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Pancreatic and Liver Maladaptations M. DuBois Fennal, PhD, RN, CNS Associate Professor Florida A&M University School of Nursing Cirrhosis Definition: A type of chronic liver disease that result in extensive hepatocellular damage. An irreversible inflammatory disease. Incidence A leading cause of death in the United States , higher in men than in women, higher in alcoholics than in non-alcoholics Etiology Classified by cause: 1. Laennec Cirrhosis Caused by alcoholism Most common type Manifest by fatty deposits that lead to full blown cirrhosis. If not corrected it will progress to alcoholic hepatitis. Biliary Cirrhosis Cause unknown Secondary Biliary Caused by obstruction Neoplasms Strictures Gallstones Postnecrotic Hepatitis B HAV Hepatitis C Drugs or other toxins Autoimmune destruction Cardiac Cirrhosis Right sided heart failure Prolonged elevated venous pressure Liver congestion Metabolic Cirrhosis Defects and storage diseased, such as alpha1antitrypsin deficiency, glycogen storage disease, hemochromatosis, Wilson disease, glactosemia Pathophysiology Disorganization of hepatic tissue caused by diffuse fibrosis and nodular regeneration. The process creates a rough nodular appearance of the liver. The inability to detoxify substances, the inability to produce essential proteins such as clotting factor and albumin, The inability to regulate glucose and bilirubin metabolism. Signs and Symptoms Portal Hypertension Splenomegaly Acites Esophageal Varices Hepatic Encephalopathy Clinical Manifestations Parotid enlargement Esophageal varicies (bleeding) Altered coagulation Anemia Leukopenia Asterixix Peripheral edema Pounding pulse Ascites Dyspnea Spider angiomata Gynecomastia Potassium deficiency Medical Management Electrolytes CBC Bilirubin Total Protein Coagulation Studies Enzyme studies Diuretics Lactulose Neomycin Vitamin K Antacids Sedation Surgery Scleotherapy Paracentisis Leveen Shunt Portacaval Shunt Liver Transplant Nursing Management Assessment Safety Interpretation of lab data Management of medication regime Provision of comfort Fluid and electrolyte balance Nursing Diagnosis Fluid volume excess Altered thought processes Risk for injury; bleeding Risk for impaired gas exchange Impaired skin integrity Cancer of the Liver Definition: Malignant neoplasms of the liver Etiology Usually caused by metabolic spread from primary site elsewhere in the body Primary Liver Cancer may be caused by exposure to mycotoxins (aspergillums flatus) a mold found in corn, wheat and peanuts May also occur because of chronic liver disease especially cirrhosis May occur from infection of Hepatitis B,C,D Incidence More common in men than in women Higher in Blacks than in Whites Most Common during the six decade Accounts for 2% of deaths in US 18,920 new cases in 2004 14,270 deaths in 2004 Pathophysiology Hepatocellular: arise from the liver cells. Hepatocytes are damaged by invasion of DNA from most often HBV & HDV Cholangiocelluar develops in the cells of the bile duct, as a result of long standing inflammation or injury to the duct. Signs and Symptoms Nausea and vomiting Jaundice Abdominal Distention Clinical Manifestations Portal Hypertension Loss of appetite Pain Weight loss Elevated Alkaline phosphatase (ALP), Aminotransferase (ALT or SGPT), transaminase (AST or SGOT) Diagnosis Based on symptomatology Laboratory findings X-rays Liver Scan Exploratory Surgery Medical Management Management of pain Hospice Care Nursing Management Pallative Provide comfort Management of pain medication Appropriate Referrals, i.e. Hospice Pancreatitis Definition: Inflammation of the Pancreas Etiology Associated with several diseases including alcoholism, obstructive biliary tract disease (particularly choleithiasis), peptic ulcer, trauma, hyperlipidemia, and certain drugs Incidence Most common during the 5th decade of life May be acute or chronic Occurs equally in men and women (pathology, McCance & Huether), Occurs more frequently in men than in women (Lemone & Burke Pathophysiology Acute: Also called hemorrhagic pancreatitis. The triggering event may not be known. Most commonly it is believed that some sort of injury occurs or there is a disruption in the pancreatic ducts o Acini, with leakage of pancreatic enzymes into pancreatic tissue, initiating autodigestion and acute pancreatitis Signs and Symptoms Epigastric and midabdominal pain Fever Leukocytosis Inflammatory response Nausea and vomiting Paralytic ileus Peritonitis Clinical Manifestation Complaints of abdominal pain Abdominal distention Ascites Hypotension Hypovolemia Complications Shock Myocardial Insufficiency Tachypnea Hypoxemia Decrease renal blood flow Pulmonary edema Atelectasis Pleural effusion Tetany Diagnosis Based on clinical findings Identification of associated disorders and laboratory findings Elevated amylase***** Medical Management Narcotics such as morphine NPO Nasogastric suctioning IV Fluids Nursing Management Pain control NPO Bedrest Nutrition Management of fluid volume Chronic Pancreatitis May be structural or functional impairment Etiology: Alcohol abuse Idiopathic Cystic fibrosis Clinical Manifestations Pancreatic cyst Pancreatic enzyme deficiency Mal-absorption syndrome Medical Management Pain management (avoid narcotics if possible) Diet Insulin Surgery Nursing Management Pain control Education Monitor dietary intake Pancreatic Cancer Definition: Proliferation of abnormal cell growth in the pancreas Etiology Smoking Exposure to industrial chemicals Environmental toxins High fat diet Pancreatitis Diabetes Incidence More prevalent in men than women More common in blacks than in whites Occurs most often after the fifth decade Pathophysiology Most cancers of the pancreas are adenocarcinomas that cause death in one to two years. As with any cancer cells that do not contribute to livelihood of the host act as a parasite that takes from the host and eventually depletes the host of nutrients Cancer cells do not die on time and continue to multiply Signs and Symptoms Anorexia Weight loss Flatulence Dull epigastric pain Clinical Manifestations Obstruction of bile flow Jaundice Clay colored stools Dark Urine Puritis Medical Management Whipple Procedure Removal of the head of the pancreas, the entire duodenum, the distal third of the stomach, a portion of the jejunum, and the lower half of the common bile duct. The common bile duct is sutured to the end of the jejunum and the remaining pancreas and stomach are sutured to the side of the jejunum (p 606 or p 501) Nursing Management Care of the post-operative patient Airway Pain Nasogastric suctioning (drainage) Positioning (semi-fowlers) Signs and Symptoms Abdominal Pain continuous or intermittent Loss of islet cell function