Gastrointestinal, Hepatobiliary, and Pancreatic Systems Review

Liver, Gallbladder, and Pancreas

• Accessory organs of digestion.
• Produce or store digestive secretions.

Liver

• Hepatic portal circulation:
  • Liver receives oxygenated blood via the hepatic artery.
  • The hepatic portal vein brings blood from abdominal digestive organs and the spleen to the liver before it returns to the heart.
  • This system allows the liver to regulate nutrient blood levels and remove potentially toxic substances.
• Produces bile.
• Excretory function: Carries bilirubin and excess cholesterol to the intestines for elimination in feces.

Liver Functions

• Carbohydrate metabolism.
• Amino acid metabolism.
• Lipid metabolism.
• Synthesis of plasma proteins.
• Phagocytosis by Kupffer cells.
• Formation of bilirubin.
• Storage of various substances.
• Detoxification.
• Activation of vitamin D.

Gallbladder

• Stores bile produced by the liver.
• Duodenal mucosa secretes cholecystokinin to stimulate gallbladder contraction.
• Contraction of the gallbladder forces bile into the cystic duct, then into the common bile duct, which empties into the duodenum to digest fatty foods and partially digested proteins.

Pancreas

• Produces digestive enzymes:
  • Amylase: Converts starch to maltose.
  • Lipase: Converts emulsified fats to fatty acids and monoglycerides.
  • Trypsin: Converts polypeptides into shorter chains of amino acids (peptides).
• Secretes bicarbonate juice, which contains digestive enzymes.

Gastrointestinal, Hepatobiliary, and Pancreatic Systems Data Collection

• Health history and family history (see Table 32.2, pages 578-579).
• Physical examination (see Table 32.3, page 580).

Abdominal Quadrants and Regions

• Right Upper (RUQ), Left Upper (LUQ), Right Lower (RLQ), Left Lower (LLQ).
• Nine abdominal regions: Right and Left Hypochondriac, Epigastric, Right and Left Lumbar, Umbilical, Right and Left Iliac, Hypogastric.

Diagnostic Tests

Laboratory Tests

• Complete blood count (CBC).
• Electrolytes.
• Bilirubin levels in stool and urine.
• Liver enzymes.
• Ammonia levels.
• Pancreatic enzymes.
• Prothrombin time (PT).
• Stool tests for fat content (see Table 32.6, pages 584-585 for specific labs related to liver and pancreas).

Radiographic Tests

• Computed Tomography (CT) scan.

Nuclear Scans

• Hepatobiliary scan (Cholescintigraphy, Hepatobiliary scintigraphy, HIDA scan - Hepatobiliary Iminodiacetic Acid, IDA - Iminodiacetic Acid).
• Liver scan via injection of a slightly radioactive medium to form a composite picture of the liver.

Endoscopy

• Endoscopic Retrograde Cholangiopancreatography (ERCP):
  • Shows pancreatic and biliary ducts.
  • Used for biopsy, stone/tumor removal, and stent placement.

Ultrasonography

• Endoscopic ultrasonography.

Percutaneous Liver Biopsy

• Needle inserted through the skin into the liver to obtain a tissue sample.
• Used to detect liver cancer, cirrhosis, or hepatitis.
• Post-procedure care:
  • Patient lies on their right side for 1-2 hours, then in the supine position for an additional 2-3 hours to prevent bleeding.
  • Monitor vital signs and the puncture site for several hours.
  • Patient should avoid coughing, straining, exercise, and heavy lifting for one week.

Hepatitis

• Inflammation of the liver cells.

Causes

• Bacterial infection.
• Medications, alcohol, and chemicals toxic to the liver.
• Metabolic or vascular disorders.
• Often caused by a virus.

Types of Viral Hepatitis

• Hepatitis A virus (HAV).
• Hepatitis B virus (HBV).
• Hepatitis C virus (HCV).
• Hepatitis D virus (HDV).
• Hepatitis E virus (HEV).
• HAV, HCV, and HBV are the most common in the United States.

Mode of Transmission:

• HAV: Fecal/oral route (fecal contact; fecal contaminated food, water, or raw shellfish; poor sanitation).
• HBV: Blood or body fluids (saliva, semen, menstrual/vaginal fluid; contaminated equipment).
• HCV: Blood or body fluids that contain blood: IV drug use; in the past: blood transfusions.
• Both HBV and HCV: Needle sticks (healthcare workers).

Prevention

• Transmission precautions.
• Standard precautions.
  • Hand hygiene.
• Available vaccines:
  • HAV.
  • Immunoglobulin (IG) after exposure.
  • Public health measures.

Signs and Symptoms

• Can be asymptomatic.
• Prodromal stage:
  • Flu-like symptoms (fatigue, nausea/vomiting), right upper quadrant (RUQ) pain.
• Icteric stage (jaundice):
  • Jaundice, worsening symptoms, pale stools, pruritus, dark urine, RUQ pain.
• Convalescent:
  • Return to normal liver function.
  • Recovery varies and depends on the type of hepatitis.

Complications

• Liver failure:
  • Acute (sudden & severe).
  • Chronic.
• Chronic infection (hepatitis).
• Carrier of virus:
  • Asymptomatic.
  • No active illness, but can still infect others.
  • Increases risk of liver cancer.

Diagnostic Tests

• Serum tests:
  • Serological tests (determines the specific virus).
  • Liver enzymes.
  • Serum bilirubin.
  • Prothrombin (clotting factor- may be prolonged) - see Table 35.2 pg. 654
• Liver biopsy (to determine liver damage).

Therapeutic Interventions

• Identify the cause.
• Monitor liver function.
• Relieve symptoms.
• Prevent cirrhosis.
• Educate on hydration and nutrition (due to N/V).
• Rest.
• Avoid alcohol and liver-toxic drugs (Box 35.1 pg. 653).

Specific Interventions

• HAV: Supportive care.
• HBV:
  • Antivirals.
  • Pegylated interferon therapy.
  • Liver transplant.
• HCV: Direct-acting antiviral medications.
  • Elbasvir/grazoprevir (Zepatier).
  • Sofosbuvir/ledipasvir (Harvoni).
  • Sofosbuvir/velpatasvir (Epculsa).
  • Glecaprevir/pibrentasvir (Mavyret).

Nursing Diagnoses

• Acute Pain.
• Imbalanced Nutrition: Less than body requirements.
• Risk for Impaired Liver Function.
• Risk for Impaired Skin Integrity (related to pruritus).
• Ineffective Health Management (see pg. 654-655).

Acute Liver Failure

Pathophysiology

• Sudden massive loss of liver tissue.
• Severe damage leads to impaired liver function.

Etiology

• Box 35.1 pg. 653
• Acetaminophen Toxicity- most common cause
  • Intake not to exceed 3000 mg in a 24-hour period (if no liver disease).

Prevention

• Be sure to look at Box 35.2 pg. 656

Signs and Symptoms

• Early: Vague (fatigue, GI upset, diarrhea).
• Jaundice.
• Hepatic encephalopathy (caused by increased ammonia levels):
  • Confusion.
  • Hepatic coma.
• Bleeding.
• Abdominal distention.

Diagnostic Serum Tests

• Alanine aminotransferase (ALT): High.
• Aspartate aminotransferase (AST): High.
• Bilirubin: High.
• Prothrombin time (PT): High/prolonged (marked elevation is an ominous sign).
• Potassium: Low.
• Blood glucose: Low.

Therapeutic Interventions

• Supportive care:
  • IV fluids.
  • Medications to manage bleeding risk (PPIs or H-2 blockers).
• Hepatic encephalopathy treatment:
  • Lactulose (helps prevent hepatic encephalopathy by excreting ammonia in the stool).
  • Maintain airway (elevate head 30 degrees, NPO, NG tube, and ET tube available).
  • Decrease stimulation and bedrest.
  • Discontinue most drugs (liver metabolizes most drugs).
  • Possible dialysis for overdose.

Cirrhosis/Chronic Liver Disease

• Cirrhosis is the progressive replacement of healthy liver tissue with scar tissue, resulting from a chronic liver disease.
• Often irreversible unless the cause is identified early and treated.

Etiology

• Chronic alcohol use.
• Chronic HBV or HCV.
• Nonalcoholic steatohepatitis (NASH): Fatty liver disease due to buildup of fat in the liver.
  • Common in those with diabetes, obesity, heart disease, or elevated cholesterol levels.

Pathophysiology

• Inflammation of liver cells.
• Infiltration with fat and white blood cells.
• Fibrotic scar tissue replaces liver tissue.
• Abnormal regeneration of the liver.
• Impaired liver blood flow.
• Impaired liver function.

Signs and Symptoms

• As liver function becomes impaired, many signs and symptoms appear:
  • Anorexia, nausea, weight loss.
  • Ascites.
  • Bruising and muscle cramping.
  • Weakness and fatigue.
  • Dull right upper quadrant pain.
  • Gastrointestinal bleeding.
  • Itching (from bile products deposited in the skin).
  • Jaundice.
  • Spider angiomata (central arteriole surrounded by smaller vessels).
• Palpation: enlarged, firm, and tender liver.

Complications

Clotting Defects

• Decreased prothrombin & fibrinogen production.
• Low vitamin K levels.
• Bruising, DIC, hemorrhage can occur.

Portal Hypertension

• Persistent elevated BP in portal vein; scarring obstructs blood flow in portal vein, blood backs up into surrounding blood vessels; pressure causes abdominal veins to become enlarged & visible, rectal hemorrhoids, spleen enlargement, esophageal varices.
  • Varices (can cause severe bleeding; avoid excessive pressure: straining such as w/ a BM, coughing, vomiting).

Ascites

• Fluid accumulation in the abdominal cavity.

Hepatic Encephalopathy

• Caused by increased ammonia levels
  • S&S: confusion, asterixis, fetor hepaticus; can gradually lose consciousness and become comatose.

Hepatorenal Syndrome

• Secondary kidney failure.

Wernicke–Korsakoff Syndrome

• Brain disorder caused by thiamine deficiency.

Diagnostic Tests

• Liver enzymes (ALT, AST): Elevated.
• Bilirubin: Elevated.
• Ammonia: Elevated.
• PT: Prolonged (bleed easier).
• Abdominal x-ray.
• Computed tomography (CT) scan.
• Magnetic resonance imaging (MRI).
• Abdominal ultrasound.
• Esophagogastroduodenoscopy (EGD).
• Liver biopsy.

Therapeutic Interventions

Ascites

• Diuretics.
• Sodium restriction.
• Fluid restriction.
• Albumin infusion.
• Paracentesis.
• Transjugular intrahepatic portosystemic shunt (TIPS).

Esophageal Varices

• Beta blockers (for prevention).
• Variceal ligation.
• Bleeding varices- medical emergency.
  • Vasoconstrictor.
  • Variceal ligation.
  • TIPS.
  • Transfusion.
  • Antibiotic prophylaxis.
  • Balloon tamponade (temporarily).

Hepatic Encephalopathy

• Avoid: narcotics, benzodiazepines, & alcohol.
• Lactulose (causes ammonia to be excreted through stool).
• Rifaximin (Xifaxan).
• K+ replacement (for hypokalemia).

Nursing Diagnoses

• Excess Fluid Volume.
• Imbalanced Nutrition: Less than body requirements.
• Acute Confusion.
• Ineffective Breathing Pattern.
• Risk for Deficient Fluid Volume (see pg. 660-661).

Liver Transplant

Candidates

• Liver failure from:
  • Cirrhosis.
  • Hepatitis.
  • Biliary disease.
  • Metabolic disorders.
  • Hepatic vein obstruction.
• Anti-rejection medications (for life).

Signs of Rejection

• Pulse > 100 beats per minute.
• Temperature > 101°F (38°C).
• RUQ pain.
• Increased jaundice.
• Elevated liver enzymes (ALT, AST), bilirubin, alkaline phosphatase (ALP), and PT.

Cancer of the Liver

• Usually metastasized from another site.

Risk Factors

• Chronic HBV or HCV.
• Nutritional deficiencies.
• Heavy alcohol use or smoking.
• Exposure to hepatotoxins.

Signs and Symptoms

• Encephalopathy.
• Abnormal bleeding.
• Jaundice.
• Ascites.

Diagnostic Tests

• Elevated alkaline phosphatase (ALP) & alpha-fetoprotein.
• MRI.
• CT.
• Ultrasound.
• Biopsy.

Therapeutic Interventions

• Surgery.
• Chemotherapy
  • Sorafenib (Nexavar).
• Radiation.

Acute Pancreatitis

Pathophysiology

• Inflammation of the pancreas caused by autodigestion.
• Pancreatic enzymes are activated while still in the pancreas and begin to digest the pancreas.
• Large amounts of enzymes are released by inflamed cells.
  • Trypsin destroys pancreatic tissue and causes vasodilation.
  • Increased capillary permeability leads to fluid loss to the retroperitoneal space, causing shock.

Etiology

• Alcohol.
• Cholelithiasis (gallstones).
• Elevated triglycerides.
• Endoscopic retrograde cholangiopancreatography (ERCP)-induced pancreatitis.
• Pancreatic tumors.
• Medications (rarely).
• Smoking increases risk.
• Idiopathic (unknown).

Signs and Symptoms

• Abdominal pain:
  • Severe epigastric/LUQ pain that radiates to the chest, back, and flanks.
• Guarding.
• Rigid ("board-like") abdomen.
• Hypotension or shock.
• Shallow respirations.
• Low-grade fever.
• Tachycardia.
• Nausea and vomiting.
• Jaundice.

Complications

• Systemic inflammatory response syndrome (SIRS).
• Cardiovascular failure.
• Acute respiratory distress syndrome (ARDS).
• Acute kidney injury.
• Hemorrhage:
  • Turner sign (purplish discoloration of flanks).
  • Cullen sign (purplish discoloration around umbilicus).
• Infection.

Diagnostic Tests

• Presence of two items:
  • Abdominal pain
  • Serum amylase (normal: 100-300 units/L) and/or serum lipase (normal: 0-60 units/L) > 3 times normal.
• Abdominal imaging:
  • CT scan.
  • MRI.
  • Ultrasound.

Therapeutic Interventions

• Aggressive IV fluids (first 24 hours).
• Nutrition:
  • Mild: Oral.
  • Severe: Enteral.
• Analgesics (pain relief essential; a nursing priority).
• Antibiotics for infection or sepsis.

Chronic Pancreatitis

Pathophysiology

• Progressive fibro-inflammatory disease.
• Pancreatic ducts become obstructed, dilated, and finally atrophied.
• Ulceration of pancreatic cells and tissue death.
• The pancreas becomes smaller and hardened.
• Exocrine insufficiency occurs (progressively smaller amounts of pancreatic enzymes are produced).

Etiology

• Alcohol abuse.
• Obstructive biliary disease.
• Hyperlipidemia.
• Idiopathic.
• Genetic.
• Autoimmune.

Risk Factors

• Smoking & repeated attacks of acute pancreatitis.

Signs and Symptoms

• Asymptomatic.
• Epigastric or left upper quadrant (LUQ) pain worsens after eating.
• Nausea and vomiting.
• Weight loss.
• Steatorrhea (greasy, foul-smelling, loose stools).
• Fatty food intolerance.
• Remissions and exacerbations.

Complications

• Abscesses.
• Fistulas.
• Pleural effusion.
• Malabsorption & fat intolerance.
• Diabetes.
• Pancreatic cancer.

Diagnostic Tests

• CT scan.
• MRI.
• Endoscopic ultrasound.
• Pancreatic enzymes normal or low.
• High fecal fat level.

Therapeutic Interventions

• Stop alcohol use.
• Small low-fat meals.
• NSAIDs, analgesics, and proton pump inhibitors (PPIs).
• Pancreatic enzyme supplements.
• Stents.
• Surgery.

Nursing Diagnoses

• Acute Pain.
• Imbalanced Nutrition: Less than body requirements.
• Ineffective Breathing Pattern.
• Risk for Injury (see pg. 665-666).

Cancer of the Pancreas

• Ductal adenocarcinoma of the exocrine pancreas.
• Spreads rapidly.

Risk Factors

• Smoking.
• Obesity.
• Work exposure to chemicals (used in dry cleaning & metal industries).
• Physical inactivity.
• Diabetes mellitus.
• Chronic pancreatitis.
• Cirrhosis.
• H. Pylori infection.
• Heredity.
• Prevention includes eating high-folate & lycopene fruits & veggies; avoiding risk factors (smoking).

Signs and Symptoms

• None early typically.
• If early: epigastric or back pain, anorexia, nausea, fatigue, malaise.
• Usually has metastasized:
  • Weight loss (classic sign).
  • Abdominal pain radiates to back
    • Worsens at night, gnawing.
    • Becomes increasingly severe & unrelenting as tumor grows
  • Anorexia, nausea and vomiting, fullness after eating.
• Obstructed bile duct: jaundice, pruritis, dark urine, light-colored stools.
• Depression.
• Recent diagnosis of diabetes mellitus.

Preoperative Complications

• Malnutrition.
• Spread of cancer.
• Gastric or duodenal obstruction.

Postoperative Complications

• Pneumonia or atelectasis.
• Infection.
• Fistula formation.
• Malabsorption syndrome.
• Thrombophlebitis (makes clotting easier).

Diagnostic Tests

• Serum amylase/lipase.
• ALP.
• Bilirubin.
• Coagulation studies (clotting time).
• Carbohydrate antigen 19-9 (confirms the presence of cancer).
• CT, MRI, PET, ultrasound.
• ERCP.
• Pancreatic biopsy (gives definitive diagnosis).

Therapeutic Interventions

• Surgery
  • Whipple procedure (pancreatoduodenectomy).
  • Distal pancreatectomy (tail of the pancreas).
  • Total pancreatectomy: Rare.
• Stent or bypass relieves biliary obstruction.
• Chemotherapy.
• Radiation.

Nursing Diagnoses

• Imbalanced Nutrition: Less than Body Requirements.
• Acute Pain.
• Risk for Deficient Fluid Volume.
• Risk for Impaired Tissue Integrity.

Patient Education

• Blood glucose monitoring.
• Administering insulin.
• Management of hyper/hypoglycemia.
• Pancreatic enzyme replacement.
• Dressing changes.
• Complications to report.
• Hospice/home health referral.

Gallbladder Disorders

Cholecystitis

• Inflammation.
  • Acute: gallstone blocks common bile duct
    • Treated immediately to prevent gallbladder rupture
  • Chronic: repeated attacks of acute and irritation from gallstones.

Cholelithiasis (Cholecystolithiasis)

• Stones
  • Formed from cholesterol or calcium.

Choledocholithiasis

• Stones in the common bile duct.

Etiology (Cholelithiasis)

• Risk increases with age.
• Family history.
• Obesity.
• Bile stasis.
• Diabetes.
• Cirrhosis.
• Pregnancy.
• Estrogen.
• High cholesterol intake.
• Frequent fasting.
• Sedentary lifestyle.
• More often in women.

Signs and Symptoms

• Silent stones.
• Elevated vital signs.
• Vomiting.
• Jaundice.
• Biliary colic:
  • Epigastric pain may radiate back to behind the right scapula or right shoulder.
• Nausea/vomiting.
• Indigestion.
• RUQ tenderness.
• Positive Murphy sign.

Complications

• Acute cholangitis (inflammation of the bile ducts).
• Necrosis/perforation of gallbladder.
• Fistulas.
• Adenocarcinoma of gallbladder.
• Acute pancreatitis if the pancreatic duct is obstructed.

Diagnostic Tests

• Ultrasound:
  • Endoscopic.
• CT scan.
  • Magnetic resonance cholangiopancreatography (MRCP).
  • ERCP.
• Cholescintigraphy (Hepatobiliary iminodiacetic acid scan- HIDA).
• Elevated WBC count.
• Elevated direct bilirubin.

Therapeutic Interventions

• Analgesics.
• Bile acid dissolution agents
  • Ursodiol (Actigall).
• Itch relief
  • Colestipol (Colestid).
  • Cholestyramine (Questran).
• Antiemetics.

Cholelithiasis Treatment

Cholecystectomy

• Laparoscopic surgery
  • Most common.
• Traditional surgery (open).
  • T-tube.
• Medication to dissolve stones.

Traditional Cholecystectomy Post-Op Problems

• Incisional pain prevents deep breathing postoperatively because deep breathing causes the diaphragm to press on the operative site.
  • Nursing interventions to help with deep breathing would be:
    • Provide analgesics for pain relief
    • Encourage coughing and deep breathing
    • Assist in splinting during coughing

Nursing Diagnoses

• Acute Pain.
• Risk for Deficient Fluid Volume.

Postoperative Nursing Diagnoses

• Ineffective Breathing Pattern.
• Risk for Impaired Skin Integrity.