Download REIMBURSEMENT ISSUES

Chapter 6
Care of the Patient with a
Gallbladder, Liver, Biliary Tract,
or Exocrine Pancreatic Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Laboratory and Diagnostic
Examinations
•
•
•
•
•
•
•
•
Serum bilirubin test
Liver enzyme tests
Serum protein test
Oral cholecystography (gallbladder series)
Intravenous cholangiography (IV cholangiogram)
Operative cholangiography
T-tube cholangiogram
Ultrasound of the liver, gallbladder, and biliary
system
• Gallbladder scanning
• Liver biopsy
• Liver scanning
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Laboratory and Diagnostic
Examinations
(continued)
• Blood ammonia
• Hepatitis virus studies
• Serum amylase test
• Urine amylase test
• Ultrasound of pancreas
• Computerized tomography of the abdomen
• Endoscopic retrograde cholangiopancreatography of
the pancreatic duct (ERCP)
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis

Etiology/pathophysiology
• Chronic, degenerative disease of the liver
• Scar tissue restricts the flow of blood to the liver
• Types of cirrhosis




Laennec’s cirrhosis
Postnecrotic cirrhosis
Primary biliary cirrhosis
Secondary biliary cirrhosis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 4
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Etiology/pathophysiology (continued)
• Alteration of liver function



Reduced ability to construct albumin
Obstruction of portal vein
Increased pressure in veins that drain GI tract
• Complications




Portal hypertension due to vein obstruction by cirrhosis
Ascites – excessive fluid and albumin in peritoneal cavity
Esophageal varices due to portal hypertension
Hepatic encephalopathy – ammonia intoxication causing
brain damage – check for flapping hands
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Clinical manifestations/assessment
• Early stages


Abdominal pain’ anorexia, N/V,
Liver is firm and easy to palpate
• Late stages




Dyspepsia;Changes in bowel habits
Nausea and vomiting
Jaundice and ecchymoses
Gradual weight loss
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 6
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Clinical manifestations/assessment (continued)
• Late stages (continued)






Ascites
Enlarged spleen
Spider angiomas
Anemia
Bleeding tendencies –
o Epistaxis; Hematuria; Purpura; bleeding gums
Disorientation
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 7
Figure 6-2
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Systemic clinical manifestations of liver cirrhosis.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 8
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Medical management/nursing interventions
• Pharmacological management

Antiemetics
o Benadryl and Dramamine
o Contraindicated: Vistaril, Compazine, and Atarax
• Eliminate the cause!



Alcohol
Hepatotoxins
Environmental exposure to harmful chemicals
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 9
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Medical management/nursing interventions
(continued)
• Diet






Well-balanced
High in calories -2500-3000 cal
Moderate in protein 75G
Low in fat
Low in sodium 1-2 G
Supplemental vitamins (especially B group) and folic acid
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Medical management/nursing interventions
(continued)
• Treatment of complications

Ascites
o Bed rest
o Strict I&O
o Restrict fluids and sodium
o Diuretics: Aldactone, Lasix, HCTZ
o Vitamins K, C, and folic acid supplements
o LeVeen peritoneal-jugular shunt
o Paracentesis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 11
Figure 6-3 Decreases ascites
(From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.)
LeVeen continuous peritoneal jugular shunt.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Medical management/nursing interventions
(continued)
• Treatment of complications (continued)

Ruptured esophageal varices
o Maintain airway; establish IV
o Vasopressin drip to control bleeding
o Sengstaken-Blakemore tube
o Endoscopic sclerotherapy
o Portacaval shunt
o Blood transfusions
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 13
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cirrhosis (continued)

Medical management/nursing interventions
(continued)
• Treatment of complications (continued)

Hepatic encephalopathy
o Decrease protein in diet
o Avoid drugs that are detoxified by the liver
o *Lactulose – pulls ammonia from blood into bowel
and causes osmotic laxative effect
*http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682338.html
o
Neomycin – “causes a reduction in mucosal
glutaminase activity and thereby decreases the ability
of the mucosa to consume glutamine and produce
ammonia”. http://www.ncbi.nlm.nih.gov/pubmed/7741004
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 14
Normal labs
•
•
•
•
•
•
•
Total bilirubin: 0.3 to 1mg/dL
AST: 0-35 units/dL
ALT: 4-36 units/dL
Alkaline Phosphatase; 30-120 units/ dL
Albumin: 3.5 – 5 /dL
Total protein: 6.4 – 8.4 g/dL
Lipase: 10- 140 units/ L
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 15
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer

Etiology and pathology
• Hepatocellular carcinoma most commonly seen
• Cirrhosis of the liver and hepatitis C and B are also
elevated risk factors
• In the United States liver cancer is seen more in people
over age 40
• Metastatic carcinoma of the liver is seen more than
primary liver cancer due to high vascularity and blood
flow
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer

Clinical manifestations
•
•
•
•
•
Hepatomegaly*
Weight loss*
Peripheral edema*
Ascites*
Portal hypertension*

•
•
•
•
*also seen in cirrhosis
Dull epigastric pain
Jaundice (visible with bili level over 2.5mg/dL)
Anorexia, N/V
Extreme weakness
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 17
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver cancer

Diagnostic tests
•
•
•
•
•
•
Liver scan
Ultrasound
CT scan
Magnetic resonance imaging
ERCP
Liver biopsy – needle aspirate

How do you position the patient to recover from a liver
biopsy?
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 18
Disorders of the Liver, Biliary
Tract, Gallbladder, and Pancreas
• Liver cancer

Medical management/nursing interventions
• Palliative care
• Surgery – excision or removal with transplant
• Chemotherapy - 5FU via hepatic artery or portal vein
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 19
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis

Etiology/pathophysiology
• Inflammation of the liver resulting from several types of
viral agents or exposure to toxic substances
• Hepatitis A



Most common
Oral-fecal transmission
“A” for awfully dirty hands
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 20
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Etiology/pathophysiology (continued)
• Hepatitis B


Transmission by contaminated serum; blood transfusion,
contaminated needles, dialysis, or direct contact with
infected body fluids
It “B” in the blood and body fluids
• Hepatitis C


Transmitted through contaminated needles and blood
transfusions
“C” the needles with the blood on them
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 21
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Etiology/pathophysiology (continued)
• Hepatitis D


Co-infection with hepatitis B
“D’sex ain’t worth it”
• Hepatitis E



Fecal contamination of water
Rare in the United States; usually in developing countries
“EWW” the water looks brown
• Hepatitis G

“Gee” I don’t want transfusions from over there
****Reportable to CDC****
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 22
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
•
May be asymptomatic
General malaise
Aching muscles
Photophobia
Headaches
Chills
Abdominal pain
Dyspepsia
Nausea
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 23
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Clinical manifestations/assessment (continued)
•
•
•
•
•
•
•
•
Diarrhea/constipation
Pruritus
Hepatomegaly
Enlarged lymph nodes
Weight loss
Jaundice
Dark amber urine
Clay-colored stools
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 24
Figure 6-5
(From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year
Book—Europe.)
Severe jaundice.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 25
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Medical management/nursing interventions
•
•
•
•
Hospitalization for bilirubin > 10mg/dl or inc. PT, INR
Treat symptoms
Bed rest
Small, frequent meals


Low-fat, low protein and high-carbohydrate
NO ETOH
• IV fluids for dehydration
• Vitamin C, vitamin B–complex, vitamin K
• Avoid unnecessary medications, especially sedatives
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 26
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Hepatitis (continued)

Medical management/nursing interventions
(continued)
• Gamma globulin or immune serum globulin
• Hepatitis B immune globulin (HBIG)

Should be given to anyone exposed to hepatitis B
• Hepatitis B vaccine

Should be given to people identified as high risk for
developing hepatitis B
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 27
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses

Etiology/pathophysiology
• May be single or multiple
• Abscess forms in the liver due to invading bacteria
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 28
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses (continued)

Clinical manifestations/assessment
• Fever
• Chills
• Abdominal pain and tenderness in the right upper
quadrant
• Hepatomegaly
• Jaundice
• Anemia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 29
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Liver abscesses (continued)

Diagnostic tests
•
•
•
•

Radiograph
Ultrasound
CT scan
Liver scan
Medical management/nursing interventions
•
•
•
•
IV antibiotic therapy specific to organism
Percutaneous drainage of liver abscess
Open surgical drainage if abscess ruptures
Treatment is deemed proper if symptoms decrease
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 30
Disorders of the Liver, Biliary
Tract, Gallbladder, and Pancreas
• Cholecystitis &
cholelithiasis
• Etiology/pathophysiology
An obstruction, gallstone, or
tumor keeps bile from
leaving the gallbladder, and
the trapped bile acts as an
irritant, causing edema
• Risk factors: Female;
American Indian or white;
obesity; pregnancy; diabetes;
multiparous women; use of birth
control
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 31
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Indigestion after eating foods high in fat
Severe, colicky pain in the right upper quadrant
Anorexia
Nausea and vomiting
Flatulence
Increased heart and respiratory rates
Diaphoresis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 32
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)

Clinical manifestations/assessment (continued)
•
•
•
•
•
•
Low-grade fever
Elevated WBC
Mild jaundice
Steatorrhea (fatty stool)
Clay colored stool – bile duct is blocked
Dark amber urine
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 33
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)

Medical management/nursing interventions
• Mild attacks






Pharmacological management
o Antispasmodic and analgesic medications
o Demerol (meperidine)
o Antibiotics
Bed rest
NG tube to suction
NPO
IV fluids
Dietary recommendations: Avoid spicy foods when
allowed PO intake; low fat
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 34
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cholecystitis and cholelithiasis (continued)

Medical management/nursing interventions
(continued)
• Lithotripsy – shock waves through water or a cushion to
pulverize the stone(s) to sizes that can be excreted
• Cholecystectomy



Laparoscopic removal
Open – may need T-tubes if common bile duct is
edematous
May need to aspirate bile from gallbladder before it can
be removed
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 35
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis

Etiology/pathophysiology
• Inflammation of the pancreas

Acute or chronic
• Predisposing factors





Damage to the tract
Alcohol overuse
Trauma
Infectious disease
Certain drugs
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 36
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)

Clinical manifestations/assessment
• Elevated lipase level (5-40 x normal)
• Abdominal pain – LUQ

•
•
•
•
•
•
•
Relieved by fetal or forward leaning positions
Anorexia; nausea and vomiting
Malaise
Low-grade fever
Jaundice
Weight loss
Steatorrhea
Tachycardia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 37
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Pancreatitis (continued)

Medical management/nursing interventions
• Pharmacological management




•
•
•
•
Antiemetics
Analgesics
Anticholinergics
Antacids
NPO – WHY?
IV fluids
NG tube
Hyperalimentation
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 38
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas

Etiology/pathophysiology
• Unknown
• Risk factors


Risk increases with age
Cigarette smoking; exposure to chemical carcinogens;
diabetes mellitus; pancreatitis; diet high in meat, fat, and
coffee; obesity
• May be metastasis from the lung, stomach, duodenum,
or common bile duct (CBD)
• May live only 4 to 8 months after diagnosis
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 39
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas (continued)

Clinical manifestations/assessment
• Abdominal pain in 85% of patients – worse at night

•
•
•
•
•
•
•
Steady, dull, aching pain in the epigastric area
Anorexia
Fatigue
Nausea and flatulence
Change in stools
Weight loss
Jaundice and pruritis
Onset of diabetes mellitus – 50%
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 40
Disorders of the Liver, Biliary Tract,
Gallbladder, and Pancreas
• Cancer of the pancreas (continued)

Medical management/nursing interventions
• Surgery


Whipple procedure
o Like Billroth 2 but pancreas is attached to middle of
jejunum and bile ducts are attached to end of jejunum
Total pancreatectomy with resection of parts of the GI
tract
• Chemotherapy
• Radiation
• Nerve block to celiac plexus nerve
 Prognosis is poor. 5 year survival is <10%
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 41
Figure 6-9
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Whipple’s procedure, or radical pancreaticoduodenectomy.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 42