Liver and Pancreas: Functions, Diseases, and Clinical Management

What is the primary role of the liver in glucose metabolism?

The liver regulates blood glucose levels by converting glucose to glycogen for storage and releasing it as needed, and by synthesizing glucose through gluconeogenesis.

What is ammonia converted into by the liver?

Ammonia (byproduct from protein) is converted into urea for excretion in urine.

What plasma proteins does the liver synthesize?

The liver synthesizes all plasma proteins except gamma-globulin, including albumin and blood clotting factors (vitamin K needed to make prothrombin and factors).

how does the liver help with fat metabolism

Fatty acids can be broken down to produce energy

What vitamins and mineral can be stored in liver

Vitamins A, B, D and several B-complex vitamins are stored in the liver.

What is the function of bile produced by the liver?

Bile aids in digestion and is stored in the gallbladder before being released into the intestines.

How is bilirubin excreted?

hepatocytes remove bilirubin from blood and converted into urobilinogen and eventually eliminated through urine

What is cirrhosis?

Cirrhosis is end-stage liver disease characterized by extensive degeneration of liver cells and results in replacement with scar tissue.

what are some factors that lead to liver destruction

excessive alcohol, malnourished with reduced protein intake

What are common causes of cirrhosis?

Common causes include chronic liver disease, Hepatitis C, nonalcoholic steatohepatitis (NASH), and alcohol-induced liver disease. Extreme diet, malabsorption, obesity

How is cirrhosis classified

by severity, increase in severity as disease progresses

What are the manifestations of compensated cirrhosis?

In compensated cirrhosis, it is early, blood tests may appear normal despite liver dysfunction. Less severe, vague symptoms, can be asymptomatic

What are the manifestations of decompensated cirrhosis

1 or more complications, late cirrhosis results from failure to synthesize proteins, clotting factors, and have portal hypertension

what are early manifestations of cirrhosis

fatigue, N/V, enlarged liver due to body compensating for issues

What is portal hypertension?

Portal hypertension is increased pressure in the liver's circulatory system, leading to complications like ascites and varices.

what are late manifestations of cirrhosis

jaundice, peripheral edema, ascites, skin lesions, hematologic disorders, endocrine disturbances, peripheral neuropathies

What are the hematologic problems associated with cirrhosis?

Hematologic problems include splenomegaly, thrombocytopenia, leukopenia, and anemia due to the liver's inability to produce clotting factors.

What endocrine issues can arise from cirrhosis in women?

Women may experience amenorrhea and vaginal bleeding due to hormonal imbalances.

What are esophageal varices?

Esophageal varices are enlarged veins at the lower end of the esophagus that develop due to collateral circulation from portal hypertension.

what is the treatment for prevention of hemorrhage of esophageal and gastric varices

avoid alcohol, aspirin, NSAIDS

Beta blockers reduce pressure and rupture risk

what is the treatment for bleeding of varices

•Manage airway

•PRBCs, FFP, vit K, PPI: Zantac

•Octreotide (less side effects) or vasopressin to decrease portal HTN

•Lactulose and rifaximin to prevent encephalopathy

•Antibiotics to prevent infection

•Endoscopy

•EVL, sclerotherapy, balloon tamponade

What is ascites, and how is it related to cirrhosis?

Ascites is the accumulation of fluid in the peritoneal cavity due to portal hypertension and impaired albumin synthesis.

Treatment for edema and ascites

Limit sodium to 2g a day

Albumin

Diuretics: Furosemide, Spironolactone

Paracentesis: monitor for low fluid volume

What neurological condition can arise from cirrhosis?

Hepatic encephalopathy can occur, characterized by impaired consciousness and behavioral changes due to increased serum ammonia.

What are the symptoms of hepatic encephalopathy?

Symptoms include impaired consciousness, inappropriate behavior, difficulty sleeping, and asterixis.

What is asterixis

sign in neuro exam for hepatic encephalopathy

Flapping tumors: common in arms and hands when extended forward

can indicate trending to a coma

Treatment for encephalopathy

Reduce ammonia with lactulose (patient will have bowel movements)

Safety: fall risk due to impaired LOC

Assess LOC q2h

assess response to meds

minimize prevent constipation

what causes jaundice

results from decreased ability to conjugate and excrete bilirubin that can be due to obstruction of bile ducts causing yellow skin and sclera eyes

why are skin lesions developed in cirrhosis patients and what type of lesions

lesions due to increased estrogen levels as liver is unable to metabolize hormones

- spider angiomas, palmar erythema

Why does peripheral edema occur in cirrhosis

Increased pressure from portal and fluid overload due to loss of albumin, need diuretics to remove fluid

What is hepatorenal syndrome

renal failure development due to liver disease, no structural changes to kidneys

What dietary changes are recommended for patients with cirrhosis?

Patients are advised to avoid alcohol and may require adjustments in protein intake to manage symptoms.

What is the relationship between cirrhosis and peripheral neuropathy?

Peripheral neuropathy is common in alcoholic cirrhosis and is often related to B vitamin deficiencies.

What is the significance of bilirubin in liver function?

Bilirubin is a pigment derived from hemoglobin breakdown; the liver modifies it for excretion, and elevated levels indicate liver dysfunction.

What are the common diagnostic studies for cirrhosis?

Common diagnostic studies include liver function tests (ALT, AST, bilirubin), ultrasound, CT, MRI, and liver biopsy.

what is the goal of care in cirrhosis

Goal is to slow the progression of the cirrhosis and prevent complications.

Rest, administer vitamin B, avoid alcohol/ aspirin, Tylenol, NSAIDS

What is the impact of cirrhosis on blood clotting?

Cirrhosis leads to coagulation problems due to the liver's inability to produce prothrombin and other clotting factors.

What is the role of vitamin K in liver function?

Vitamin K is necessary for the synthesis of prothrombin and other clotting factors in the liver.

What is the relationship between cirrhosis and splenomegaly?

Cirrhosis can cause splenomegaly due to backup of blood into the spleen, leading to an overactive spleen.

What dietary changes are recommended for a patient with cirrhosis without complications?

High in calories (3000 cal/day), high carbohydrate, low fat, with protein restriction rarely needed

What is the recommended meal frequency for patients with ascites due to cirrhosis?

Small, frequent meals rather than large meals.

Low sodium, fluid restriction

What is the role of probiotic yogurt in cirrhosis management?

1-2 cups of probiotic yogurt three times a day can reduce intestinal flora imbalance by decreasing E. Coli counts.

What vitamin supplementation is advised for patients with cirrhosis?

Water-soluble forms of fat-soluble vitamins A, D, and E, along with folic acid and iron to prevent anemia.

When should protein restriction be considered in cirrhosis patients?

Only if hepatic encephalopathy develops that cannot be managed effectively with Lactulose and other treatments.

Paracentesis

surgical puncture to remove fluid from the abdomen usually those with ascites, position in high fowlers or sitting on side of bed

Monitor vitals for low BP, increased HR=hypovolemia

Monitor for electrolyte imbalances, infections

What are the main functions of the pancreas?

Digestive function (breaks down carbohydrates, fats, proteins, and neutralizes stomach acid) and endocrine function (secretes insulin, glucagon, and somatostatin).

What is acute pancreatitis?

Acute inflammation of the pancreas leading to blockage of pancreatic enzymes into tissue and causing autodigestion and severe pain, varying from mild edema to severe necrosis.

What is the most common cause of acute pancreatitis?

Gallstones (common in woman)

Chronic alcohol use in men

What are the manifestations of acute pancreatitis?

Severe pain in LUQ or mid epigastric, jaundice, nausea/vomiting, abdominal tenderness, low fever, and tachycardia.

What is a pseudocyst in the context of acute pancreatitis?

An accumulation of fluid, pancreatic enzymes, and debris surrounded by a wall, which can resolve spontaneously or perforate. Palpable mass on assessment

What is a pancreatic abscess

infected pseudocyst which can lead to necrosis, needs prompt surgery

signs: palpable mass with high fever, high WBC

What diagnostic tests are used for acute pancreatitis?

Abdominal ultrasound, X-ray, CT scan (best test), and ERCP.

What are laboratory tests for pancreatitis

Elevated amylase and lipase within 24 hrs.

- Elevated liver, triglycerides, glucose, bilirubin, WBC

Decreased calcium

What is the focus of chronic pancreatitis treatment?

Preventing attacks, pain relief, and controlling exocrine and endocrine insufficiency.

Pain relief for pancreatitis

IV morphine/Opiods

Antispasmodics for diarrhea

KEEP PATIENT NPO: eating makes pain worse, suppress enzymes

NGT

Position changes: flexed trunk and knees drawn to abdomen or side lying with HOB elevated

Prevention or alleviation of shock

•IVF and nutrient replacement

•Blood volume replacements: Albumin

•Central Venous Pressure (CVP) Monitoring

•Vasoactive drugs: Dopamine

How to decrease pancreatic enzymes

•NPO

•NG tube to low int. suctioning

•Antacids

GUT rest

Correction of F/E imbalances

•Aggressive IVF; nutrient replacement

•CVP

•Blood volume replacements

Nutrition therapy

Initial NPO status

Enteral or TPN depends on tolerance

Small frequent feedings when able to

Chronic pancreatitis

•Inflammatory disorder with progressive destruction of the pancreas due to alcohol/gallstones/tumors/cysts/autoimmune

Chronic obstructive pancreatitis

-Inflammation of sphincter of Oddi

-Cancer of ampulla of Vater, duodenum, or pancreas

Chronic nonobstructive pancreatitis

commonly caused by alcohol abuse which leads to inflammation and sclerosis

chronic pancreatitis manifestations

abdominal pain

Malabsorption, malnutrition

constipation

Jaundice, dark urine

Steatorrhea

diabetes

What dietary recommendations are made for patients with chronic pancreatitis?

Low-fat, high-carbohydrate diet with small, frequent feedings and no alcohol.

Pancrelipase (Pancrease)

pancreatic enzymes replacement, given with meals to help digest and absorb food and nutrients

What is choledochojejunostomy?

A surgical procedure that diverts bile around the ampulla of Vater to alleviate obstruction.

What is the significance of monitoring fluid and electrolytes in acute pancreatitis?

To prevent complications such as shock and to manage hydration status.

What is the purpose of NG tube suctioning in acute pancreatitis?

To decrease pancreatic secretions and relieve abdominal pressure.

What is the treatment for pancreatic abscess?

Prompt surgical drainage is required due to the risk of rupture and infection.

What should be monitored in patients with chronic pancreatitis?

Signs of malnutrition, pain levels, and complications such as pseudocysts.

What is the role of counseling in chronic pancreatitis management?

To encourage abstinence from alcohol and smoking, which can exacerbate the condition.

What is the importance of dietary teaching in chronic pancreatitis?

To help manage symptoms and prevent further damage to the pancreas.

What are the potential nursing interventions for acute pancreatitis?

Monitor vital signs, assess fluid and electrolytes, manage pain, and maintain NPO status.

What is the impact of alcohol on chronic pancreatitis?

Excessive and prolonged consumption can lead to progressive destruction of pancreatic tissue.