Download 13.Liver.Pancreas

LIVER and PANCREAS
DYSFUNCTION
Zelne Zamora, DNP, RN
PANCREAS

Exocrine



Secretes digestive
enzymes into the
small intestines
Breakdown of CHO,
protein, and fats
Endocrine



Produces hormones
Insulin
Glucagon
EXOCRINE FUNCTION

CCK: Cholecystokinin


Secretin




Stimulus for enzyme
secretion
Secretion of bicarb and
water
Lipase: Fats
Amylase: Carbohydrates
Trypsin: Proteins
EXOCRINE FUNCTION



90% of pancreatic
digestive enzymes are
proteolytic
Trypsin
Chymotrypsin


splits proteins into
peptones
Elastase

Breakdown elastic
tissue
EXOCRINE FUNCTION

Amylolytic



Breakdown of
carbohydrates
Amylase
Lipolytic



Breakdown of fats
Lipase
Phospholipase A
ENDOCRINE FUNCTION
Islet of Langerhans
 Alpha cells


Beta cells


Glucagon: ↑ blood
glucose
Insulin: ↓ blood
glucose
Delta cells

Somatostatin
PANCREATITIS



Inflammation of the
pancreas
Autodigestion of the
pancreas by
pancreatic enzymes
Cellular destruction
and organ damage
ACUTE PANCREATITS

Acute



Mild or Nonhemorrhagic
Severe or
Hemorrhagic
Fulminant
EPIDEMIOLOGY



185,000 cases each
year
150,000 cholelithiasis
or sustained alcohol
abuse
African-Americans
are at ↑ risk
CAUSES







Alcohol consumption
Gallstones
Pancreatic
obstruction
Drugs and toxins
Hyperlipidemia
Family history
Trauma and
iatrogenic factors
SIGNS and SYMPTOMS

Severe abdominal pain







Epigastrium radiating to
midback
Not relieved by vomiting
Fever, malaise
Nausea, vomiting
Rigid and distended
Rebound tenderness
Absent or diminished
bowel sounds
SIGNS and SYMPTOMS

Dyspnea and
Tachypnea


Grey Turner’s sign


Large ecchymosis
appearing in the
flanks
Cullen’s sign


Pulmonary infiltrates
Ecchymosis in
umbilical area
Hypovolemic Shock
DIAGNOSTIC FINDINGS

Serum Amylase


Serum Lipase



Normal (23-85 u/L)
Normal (0-160 u/L)
Serum trypsinogen:
elevated
Urinary amylase:
elevated
DIAGNOSTIC FINDINGS




Hematocrit: initially
elevated then later
decreased
WBC: elevated
C-reactive protein:
elevated
Liver function tests:
elevated
DIAGNOSTIC FINDINGS




Sodium and
Potassium: decreased
Blood glucose:
elevated
Serum Calcium:
decreased
Albumin and
Magnesium:
decreased
DIAGNOSTIC FINDINGS





Abdominal and Chest X-ray
CT scan, Ultrasound, MRI
Endoscopic Retrograde
Cholangiopancreatography
(ERCP)
Aspiration biopsy
Stool studies: steatorrhea
COMPLICATIONS

Hypovolemic shock




3rd spacing
Hemorrhage
Vomiting
Decreased protein
intake
COMPLICATIONS

Pulmonary
complications




Atelectasis
Acute lung injury
Pleural effusion
ARDS
COMPLICATIONS

Cardiovascular


Release of myocardial
depressant factor
Pancreatic
pseudocyst


Cavity next to
pancreas
Filled with necrotic
products
COMPLICATIONS

Pancreatic abscess




2-4 weeks after
episode
Necrosis of tissue
Relocation of bacteria
Hypocalcaemia can
occur with severe
disease
COMPLICATIONS

Fluid and electrolytes



Vomiting
NG suction
Redistribution of fluids
TREATMENT

Pain Management

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IV opioid analgesics
Dilaudid IV PCA
Demerol and
Morphine IV
GI rest


Decrease stimulation
of pancreas
Nasogastric tube
insertion
TREATMENT




Fluid and Electrolyte
replacement
Cessation of alcohol
consumption
Nutrition: enteral
versus parenteral
Surgery if there is
biliary obstruction
TREATMENT

Respiratory




Oxygen
Monitor oxygen
saturation
Arterial blood gas
Ventilator support
TREATMENT

Fluid volume deficit





IV fluids
Plasma expanders
Vasopressors
Blood replacement
Strict intake and output
TREATMENT

Fluid and electrolyte
imbalance



LR or IV maintenance
fluid containing K+
Calcium gluconate
Hypocalcemia


Chvostek’s sign
Trousseau’s sign
TREATMENT

Pseudocyst, abscess
or fistula



Monitor for signs and
symptoms of shock
Prepare patient for
surgery
Watch for infections
post-operatively
TREATMENT



Biliary drainage tube
Surgical debridement
ERCP



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
Sphinceterotomy
Gallstone removal
Stent placement
Balloon dilatation
Laparoscopic
cholecystectomy with
CBDE
MEDICATIONS

Viokase


Pancrease


Replace pancreatic
enzymes
Replace pancreatic
enzymes
Glucagon

Treat hypoglycemia
NURSING IMPLICATIONS

Vital signs



Laboratory values



Hypovolemic shock
Sepsis
Amylase, Lipase
BMP
Fluid and electrolytes



NPO
NGT
Nutrition
NURSING IMPLICATIONS


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Administer pain
medication
Monitor blood
glucose
Monitor intake and
output
Daily weight
CHRONIC PANCREATITIS


Persistent
inflammation of the
pancreas
Scarring and
calcification of the
pancreatic ducts
CAUSES


70% is caused by
alcohol abuse
20% is caused by
obstruction, trauma,
metabolic
disturbances
SIGNS & SYMPTOMS

80% of pancreatic
destruction causes



Malabsorption
resulting in nutritional
deficits
Diarrhea and
steatorrhea
Impaired glucose
regulation
DIAGNOSTIC FINDINGS



LFT, CMP, CBC, ESR
Stool studies
Abdominal CT scan


Abdominal US


Images organ, detect
inflammation
Detect inflammation and
calcifications
ERCP

looks for stones
TREATMENT

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GI rest
Pain control
No Alcohol
Daily weight
TREATMENT


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Low fat, protein, and
high carbohydrate
diet
Oral pancreatic
enzymes
Monitor blood
glucose
TREATMENT



Replacement of fat
soluble vitamins
Octreotide
(Sandostatin)
Celiac plexus block
LIVER FUNCTION

Glucose metabolism



Ammonia conversion



Glycogenolysis
Gluconeogenesis
Ammonia to urea
Urea excreted in the
urine
Protein metabolism

Synthesis of plasma
proteins
LIVER FUNCTION

Fat metabolism


Vitamin and iron
storage




Fatty acids broken
down for energy
Vitamin A,B,D, and Bcomplex vitamins
Bile formation
Bilirubin excretion
Drug metabolism
LIVER FUNCTION TESTS


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ALT: Alanine
aminotransferase
ALP: Alkaline
phosphotase
AST: Aspartate
aminotransferase
Bilirubin
Albumin
LIVER PANEL



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Total Protein
GGT: Gammaglutamyl transferase
LDH: Lactic acid
dehydrogenase
Prothrombin time
HEPATIC DYSFUNCTION


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Primary liver disease
Obstruction of bile
flow
Altered hepatic
circulation
Acute or chronic
CAUSES

Toxicities:


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Chemicals, Plants,
Drugs
Bacterial invasion
Nutritional deficiency
Autoimmune
Hepatitis
Viruses

Hepatitis A,B,C,D,E
CHRONIC LIVER DISEASE



12th leading cause of
death in the United
states among young
and middle-aged
adults
40% associated with
alcohol use
Cirrhosis
SIGNS & SYMPTOMS



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Jaundice
Portal hypertension
Ascites and varices
Nutritional
deficiencies
Hepatic
encephalopathy
Coma
JAUNDICE

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Bilirubin level >2.5
mg/dL
All body tissue
become tinged yellow
Hepatocellular
jaundice
Obstructive jaundice
PORTAL HYPERTENSION



Increased pressure
through portal
venous system
Obstructed blood
flow through
damaged liver
Commonly
associated with liver
cirrhosis
PORTAL HYPERTENSION

GI bleeding


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Black tarry stool
Hematemesis
Encephalopathy
Coagulopathy
Ascites
ASCITES

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Backup of venous
blood flow from portal
HTN
Failure to metabolize
aldosterone
Movement of fluid
from vessels to
peritoneal space
Accumulation of
albumin-rich fluid
HEPATIC ENCEPHALOPATHY



Life-threatening
complication of liver
disease
Liver unable to
detoxify toxic
byproducts of
metabolism
Ammonia is the
major etiologic factor
of encephalopathy
HEPATIC ENCEPHALOPATHY



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Mental changes
Motor disturbances
Altered mood and
sleep patterns
Asterixis “liver flap”
 Flapping tremor of
the hands
Constructional
apraxia
VIRAL HEPATITIS




Systemic, viral
infection
Necrosis and
inflammation of liver
cells
Altered liver function
5 definitive types of
viral hepatitis

Hepatitis A, B, C, D, E
HEPATITIS A


Hepatitis A Virus
Fecal-oral
transmission




Poor sanitation
Person-person
contact
Water and food borne
Incubation

15-50 days
SIGNS and SYMPTOMS
Hepatitis A Phases
 Preicteric






Flu-like symptoms
Fatigue
Loss of appetite
Nausea
Cough
Joint pain
SIGNS and SYMPTOMS

Icteric







Jaundice
Dark colored urine
RUQ pain
Itchy skin
Clay-colored stools
Poor appetite
Some preicteric
symptoms subside
SIGNS and SYMPTOMS

Post icteric phase


Things start to return
to normal
Fatigue can remain
HEPATITIS A





Mild with recovery
No carrier state
Spread from person to
person – poor hand
washing, intimate kissing
(fecal oral)
Spread by food or water
Doesn’t usually lead to
chronic state
HEPATITIS A
Prevention
 Hand washing
 Safe water supplies
 Proper sanitation
 Sewage disposal
 HAV vaccination
Medical Management
 Bed rest during acute
stage
 Small frequent meals
 Supplemental IV with
glucose
 Gradual progressive
ambulation
HEPATITIS B






Hepatitis B Virus
Parenteral transmission –
serum or blood
Intimate contact with
carriers
Transfer of blood or
serum through shared
needles
Perinatal: mother to baby
Occupational hazard to
health care workers
HEPATITIS B






Hemodialysis
Tattooing or body
piercing
Perinatal: mother to baby
Occupational hazard to
health care workers
Can lead to chronic state
Can develop cirrhosis
later
HEPATITIS B





Incubation: 28-160
days
Symptoms: rash and
arthralgias
Outcome: may be
severe
Carrier state possible
Increased risk of
chronic hepatitis
HEPATITIS B
Prevention
 Hand washing
 Wear gloves when
handling body fluids
 safe sex
 HBV vaccination
 Hepatitis B
Immunoglobulin
Medical management
 Alpha-interferon
 Lamivudine (Epivir)
and adefovir
(Hepsera)
 Bed rest until s/s
subside
 Restrict activities
 Adequate nutrition
HEPATITIS B PANEL



HBsAg: Hepatitis B
surface antigen
HBsAb or Anti-HBs:
Hepatitis B surface
antibody
HBcAb: Hepatitis B core
antibody
HEPATITIS C




Hepatitis C Virus
Non-A, Non-B virus
Blood transfusion transmission
Exposure to contaminated blood
HEPATITIS C





Shared needles of drug
abusers
Intimate contact with infected
partner [Rare]
Increased risk for STDs
90% of transfusion –
associated hepatitis
Can lead to chronic hepatitis,
liver failure and liver cancer
HEPATITIS C





Incubation: 15-160
days
Symptoms: similar to
HBV. Less severe
and anicteric
Chronic carrier state
Can lead to chronic
liver disease
Increased risk for
cancer
HEPATITIS C


No benefit from rest,
diet, or vitamin
supplements
Antiviral agents



Interferon (Intron-A)
Ribavirin (Rebetol)
Side effect: hemolytic
anemia
HEPATITIS D





Delta agent
HBV surface antigen
required for replication
Incubation: 21-140
days
Symptoms: similar to
HBV
Can lead to carrier
state, chronic active
hepatitis, and cirrhosis
HEPATITIS E







Hepatitis E Virus
Fecal-oral transmission –
esp. contaminated water
Low risk for person to
person contact
Incubation: 15-65 days
Symptoms: Similar to HAV
Severe in pregnant women
Seen commonly in Asia
HEPATITIS G and GB VIRUS C





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
Non A-E virus
Incubation: 14-145 days
2 isolates of same virus
Resembles HCV – similar
transmissions
Autoantibodies are absent
Co-infection with other
viruses
Persistent infection – up to
9 years
No Tx
TOXIC HEPATITIS


Resembles viral hepatitis
Exposure to toxic
chemicals





Medications
Botanicals
Alcohol
Industrial chemicals
Remove causative agent
TOXIC HEPATITIS





Anorexia, nausea,
vomiting
Jaundice
Hepatomegaly
No effective antidotes
Delay in treatment
can result in
increased severity
DRUG INDUCED HEPATITIS



Most common cause
of acute liver failure
50% of all cases in
the U.S.
Acetaminophen has
been identified as the
leading cause of
acute liver failure
DRUG INDUCED HEPATITIS


Onset is abrupt
Early symptoms


Late symptoms


Fever, chills, rash,
arthralgia, pruritus,
anorexia
Jaundice, dark urine,
enlarged and tender liver
Treatment

Short course of highdose corticosteroids
TREATMENT





Rest
Small, frequent
meals
Low protein, fat, and
high carbohydrate
IV fluid containing
dextrose as needed
Monitor labs