal of precipitating cause 159 Acute Pancreatitis Interprofessional Care (2 of 7) Conservative therapy Supportive care • Aggressive hydration • Pain management IV opioid analgesics, antispasmodic agent • Management of metabolic complications Oxygen, glucose levels • Minimizing pancreatic stimulation NPO status, NG suction, decreased acid secretion, enteral nutrition if needed 160 Acute Pancreatitis Interprofessional Care (3 of 7) Conservative therapy Shock • Plasma or plasma volume expanders (dextran or albumin) Fluid/electrolyte problems • Lactated Ringer’s solution • Central venous pressure readings 161 Acute Pancreatitis Interprofessional Care (4 of 7) Conservative therapy Ongoing hypotension • Vasoactive drugs: dopamine Prevent infection • Enteral nutrition • Antibiotics • Endoscopically or CT-guided percutaneous aspiration 162 Acute Pancreatitis Interprofessional Care (5 of 7) Surgical therapy For gallstones • ERCP plus endoscopic sphincterotomy • Laparoscopic cholecystectomy Uncertain diagnosis Not responding to conservative therapy Drainage of necrotic fluid collections 163 Acute Pancreatitis Interprofessional Care (6 of 7) Drug therapy IV morphine Antispasmodics Carbonic anhydrase inhibitors Antacids Proton pump inhibitors 164 Acute Pancreatitis Interprofessional Care (7 of 7) Nutrition therapy NPO status initially Enteral versus parenteral nutrition Monitor triglycerides if IV lipids given Small, frequent feedings when able • High-carbohydrate No alcohol Supplemental fat-soluble vitamins 165 Acute Pancreatitis Nursing Assessment (1 of 6) Subjective data Health history • • • • • • Biliary tract disease Alcohol use Abdominal trauma Duodenal ulcers Infection Metabolic disorders 166 Acute Pancreatitis Nursing Assessment (2 of 6) Subjective data Medications • Thiazides • NSAIDs Surgery or other treatments • Pancreas, stomach, duodenum, biliary tract • ERCP 167 Acute Pancreatitis Nursing Assessment (3 of 6) Subjective data: Alcohol use Fatigue Nausea, vomiting, anorexia Dyspnea Pain 168 Acute Pancreatitis Nursing Assessment (4 of 6) Objective data Restlessness, anxiety, low-grade fever Flushing, diaphoresis Discoloration of abdomen/flank Cyanosis Jaundice Decreased skin turgor Dry mucous membranes 169 Acute Pancreatitis Nursing Assessment (5 of 6) Objective data Tachypnea Basilar crackles Tachycardia Hypotension Abdominal distention/tenderness Diminished bowel sounds 170 Acute Pancreatitis Nursing Assessment (6 of 6) Possible diagnostic findings: Increased serum amylase/lipase levels Leukocytosis Hyperglycemia Hypocalcemia Abnormal findings on ultrasonography/CT scans Abnormal findings on ERCP 171 Case Study (4 of 8) A.J.’s laboratory results show Elevated serum amylase and lipase levels Mild leukocytosis 172 Case Study (5 of 8) She undergoes an ERCP, which revealed the presence of gallstones blocking the common bile duct. She is currently on NPO status and receiving IV morphine for pain control. 173 Case Study (6 of 8) When you plan care for A.J., what priority clinical problems would you identify for her? 174 Acute Pancreatitis Clinical Problems Pain Fluid imbalance Electrolyte imbalance Nutritionally compromised 175 Acute Pancreatitis Planning Patient will have Relief of pain Normal fluid and electrolyte balance Minimal to no complications No recurrent attacks 176 Acute Pancreatitis Nursing Implementation (1 of 8) Health promotion Assessing patient for risk factors Encouraging of early treatment of these factors Ceasing alcohol intake Early diagnosis/treatment of biliary tract disease 177 Acute Pancreatitis Nursing Implementation (2 of 8) Acute care Monitoring vital signs • Hypotension, fever, tachypnea Monitor response to IV fluids Closely monitor fluid and electrolyte balance Assess respiratory function 178 Case Study (7 of 8) For what electrolyte imbalances would you monitor A.J.? Explain the rationale for your answer. 179 Acute Pancreatitis Nursing Implementation (3 of 8) Acute care Monitor fluid and electrolyte balance • Chloride, sodium, and potassium • Hypocalcemia Tetany Calcium gluconate to treat • Hypomagnesemia 180 Acute Pancreatitis Nursing Implementation (4 of 8) Acute care Pain assessment and management • Opioids • Position of comfort, frequent position changes Flex trunk and draw knees to abdomen Side-lying with head of bed elevated 45 degrees Frequent oral/nasal care Proper administration of antacids 181 Acute Pancreatitis Nursing Implementation (5 of 8) Acute care Observation for signs of infection TCDB, semi-Fowler’s position Observation for paralytic ileus, renal failure, mental changes Monitor serum glucose Postop wound care 182 Case Study (8 of 8) A.J. is recuperating from her acute pancreatitis without difficulty. Her health care provider writes an order for her to be discharged home. What would be your priority teaching to be completed prior to her leaving? 183 Acute Pancreatitis Nursing Implementation (6 of 8) Ambulatory care Physical therapy Counseling regarding abstinence from alcohol and smoking 184 Acute Pancreatitis Nursing Implementation (7 of 8) Ambulatory care Diet teaching • Low-fat, high-carbohydrate • No crash diets Patient/family teaching • Signs of infection, diabetes, steatorrhea • Exogenous enzyme supplementation 185 Acute Pancreatitis Nursing Implementation (8 of 8) Expected outcomes Have adequate pain control Maintain adequate fluid and electrolyte balance Be knowledgeable about treatment plan to restore health Get help for alcohol use and smoking cessation (if needed) 186 Chronic Pancreatitis Continuous, prolonged inflammatory, and fibrosing process of the pancreas Etiology Alcohol, gallstones, tumor, pseudocysts, trauma, systemic disease Autoimmune pancreatitis Cystic fibrosis 187 Chronic Pancreatitis Pathophysiology Two major types Chronic obstructive pancreatitis • Inflammation of sphincter of Oddi • Cancer of ampulla of Vater, duodenum, or pancreas Chronic nonobstructive pancreatitis • Inflammation and sclerosis in head of pancreas and around duct • Most common cause is alcohol use 188 Chronic Pancreatitis Clinical Manifestations (1 of 2) Abdominal pain Located in same areas as in acute pancreatitis Heavy, gnawing feeling; burning and cramp-like More frequent until almost constant Malabsorption with weight loss Constipation Mild jaundice with dark urine Steatorrhea Diabetes 189 Chronic Pancreatitis Clinical Manifestations (2 of 2) Complications include Pseudocyst formation Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion Splenic vein thrombosis Pseudoaneurysms Pancreatic cancer 190 Chronic Pancreatitis Diagnostic Studies (1 of 3) Confirming diagnosis can be hard Based on Signs/symptoms Laboratory studies Imaging 191 Chronic Pancreatitis Diagnostic Studies (2 of 3) Laboratory tests Serum amylase/lipase levels • May be elevated slightly or not at all Increased serum bilirubin level Increased alkaline phosphatase level Mild leukocytosis Increased sedimentation rate 192 Chronic Pancreatitis Diagnostic Studies (3 of 3) ERCP CT, MRI, MRCP, abdominal ultrasound, EUS Stool samples for fat content Decreased fat-soluble vitamin and cobalamin levels Glucose intolerance/diabetes Secretin stimulation test 193 Chronic Pancreatitis Interprofessional Care (1 of 4) Analgesics for pain relief (morphine or fentanyl patch [Duragesic]) Diet Bland, low-fat Small, frequent meals No smoking No alcohol or caffeine 194 Chronic Pancreatitis Interprofessional Care (2 of 4) Pancreatic enzyme replacement Contain amylase, lipase, trypsin Bile salts Insulin or oral hypoglycemic agents Acid-neutralizing and acid-inhibiting drugs Antidepressants 195 Chronic Pancreatitis Interprofessional Care (3 of 4) Surgery Indicated when biliary disease is present or if obstruction or pseudocyst develops Diverts bile flow or relieves ductal obstruction Choledochojejunostomy Roux-en-Y pancreatojejunostomy 196 Chronic Pancreatitis Interprofessional Care (4 of 4) Endoscopic procedures Pancreatic drainage ERCP with sphincterotomy and/or stent placement 197 Gallbladder Disease (1 of 2) Cholelithiasis Most common disorder of biliary system Stones in gallbladder Cholecystitis Inflammation of gallbladder Usually associated with gallstones 198 Case Study (1 of 10) A.L. is a 45-year-old mother of three who presents to the ED. She has acute abdominal pain in her right upper quadrant. She rates the pain as a 7 out of 10. 199 Case Study (2 of 10) A.L. is 5 ft 3 in tall and weighs 170 pounds. She works as a florist and does not exercise. What risk factors does A.L. have for gallbladder disease? 200 Gallbladder Disease (2 of 2) Common health problem Risk factors Female Multiparity Age older than 40 years Estrogen therapy Sedentary lifestyle Familial tendency Obesity 201 Etiology and Pathophysiology (1 of 5) Cholelithiasis Cause of gallstones unknown Develop when balance that keeps cholesterol, bile salts, and calcium in solution is changed, leading to precipitation Bilirubin and protein may also precipitate Bile secreted by liver may be supersaturated with cholesterol (lithogenic bile) 202 Etiology and Pathophysiology (2 of 5) Cholelithiasis Stasis of bile leads to supersaturation and changes in composition of bile (biliary sludge) Immobility, pregnancy, and inflammatory or obstructive lesions in biliary system, decreased bile flow 203 Etiology and Pathophysiology (3 of 5) Cholelithiasis Stones may stay in gallbladder or may migrate to cystic or common bile duct Cause pain as they pass through ducts • May lodge in ducts and cause an obstruction 204 Gallbladder with Gallstones (Fig. 48.14) 205 Etiology and Pathophysiology (4 of 5) Cholecystitis Most often associated with obstruction from stones or sludge Acalculous cholecystitis • Older adults and critically ill • Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes • Biliary stasis • Adhesions, cancer, anesthesia, opioids 206 Etiology and Pathophysiology (5 of 5) Cholecystitis Inflammation • • • • • Confined to mucous lining or entire wall Gallbladder is edematous and hyperemic May be distended with bile or pus Cystic duct may become occluded Scarring and fibrosis after attack 207 Case Study (3 of 10) For what additional clinical manifestations of cholecystitis would you assess A.L.? 208 Clinical Manifestations (1 of 5) Vary from severe to none at all Pain more severe when stones moving or obstructing Steady, excruciating Tachycardia, diaphoresis, prostration Residual tenderness in RUQ Occur 3 to 6 hours after high-fat meal or when patient lies down 209 Clinical Manifestations (2 of 5) When total obstruction occurs: Dark amber urine Clay-colored stools Pruritis Intolerance to fatty foods Bleeding tendencies Steatorrhea 210 Clinical Manifestations (3 of 5) In addition to pain Indigestion Fever, chills Jaundice Pain, tenderness RUQ • Referred to right shoulder, scapula Nausea/vomiting Restlessness Diaphoresis 211 Clinical Manifestations (4 of 5) Inflammation Leukocytosis Fever Assessment findings RUQ or epigastrium tenderness Abdominal rigidity 212 Clinical Manifestations (5 of 5) Chronic cholecystitis Fat intolerance Dyspepsia Heartburn Flatulence 213 Complications Cholecystitis Gangrenous cholecystitis Subphrenic abscess Pancreatitis Cholangitis Biliary cirrhosis Fistulas Gallbladder rupture leads to peritonitis Choledocholithiasis 214 Case Study (4 of 10) What diagnostic studies would you expect the health care provider to order for A.L.? 215 Diagnostic Studies (1 of 2) Ultrasound ERCP Percutaneous transhepatic cholangiography 216 Diagnostic Studies (2 of 2) Laboratory tests Increased WBC count Increased serum bilirubin level Increased urinary bilirubin level Increased liver enzyme levels Increased serum amylase level 217 Case Study (5 of 10) A.L.’s laboratory values show an elevated WBC count and bilirubin level. The health care provider orders ultrasonography, which confirms the presence of gallstones. 218 Case Study (6 of 10) A.L. asks what her treatment options are. How would you respond? 219 Interprofessional Care: Cholelithiasis (1 of 3) Treatment dependent on stage of disease Oral dissolution therapy Ursodeozycholic acid (Ursodiol) Chenodeozycholic acid (Chenodiol) 220 Interprofessional Care: Cholelithiasis (2 of 3) ERCP with sphincterotomy Visualization Dilation Placement of stents Open sphincter of Oddi, if needed Endoscope passed to duodenum Stones removed with basket or allowed to pass in stool 221 Endoscopic Sphincterotomy (Fig. 48.15) 222 Interprofessional Care: Cholelithiasis (3 of 3) Extracorporeal shock-wave lithotripsy (ESWL) If stones cannot be removed via endoscope High-energy shock waves disintegrate gallstones Takes 1 to 2 hours Used in conjunction with bile acids 223 Interprofessional Care: Cholecystitis Control possible infection Cholecystotomy Antibiotic treatment NG tube for severe nausea/vomiting Opioids for pain control Anticholinergics Decrease GI secretions Counteract smooth muscle spasms 224 Interprofessional Care: Surgical Therapy (1 of 2) Laparoscopic cholecystectomy Treatment of choice Removal of gallbladder through 1 to 4 puncture holes Minimal postoperative pain Resume normal activities, including work, within 1 week Few complications 225 Interprofessional Care: Surgical Therapy (2 of 2) Incisional (open) cholecystectomy Removal of gallbladder through right subcostal incision T-tube inserted into common bile duct • Ensures patency of duct • Allows excess bile to drain 226 Placement of T-Tube (Fig. 48.16) 227 Interprofessional Care: Transhepatic Biliary Catheter Preoperative or palliative When endoscopic drainage fails Inserted percutaneously and attached to drainage bag Replace fluids lost with electrolyte-rich drinks Skin care important 228 Interprofessional Care: Drug Therapy (1 of 2) Most common Analgesics • Morphine Anticholinergics • Atropine Fat-soluble vitamins (A, D, E, K) Bile salts 229 Interprofessional Care: Drug Therapy (2 of 2) Cholestyramine may be given for pruritus Comes in powder form, mixed with milk or juice Monitor for side effects nausea/vomiting, diarrhea or constipation, skin reactions Check drug-to-drug interactions 230 Interprofessional Care: Nutrition Therapy (1 of 2) Small, frequent meals with some fat Diet low in saturated fat High in fiber and calcium Reduced-calorie diet if patient is obese Avoid rapid weight loss 231 Interprofessional Care: Nutrition Therapy (2 of 2) After laparoscopic cholecystectomy Liquids first day Light meals for a few days After incisional cholecystectomy Liquids to regular diet once bowel sounds have returned May need to restrict fats for 4 to 6 weeks 232 Nursing Management: Assessment (1 of 6) Subjective data Medical history • Obesity, multiparity, infection, cancer, extensive fasting, pregnancy Medication use • Estrogen, oral contraceptives Surgical history • Previous abdominal surgery 233 Nursing Management: Assessment (2 of 6) Subjective data: Positive family history Sedentary lifestyle Weight loss, anorexia Indigestion, fat intolerance Nausea and vomiting, dyspepsia Chills 234 Nursing Management: Assessment (3 of 6) Subjective data: Clay-colored stools Steatorrhea Flatulence Dark urine Pain Pruritus 235 Nursing Management: Assessment (4 of 6) Objective data Fever Restlessness Jaundice, icteric sclera Diaphoresis Tachypnea Splinting 236 Nursing Management: Assessment (5 of 6) Objective data Tachycardia Palpable gallbladder Abdominal guarding and distention 237 Nursing Management: Assessment (6 of 6) Abnormal diagnostic findings Increased serum liver enzymes Increased alkaline phosphatase Increased bilirubin Absence of urobilinogen in urine Increased urinary bilirubin Leukocytosis Abnormal gallbladder ultrasound findings 238 Case Study (7 of 10) As you admit A.L. to the medical-surgical unit, you develop a plan of care for her. Identify appropriate clinical problems for A.L. 239 Nursing Management: Clinical Problems Pain Impaired GI function 240 Nursing Management: Planning Overall goals Relief of pain and discomfort No complications No recurrent attacks of cholecystitis or gallstones 241 Nursing Management: Implementation (1 of 12) Health promotion Screen for predisposing factors Teaching for at-risk ethnic groups Early detection of chronic cholecystitis • Manage with low-fat diet 242 Nursing Management: Implementation (2 of 12) Acute care Nursing goals • • • • • Treat pain Relieve nausea and vomiting Provide comfort and emotional support Maintain fluid and electrolyte balance and nutrition Observe for complications 243 Case Study (8 of 10) What interventions would you use to manage A.L.’s pain? 244 Nursing Management: Implementation (3 of 12) Acute care Pain management • Give drugs as needed before pain becomes severe • Observe for side effects Comfort measures • Clean bed • Positioning • Oral care 245 Nursing Management: Implementation (4 of 12) Acute care Manage nausea and vomiting • NG tube, gastric decompression Oral hygiene, care of nares Accurate intake and output Maintaining suction • Antiemetics • Comfort measures 246 Nursing Management: Implementation (5 of 12) Acute care Pruritus relief measures • • • • • • • Antihistamines Baking soda or Alpha Keri baths Lotions Soft linen Control of temperature Short, clean nails Scratch with knuckles rather than nails 247 Nursing Management: Implementation (6 of 12) Acute care Monitor for complications • Obstruction • Bleeding • Infection 248 Nursing Management: Implementation (7 of 12) Acute care Post-ERCP care • • • • • Assessment for complications Vital signs, pain, amylase and lipase levels Bed rest NPO until return of gag reflex Patient teaching 249 Case Study (9 of 10) A.L. undergoes a laparoscopic cholecystectomy and is scheduled to returns to your unit. What nursing interventions would you plan when caring for A.L.? 250 Nursing Management: Implementation (8 of 12) Postoperative care Laparoscopic cholecystectomy • Monitor for complications • Patient comfort Referred pain to shoulder pain from CO2 Sims’ position Deep breathing, ambulation, analgesia • Clear liquids • Discharged same day 251 Nursing Management: Implementation (9 of 12) Postoperative care Incisional cholecystectomy • • • • Maintain adequate ventilation Prevent respiratory complications General postoperative nursing care Maintain drainage tubes (T-tube, Penrose tube, or Jackson-Pratt tube), if present • Replace lost fluids and electrolytes 252 Case Study (10 of 10) A.L. is ready to be discharged. What instructions will you give her for home care? 253 Nursing Management: Implementation (10 of 12) Ambulatory care Diet teaching • Low-fat • Weight reduction if needed • Fat-soluble vitamin supplements Teach what to report Follow-up care 254 Nursing Management: Implementation (11 of 12) Ambulatory care Laparoscopic cholecystectomy • Remove bandages day after surgery and then can shower • Report signs of infection • Gradually resume activities • Return to work in 1 week • May need low-fat diet for several weeks 255 Nursing Management: Implementation (12 of 12) Ambulatory care Open-incision cholecystectomy • No heavy lifting for 4 to 6 weeks • Usual activities when feeling ready • May need low-fat diet for 4 to 6 weeks 256 Nursing Management: Evaluation Expected outcomes Appear comfortable and has pain relief Remain free from complications 257
