Timby Ch. 47 Caring for Clients with Disorders of the liver, gallbladder, or pancreas

How many lobes does the liver have?

Four

Liver

Receives arterial blood from the hepatic artery

What makes up the common bile duct?

Hepatic duct and the cystic duct

Common bile duct

Empties into the small intestine (duodenum)

Sphincter of Oddi

Controls the amount of bile into the small intestine (duodenum)

Changes of the liver with aging

Decreased organ weight, blood flow, and size and number of hepatocytes; increase in fibrous tissue; and changes in metabolism of medications

Jaundice

greenish-yellow staining of tissues by bilirubin

What causes jaundice?

Abnormally high concentration of the pigment bilirubin in the blood

Functions of the liver

Metabolizes glucose; regulates blood glucose concentration; converts glucose to glycogen to maintain normal glucose levels; synthesizes amino acids from the breakdown of protein or lactate that muscles produce during exercise to form glucose; converts ammonia into urea; metabolizes proteins and fats; stores vitamins A, B12, D, and some B complex as well as iron and copper; metabolizes drugs, chemicals, bacteria, and other foreign elements; forms and excretes bile; excretes bilirubin; synthesizes factors needed for blood coagulation

Bilirubin

Produced in the liver, spleen, and bone marrow. Results from hemoglobin metabolism and is Abby product of hemolysis (RBC destruction)

Serum bilirubin leaves increase when:

There's excessive destruction of RBCs, or the liver cannot excrete bilirubin normally

2 forms of bilirubin

Indirect or unconjugated & direct or conjugated

Indirect or unconjugated bilirubin

Binds with protein as it circulates in the blood. Normally circulates in the blood when it's elevated

Direct or conjugated bilirubin

Circulates freely in the blood until reaching the liver. It's excreted in the bile

Test for indirect bilirubin levels

No direct test. They're calculated by subtracting direct bilirubin levels from total bilirubin levels

3 forms of jaundince

Hemolytic, hepatocellular, and obstructive

Hemolytic jaundice

Caused by excess destruction of RBCs

Hepatocellular jaundice

Caused by liver disease (damaged liver cells cannot clear normal amounts of bilirubin from the blood)

Obstructive jaundice

Caused by a block in the passage of bile between the liver and intestinal tract

Cirrhosis

Chronic, degenerative liver disorder caused by generalized cellular damage

What happens when bile drains into the intestine?

Client experiences malabsorption and an inability to absorb fat soluble vitamins (A, D, E, and K)

Complications of advanced cirrhosis

Portal Hypertension, esophageal varices, ascites, and hepatic encephalopathy

3 types of cirrhosis

Alcoholic, postnecrotic, and biliary

Alcoholic cirrhosis

Most common type of cirrhosis, results from chronic alcohol intake and is frequently associated with poor nutrition. It can also follow chronic poisoning with certain chemicals or ingestion of hepatotoxic drugs. Characterized by necrotic liver cells, which are gradually replaced by scar tissue.

Postnecrotic cirrhosis

Results from destruction of liver cells secondary to infection, metabolic liver disease, or exposure to hepatotoxins or industrial chemicals

Biliary cirrhosis

Scarring occurs around the bile ducts in the liver. Usually related to chronic biliary obstruction and infection. Progressive autoimmune disease of the liver.

Compensated cirrhosis

Less severe sign of cirrhosis. Symptoms are more vague. As the disease progresses, it's referred to as decompensated cirrhosis

Signs and symptoms of decompensated cirrhosis

They're very pronounced and indicate liver failure.

Symptoms of cirrhosis

Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation, with accompanying weight loss. Many clients report clay colored or whitish stools as a result of no bile in the GI tract. May also report dark or "tea colored" urine from increased concentrations of urobilin. The abdomen may appear distended. Skin, sclera, or oral mucous membranes are jaundiced.

Caput medusae

Dilated veins over the abdomen with cirrhosis

Men with cirrhosis may have

Gynecomastia (enlarged breasts) because they can't fully metabolize estrogen, and they may have testicular atrophy

Palmar erythema

Bright pink palms from cirrhosis

Cutaneous spider angiomata

Tiny, spiderlike blood vessels from cirrhosis

Liver biopsy

Most conclusive diagnostic procedure to reveal hepatic fibrosis. Performed under mild sedation or through a surgical incision

What may place the client at high risk for hemorrhage?

Prolonged prothrombin time (PT) and low platelet count

IV administration of vitamin K or infusions of platelets

Treatment done before liver biopsy to reduce the risk of bleeding

Ultrasound scanning

May be done to distinguish the density of scar tissue and parenchyma cells

What's the cure for cirrhosis

No specific cure exists. Should try to relieve associated symptoms. An optimal diet and vitamin and nutritional supplements promote healing of liver cells.

Enteral or parenteral feedings

May be used to treat malnutrition

Vitamin K

Used to correct coagulopathy

Diet for cirrhosis

Restrict fat for Clients with fat malabsorption (steatorrhea); recommend high calorie diet for Clients with malnutrition, weight loss, or infection; carbohydrate controlled diet is used for Clients with diabetes or insulin resistance; and small, frequent meals

Altered ammonia metabolism

May be responsible for precipitating hepatic encephalopathy

Lactulose

Administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some client's.

Antacids or H2 receptor antagonists

May be used to reduce gastric disturbances and decrease the potential for GI bleeding

Potassiums sparing (PPIs)

Used to treat ascites

Signs of alcohol withdrawal

Increase in BP, pulse, and temperature.

What position should client be in after a liver biopsy

On the right side of the body

Portal system

Consists of gastric veins from the stomach, the mesenteric vein from the intestines, the splenic vein from the spleen and pancreas, and the portal vein. All these veins drain into and through the liver and out the hepatic veins into the inferior vena cava

Client & family teaching for cirrhosis

Follow diet recommended by the physician; consult a dietitian if you require a special diet; avoid alcohol, taking tranquilizers, or inhaling chemicals such as benzene or vinyl chloride; rest frequently; avoid exposure to people with known infections; continue skin care; avoid nonprescription drugs especially aspirin; be prepared for rejection as a blood donor; and contact physician immediately about vomiting of blood, tarry stools, extreme fatigue, yellow skin, light colored stools, or dark urine

Portal hypertension

When intrahepatic veins compress and blood backs up in portal system, which is the venous pathway through the liver

Signs and symptoms of portal hypertension

GI bleeding as evidenced by vomiting of blood, or black, tarry stools or bloody stools; ascites; and decreased platelets

How many lobes does the liver have?

Four

Liver

Receives arterial blood from the hepatic artery

What makes up the common bile duct?

Hepatic duct and the cystic duct

Common bile duct

Empties into the small intestine (duodenum)

Sphincter of Oddi

Controls the amount of bile into the small intestine (duodenum)

Changes of the liver with aging

Decreased organ weight, blood flow, and size and number of hepatocytes; increase in fibrous tissue; and changes in metabolism of medications

Jaundice

greenish-yellow staining of tissues by bilirubin

What causes jaundice?

Abnormally high concentration of the pigment bilirubin in the blood

Functions of the liver

Metabolizes glucose; regulates blood glucose concentration; converts glucose to glycogen to maintain normal glucose levels; synthesizes amino acids from the breakdown of protein or lactate that muscles produce during exercise to form glucose; converts ammonia into urea; metabolizes proteins and fats; stores vitamins A, B12, D, and some B complex as well as iron and copper; metabolizes drugs, chemicals, bacteria, and other foreign elements; forms and excretes bile; excretes bilirubin; synthesizes factors needed for blood coagulation

Bilirubin

Produced in the liver, spleen, and bone marrow. Results from hemoglobin metabolism and is Abby product of hemolysis (RBC destruction)

Serum bilirubin leaves increase when:

There's excessive destruction of RBCs, or the liver cannot excrete bilirubin normally

2 forms of bilirubin

Indirect or unconjugated & direct or conjugated

Indirect or unconjugated bilirubin

Binds with protein as it circulates in the blood. Normally circulates in the blood when it's elevated

Direct or conjugated bilirubin

Circulates freely in the blood until reaching the liver. It's excreted in the bile

Test for indirect bilirubin levels

No direct test. They're calculated by subtracting direct bilirubin levels from total bilirubin levels

3 forms of jaundince

Hemolytic, hepatocellular, and obstructive

Hemolytic jaundice

Caused by excess destruction of RBCs

Hepatocellular jaundice

Caused by liver disease (damaged liver cells cannot clear normal amounts of bilirubin from the blood)

Obstructive jaundice

Caused by a block in the passage of bile between the liver and intestinal tract

Cirrhosis

Chronic, degenerative liver disorder caused by generalized cellular damage

What happens when bile drains into the intestine?

Client experiences malabsorption and an inability to absorb fat soluble vitamins (A, D, E, and K)

Complications of advanced cirrhosis

Portal Hypertension, esophageal varices, ascites, and hepatic encephalopathy

3 types of cirrhosis

Alcoholic, postnecrotic, and biliary

Alcoholic cirrhosis

Most common type of cirrhosis, results from chronic alcohol intake and is frequently associated with poor nutrition. It can also follow chronic poisoning with certain chemicals or ingestion of hepatotoxic drugs. Characterized by necrotic liver cells, which are gradually replaced by scar tissue.

Postnecrotic cirrhosis

Results from destruction of liver cells secondary to infection, metabolic liver disease, or exposure to hepatotoxins or industrial chemicals

Biliary cirrhosis

Scarring occurs around the bile ducts in the liver. Usually related to chronic biliary obstruction and infection. Progressive autoimmune disease of the liver.

Compensated cirrhosis

Less severe sign of cirrhosis. Symptoms are more vague. As the disease progresses, it's referred to as decompensated cirrhosis

Signs and symptoms of decompensated cirrhosis

They're very pronounced and indicate liver failure.

Symptoms of cirrhosis

Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation, with accompanying weight loss. Many clients report clay colored or whitish stools as a result of no bile in the GI tract. May also report dark or "tea colored" urine from increased concentrations of urobilin. The abdomen may appear distended. Skin, sclera, or oral mucous membranes are jaundiced.

Caput medusae

Dilated veins over the abdomen with cirrhosis

Men with cirrhosis may have

Gynecomastia (enlarged breasts) because they can't fully metabolize estrogen, and they may have testicular atrophy

Palmar erythema

Bright pink palms from cirrhosis

Cutaneous spider angiomata

Tiny, spiderlike blood vessels from cirrhosis

Liver biopsy

Most conclusive diagnostic procedure to reveal hepatic fibrosis. Performed under mild sedation or through a surgical incision

What may place the client at high risk for hemorrhage?

Prolonged prothrombin time (PT) and low platelet count

IV administration of vitamin K or infusions of platelets

Treatment done before liver biopsy to reduce the risk of bleeding

Ultrasound scanning

May be done to distinguish the density of scar tissue and parenchyma cells

What's the cure for cirrhosis

No specific cure exists. Should try to relieve associated symptoms. An optimal diet and vitamin and nutritional supplements promote healing of liver cells.

Enteral or parenteral feedings

May be used to treat malnutrition

Vitamin K

Used to correct coagulopathy

Diet for cirrhosis

Restrict fat for Clients with fat malabsorption (steatorrhea); recommend high calorie diet for Clients with malnutrition, weight loss, or infection; carbohydrate controlled diet is used for Clients with diabetes or insulin resistance; and small, frequent meals

Altered ammonia metabolism

May be responsible for precipitating hepatic encephalopathy

Lactulose

Administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some client's.

Antacids or H2 receptor antagonists

May be used to reduce gastric disturbances and decrease the potential for GI bleeding

Potassiums sparing (PPIs)

Used to treat ascites

Signs of alcohol withdrawal

Increase in BP, pulse, and temperature.

What position should client be in after a liver biopsy

On the right side of the body

Portal system

Consists of gastric veins from the stomach, the mesenteric vein from the intestines, the splenic vein from the spleen and pancreas, and the portal vein. All these veins drain into and through the liver and out the hepatic veins into the inferior vena cava

Client & family teaching for cirrhosis

Follow diet recommended by the physician; consult a dietitian if you require a special diet; avoid alcohol, taking tranquilizers, or inhaling chemicals such as benzene or vinyl chloride; rest frequently; avoid exposure to people with known infections; continue skin care; avoid nonprescription drugs especially aspirin; be prepared for rejection as a blood donor; and contact physician immediately about vomiting of blood, tarry stools, extreme fatigue, yellow skin, light colored stools, or dark urine