Liver, Biliary Tract, and Pancreas Problems

Liver, Biliary Tract, and Pancreas Problems

Instructor: Professor Michele Crabb, MSN, RN, Nurse Educator
Source: Chapter 48, Spring

Hepatitis

  • Inflammation of the liver

  • Most common cause: viral infections

    • Types of hepatitis: A, B, C, D, E

  • Hepatocytes targeted by:

    • Direct action of the virus

    • Cell-mediated immune response

  • Other causes of hepatitis:

    • Alcohol

    • Medications

    • Chemicals

    • Autoimmune diseases

    • Metabolic problems

Hepatitis A (HAV)

  • General Overview:

    • Self-limiting infection

    • Causes mild flu-like illness and jaundice

    • Transmitted primarily via fecal-oral route

    • Sources: contaminated food, milk, water, shellfish

  • Incubation and Infectious Period:

    • Incubation period: 15 to 50 days

    • Most infectious: 2 weeks before onset of symptoms

    • Remains infectious until 1-2 weeks after the onset of symptoms

  • Diagnostic Testing:

    • Presence of HAV IgM indicates acute hepatitis

Hepatitis A Risk Factors

  • Crowded living environments

  • Exposure to poor sanitation

  • Improper food handling

  • Homelessness

  • At-risk populations:

    • Drug users

    • Men who have sex with men (MSM)

    • Persons traveling to developing countries

Hepatitis A Prevention

  • Preventive Measures:

    • Strict handwashing

    • Avoid contaminated food and water

    • Follow universal precautions when handling stool and needles

  • Vaccination:

    • Hepatitis A vaccine; two doses needed

    • Doses: 6-12 months apart

  • Post-exposure prophylaxis:

    • Administer HAV vaccine and immune globulin (IG)

Hepatitis B (HBV)

  • General Overview:

    • Blood-borne pathogen

    • Can cause acute or chronic hepatitis

    • Incidence has decreased due to vaccination

  • Transmission:

    • Contact with infected blood or body fluids

    • Contact with contaminated needles

    • Hemodialysis

    • Sexual contact with infected partner

    • Perinatal transmission

  • Incubation and Infectious Period:

    • Incubation period: 60 to 180 days

    • Infectious before and after symptoms appear

    • Remains infectious for several months

    • Carriers can be infectious for life

Hepatitis B At-Risk Populations

  • Unprotected anal intercourse

  • Intravenous (IV) drug users

  • Dialysis patients

  • Health care personnel

  • Public safety workers

  • Blood product recipients

  • Prisoners, veterans, and homeless individuals

Hepatitis B Diagnostic Testing

  • Presence of hepatitis B surface antigen (HBsAg) in the blood indicates infection (contagious stage)

  • If HBsAg is present after 6 months, it indicates carrier or chronic hepatitis

  • Presence of antibodies to HBsAg indicates recovery and hepatitis B immunity

Hepatitis B Complications

  • Fulminant hepatitis (severe acute hepatitis)

  • Chronic liver disease (fibrosis)

  • Cirrhosis

  • Primary hepatocellular carcinoma

  • Increased comorbidities (e.g., cardiovascular disease, hypertension, renal disease, osteoporosis, hyperlipidemia)

Hepatitis B Prevention

  • Strict handwashing

  • Blood donor screening

  • Needle precautions

  • Avoid sexual contact with partners who test positive for HBsAg

  • Vaccination and Prophylaxis:

    • Hepatitis B vaccination available

    • Hepatitis B immune globulin for exposure if never had hepatitis B or prior vaccination

Hepatitis C (HCV)

  • General Overview:

    • Can result in acute illness and chronic infection

    • Most common among IV drug users and MSM with HIV infections

  • Transmission:

    • Contact with contaminated needles

    • Blood or body fluid exposure

    • Hemodialysis

    • Anal intercourse

  • Incubation and Infectious Period:

    • Incubation period: 2 weeks to 6 months

    • Infectious 1-2 weeks before symptoms appear and continues during the clinical course

    • 75%-85% of cases progress to chronic HCV and remain infectious

Hepatitis C At-Risk Populations

  • Parental drug users

  • Patients receiving frequent transfusions (especially pre-1992)

  • Healthcare personnel

  • MSM

  • Prisoners

Hepatitis C Diagnostic Testing

  • Positive antibody test (anti-HCV) indicates exposure

  • Positive viral load confirms active infection

Hepatitis C Complications

  • Chronic liver disease

  • Cirrhosis

  • Primary hepatocellular carcinoma

  • Prevention:

    • Strict handwashing

    • Needle precautions

    • No vaccine available

    • No postexposure prophylaxis

Hepatitis D (HDV)

  • Also called delta virus

  • Not common in the US

  • Causes infections only in the presence of active HBV infection

  • Transmission: Same as HBV

  • Incubation and Infectious Period:

    • Incubation period: 2 to 26 weeks

    • Infectious at all stages of HDV infection

Hepatitis D Testing

  • Serological testing for HDV includes detection of hepatitis D antigen (HDAg) early and anti-HDV antibody later in the disease

  • At Risk Populations: Same as HBV

  • Complications:

    • Chronic liver disease

    • Fulminant hepatitis

Hepatitis D Prevention

  • Same as hepatitis B prevention

  • Note: No vaccine for HDV

Hepatitis Pathophysiology

  • Acute Hepatitis:

    • Significant hepatocyte destruction

    • Restoration possible post-resolution

  • Chronic Hepatitis:

    • Continuous hepatocyte destruction leading to fibrosis, cirrhosis, liver failure, and death

Viral Hepatitis Manifestations

  • Acute Phase:

    • Duration: 1-6 months

    • Highly infectious period

    • Symptoms include flu-like symptoms, nausea/vomiting/diarrhea/constipation, anorexia, jaundice, skin rashes, and RUQ tenderness

    • Changes in urine/stool characteristics

  • Chronic Phase:

    • Elevated liver enzymes

    • Ascites and bilateral lower extremity edema

    • Spider angiomas, palmar erythema

    • Hepatomegaly, bleeding problems, fatigue, jaundice

Skin Variations in Hepatitis

  • Spider Angiomas: Small, dilated blood vessels resembling spider veins often associated with cirrhosis.

  • Palmar Erythema: Reddening of palm skin, common in liver disorders.

Viral Hepatitis Diagnostic Studies

  • Testing Includes:

    • History and physical assessment

    • Liver function tests

    • Specific antigen or antibody testing for each hepatitis type

    • Viral load tests

    • Liver biopsy

    • Imaging tests like FibroScan and MRI elastography

    • FibroSure biomarkers

Hepatitis Treatment

  • Acute Viral Hepatitis:

    • No specific treatment; supportive care emphasizes rest and education to prevent transmission

    • Avoid hepatotoxic medications and alcohol

    • Possibly involve multiple specialists

    • Ensure well-balanced nutrition and supplemental vitamins (B-complex & potassium)

    • Antihistamines and antiemetics for symptom relief

  • Chronic Hepatitis B Goals:

    • Drug therapy aims to decrease viral load and liver enzymes

    • Treatment does not cure disease but suppresses viral replication to prevent complications

Chronic Hepatitis B Medications

  • Nucleoside and Nucleotide Analogs:

    • Inhibit viral DNA replication

    • Halt synthesis of faulty viral DNA blocks

  • Interferon Therapy:

    • Natural immune protein given subcutaneously

    • Side effects can include flu-like symptoms and depression

  • Monitor liver function tests and CBC every 4-6 weeks during treatment

Chronic Hepatitis C Medications

  • Treatment Becoming Patient-Specific:

    • Based on HCV genotype, severity of liver disease, presence of comorbidities

    • Goal: Eradicate the virus and prevent HCV-related complications

    • Utilization of Direct Acting Antivirals (DAAs) to prevent viral replication, typically over 12 weeks with combination therapies

Cirrhosis

  • Definition: End-stage liver disease; progressive condition resulting from chronic liver failure

  • Pathophysiology:

    • Characterized by irreversible hepatocyte damage resulting in fibrosis and changes in liver architecture affecting blood flow

    • Impaired blood flow leads to diminished liver function

Cirrhosis Causes

  • Chronic hepatitis C

  • Nonalcoholic steatohepatitis (NASH)

  • Alcoholism

  • Nonalcoholic fatty liver disease (NAFLD)

  • Extreme dieting and biliary conditions

Cirrhosis Signs and Symptoms

  • Early Symptoms:

    • Often vague, including fatigue, hepatomegaly, potential normal liver function tests

  • Late-Stage Symptoms:

    • Result from liver failure and portal hypertension, prompting medical attention

    • Include jaundice, skin lesions, hematologic and endocrine problems, peripheral neuropathy, and a variety of systemic symptoms

Neurologic and Integumentary Symptoms

  • Hepatic encephalopathy: Neuropsychiatric changes due to toxin accumulation, primarily ammonia.

  • Peripheral neuropathy: Neuropathy evident in hands and feet.

  • Skin manifestations: Jaundice indicates liver dysfunction; spider angioma, and palmar erythema may occur.

Cirrhosis Complications

  • Common Complications Include:

    • Portal hypertension, which leads to:

    • Esophageal varices

    • Ascites

    • Coagulation defects

    • Jaundice

    • Hepatic encephalopathy

    • Hepatorenal syndrome

Portal Hypertension

  • Caused by obstruction of blood flow through liver circulatory system leading to increased pressure in the portal vein, causing collateral vessels to develop

    • Can cause splenomegaly and variceal dilation in esophagus, stomach, intestines, abdomen, and rectum

Caput Medusae

  • Presenting with visible, swollen veins radiating from the navel; indicative of severe portal hypertension

Varices

  • Fragile, tortuous, dilated esophageal veins susceptible to rupture and hemorrhage; signs include hematemesis and are often medical emergencies

  • Gastric varices: Found in upper stomach; may lead to melena

Ascites

  • Definition: Fluid accumulation in the peritoneal cavity, typically caused by venous congestion of hepatic capillaries

  • Mechanism: proteins leak into the peritoneal cavity, due to altered osmotic pressure leading to further fluid retention; hypoalbuminemia decreases oncotic pressure

Symptoms and Complications of Ascites

  • Manifested as abdominal distention and weight gain

  • Risks include dehydration, poor urinary output, and hypokalemia; may lead to bacterial peritonitis primarily due to Escherichia coli

Coagulation Defects

  • Due to decreased synthesis of bile fats hampering fat-soluble vitamin absorption (notably vitamin K and clotting factors II, VII, IX, X); increased bleeding risk

Jaundice

  • Results from the liver's inability to metabolize bilirubin due to edema and scarring, presenting as yellowing of skin and sclera, with dark urine and clay-colored stools

Hepatic Encephalopathy

  • Neuropsychiatric syndrome from inability to detoxify neurotoxin, mainly ammonia

  • Symptoms: neurological changes, asterixis (flapping tremors) particularly in arms/hands, apraxia, and fetor hepaticus (sweet, musty breath odor)

Hepatorenal Syndrome

  • Progressive renal failure stemming from liver failure, indicators include decreased urine output and increased biliary products

  • Poor prognosis; transplantation is the only solution that can reverse the condition

Cirrhosis Laboratory/Diagnostic Testing

  • Key Tests:

    • History and physical assessment

    • Decreased albumin and blood cells, prolonged PT/INR

    • Liver Function Tests

    • Diagnostic imaging: liver biopsy, EGD, ultrasound elastography

Management of Ascites

  • Prevention and Management:

    • Sodium restriction (1-2 grams/day)

    • Monitoring of fluid/electrolyte balance

    • Albumin infusion to maintain oncotic pressure

    • Daily weight checks; diuretics (spironolactone + furosemide)

    • Paracentesis when necessary

Paracentesis

  • Procedure:

    • Ultrasound-guided placement of a sterile catheter to withdraw peritoneal fluid for symptomatic relief

    • Monitor incision sites for complications such as bleeding/infection

    • Ensure weight measurements pre/post-procedure

Managing Hemorrhage

  • Preventative Therapies for Varices:

    • Avoid alcohol and NSAIDs

    • Proton pump inhibitors for distress

    • Nonselective beta-blockers (e.g., Propranolol) to decrease bleeding risk

    • Treatments for excessive bleeding: Octreotide acetate (Sandostatin) and vasopressin

    • Blood products like FFP and PRBCs if necessary

Endoscopic Therapies

  • Endoscopic Variceal Ligation (EVL):

    • Application of rubber bands around varices to decrease blood supply, usually with no complications

  • Endoscopic Sclerotherapy (EST):

- Injection with a sclerosing agent may cause mucosal ulcerations and require further interventions for control of bleeding

Balloon Tamponade

  • Insertion used when endoscopic methods fail; mechanically compresses varices to control bleeding with precise monitoring to prevent necrosis

Transjugular Intrahepatic Portal-Systemic Shunt (TIPS)

  • Non-surgical procedure that connects portal and hepatic veins to reduce pressure; indicated for those not responding to other treatments

Managing Hepatic Encephalopathy

  • Goal: Slow or halt ammonia accumulation to improve mental status

  • Lactulose:

    • First-line agent; traps ammonia for fecal excretion. Administered orally, NG tube, or enema

Managing Nutrition in Cirrhosis

  • Dietary Needs for Patients:

    • High-calorie (3000 cal/day)

    • High carbohydrate intake; moderate to low fat

    • Collaboration with dietitians, possible enteral or parenteral nutrition

    • Vitamin supplements like thiamine, folic acid, and cobalamin

Cirrhosis Care Management

  • Involvement of case managers for home care

  • Support for alcohol abstinence, educate on complications and care of ascites drain

  • Remind patients to avoid OTC drugs potentially toxic to the liver

Acute Liver Failure

  • Definition: Potentially fatal syndrome marked by rapid liver dysfunction without prior liver disease history; often has encephalopathy

  • Commonly linked to acetaminophen use; other drugs include herbal supplements and anticonvulsants

Manifestations and Diagnostic Testing

  • Clinical indicators include jaundice and changes in cognitive function; complications may include cerebral edema

  • Key Tests: BUN, blood counts, liver function tests, CT/MRI imaging

Nursing Care for Acute Liver Failure

  • Admission to ICU for immediate monitoring

  • Avoid nephrotoxic medications, maintain fluid balance, and conduct frequent neuro assessments

  • Changing positioning to ensure optimal cerebral perfusion

Liver Cancer

  • Definition: Primary liver cancer arises in the liver and is the second cause of cancer mortality

  • Risk Factors: Chronic liver conditions like cirrhosis, and liver viral infections (HBV, HCV)

  • Types of Liver Cancer:

    • Hepatocellular carcinoma (HCC)

    • Intrahepatic cholangiocarcinoma (bile duct cancer)

Clinical Manifestations and Diagnostic Studies

  • Symptoms: Often subtle, can include hepatomegaly, fatigue, ascites, and late-stage indications of fever and jaundice

  • Imaging Tests: Ultrasound, MRI, CT scans; serum alpha-fetoprotein (AFP) measurements

Management of Liver Cancer

  • Prevention: Focus on chronic HBV and HCV, chronic alcohol screening amongst at-risk populations

  • Treatment Approaches Based on Stage: Surgical resection techniques and adjunctive therapies (TACE, systemic treatments) justified by tumor considerations

Liver Transplantation

  • Rationale: Most effective for acute/chronic liver diseases. Commonly indicated for cirrhosis resulting from chronic hepatitis infections

  • Donor Sources: Living/deceased, ensuring equitable distribution by health organizations

Contraindications for Transplantation

  • Severe cardiovascular or respiratory disease, advanced cancer, active substance abuse, and noncompliance with treatment

Transplantation Complications

  • Common Postoperative Complications:

    • Graft rejection: usually manifests within 4-10 days post-op

    • Infections: may arise throughout recovery.

    • Hepatic complications (bile leaks, abscess formation) leading to jaundice and pain. Chronic kidney injury secondary to immunosuppressants or other issues

Pancreatic Disorders

  • Acute Pancreatitis: Inflammation characterized by premature activation of pancreatic enzymes that result in autodigestion, which can be life-threatening

  • Most Common Causes: Gallbladder disease in women; chronic alcohol use in men; drug reactions, pancreatic cancer, and hypertriglyceridemia in all patients

Acute Pancreatitis Manifestations

  • Sudden severe abdominal pain in the mid-epigastric region or LUQ; symptoms manifest through tenderness and guarding

  • Other indicators may include fever, hypotension, tachycardia (indicating potential hemorrhage), and complications like shock, jaundice, and weight loss

Complications of Acute Pancreatitis

  • Severity depends on the extent of pancreatic destruction: potential recovery, chronic pancreatitis, or local/systemic complications (e.g., cardiovascular, respiratory issues)

Pancreatic Pseudocyst

  • Collection of fluid, enzymes, and debris forming a wall next to the pancreas; can resolve naturally or require drainage if symptomatic

  • Symptoms include abdominal pain and palpable masses

Pancreatic Abscess

  • Infected pseudocyst from extensive necrosis; risk of rupture; urgent surgical drainage indication due to sepsis risk

Diagnostic Testing for Acute Pancreatitis

  • Key Tests: Serum amylase and lipase levels, imaging studies (CT, ERCP) used for diagnosis and evaluating damage

Acute Pancreatitis Management

  • Goals of Treatment: Pain management, prevention of shock, reducing pancreatic secretions, correcting fluid imbalances, and potentially removing causative factors

  • Strategies Include:

    • IV/PO pain management, fluid resuscitation, and infection control via antibiotics

    • Dietary adjustments to minimize pancreatic stimulation

Chronic Pancreatitis

  • Definition: Progressive destruction of pancreatic tissue, often due to chronic alcohol consumption, leading to pancreatic insufficiency

  • Manifestations: Intermittent abdominal pain unrelieved by antacids, with nutritional malabsorption indicated by weight loss and steatorrhea

Diagnostic Testing

  • Slight elevation of amylase/lipase; stool samples to measure fat; imaging tests for diagnosis validation

Treatment Strategy

  • Nonsurgical Options: Includes enzyme replacement therapy, dietary modifications (high-caloric, low-fat diet), and potential surgical options for refractory cases

Pancreatic Cancer

  • Primarily arises in the head; early diagnosis is difficult, presenting severe challenges for treatment

  • Risk Factors: Smoking, chronic pancreatitis, diabetes, and age, among others

Clinical Manifestations

  • Subtle early symptoms may involve abdominal pain radiating to back, anorexia, rapid weight loss, jaundice, and digestive disturbances

Diagnostic Testing

  • Laboratory tests may show elevated amylase/lipase with imaging studies essential for detecting tumors

Treatment Overview

  • Nonsurgical Management: Chemotherapy and radiation therapy; surgical resection remains the most effective option if detected early; typically involves complex procedures like Whipple’s procedure

The Whipple Procedure

  • Description: Extensive surgical intervention to manage head-of-pancreas cancer; includes removal of surrounding organs and reconstruction of digestive pathways

  • Postoperative Care: Includes npo status, monitoring for complications, and fluid/electrolyte management

Biliary Tract Problems

Cholelithiasis

  • Definition: Most common disorder of the biliary system involving gallstones, typically cholesterol-based

  • Causes and Effects: Stasis may lead to supersaturation of bile, resulting in inflammation and potentially arrowing into cholecystitis

Cholecystitis

  • Acute/chronic inflammation of the gallbladder frequently associated with gallstones

  • Sets of Cholecystitis:

    • Acalculous: inflammation without stones, typically in critically ill patients

    • Calculous: stone-induced inflammation, leading to obstruction and infection

Signs, Symptoms, and Diagnostic Testing

  • Symptoms may vary from nausea, vomiting, and abdominal pain, depending on the type of cholecystitis; diagnostic imaging and lab tests confirm distinctions

Treatment Management

  • Includes pain management, potential surgery (open/laparoscopic cholecystectomy), and monitoring for complications post-therapy