NCLEX Study Guide: Hepatic, Pancreatic, and Biliary Disorders

NCLEX Study Guide: Hepatic, Pancreatic, and Biliary Disorders

1. Hepatitis, Cirrhosis, and Liver Cancer

Hepatitis

• Definition: Inflammation of the liver caused by viruses, alcohol, toxins, or autoimmune diseases.


• Types of Hepatitis:
  

• Acute Phase (1-6 months):

  • Flu-like symptoms: Fatigue, nausea, vomiting, fever.
  • RUQ discomfort, hepatomegaly.
  • Jaundice, dark urine, clay-colored stools (due to bilirubin accumulation).
  • Pruritus (bile salt deposits in skin).

• Chronic Hepatitis (B & C):

  • Persistent inflammation leads to cirrhosis and liver cancer.
  • Asymptomatic for years or vague symptoms like fatigue and joint pain.

Treatment for Hepatitis:

• Supportive care: for HAV & HEV (rest, hydration, small frequent meals).
• Medications for HBV & HCV:
  • HBV: Antivirals (Tenofovir, Entecavir), interferon.
  • HCV: Direct-acting antivirals (Sofosbuvir, Ledipasvir).
• Autoimmune Hepatitis: Corticosteroids, azathioprine.

Nursing Interventions for Hepatitis:

• Monitor liver function tests (ALT, AST, bilirubin, albumin, PT/INR).
• Encourage rest and nutrition: High-calorie, high-carb, moderate protein, low-fat diet.
• Prevent transmission: Hand hygiene, vaccine education, safe needle practices.

Cirrhosis

• Definition: End-stage liver disease characterized by fibrosis, scarring, and loss of liver function.
• Causes of Cirrhosis:
  • Chronic Hepatitis B & C.
  • Alcoholic Liver Disease (Laennec’s Cirrhosis).
  • Non-Alcoholic Fatty Liver Disease (NAFLD) & Non-Alcoholic Steatohepatitis (NASH).

Symptoms of Cirrhosis:

• Early Symptoms:

  • Fatigue, weight loss, weakness, hepatomegaly.
  • RUQ pain, GI disturbances.

• Late Symptoms:

  • Jaundice, pruritus (bile buildup).
  • Ascites, peripheral edema (fluid retention).
  • Hepatic encephalopathy: Confusion, asterixis (flapping tremor), coma.
  • Coagulopathy: Prolonged PT/INR, bruising, bleeding tendencies.
  • Esophageal varices: GI bleeding, hematemesis.

Treatment of Cirrhosis:

• Diuretics (Spironolactone, Furosemide): Reduce ascites.
• Beta-blockers (Propranolol): Prevent variceal bleeding.
• Lactulose & Rifaximin: Reduce ammonia levels in hepatic encephalopathy.
• Paracentesis: Remove fluid from ascites.
• Avoid alcohol, hepatotoxic drugs (NSAIDs, acetaminophen).

Nursing Interventions for Cirrhosis:

• Monitor for GI bleeding (black stools, hematemesis).
• Daily weights, abdominal girth measurements for ascites.
• Low-sodium, high-protein (if no encephalopathy) diet.

Liver Cancer

• Definition: Primarily hepatocellular carcinoma (HCC) often secondary to cirrhosis or hepatitis B/C infection.

Symptoms of Liver Cancer:

• Unintentional weight loss.
• Jaundice, hepatomegaly, ascites.
• RUQ pain.
• Increased Alpha-Fetoprotein (AFP) levels.

Treatment of Liver Cancer:

• Surgical Resection (for localized tumors).
• Liver Transplant (if meets criteria).
• Transarterial Chemoembolization (TACE).
• Systemic Therapy (Sorafenib, immunotherapy).

Nursing Care for Liver Cancer:

• Pain management (opioids, NSAIDs).
• Monitor liver function and AFP levels.
• Nutritional support, symptom relief.

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2. Complications of Chronic Hepatitis & Cirrhosis

3. Liver Transplant Patient Care

Pre-Transplant:

• Assess MELD score (Model for End-Stage Liver Disease).
• Optimize nutrition and control ascites, encephalopathy.

Post-Transplant:

• Lifelong immunosuppression (Tacrolimus, Mycophenolate).
• Monitor for signs of rejection (fever, jaundice, elevated LFTs).
• Prevent infection (vaccinations, hand hygiene).

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4. Pancreatitis & Pancreatic Cancer

Acute Pancreatitis

• Causes: Gallstones, alcohol abuse, hypertriglyceridemia, medications.

Symptoms:

• Epigastric pain radiating to the back.
• Nausea, vomiting, fever, tachycardia.
• Cullen’s sign (periumbilical bruising), Grey Turner’s sign (flank bruising).

Treatment:

• NPO, IV fluids, pain management (opioids, NSAIDs).
• NG tube if severe nausea/vomiting.
• Antibiotics only if infection present.

Nursing Care:

• Monitor for complications (pseudocysts, necrotizing pancreatitis).
• Encourage low-fat diet post-recovery.
• Monitor electrolytes (hypocalcemia, hypomagnesemia).

Chronic Pancreatitis

• Causes: Chronic alcohol abuse, cystic fibrosis, autoimmune disease.

Symptoms:

• Chronic pain, steatorrhea, weight loss, diabetes.

Treatment:

• Pancreatic enzyme replacement (pancrelipase).
• Insulin if diabetes develops.
• Pain control (opioids, NSAIDs).

Pancreatic Cancer

• Causes: Smoking, chronic pancreatitis, obesity, family history.

Symptoms:

• Painless jaundice, weight loss, vague epigastric pain.
• Courvoisier’s sign (palpable gallbladder, jaundice).

Treatment:

• Whipple procedure (pancreaticoduodenectomy).
• Chemotherapy (gemcitabine-based regimens).

Nursing Care:

• Post-op care (pain control, NG tube, nutritional support).
• Palliative care for late-stage disease.

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5. Causes, Symptoms, Treatments, and Nursing Care for Biliary Diseases

A. Cholelithiasis (Gallstones)

• Definition: Formation of stones (calculi) in the gallbladder.

Causes & Risk Factors:

• "5 F's": Female, Fat, Forty, Fertile, Fair (Caucasian).
• Obesity, rapid weight loss, pregnancy.
• High-fat diet, sedentary lifestyle, family history.
• Diabetes, hyperlipidemia, estrogen therapy.

Symptoms of Gallstones:

• May be asymptomatic (silent stones).
• Biliary colic (RUQ pain radiating to right shoulder/back) triggered by fatty meals.
• Nausea, vomiting, dyspepsia, bloating.

Treatment for Gallstones:

• Asymptomatic: No treatment needed.
• Symptomatic:
  • Ursodiol (Actigall) or Chenodiol: Dissolves cholesterol-based stones.
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): Removes stones from bile duct.
  • Cholecystectomy (Lap or Open): Definitive treatment if recurrent symptoms.

Nursing Care for Gallstones:

• Pain management: NSAIDs, opioids (if severe).
• Low-fat diet, small frequent meals.
• Monitor for complications like cholecystitis.

B. Cholecystitis (Inflammation of Gallbladder)

• Definition: Inflammation of the gallbladder, usually due to gallstones (90% cases).

Causes:

• Gallstones blocking the cystic duct (calculous cholecystitis).
• Acalculous cholecystitis (no stones): Caused by sepsis, trauma, burns, prolonged fasting, TPN.

Symptoms of Cholecystitis:

• Severe RUQ pain radiating to right shoulder/back.
• Murphy’s sign: Pain on deep inspiration when palpating RUQ.
• Fever, nausea, vomiting.
• Jaundice (if bile duct is obstructed).

Complications of Untreated Cholecystitis:

• Gangrenous cholecystitis → perforation → peritonitis.
• Cholangitis (bile duct infection).
• Pancreatitis (if bile backs up into pancreas).

Treatment for Cholecystitis:

1. NPO, IV fluids, pain control (NSAIDs or opioids).
2. IV antibiotics (Ceftriaxone + Metronidazole).
3. Cholecystectomy (preferred treatment).
4. Percutaneous cholecystostomy (if surgery is contraindicated).

Nursing Care for Cholecystitis:

• Pain control, monitor for worsening infection.
• NG tube if severe vomiting.
• Post-surgery: Ambulation, low-fat diet, incision care.

C. Biliary Obstruction (Choledocholithiasis & Cholangitis)

• Definition: Blockage of bile flow due to gallstones in the common bile duct or tumors.

Symptoms of Biliary Obstruction:

• Jaundice (yellow skin, dark urine, clay-colored stools).
• RUQ pain, fever, chills (Charcot’s Triad in cholangitis).
• Pruritus (itching from bile salts in skin).

Complications:

• Severe cholangitis (life-threatening infection).
• Sepsis, liver abscess, cirrhosis.

Treatment of Biliary Obstruction:

• ERCP (Endoscopic stone removal, stent placement).
• Percutaneous transhepatic cholangiography (PTC) if ERCP fails.
• Cholecystectomy if gallstones are the cause.

Nursing Care for Biliary Obstruction:

• Monitor for infection, sepsis (fever, tachycardia, hypotension).
• Administer bile acid sequestrants (Cholestyramine) for itching.
• Low-fat diet, hydration, post-ERCP monitoring.

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NCLEX Key Points for Biliary Diseases

• Gallstones (cholelithiasis) may be silent or cause RUQ pain after fatty meals.
• Cholecystitis = Fever, RUQ pain, Murphy’s sign, nausea.
• Biliary obstruction causes jaundice, dark urine, clay-colored stools.
• Cholangitis is a medical emergency (Charcot’s Triad = Fever + RUQ pain + Jaundice).
• ERCP removes bile duct stones; cholecystectomy is definitive treatment.

6. Care for Patients Undergoing Gallbladder Surgeries

Types of Gallbladder Surgeries

1. Laparoscopic Cholecystectomy (Lap Chole): Preferred Method.

   • Minimally invasive procedure to remove the gallbladder.
   • Faster recovery, less pain, and fewer complications.

2. Open Cholecystectomy:

   • Performed if laparoscopy is not possible (e.g., severe inflammation, adhesions, obesity).
   • Requires a larger abdominal incision and longer recovery.

3. Endoscopic Retrograde Cholangiopancreatography (ERCP):

   • Used to remove gallstones from the bile duct without gallbladder removal.
   • May be performed before or after surgery if bile duct stones are present.

Preoperative Nursing Care for Cholecystectomy

• Assess for allergy to iodine/contrast dye (if ERCP planned).
• Ensure NPO status for at least 8 hours before surgery.
• Administer prophylactic antibiotics (if ordered).
• Educate patient about post-op expectations:
  • Shoulder pain may occur due to CO₂ retention (lap chole).
  • Early ambulation helps relieve discomfort.
  • Possible need for NG tube (if open surgery).

Postoperative Nursing Care

Laparoscopic Cholecystectomy:

• Encourage early ambulation to relieve shoulder pain from CO₂ gas.
• Manage pain with NSAIDs or opioids (if needed).
• Monitor for signs of bile leakage or peritonitis:
  • Fever, increasing abdominal pain, tachycardia, hypotension.
• Dietary instructions:
  • Start with clear liquids, then advance to low-fat diet.
  • Avoid gas-forming foods (beans, broccoli, carbonated drinks).

Open Cholecystectomy:

• Monitor incision for infection (redness, swelling, drainage).
• Prevent atelectasis/pneumonia: Encourage deep breathing, incentive spirometry, early ambulation.
• Monitor drains (if present):
  • T-tube (if bile duct exploration done):
  • Drains bile externally until edema subsides.
  • Normal output: 300-500 mL/day initially, decreasing gradually.
  • Keep the bag below the incision level; never clamp without order.
• Pain management: PCA pump or IV opioids initially, then oral analgesics.

Complications After Gallbladder Surgery

Patient Education for Postoperative Recovery

• Activity:
  • Avoid heavy lifting for 4-6 weeks (open cholecystectomy).
  • Return to normal activities in 1-2 weeks (lap chole).
• Diet:
  • Resume normal diet gradually; low-fat diet initially.
  • Increase fiber to prevent constipation.
• Incision & Drain Care:
  • Keep laparoscopic incisions dry and clean.
  • If T-tube is present, teach proper care (empty bag, monitor output).

When to Call the Provider:

• Fever >101°F (38.3°C), worsening pain, yellowing of skin/eyes.
• Signs of bile leakage (abdominal distention, severe pain, nausea, vomiting).

Key NCLEX Points for Gallbladder Surgery

• Lap Chole = Early ambulation to relieve shoulder pain.
• Open Chole = Longer recovery, monitor incision & drains.
• T-Tube = Keep drainage bag below incision level, monitor output.
• Low-fat diet initially, gradually return to normal diet.
• Watch for complications: Bile leak, infection, post-cholecystectomy syndrome.