Comprehensive Study Guide: Hepatobiliary and Pancreatic Systems

Liver

• Functions: The liver, the largest internal organ, performs four key functions:

  • Endocrine: Processes hormones like glucocorticoids, mineralocorticoids, and sex hormones.

  • Exocrine: Produces bile salts for fat digestion.

  • Digestive: Processes carbohydrates, proteins, and lipids, and stores vitamins and minerals.

  • Hematologic: Stores blood, removes bilirubin, produces clotting factors, and plays a role in blood cell formation (hematopoiesis).

• Types of Liver Injury:

  • Primary: Direct damage to liver tissue (parenchyma) or blood flow.

  • Secondary: Damage resulting from outside forces.

• Consequences of Liver Damage:

  • Inadequate protein metabolism: Leads to loss of clotting factors and albumin.

    • Loss of albumin: Reduces oncotic pressure, resulting in edema and ascites.

  • Abnormal glycogen storage and glucose release: Causes unstable blood glucose levels.

• Assessment of Liver Function:

  • History and Physical: Obtain a detailed history, including diet and abdominal pain assessment.

  • Diagnostic Tests: Ultrasound, CT, MRI, and liver biopsy.

    • Liver Biopsy: The gold standard for diagnosing liver diseases.

  • Laboratory Tests: Assess liver function, response to treatment, and disease progression.

Common Liver Disorders

• Hepatitis: Inflammation of the liver, potentially caused by viral infections, alcohol abuse, or medications.

  • Types: Hepatitis A, B, C, D, and E.

  • Types of Viral Hepatitis

    Hepatitis is an inflammation of the liver that can be caused by viral infections, alcohol, medications, chemicals, autoimmune disease, or metabolic problems. Viral hepatitis is the most common cause of hepatitis in the United States. There are five main types of viral hepatitis, each caused by a different virus:

    • Hepatitis A

    • Hepatitis B

    • Hepatitis C

    • Hepatitis D

    • Hepatitis E

    Each type of viral hepatitis has different modes of transmission, treatments, and potential complications.

    Hepatitis A

    • Hepatitis A is caused by an RNA virus transmitted through the fecal-oral route via contaminated food or water.

    • HAV infection does not become chronic, and incidence has decreased with the use of vaccination.

    • Almost all cases of acute hepatitis A resolve completely without complications.

    Hepatitis B

    • Hepatitis B is caused by a DNA virus that is considered a bloodborne pathogen.

    • Hepatitis B can cause both acute and chronic infection.

    • The incidence of HBV infection has decreased with the use of vaccination.

    • Transmission occurs:

      • Perinatally

      • Percutaneously

      • Through small cuts on mucosal surfaces and exposure to infected blood, blood products, or other body fluids

    • HBV is detectable in almost every body fluid.

    • People at risk for HBV infection include:

      • Men who have sex with men

      • Household contacts of chronically infected individuals

      • Patients on hemodialysis

      • Healthcare and public safety workers

      • Prisoners, veterans, and homeless people

      • People who inject drugs

      • Recipients of blood products

    • Acute infection may be asymptomatic or present with mild symptoms.

    • Chronic infection can cause cirrhosis and liver failure.

    Hepatitis C

    • Hepatitis C is caused by an RNA virus transmitted percutaneously.

    • Transmission occurs through:

      • IV drug use

      • High-risk sexual behavior

      • Occupational exposure

      • Perinatal exposure

      • Blood transfusions before 1992

    • Acute HCV infection can range from asymptomatic to mild symptoms.

    • Chronic infection can cause cirrhosis and liver failure.

    Hepatitis D

    • Hepatitis D is caused by a defective single-stranded RNA virus called the delta virus that requires HBV to replicate.

    • HDV is transmitted percutaneously.

    • There is no vaccine for HDV.

    Hepatitis E

    • Hepatitis E is caused by an RNA virus that is transmitted through the fecal-oral route.

    • The most common mode of transmission is drinking contaminated water.

    • HEV infection is typically acute and self-resolving.

    • There are few cases of HEV in the United States.

    Acute vs. Chronic Viral Hepatitis

    • Acute infection occurs when a large number of hepatocytes are destroyed.

    • The liver cells can regenerate after the resolution of the infection.

    • Chronic infection can cause fibrosis and progress to cirrhosis.

    General Manifestations of Hepatitis

    Many patients with acute hepatitis are asymptomatic. Common symptoms, if they occur, are often intermittent or ongoing and can include:

    • Anorexia, nausea, and vomiting

    • Malaise, fatigue, and lethargy

    • Muscle and joint pain

    • Right upper quadrant tenderness

    The acute phase is the most infectious and can last 1 to 6 months. Symptoms during the incubation period may include a decreased sense of smell, finding food repugnant, and a distaste for cigarettes. During the acute phase, physical assessment findings may include:

    • Hepatomegaly

    • Lymphadenopathy

    • Splenomegaly

    The acute phase can be either icteric (jaundice) or anicteric. Icteric patients may also have:

    • Dark urine

    • Light or clay-colored stools

    • Pruritus

    The convalescent phase begins as jaundice disappears and can last from weeks to months. Major problems during this phase include malaise and easy fatigability. Hepatomegaly persists during the convalescent phase, but splenomegaly subsides.

    Complications of Viral Hepatitis

    Viral hepatitis can lead to a variety of complications, including:

    • Acute liver failure

    • Chronic hepatitis

    • Cirrhosis

    • Portal hypertension

    • Liver cancer

    Acute liver failure, also called fulminant hepatic failure, can manifest with:

    • Encephalopathy

    • GI bleeding

    • Disseminated intravascular coagulation

    • Fever and leukocytosis

    • Renal manifestations

    Chronic hepatitis occurs in some HBV and most HCV infections. Chronic HBV is more likely to develop if the infection was acquired at birth or during childhood. Chronic HBV can remain asymptomatic for years, but complications such as liver cirrhosis, liver failure, and liver cancer can develop in 15-40% of people with HBV. HCV is more likely than HBV to become chronic.

    Other complications of hepatitis include:

    • Skin manifestations such as spider angiomas, palmar erythema, and gynecomastia

    • Enlargement of the spleen, liver, and cervical lymph nodes

    • Hepatic encephalopathy

    • Ascites

    Hepatic encephalopathy is a potentially life-threatening complication that results from the liver’s inability to remove toxins, especially ammonia, from the blood. It presents as a range of neurologic, psychiatric, and motor disturbances.

    Ascites is the accumulation of excess fluid in the peritoneal cavity due to the reduction of protein, and thus oncotic pressure, in the blood.

    • Diagnosis: Specific antigen/antibody tests, viral load, liver function tests, genotype testing, liver biopsy.

    • Treatment:

      • Acute hepatitis: Supportive care (adequate nutrition, rest, avoid alcohol and liver-damaging drugs, notify possible contacts).

      • Acute HBV: Treatment only if severe.

      • Acute HCV: Direct-acting antivirals (DAAs).

      • Drug Therapy: Antihistamines, antiemetics to manage symptoms.

  • Nursing Management:

    • Assessment: Health history (exposure to infected persons, contaminated food/water, toxins, past blood transfusions, high-risk behaviors), medication use, symptoms (fatigue, anorexia, abdominal discomfort, jaundice, etc.), physical examination findings (fever, hepatomegaly, splenomegaly).

    • Clinical Problems: Nutritional compromise, activity intolerance, risk for bleeding.

    • Implementation: Acute care (comfort measures, adequate nutrition, rest, modified activity plan), ambulatory care (diet teaching, prevention of transmission, symptom management, follow-up care).

    • Evaluation: Monitor for improvement in food/fluid intake, activity tolerance, and avoidance of hepatotoxic agents.

• Cirrhosis: Irreversible end-stage liver disease characterized by destruction of liver cells and replacement with fibrous tissue.

  • Causes: Chronic hepatitis C, non-alcoholic steatohepatitis (NASH), alcohol-induced liver disease, extreme dieting, malabsorption, obesity, environmental factors, and genetic predisposition.

  • Clinical Manifestations:

    • Early: Fatigue, enlarged liver (hepatomegaly).

    • Late: Result from liver failure and portal hypertension, including jaundice, ascites, esophageal varices, hepatic encephalopathy, and bleeding tendencies.

  • Complications: Portal hypertension, esophageal and gastric varices, hepatic encephalopathy, ascites, bleeding, and spontaneous bacterial peritonitis.

  • Diagnostic Studies: Liver enzyme tests, total protein and albumin levels, serum bilirubin, cholesterol, prothrombin time, ultrasound elastography, and liver biopsy.

  • Treatment:

    • Focuses on symptom management and preventing/treating complications.

    • Ascites: Sodium restriction, diuretics, fluid removal (paracentesis), albumin, Tolvaptan.

    • Esophageal/Gastric Varices: Prevention of bleeding (avoid alcohol, aspirin, and NSAIDs, non-selective beta-blockers).

    • Hepatic Encephalopathy: Reduce ammonia formation (lactulose, rifaximin), treat precipitating causes (control GI bleeding, lower dietary protein intake).

    • Acute Bleeding: Stabilization, airway management, IV therapy, blood products, medications (Octreotide, Vasopressin), endoscopic therapies.

    • Long-term Management: Non-selective beta-blockers, repeated band ligation, portosystemic shunts.

  • Nursing Management:

    • Nursing Care for Cirrhosis: Requires constant and rigorous monitoring both in and out of the hospital. Nurses play a crucial role in managing and preventing complications and improving the patient's quality of life.

    • Assessment: Obtain a detailed history, including alcohol use, assess for symptoms (fatigue, anorexia, jaundice, edema, etc.), and physical examination findings (ascites, spider angiomas, etc.), monitor lab values (liver function tests, bilirubin, albumin, etc.).

    • Clinical Problems: Nutritional compromise, ineffective tissue perfusion, activity intolerance, fluid imbalance.

    • Implementation: Provide supportive care (rest, administration of B-complex vitamins, avoidance of alcohol and hepatotoxic drugs), manage ascites (sodium restriction, diuretics, paracentesis), address esophageal varices (prevent bleeding, administer medications if bleeding occurs), manage hepatic encephalopathy (ensure a safe environment, monitor neurologic status, prevent constipation), provide patient education on diet, medications, and symptom management.

    • Evaluation: Assess for improvement in comfort, minimal complications, and return to a normal lifestyle as possible.

Gallbladder

• Functions:

  • Stores bile.

  • Concentrates bile.

  • Excretes bile when stimulated by cholecystokinin (CCK).

• Bile Salts: Emulsify fats, aiding in digestion.

Common Gallbladder Disorders

• Cholelithiasis (Gallstones): Formation of gallstones in the gallbladder.

  • Causes: Not fully understood, but related to high caloric intake, low stomach acid, autoimmune issues, leaky gut, allergies, stress, low fiber/fat diets, high blood sugar, sedentary lifestyle, genetics, and infections.

  • Clinical Manifestations:

    • May be asymptomatic, with vague distress after fatty meals.

    • Biliary colic: Severe, colicky pain in the right upper quadrant (RUQ).

    • Fever, nausea, vomiting, sweating, tachycardia.

  • Complications: Cholecystitis, jaundice, hepatocyte damage.

  • Diagnosis: Ultrasound, lab tests (elevated WBC and bilirubin).

  • Treatment:

    • Dietary Changes: Hydration, reduced fat intake, frequent small meals, digestive enzymes, fiber.

    • ERCP: Endoscopic retrograde cholangiopancreatography for stone removal or stent placement.

    • MRCP: Magnetic resonance cholangiopancreatography for visualization of the biliary tree.

    • Surgery: Cholecystectomy for symptomatic cases.

• Cholecystitis: Inflammation of the gallbladder, often caused by gallstone obstruction.

  • Types:

    • Calculous Cholecystitis: Due to gallstones.

    • Acalculous Cholecystitis: Seen in older adults and critically ill patients, related to prolonged immobility, fasting, and other factors.

  • Clinical Manifestations:

    • Colicky RUQ pain, fever, positive Murphy's sign, nausea, vomiting, diaphoresis, tachycardia, pain radiating to the right shoulder.

    • Jaundice may occur due to bile duct obstruction.

  • Complications: Gangrene, sepsis, abscess formation, pancreatitis, cholangitis.

  • Diagnosis: HIDA scan, ultrasound, CT scan, lab tests (elevated WBC, ALP, bilirubin).

  • Treatment:

    • Laparoscopic Cholecystectomy: Minimally invasive surgery to remove the gallbladder.

    • Open Cholecystectomy: May be necessary in some cases.

    • T-tube Placement: For bile drainage.

    • Pain Management: Opioids, anticholinergics.

    • Antibiotics: To treat infection.

• Choledocholithiasis: Obstruction of the common bile duct by gallstones.

  • Clinical Manifestations: Steatorrhea, jaundice, dark urine, pruritus, potential secondary pancreatitis or cholangitis.

  • Diagnosis: Ultrasound, CT scan.

  • Treatment: ERCP or MRCP for stone removal.

Nursing Management of Gallbladder Disorders:

• Assessment: Obtain a thorough history, including medication use, assess for symptoms (pain, nausea, vomiting, jaundice, etc.) and risk factors (obesity, family history, etc.), and monitor vital signs and lab results.

• Clinical Problems: Pain, impaired GI function, risk for infection, potential knowledge deficit.

• Implementation: Provide pain management (analgesics, positioning), manage nausea and vomiting (antiemetics, NG tube), promote comfort (clean bed, oral care), monitor for complications (obstruction, bleeding, infection), provide patient education on diet, medications, and post-operative care.

• Evaluation: Assess for pain relief, improvement in GI function, and absence of complications.

Pancreas

• Functions: The pancreas has both exocrine and endocrine functions.

  • Exocrine: Produces digestive enzymes, ions, and water.

  • Endocrine: Secretes hormones, including insulin and glucagon, to regulate blood sugar levels.

Common Pancreatic Disorders

• Acute Pancreatitis: Sudden inflammation of the pancreas caused by autodigestion of the pancreatic tissue by its own enzymes.

  • Causes: Gallstones, alcohol abuse, high triglyceride levels, trauma, medications, infections, and other factors.

  • Pathophysiology:

    • Injury to pancreatic cells triggers the activation of pancreatic enzymes (like trypsinogen to trypsin) within the pancreas, leading to inflammation, bleeding, and autodigestion.

  • Clinical Manifestations:

    • Severe abdominal pain (epigastric or LUQ), often radiating to the back.

    • Nausea, vomiting, fever, tachycardia, hypotension, abdominal distension and tenderness.

  • Complications:

    • Local: Pseudocyst formation, abscess, necrosis, hemorrhage.

    • Systemic: Systemic Inflammatory Response Syndrome (SIRS), shock, multiple organ dysfunction syndrome (MODS), respiratory failure, acute kidney injury.

  • Diagnosis:

    • Laboratory Tests: Elevated serum amylase and lipase levels, leukocytosis, hyperglycemia, hypocalcemia.

    • Imaging Studies: Abdominal ultrasound, CT scan, ERCP, MRCP.

  • Treatment:

    • Supportive Care: Pain management, NPO status, IV fluids, electrolyte correction, respiratory support, and nutritional support.

    • Treatment of Underlying Cause: ERCP for gallstone removal or stent placement.

  • Nursing Management:

    • Assessment: Obtain a detailed history, including alcohol use, assess for signs and symptoms (abdominal pain, nausea, vomiting, fever, etc.), monitor vital signs and lab results, assess for complications.

    • Clinical Problems: Pain, fluid and electrolyte imbalance, risk for infection, potential for respiratory compromise.

    • Implementation: Maintain NPO status, administer IV fluids and analgesics, monitor fluid and electrolyte balance, assess respiratory function, provide pain management, monitor for complications (infection, organ failure, etc.), provide patient education on diet, alcohol cessation, and symptom management.

    • Evaluation: Evaluate for pain relief, hemodynamic stability, resolution of inflammation, and prevention of complications.

• Chronic Pancreatitis: Continuous inflammation of the pancreas leading to irreversible damage.

  • Causes: Long-term alcohol abuse, gallstones, genetic disorders, autoimmune conditions.

  • Types:

    • Chronic Obstructive Pancreatitis: Inflammation and blockage of the pancreatic duct.

    • Chronic Nonobstructive Pancreatitis: More common, involves destruction of the pancreas with fibrosis.

  • Clinical Manifestations:

    • Recurrent or persistent abdominal pain, often radiating to the back.

    • Weight loss, steatorrhea (fatty stools) due to malabsorption.

    • May develop diabetes mellitus.

  • Complications:

    • Pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites, pleural effusion, splenic vein thrombosis, and increased risk of pancreatic cancer.

  • Diagnosis:

    • Based on clinical history, symptoms, lab tests (amylase/lipase may be slightly elevated or normal), and imaging studies (CT, MRI, ERCP).

  • Treatment:

    • Pain Management: Opioids, nerve blocks.

    • Pancreatic Enzyme Replacement Therapy (PERT): To improve digestion and nutrient absorption.

    • Lifestyle Modifications: Smoking cessation, alcohol avoidance.

    • Dietary Modifications: Low-fat diet.

  • Nursing Management:

    • Assessment: Assess for pain, weight loss, steatorrhea, and signs of complications.

    • Clinical Problems: Chronic pain, malnutrition, potential for diabetes mellitus.

    • Implementation: Manage pain, provide nutritional support, educate on dietary modifications, monitor blood sugar levels.

Crucial Role of Nursing in Care Management

• Patient Education: Nurses play a critical role in educating patients about their conditions, treatment options, potential complications, and self-management strategies.

• Symptom Management: Nurses are instrumental in providing comfort measures, managing pain, addressing nausea and vomiting, and ensuring patient safety.

• Monitoring and Early Detection of Complications: Nurses carefully monitor patients for signs of complications, such as infection, bleeding, organ failure, and electrolyte imbalances, enabling prompt interventions.

• Coordination of Care: Nurses collaborate with the interdisciplinary team to provide holistic care, coordinating consultations, treatments, and discharge planning.

• Psychosocial Support: Nurses provide emotional support, address anxiety and fears, and help patients cope with the challenges of chronic illnesses.