Ch. 48

Liver, Biliary Tract, and Pancreas Problems

Hepatitis Definition

Inflammation of the liver

Most Common Cause of Hepatitis

Viral infection

Non-Viral Causes of Hepatitis

Alcohol, medications, chemicals, autoimmune diseases, and metabolic problems

Hepatitis A Virus (HAV) Transmission Route

Fecal-oral route via contaminated food or drinking water

HAV Chronic Infection Risk

No chronic stage; acute and self-limiting

HAV Prevention Strategy

Personal/environmental hygiene, HAV vaccine, and post-exposure prophylaxis (IG)

Hepatitis B Virus (HBV) Transmission Route

Blood and body fluid exposure (perinatal, percutaneous, mucosal)

HBV High-Risk Populations

Men who have sex with men, hemodialysis patients, healthcare workers, IV drug users

HBV Prevention Strategy

Series of 3 IM vaccinations (Recombivax HB/Engerix-B) and HBIG post-exposure

Hepatitis C Virus (HCV) Transmission Route

Percutaneous exposure (IV drug use, high-risk sex, blood transfusions before 1992)

HCV Vaccination Status

No vaccine available for HCV

HCV Chronic Infection Progression

Majority of cases become chronic, leading to cirrhosis and liver failure

HCV Screening Recommendation

Screen all persons born between 1945 and 1965 (Baby Boomers)

Hepatitis D Virus (HDV) Requirement

Defective RNA virus that requires HBV to replicate

Hepatitis E Virus (HEV) Transmission Route

Fecal-oral route via contaminated drinking water in poor sanitation areas

Acute Hepatitis Incubation Symptoms

Anorexia, distaste for cigarettes, finding food repugnant, decreased sense of smell

Acute Hepatitis Physical Findings

Hepatomegaly, splenomegaly, lymphadenopathy, jaundice (icteric), dark urine, clay stools, pruritus

Convalescent Phase Manifestation

Begins as jaundice disappears; persistent malaise, fatigue, and hepatomegaly

Fulminant Hepatic Failure Definition

Rapid, severe, fatal acute liver failure leading to encephalopathy, DIC, and renal failure

Fulminant Hepatic Failure Primary Cure

Liver transplantation

Hepatic Encephalopathy Pathophysiology

Spectrum of brain dysfunction caused by liver failure to metabolize toxins, especially ammonia

Asterixis Definition

Flapping tremors of the hands and arms seen in hepatic encephalopathy

Apraxia in Hepatic Encephalopathy

Impairment in writing and difficulty moving pen from left to right

Fetor Hepaticus Definition

Musty, sweet odor of the patient's breath in liver failure

Hepatic Encephalopathy First-Line Drug

Lactulose (Cephulac); traps ammonia in gut and acts as a laxative

Rifaximin (Xifaxan) Role in Encephalopathy

Antibiotic given to decrease ammonia-producing intestinal bacteria

Cirrhosis Definition

End-stage liver disease marked by extensive liver cell destruction and fibrous nodular replacement

Most Common Causes of Cirrhosis in US

Chronic HCV, NASH (nonalcoholic steatohepatitis), and alcohol-induced liver disease

Compensated Cirrhosis Manifestations

Few early symptoms; fatigue and enlarged liver with normal LFTs

Decompensated Cirrhosis Manifestations

Jaundice, peripheral edema, ascites, portal hypertension, varices, hepatic encephalopathy

Spider Angiomas & Palmar Erythema Cause

Inability of the liver to metabolize steroid hormones, leading to increased circulating estrogen

Cirrhosis Hematologic Complications

Thrombocytopenia, leukopenia, anemia, and coagulation disorders (splenomegaly from portal HTN)

Cirrhosis Endocrine Effects in Males

Gynecomastia, loss of axillary/pubic hair, testicular atrophy, impotence, loss of libido

Peripheral Neuropathy Cause in Cirrhosis

Dietary deficiencies of thiamine, folic acid, and cobalamin (Vitamin B12)

Portal Hypertension Definition

Increased venous pressure in the portal circulatory system

Portal Hypertension Complications

Splenomegaly, collateral veins, ascites, and gastric/esophageal varices

Esophageal & Gastric Varices Risk

Fragile, enlarged veins that bleed easily; most life-threatening complication of cirrhosis

Esophageal Varices Bleeding Prevention Drug

Nonselective beta-blockers (e.g. propranolol) to reduce portal pressure

Acute Variceal Bleed Drug Therapy

Octreotide (Sandostatin) or Vasopressin to constrict splanchnic vessels

Endoscopic Variceal Ligation (EVL)

Banding procedure placed endoscopically around varices to stop active bleeding

Balloon Tamponade Safety Precaution

Keep scissors at the bedside for immediate airway cut if balloon migrates

Ascites Pathophysiology

Fluid accumulation in peritoneal cavity from portal HTN, low albumin (low oncotic pressure), and hyperaldosteronism

Ascites Management Interventions

Sodium restriction, diuretics (spironolactone/furosemide), albumin infusion, paracentesis, TIPS

Paracentesis Nursing Preparation

Have patient void immediately before procedure; place in high Fowler's position

TIPS Procedure Full Name & Purpose

Transjugular Intrahepatic Portosystemic Shunt; tract created between portal and hepatic vein to lower portal pressure

Hepatorenal Syndrome Definition

Functional renal failure with azotemia, oliguria, and intractable ascites without structural kidney damage

Pruritus Nursing Relief Measures

Cholestyramine/hydroxyzine, baking soda/Alpha Keri baths, cool lotions, rub skin with knuckles

Cirrhosis Nutritional Recommendations

High calorie (3000 cal/day), high carbohydrate, low fat, low sodium for ascites

Acute Pancreatitis Pathophysiology

Autodigestion of the pancreas caused by early activation of pancreatic enzymes (trypsinogen to trypsin)

Primary Etiology of Acute Pancreatitis in Women

Gallbladder disease (gallstones)

Primary Etiology of Acute Pancreatitis in Men

Chronic alcohol use

Acute Pancreatitis Classic Pain Description

Sudden, deep, piercing LUQ or epigastric pain radiating to back; worsened by eating and lying flat

Acute Pancreatitis Diagnostic Blood Markers

Elevated serum amylase and serum lipase

Primary Conservative Pain Relief for Pancreatitis

NPO status to suppress pancreatic secretions and minimize stimulation

Positions of Comfort for Acute Pancreatitis

Flexing trunk with knees drawn to abdomen, or side-lying with HOB elevated 45 degrees

Tetany Assessment Sign in Pancreatitis

Hypocalcemia causing tetany (Chvostek/Trousseau signs); treated with IV calcium gluconate

Acute Pancreatitis Nutritional Advancement

NPO initially, then enteral nutrition or low-fat, high-carbohydrate small frequent meals

Exogenous Pancreatic Enzyme Teaching

Take enzymes with every meal and snack to aid digestion in chronic/post-pancreatitis

Cholelithiasis Definition

Presence of gallstones in the gallbladder

Cholecystitis Definition

Inflammation of the gallbladder, usually associated with gallstone obstruction

Gallbladder Disease Risk Factors (4 Fs)

Female, Forty, Fertile (multiparity), Fat (obesity) / Estrogen therapy

Biliary Sludge Cause

Stasis of bile leading to supersaturation and precipitation of cholesterol/calcium

Cholecystitis Pain Characteristics

Steady, excruciating RUQ pain radiating to right shoulder/scapula; occurs 3 to 6 hours after fat meal

Obstructive Jaundice Manifestations

Dark amber urine, clay-colored stools, pruritus, steatorrhea, bleeding tendencies

Cholecystitis Complications

Gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis, peritonitis from rupture

Extracorporeal Shock-Wave Lithotripsy (ESWL)

High-energy shock waves used to disintegrate gallstones when endoscope fails

Laparoscopic Cholecystectomy Advantage

Treatment of choice; 1-4 small puncture holes, minimal pain, return to work in 1 week

Laparoscopic Post-Op CO2 Pain Relief

Sims' position (left side with right knee flexed), early ambulation, and deep breathing

Incisional Cholecystectomy Post-Op Tube

T-tube inserted into common bile duct to ensure duct patency and drain excess bile

Incisional Cholecystectomy First Nursing Action for Splinting

Administer prescribed analgesic prior to instructing coughing/deep breathing

Cholecystectomy Dietary Teaching

Low-fat, high-fiber diet; restrict fats for 4 to 6 weeks post-open incision