L3 Hepatobiliary and Pancreatic problem

p.5-10, 12-13, 30-34 physiology skipped

Which gallbladder disease does the following description refers to ?

• Steady RUQ/epigastric pain;

• no fever/infection.

Biliary Colic

What is the primary mechanism of Biliary Colic

Transient blockage of the cystic duct by a stone.

Which gallbladder disease does the following description refers to ?

• Persistent RUQ pain, fever,

• positive Murphy’s sign.

1. Assess RUQ pain / tenderness

2. Press your fingertips under the liver border at the right costal margin

3. Ask the client to inhale deeply

4. Note the degree of tenderness

+ve Murphy’s sign: Sharp pain that causes the client to hold the breath (inspiratory arrest 吸氣停止)

Cholecystitis

What is the primary mechanism of Cholecystitis

Prolonged blockage of the cystic duct; gallbladder becomes inflamed/infected.

Which gallbladder disease does the following description refers to ?

• Pain + Jaundice

Choledocholithiasis

What is the primary mechanism of Choledocholithiasis

Stone in the Common Bile Duct (CBD).

Which gallbladder disease does the following description refers to ?

• Charcot’s Triad:

  • Fever, Jaundice, RUQ pain.

Cholangitis

What is the primary mechanism of Cholangitis

Infected obstruction of the CBD.

Which gallbladder disease does the following description refers to ?

• Severe epigastric pain radiating to back; elevated pancreatic enzymes.

Biliary Pancreatitis

What is the primary mechanism of Biliary Pancreatitis

Stone blocks the pancreatic duct outflow.

Which gallbladder disease is a clinical emergency (Life-threatening)

Cholangitis

• Infected obstruction of the CBD.

• Charcot’s Triad:

  • Fever, Jaundice, RUQ pain.

In LFT, what does the marker “ Bilirubin” indicates ?

• a marker of haem catabolism

  • The level of conjugated (direct) bilirubin reflects biliary obstruction,

  • unconjugated (indirect) bilirubin is a reflection of haemolysis

In LFT, what is “ Albumin, prothrombn” ?

markers of protein synthesis.

In LFT, what does the marker “Bilirubin” (total ± direct) indicates / reflect?

jaundice severity (production, processing, or drainage problem)

In LFT, what does the marker “Albumin + INR (PT)” indicates / reflect?

synthetic liver function (severity/chronicity)

In LFT, what does the marker “ Transaminases” refers to & indicates?

Serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

• markers of hepatocellular damage

• “cell leak” enzymes

In LFT, what does the marker “ ALP, GGT” indicates ?

Hepatic alkaline phosphatase (ALP) and γ-glutaryl transpeptidase levels (GGT)

• reflect cholestasis / bile duct obstruction (bile flow problem)

• ALP could also be raised in bone disease

In LFT, what does the marker “Urea and anmmonia” indicates?

markers of protein catabolism

In LFT, what does the marker “Haemoglobin” indicates? (2)

• anaemia associated with chronic bleeding from oesophageal varices;

• macrocytosis associated with abnormal lipid synthesis, which occurs in alcoholism

In LFT, what does the marker “Cholesterol & triglycerides” indicates?

reflect abnormal lipid metabolism

In LFT, what does the marker “Immunoglobulins” indicates?

• raised concentrations reflect the reduced phagocytosis of absorbed antigen by Kupffer cells

  • Kupffer cells phagocytose and catalyze bacterial and other antigens absorbed from the GI tract

• resulting in increased activity at other antibody-producing sites

In LFT, what does the marker “alpha 1 antitrypsin” indicates?

deficiency associated with cirrhosis

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a protective protein made by the liver that travels through the bloodstream to shield the lungs from destructive inflammatory enzymes

In LFT, what does the marker “Alpha fetoprotein” indicates?

marker of hepatocellular carcinoma

In LFT, what is the purpose of checking drug half-life

sometimes measured where drug metabolism is compromised

A patient has jaundice and pruritus.
Which lab pattern most strongly suggests biliary obstruction?

ALP ↑↑ + GGT ↑↑ with direct (conjugated) bilirubin ↑, ALT/AST mild–moderate ↑

First nursing priority in a cirrhotic patient with confusion:

Perform an ABCD assessment, check vital signs + capillary blood glucose, and assess for immediate deterioration

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• Airway: Is the patient protecting it? Aspiration risk? GCS trend

  • if drowsy/vomiting → side position, suction ready,

    consider NBM.

• Breathing: RR, SpO2, work of breathing; give O2 if needed.

• Circulation: BP, HR, perfusion, temperature; consider sepsis screening.

• Disability: Capillary blood glucose (fast, reversible), GCS/AVPU, pupils.

• Exposure: Look for bleeding, infection sources, trauma, needle marks

Put on monitoring: SpO2, ECG, BP cycling, temperature

What will you suspect / think about if the patient show confusion ?

• Hypoxia, hypotension/shock, sepsis, hypoglycaemia, drug toxicity,

  intracranial event, or HE.

  • Stabilize and rule out immediately reversible threats first

When assessing the airway, if GCS is = / < 7, what will we consider ?

Intubation

What is the nursing priority for a cirrhosis patent with confusion after performing the ABCDE assessment ?

Establish IV access and prepare fluid

• because hypotension will become more difficult to set up IV HB

What is the purpose of giving lactulose in manageing a cirrhotic patient with confusion ? Suggest whether it is appropriate to be the first priority decision/

• Lactulose is appropriate if hepatic encephalopathy is likely, but after initial stabilization

• if reduced consciousness or aspiration risk

  →oral lactulose may be unsafe without airway assessment

• If severe HE, may need NG administration under appropriate precautions

Explain the use of lactulose in treating hepatic encephalopathy

• Non-absorbable disaccharide that acidifies the colon, converting ammonia (NH3) to ammonium (NH4+) and reducing absorption

• Dose: 20–30 mL orally every 1–2 hours until 2–3 soft stools/day

• Rectal enema: For Grade III/IV HE or when oral route not possible

What is the purpose of urgent CT brain in manageing a cirrhotic patient with confusion ? Suggest whether it is appropriate to be the first priority decision/

• Consider CT if: head trauma/fall, focal neurology, anticoagulation, sudden severe headache, seizure etc..

• Still: stabilize first (ABCD) before transport/imaging.

What is the purpose of start rifaximin in manageing a cirrhotic patient with confusion ? Suggest whether it is appropriate to be the first priority decision/

• adjunct, not first-line in acute moment

• It is usually add-on for recurrent HE or after lactulose.

• Not an immediate “first priority” action in an unstable/confused patient.

Explain the use of rifaximin in treating hepatic encephalopathy

• Antibiotic with minimal absorption in the gastrointestinal tract

  • resulting in high concentrations within the intestines

• reduce ammonia production by targeting and eliminating ammonia-producing

  bacteria in the colon

  • works by binding to bacterial DNA-dependent RNA polymerase, inhibiting bacterial RNA synthesis

• often considered for patients who do not respond to lactulose / those who

  experience intolerance

Describe the pathophysiology of Hepatic Encephalopathy

• Ammonia that results from bacterial and enzymatic deamination

  of amino acids in the intestines normally goes to the liver via

  the portal circulation where it is converted to urea, and to be excreted by the kidney

• When blood is shunted past the liver via the collateral vessels or the

  liver is so damaged that it is unable to convert ammonia to urea

• Ammonia levels in the systemic circulation increase & accumulate

• The ammonia crosses the blood-brain barrier and produces neurologic manifestations.

  • neurotoxic effects of ammonia includes: abnormal

    neurotransmission, astrocyte swelling, and inflammatory cytokines

List & explain the risk factors of Hepatic Encephalopathy (10)

Cerebral depressants (e.g., opioids)	↓ Metabolism by liver, causing ↑ drug levels and cerebral depression
Constipation	↑ Ammonia production from bacterial action on feces
Dehydration / diuretic overuse	Potentiates ammonia toxicity
GI bleeding	↑ Ammonia in GI tract
Hypokalemia	Potassium needed by brain to metabolize ammonia
Hypovolemia	↑ Ammonia because of hepatic hypoxia Impaired cerebral, liver, and renal function because of ↓ blood flow
Infection	↑ Metabolic rate and cerebral sensitivity to toxins
Metabolic alkalosis	Facilitate transport of ammonia across blood-brain barrier , ↑ Renal production of ammonia
↑ Metabolism	↑ Workload of liver
Uremia (renal failure)	Retention of nitrogenous metabolites

List the nursing management after administrating lactulose in treating hepatic encephalopathy (4)

• LOC and mental status

• Bowel frequency (target 2–3/day)

• Electrolyte imbalances (especially potassium)

• Signs of dehydration

Suggest the s/s for Grade II Hepatic Encephalopathy

Confusion, lethargy, disorientation to time, and presence of asterixis (flapping tremor)

List the nutritional nursing management for hepatic encephalopathy (2)

• NO NEED protein intake restriction

  • should maintain protein intake at around 1.2 to 1.5 gm/kg/d.

• Small meals throughout the day to prevent fasting, which can increase ammonia production

Suggest the best diagnosis base on the following assessment findings: (+ explain why not the others conditions)

Acute Biliary Pancreatitis (most likely)

• Gallstones + dilated CBD + elevated enzymes

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Acute Cholangitis

• Jaundice + fever (though no fever yet)

Peptic Ulcer Perforation

• Less likely, no peritoneal signs

Hepatitis

• Unlikely with high lipase/amylase

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