CHAPTER 48 Liver, Biliary Tract, and Pancreas Problems

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. How would the nurse respond?

“You will need to be tested first; then treatment can be determined.”

“The hepatitis vaccine will provide immunity from this and future exposures.”

“There is nothing you can do since the patient was infectious before admission.”

“An immunoglobulin injection will be given to prevent infection or limit symptoms.”

An immunoglobulin injection will be given to prevent infection or limit symptoms.”

Rationale:

Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure.

It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

The nurse is caring for a patient recently diagnosed with viral hepatitis A. Which person would the nurse refer for an immunoglobulin (IG) injection?

A friend who delivers meals to the patient and family each week

A relative with a history of hepatitis A who visits the patient daily

A child living in the home who received the hepatitis A vaccine 3 months ago

A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient

A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient

Rationale:

IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure.

Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

Which patient has the highest risk for developing pancreatic cancer?

A 72-yr-old black man who has smoked cigarettes for 50 years

A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia

A 19-yr-old woman with a 5-year history of uncontrolled type 1 diabetes

A 23-yr-old man with cystic fibrosis–related pancreatic enzyme insufficiency

A 72-yr-old black man who has smoked cigarettes for 50 years

Rationale:

Risk factors for pancreatic cancer include chronic pancreatitis, diabetes, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine.

Blacks have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer compared with nonsmokers. The risk is related to the duration and number of cigarettes smoked.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.)

Hepatocytes are unable to convert ammonia to urea.

Osmoreceptors in the hypothalamus stimulate thirst.

An enlarged spleen removes blood cells from the circulation.

Portal hypertension causes leaking of protein and water into the peritoneal cavity.

Aldosterone is released to stabilize intravascular volume by saving salt and water.

Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

Portal hypertension causes the leaking of protein and water into the peritoneal cavity.

Aldosterone is released to stabilize intravascular volume by saving salt and water.

The inability of the liver to synthesize albumin reduces intravascular oncotic pressure.

Rationale:

Ascites related to cirrhosis are caused by decreased colloid oncotic pressure.

The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces.

Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity.

Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention.

Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse’s priority in planning care?

Prevent all oral intake.

Control abdominal pain.

Provide enteral feedings.

Avoid dietary cholesterol.

Control abdominal pain.

Rationale:

Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated.

NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Patients with pancreatitis may be NPO. Enteral feedings would not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.

The patient with suspected pancreatic cancer is having many diagnostic studies done. Which test can be used to establish the diagnosis of pancreatic cancer and for monitoring the response to treatment?

Spiral CT scan

A PET/CT scan

Abdominal ultrasound

Cancer-associated antigen 19-9

Cancer-associated antigen 19-9

Rationale:

Cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used to diagnose pancreatic cancer and monitor the response to treatment.

Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the positron emission tomography (PET)/CT scan or abdominal ultrasonography do not provide additional information.

A patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After a comprehensive evaluation, which finding is a contraindication for liver transplantation?

History of hypothyroidism

Stopped smoking cigarettes

Well-controlled type 1 diabetes

Chest x-ray shows a new lung cancer lesion

Chest x-ray shows a new lung cancer lesion

Rationale:

Contraindications for liver transplant include severe extra-hepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol use, and the inability to comprehend or comply with the rigorous post-transplant course.

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has a serum amylase level of 480 U/L and a serum lipase level of 610 U/L. Which diagnosis does the nurse expect?

Starvation

Pancreatitis

Systemic sepsis

Diabetic ketoacidosis

Pancreatitis

Rationale:

The patient with chronic alcohol use could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30 to 122 U/L) and serum lipase (normal, 31 to 186 U/L) levels as shown.

When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information would the nurse include?

Do not return to work or normal activities for 3 weeks.

A low-fat diet may be better tolerated for several weeks.

Bile-colored drainage will probably drain from the incision.

Keep the bandages on and the puncture site dry until it heals.

A low-fat diet may be better tolerated for several weeks.

Rationale:

Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks after surgery.

Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

The nurse is reviewing self-care for a patient with cirrhosis. Which statement indicates the patient needs further teaching?

“A scrotal support may be more comfortable when I have scrotal edema.”

“I need to take good care of my belly and ankle skin where it is swollen.”

“I can use pillows to support my head to help me breathe when I am in bed.”

“If I notice a fast heart rate or irregular beats, this is normal for cirrhosis.”

If I notice a fast heart rate or irregular beats, this is normal for cirrhosis.”

Rationale:

If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and would be reported to the healthcare provider because this is not normal for cirrhosis.

Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler’s or Fowler’s position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

A patient with cholelithiasis is being prepared for surgery. Which assessment finding is a contraindication for a cholecystectomy?

Low-grade fever of 100°F and dehydration

Abscess in the right upper quadrant of the abdomen

Multiple obstructions in the cystic and common bile duct

Activated partial thromboplastin time (aPTT) of 54 seconds

Activated partial thromboplastin time (aPTT) of 54 seconds

Rationale:

An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely.

Fluids can be given to eliminate the dehydration. The abscess can be assessed during surgery, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements? (Select all that apply.)

Vitamin A

Vitamin B

Vitamin D

Vitamin E

Vitamin K

Vitamin A

Vitamin D

Vitamin E

Vitamin K

Rationale:

Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.

The nurse teaches a patient about cholestyramine to reduce pruritus caused by gallbladder disease. Which statement indicates understanding of the instructions?

“This medication will help me digest fats and fat-soluble vitamins.”

“I will apply the medicated lotion sparingly to the areas where I itch.”

“The medication is a powder and needs to be mixed with milk or juice.”

“I should take this medication on an empty stomach at the same time each day.”

“The medication is a powder and needs to be mixed with milk or juice.”

Rationale:

For treatment of pruritus, cholestyramine may provide relief.

This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order would the nurse question?

Tramadol

Hydromorphone (Dilaudid)

Hydrocodone with acetaminophen

Oxycodone with aspirin (Percodan)

Hydrocodone with acetaminophen

Rationale:

The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective?

“Lactulose should be taken every day to prevent constipation.”

“It is not safe to take acetaminophen up to four times a day for pain.”

“Herbs and other spices should be used to season my foods instead of salt.”

“I will eat foods high in potassium while taking spironolactone (Aldactone).”

“Herbs and other spices should be used to season my foods instead of salt.”

Rationale:

A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided.

Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices.

Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective?

Relief of constipation

Relief of abdominal pain

Decreased liver enzymes

Decreased ammonia levels

Decreased ammonia levels

Rationale:

Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels.

Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.

An additional finding may be an improvement in level of consciousness.

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting is diagnosed with acute pancreatitis. Which intervention would the nurse include in the plan of care?

Immediately start enteral feeding to prevent malnutrition.

Insert an NG and maintain NPO status to allow pancreas to rest.

Initiate early prophylactic antibiotic therapy to prevent infection.

Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Insert an NG and maintain NPO status to allow the pancreas to rest.

Rationale:

Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal.

Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for patients with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.

The nurse is caring for a patient with acute pancreatitis from gallstones. Which clinical manifestations would the nurse expect? (Select all that apply.)

Hematochezia

Nausea and vomiting

Hyperactive bowel sounds

Left upper abdominal pain

Ascites and peripheral edema

Temperature 99.3°F (37.4°C)

Nausea and vomiting

Left upper abdominal pain

Temperature 99.3°F (37.4°C)

Rationale:

Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis.

Other manifestations include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice.

Abdominal tenderness with muscle guarding is common.

Bowel sounds may be decreased or absent. Ileus may occur and cause marked abdominal distention.

Areas of cyanosis or greenish-to-yellow-brown discoloration of the abdominal wall may occur.

Other areas of ecchymoses are the flanks (Grey Turner’s spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen’s sign, a bluish periumbilical discoloration).

The nurse is caring for a patient recently diagnosed with viral hepatitis A. Which person would the nurse refer for an immunoglobulin (IG) injection?

A friend who delivers meals to the patient and family each week

A relative with a history of hepatitis A who visits the patient daily

A child living in the home who received the hepatitis A vaccine 3 months ago

A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient

A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient

Rationale:

IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure.

Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

When planning care for a patient with cirrhosis, which clinical problem is the highest priority?

Fluid imbalance

Impaired tissue integrity

Impaired nutritional status

Ineffective breathing pattern

Ineffective breathing pattern

Rationale:

Although all these clinical problems are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill. How would the nurse respond?

“You will need to be tested first; then treatment can be determined.”

“The hepatitis vaccine will provide immunity from this and future exposures.”

“There is nothing you can do since the patient was infectious before admission.”

“An immunoglobulin injection will be given to prevent infection or limit symptoms.”

“An immunoglobulin injection will be given to prevent infection or limit symptoms.”

Rationale:

Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure.

It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would best determine if the patient has developed liver cancer?

MRI scanning

Serum α-fetoprotein level

Ventilation/perfusion scan

Abdominal girth measurement

MRI scanning

Rationale:

Hepatic ultrasonography, CT scan, and MRI scanning are used to screen for and diagnose liver cancer.

Serum α-fetoprotein level may be elevated with liver cancer or other liver problems.

Ventilation/perfusion scans are used to diagnose pulmonary emboli. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.)

Provide a high-protein, low-carbohydrate diet.

Tell the patient to use soft-bristle toothbrush and electric razor.

Teach the patient to avoid vigorous blowing of nose and coughing.

Apply gentle pressure for the shortest possible time after venipuncture.

Use the smallest gauge needle possible when giving injections or drawing blood.

Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs).

Tell the patient to use soft-bristle toothbrush and electric razor.

Teach the patient to avoid vigorous blowing of nose and coughing.

Use the smallest gauge needle possible when giving injections or drawing blood.

Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs).

Rationale:

Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues.

Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites.

The nurse would apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding.

Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.

A low-salt, low-protein, high-carbohydrate diet may be recommended.

Which patient has the highest risk for developing pancreatic cancer?

A 72-yr-old black man who has smoked cigarettes for 50 years

A 38-yr-old Hispanic woman who is obese and has hyperinsulinemia

A 19-yr-old woman with a 5-year history of uncontrolled type 1 diabetes

A 23-yr-old man with cystic fibrosis–related pancreatic enzyme insufficiency

A 72-yr-old black man who has smoked cigarettes for 50 years

Rationale:

Risk factors for pancreatic cancer include chronic pancreatitis, diabetes, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine.

Blacks have a higher incidence of pancreatic cancer than whites.

The most firmly established environmental risk factor is cigarette smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer compared with nonsmokers.

The risk is related to the duration and number of cigarettes smoked.

After teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process?

“I will use care when kissing my wife to prevent giving it to her.”

“I will need to take adefovir (Hepsera) to prevent chronic HCV.”

“Now that I have had HCV, I will have immunity and not get it again.”

“I will need to be monitored for chronic HCV and other liver problems.”

“I will need to be monitored for chronic HCV and other liver problems.”

Rationale:

Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer.

HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity.

The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration.

Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure.

HCV is treated with oral direct-acting antivirals (DAAs).

Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.