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Gallbladder/Liver/Pancreas/Lemone/25
Queens University, Charlotte, NC/Adult Health 1 Chapter 25
108
Nursing
Not Applicable
06/09/2012

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Term
Cholelithiasis
Definition
Formation of stones within the gallbladder or biliary duct system.
Term
Formation of bile occurs here
Definition
Liver
Term
Gallbladder releases bile through these sites into the intestines
Definition
Common bile duct
Sphincter of Oddi
Term
Purpose of bile salts
Definition
Increase the solubility and absorption of dietary fats
Term
Factors leading to the formation of gallstones
Definition
Abnormal bile composition
Biliary stasis
Inflammation of the gallbladder
Term
S/S of Biliary Colic
Definition
Severe steady pain in RUQ
Sudden onset following a meal
May last as long as 5 hours
Term
Medical Management of Biliary Tract Disorders
Definition
FPAIN
F - Fluid/electrolyte assessment
P - Pain reduction
A - Antiemetics to treat N/V
I - Infection control: antibiotics
N - Nutrition
*Reduce fat intake
*Ensure protein intake
*Allow some carbs, but not a lot
Term
Medications to treat Biliary Tract Disorders
Definition
Actigall (ursodiol)
Chenix (chenodiol)
Term
Actions of Actigall and Chenix
Definition
Reduce cholesterol content of gallstones
Slowly dissolve gallstones
May take 2 years or more to work
Term
Lithotripsy
Definition
Treatment for dissolving large gallstones.
Patient sits in large tub of water and ultrasound is used to align the stones with the source of shock waves.
Term
Laparoscopic Cholecystectomy
"Lap Choley"
Definition
Removal of gallbladder using a minimally invasive procedure.
Term
Cholecystectomy: Laparotomy
Definition
Open procedure for removal of gallbladder.
Used in more critical cases.
Can also remove stones from the common bile duct.
T-Tube is inserted and left in place while edema decreases.
Term
T-Tube
Definition
Maintain patency
Promote bile passage
Nurse will change dressing periodically
Position of comfort: 45 degrees, semi-Fowler's
Pin drainage bag and tubing off to the side
Bag will drain by gravity
Removal: 1-2 weeks post-op
Term
"Lap Choley" advantages
Definition
Small incisions
Short surgery
Might be outpatient
Return to work in 2-3 days
Term
Complications of Open Cholecystectomy
Definition
Hemorrhage
Atelectasis
Thrombophlebitis
Paralytic ileus
Bile leakage
Peritonitis
Term
Cholecystitis
Definition
Inflammation of the gallbladder
Term
Causes of Cholecystitis
Definition
"I BOIL"
I - Impaired drainage
B - Bacterial proliferation
O - Obstruction of biliary ducts with distention
I - Ischemia: necrosis/perforation of gallbladder wall
L - Localized chemical irritation due to retained bile
Term
Acute Cholecystitis S/S
Definition
*Pain: may be entire RUQ, tender to palpation, may radiate to back, right scapula, shoulder
*Movement/deep breathing may make pain worse
*Pain lasts longer than biliary colic (8-12 hours)
*Anorexia
*N/V
*Fever and chills may be present
Term
Biliary Stasis
Definition
Slowed emptying of gallbladder:
Gallbladder empties in response to hormonal stimulation
When gallbladder empties completely as it should, stones do NOT form!
Term
Inflammation of gallbladder
Definition
Allows excess water and bile salt reabsorption which increases the risk of lithiasis
Term
Composition of gallstones
Definition
80% consist mainly of cholesterol
20% contain a mixture of bile componenets
Term
Obstruction of Common Bile Duct Leads to:
Definition
Bile reflux into the liver which causes
*Pain
*Jaundice
*Possible liver damage
Pancreatitis: inability of pancreatic enzymes to enter small intestine.
Term
Liver Function
Definition
Glycogenesis
Glycogenolysis
Gluconeogenesis
Fat metabolism
Protein metabolism
Vitamin and Iron storage
Metabolism and detoxification of drugs and chemicals
Bile formation
Elimination of foreign/damaged cells
Term
Glycogenesis in Liver
Definition
Formation of glycogen from glucose
Term
Glycogenolysis in Liver
Definition
Glycogen (stored in liver and muscles) is converted to glucose
Term
Gluconeogenesis in Liver
Definition
Process of synthesizing glucose from non-carbohydrate sources: starting point is pyruvic acid.
Term
Fat metabolism in LIver
Definition
Fatty acids broken down into ketones
Fatty acids used for synthesis of:
*Cholesterol
*Triglycerides
*Lipoproteins
Term
Protein metabolism in Liver
Definition
Proteins are first catbolized (broken down)
Ammonia is converted to urea
Plasma proteins are synthesized: albumin and clotting factors
Term
Vitamin and Iron Storage in Liver
Definition
Vitamins A, B12, D, E, and K
Iron and copper
Term
Metabolism and Detoxification of drugs and chemicals in Liver
Definition
Conjugated or bound with chemicals
Metabolized by certain pathways
Term
Bile: Formed in Liver and Accomplishes This
Definition
*Absorbs fat
*Metabolized bilirubin by converting it from unconjugated to conjugated
*Eliminate bilirubin from the body.
Term
Liver Eliminates:
Definition
By way of Kupffer cell phagocytosis:
*Foreign cells
*Damaged blood cells
Term
Bilirubin Levels
Expected Value: Total Serum Bilirubin
Definition
0.1-1.2 mg/dL
Term
Bilirubin Levels
Expected Value: Direct (conjugated)
Definition
0.1-0.3 mg/dL
Term
Bilirubin Levels
Expected Value: Indirect (unconjugated)
Definition
<1.0 mg/dL
Term
Reasons for elevated bilirubin levels
Definition
1. Liver disease
2. Flow of bile is obstructed
3. Excessive destruction of RBCs
Term
Aging changes in the LIver
Definition
Decrease in size and weight.
Decrease in hepatic blood flow.
Increase in incidence of Hep B
Increase in severity of Hep B
Increase in incidence of liver abscesses
Term
Geriatric LFTs
Definition
Remain the SAME even though the size/weight/flow have decreased.
Term
Ascites
Definition
Accumulation of fluid in the abdomen r/t low albumin levels which reflect poor protein metabolism
Term
Additional S/S of Liver disease in Males
Definition
Gynecomastia
Testicular atrophy
Term
Liver Disease Assessment:
Inspection
Definition
Skin - dilated veins/vessels that pop up around umbilicus
Ascites
Abdominal girth
Males: gynecomastia, testicular atrophy
Term
Liver Disease Assessment:
Auscultation
Definition
Bowel sounds: may be absent
RUQ - may hear a "hum" r/t collateral circulation
Friction rub - in lungs r/t inflammation of the liver in proximity to lungs.
Term
Liver Disease Assessment:
LFTs
Definition
Serum enzymes
Serum proteins: albumin (3.5-5 normal) and total serum protein
Prothrombin time: 10-15 seconds (normal)
Ammonia level
Cholesterol
Bilirubin
Term
Post-procedure care: Liver Biopsy
Definition
Turn patient on RIGHT side: this creates pressure on the wound.
Monitor VS
Check site for hematoma
Check site for crepitus
Assess pain
No heavy lifting or strenuous activity for ONE week
Term
Crepitus
Definition
Rice Krispy crackling sound r/t air in the subcutaneous tissues.
Term
Hepatitis
Definition
Inflammation of the liver
Term
Fulminant Hepatic Failure
Definition
Sudden and severely impaired liver function in a previously healthy person: may be related to a traumatic injury
Term
Development of Fulminant Hepatic Failure
Definition
Within 2-3 weeks of the first symptoms
One thing leads to another: all happens quickly
Can lead to multi-organ system failure
Term
Fulminant Hepatic Failure: First symptoms
Definition
Jaundice
Anorexia
Term
Cirrhosis
Definition
Illness characterized by fibrosis of the liver tissue leading to
*Decreased mass
*Impaired liver function
*Altered blood flow
Term
Cirrhosis: Pathophysiology
Definition
1. Functional liver tissue is gradually destroyed and replaced by fibrous scar tissue
2. As hepatocytes and liver lobules are destroyed, metabolic functions of the liver are lost
3. Amount of scar tissue exceeds that of functional tissue
4. Flow of blood, lymphatic fluid and bile is impeded.
Term
Cirrhosis: Stages
Definition
1. Fatty liver
2. Liver fibrosis
3. Full cirrhosis
Term
Fatty liver: Prognosis
Definition
*Deposits of fat cause liver enlargement
*Strict abstinence can lead to a full recovery
Reversible stage if patient abstains from alcohol
Term
Liver Fibrosis: Prognosis
Definition
Scar tissue forms
Recovery is possible but scar tissue remains
Term
Cirrhosis: Prognosis
Definition
Growth of connective tissue destroys liver cells
Damage is irreversible
Term
Portal Hypertension
Definition
Increased pressure in the portal system causes blood to be re-routed to adjoining lower pressure vessels.
This is a shunting of blood that involves collateral vessels.
Term
Result of Portal Hypertension
Definition
Affected veins engorge and congest:
Esophageal varices
Umbilical vein varices: caput medusae
Hemorrhoids
Enlarged superior rectus veins
Term
Portal Hypertension: Pathophysiology
Definition
Hydrostatic pressure in the vessels of the portal system increases:
Capillary pressure pushes fluid out: it has to go somewhere
Ascites formation occurs (fluid shifts)
Term
Compensated Cirrhosis
Definition
Beginning stages when body is still trying to compensate for fibrotic blockages (probably not reversible at this point)
Term
Compensated Cirrhosis: S/S
Definition
VAGUE
I FEEL A PISS (*my apologies for using this language!)
I - Indigestion
F - Flatulent dyspepsia
E - Edema: peripheral
E - Erythema: palmar
L - Liver enlargement upon exam
A - Altered bowel function
P - Pain: abdominal
I - Intermittent fevers
S - Spider veins: vascular
S - Splenomegaly
Term
Decompensated Cirrhosis
Definition
Patient is very sick.
Low survival rate: poor prognosis
Term
Decompensated Cirrhosis: S/S
Definition
*Clotting issues: purpura, spontaneous bruising, epistaxis
*Jaundice
*Ascites
*Nutritionally compromised: weight loss, weakness, muscle wasting
*Circulation issues: clubbing of fingers, white nails
*Mild fevers
*Hypotension
*Liver decreases in size
*Gonadal atrophy
*Sparse body hair
*Fetor hepaticus
*LOC changes
*Renal failure
Term
Asterixis
Definition
Liver flap
Can't control hands
Term
Constructional apraxia
Definition
The inability to draw or construct simple configurations
Term
Cirrhosis: Diagnostic Findings
Definition
Elevated labs:
*Alkaline phosphatase
*LFTs
*Bilirubin
*Ammonia
*Prolonged prothrombin time (elevated)
Blood dyscrasias
Electrolyte imbalances
Term
Fetor Hepaticus
Definition
Breath of the dead
Foul-smelling breath r/t high ammonia levels
Term
Paracentesis
Definition
Aspiration of fluid from abdominal cavity
Term
Therapeutic benefit of paracentesis
Definition
Relieves ascites that doesn't respond to diuretic therapy
May withdraw fluid in moderate amounts
Large volume withdrawal: be careful, if you take off more than 4-6 liters at one time you may get hypovolemia
(May administer albumin by IV during a large-volume procedure)
Term
Paracentesis: Procedure
Definition
1. Verify informed consent (invasive procedure)
2. Describe procedure
3. Weight and measure abdominal girth prior to procedure
4. Assess baseline VS
5. Have patient VOID immediately prior to procedure
6. Position: seated, either on side of bed or in a chair with feet supported.
Term
Liver Trauma Clinical Manifestations
Definition
METER BATHH
M - muscle rigidity/spasms
E - elevated temp
T - tachycardia
E - elevated leukocytes
R - rebound tenderness
B - bowel sounds: absent or decreased
A - Abdominal pain
T - tachypnea
H - Hypotension
H - hemoglobin/hematocrit: decreased
Term
Pancreas Endocrine Function
Definition
Secrete glucagon
Secrete insulin
Term
Pancreas Exocrine Function
Definition
Produce digestive enzymes
Produce alkaline fluid
Produce fluid rich in proteins and electrolytes
Term
Pancreatitis
Definition
Inflammation of the pancreas with auto-digestion
Term
Auto-digestion of pancreas
Definition
Release of pancreatic enzymes into the tissue of the pancreas itself leading to:
Hemorrhage
Necrosis
Term
Acute pancreatitis
Definition
Spontaneous and more correctable
Milder form of acute:
* Inflammation
* Edema of pancreatic tissue
* Self-limiting
Term
Necrotizing pancreatitis
Definition
More severe form of acute:
Inflammation
Hemorrhage
Death of tissue
Term
Acute pancreatitis S/S
Definition
Pain
N/V
Fever
Jaundice
Turner's sign
Cullen's sign
Left pleural effusion
Respiratory distress
Hypotension
Shock
DIC
Renal failure
Term
Chronic pancreatitis
Definition
Longer illness; patient is sicker
Continual inflammation
Fibrosis
Gradual destruction of functional pancreatic tissue
Irreversible process leading to pancreatic insufficiency
Term
Chronic pancreatitis: Clinical Manifestations
Definition
Severe upper abdominal pain
** May be left upper pain that radiates to the back
N/V
Weight loss
Steatorrhea
Term
Chronic pancreatitis: Labs/Diagnostics
Definition
Serum amylase and WBC may NOT be significantly elevated
Hyperglycemia
ERCP most useful diagnostic study
CT scan
Ultrasound
Term
Chronic pancreatitis: Treatment
Definition
NO alcohol
Pain control
Low-fat diet
Insulin therapy
Consistent calorie diet
Exogenous pancreatic enzymes
Surgery
Term
Common causes of pancreatitis
(www.acutepancreatitis.org)
Definition
GET SMASHHHED
G - gallstones
E - ethanol (ETOH)
T - Trauma to pancreas
S - Steroid use
M - mumps
A - autoimmune
S - scorpion sting (venom)
H - hypercalcemia
H - hyperlipidemia
H - hypothermia
E - ERCP
D - Drugs
Term
Pancreatitis: Etiology and Risk Factors
(Ms. Moorman's List)
Definition
Alcoholism
Bacteria
Cystic fibrosis
Drugs
Gallstones
Hereditary pancreatitis
Hypercalcemia
Hyperlipidemia
Ischemia of pancreas
Parasites
Trauma
Viruses
Term
Treatment for acute pancreatitis
Definition
No alcohol
Choleycystectomy: remove the gallbladder
NPO
NG tube: if there is a lot of drainage
Suppress pancreatic exocrine function
Re-introduce clear liquids after pain is resolved
Bed rest
Term
Patient support for pancreatitis
Definition
Pain relief: IV morphine
F/E balance
Nutritional support: possibly TPN
Insulin administration for hyperglycemia
Pancrease: pancreatic enzyme replacement
Term
Hepatitis strains caused by an RNA virus
Definition
Hep A
Hep C
Term
Hepatitis strains caused by a DNA virus
Definition
Hep B
Term
Hepatitis A: Incubation
Definition
15-50 days (average 30)
[Text says 2-6 weeks]
Term
Hepatitis B: Incubation
Definition
1-6 months
[Text says 6-24 weeks]
Term
Hepatitis C: Incubation
Definition
15-160 days
[Text says 5-12 weeks]
Term
Hepatitis A: Duration
Definition
4-8 weeks
Term
Hepatitis B and C: Duration
Definition
Most recover in 6 months
Term
Hepatitis A: outcome
Definition
Usually a full recovery
Active immunity
Term
Hepatitis B: outcome
Definition
1-10% mortality
Increased risk:
Liver cancer
Cirrhosis
Active immunity OR may become a carrier
Term
Hepatitis C: outcome
Definition
Only 15% resolve
Most become chronic active hepatitis state
Increased risk:
Liver cancer
Cirrhosis
NO immunity: increased chronic carrier state
Term
Hepatitis A: Prevention
Definition
Vaccine
Immune globulins
HANDWASHING
Term
Hepatitis B: Prevention
Definition
Vaccine
Immune globulins
Universal precautions
NO sharing: personal hygiene items
Condom use
Autologous blood use (in transfusions, blood products)
Donor screening
Term
Hepatitis C: Prevention
Definition
Latex condoms may reduce transmission
Get vaccines for other two strains
Term
Hepatitis A: Manifestations
Definition
Anorexia: often the first symptom
Vague: mild, flu-like
Low-grade fever
Fatigue, malaise
Dyspepsia
Headache
Aversion to strong odors
Jaundice
Hepatomegaly/splenomegaly with tenderness
Term
Hepatitis B: Manifestations
Definition
Prodromal period:
Urticaria/rashes
Arthralgias
Serum sickness
Glomerularnephritis
Actual disease may be asymptomatic
Term
Hepatitis C: Manifestations
Definition
Usually asymptomatic
If symptoms: mild and nonspecific
Often recognized long after exposure
Term
Hepatitis A: Medical management
Definition
Reduce: fatigue and pruritis, and N/V
Lots of rest!!
Light, frequent meals: maintain nutrition
F/E balance
AVOID tylenol, ETOH
Term
Hepatitis B: Medical management
Definition
Evaluation for liver disease every 6-12 months
Antiviral medications, Alpha interferon
Avoid tylenol, ETOH
Term
Hepatitis C: Medical management
Definition
NO benefits from rest/diet
*Ribavirin
*Interferon
Avoid tylenol, ETOH
Term
Hepatitis A: Transmission
Definition
Fecal/oral
Term
Hepatitis B: Transmission
Definition
Blood
Body fluids
High risk:
*IV drug users
*Multiple sexual partners
*Male/male sexual activity
*Healthcare workers
Term
Hepatitis C: Transmission
Definition
Blood/body fluids
Primary risk factor: IV drug use (50% of ALL new infections)
Tattoos, piercings
Not usually transmitted through sexual activity
Term
Lactulose
Definition
Given for Hepatic Encephalopathy
Binds with excess ammonia and can be excreted in the stool
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