Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract,

1. Chapter 6 Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

2. Laboratory and Diagnostic Examinations • Serum bilirubin test • Liver enzyme tests • Serum protein test • Oral cholecystography (gallbladder series) • Intravenous cholangiography (IV cholangiogram) • Operative cholangiography • T-tube cholangiogram • Ultrasound of the liver, gallbladder, and biliary system • Gallbladder scanning • Liver biopsy • Liver scanning

3. Cholangiogram

4. Liver Biopsy

5. Laboratory and Diagnostic Examinations (continued) • Blood ammonia • Hepatitis virus studies • Serum amylase test • Urine amylase test • Ultrasound of pancreas • Computerized tomography of the abdomen • Endoscopic retrograde cholangiopancreatography of the pancreatic duct (ERCP)

7. Ammonia Breakdown

8. Bilirubin & Clinical Significance • Bilirubin is a yellowish pigment found in bile, a fluid produced by the liver. • This article discusses the laboratory test done to measure bilirubin in the blood. Total and direct bilirubin are usually measured to screen for or to monitor liver or gallbladder problems. Large amounts of bilirubin in the body can lead to jaundice. • A test may also be done to measure bilirubin in a urine sample. For information on that test, see: Bilirubin - urine. • How the Test is Performed • A blood sample is needed. For information on how this is done, see: Venipuncture . • The laboratory specialist spins the blood in a machine called a centrifuge, which separates the liquid part of the blood (serum) from the cells. The bilirubin test is done on the serum. • How to Prepare for the Test • You should not eat or drink for at least 4 hours before the test. Your health care provider may instruct you to stop taking drugs that affect the test. • Drugs that can increase bilirubin measurements include allopurinol, anabolic steroids, some antibiotics, antimalaria medications, azathioprine, chlorpropamide, cholinergics, codeine, diuretics, epinephrine, meperidine, methotrexate, methyldopa, MAO inhibitors, morphine, nicotinic acid, birth control pills, phenothiazines, quinidine, rifampin, steroids, sulfonamides, and theophylline. • Drugs that can decrease bilirubin measurements include barbiturates, caffeine, penicillin, and high-dose salicylates such as aspirin. • Why the Test is Performed • This test is useful in determining if a patient has liver disease or a blocked bile duct. • Bilirubin metabolism begins with the breakdown of red blood cells in many parts of the body. Red blood cells contain hemoglobin, which is broken down to heme and globin. Heme is converted to bilirubin, which is then carried by albumin in the blood to the liver. • In the liver, most of the bilirubin is chemically attached to another molecule before it is released in the bile. This "conjugated" (attached) bilirubin is called direct bilirubin; unconjugated bilirubin is called indirect bilirubin. Total serum bilirubin equals direct bilirubin plus indirect bilirubin. • Conjugated bilirubin is released into the bile by the liver and stored in the gallbladder, or transferred directly to the small intestines. Bilirubin is further broken down by bacteria in the intestines, and those breakdown products contribute to the color of the feces. A small percentage of these breakdown compounds are taken in again by the body, and eventually appear in the urine. • Normal Results • Direct bilirubin: 0 to 0.3 mg/dL • Total bilirubin: 0.3 to 1.9 mg/dL • Note: mg/dL = milligrams per deciliter • Normal values may vary slightly from laboratory to laboratory.

9. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis • Etiology/pathophysiology • Chronic, degenerative disease of the liver • Scar tissue restricts the flow of blood to the liver • Types of cirrhosis • Laennec’s cirrhosis • Postnecrotic cirrhosis • Primary biliary cirrhosis • Secondary biliary cirrhosis

10. Dieased Livers (Cirrhosis)

11. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Etiology/pathophysiology (continued) • Alteration of liver function • Reduced ability to metabolize albumin • Obstruction of portal vein • Increased pressure in veins that drain GI tract • Complications • Portal hypertension • Ascites • Esophageal varices • Hepatic encephalopathy

12. The Portal System

13. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Clinical manifestations/assessment • Early stages • Abdominal pain • Liver is firm and easy to palpate • Late stages • Dyspepsia • Changes in bowel habits • Nausea and vomiting • Gradual weight loss

14. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Clinical manifestations/assessment (continued) • Late stages (continued) • Ascites • Enlarged spleen • Spider angiomas • Anemia • Bleeding tendencies • Epistaxis

15. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Clinical manifestations/assessment (continued) • Late stages (continued) • Purpura • Hematuria • Bleeding gums • Jaundice • Disorientation

16. Figure 6-2 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Systemic clinical manifestations of liver cirrhosis.

18. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Medical management/nursing interventions • Eliminate the cause • Alcohol • Hepatotoxins • Environmental exposure to harmful chemicals • Antiemetics • Benadryl and Dramamine • Contraindicated: Vistaril, compazine, and Atarax

19. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Diet • Well-balanced • High calorie • Moderate protein • Low fat • Low sodium • Supplemental vitamins and folic acid

20. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Treatment of complications • Ascites • Bedrest • Strict I&O • Restrict fluids and sodium • Diuretics: aldactone, Lasix, HCTZ • Vitamins K, C, and folic acid supplements • LeVeen peritoneal-jugular shunt • Paracentesis

21. Figure 6-3 (From Beare, P.G., Myers, J.L. [1998]. Adult health nursing. [3rd ed.]. St. Louis: Mosby.) LeVeen continuous peritoneal jugular shunt.

22. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Treatment of complications (continued) • Ruptured esophageal varices • Maintain airway; establish IV • Vasopressin drip to control bleeding • Sengstaken-Blakemore tube • Endoscopic sclerotherapy • Portacaval shunt • Blood transfusion

23. Senstaken-Blakemore Tube

24. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cirrhosis (continued) • Medical management/nursing interventions (continued) • Treatment of complications (continued) • Hepatic encephalopathy • Decrease protein in diet • Avoid drugs which are detoxified by the liver • Lactulose • Neomycin

26. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis • Etiology/pathophysiology • Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances • Hepatitis A • Most common • Oral-fecal transmission

27. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Etiology/pathophysiology (continued) • Hepatitis B • Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids • Hepatitis C • Transmitted through contaminated needles and blood transfusions

28. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Etiology/pathophysiology (continued) • Hepatitis D • Co-infection with hepatitis B • Hepatitis E • Fecal contamination of water • Rare in the U.S.; usually in developing countries

29. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Clinical manifestations/assessment • General malaise • Aching muscles • Photophobia • Headaches • Chills • Abdominal pain • Dyspepsia • Nausea

30. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Clinical manifestations/assessment (continued) • Diarrhea/constipation • Pruritus • Hepatomegaly • Enlarged lymph nodes • Weight loss • Jaundice • Dark amber urine • Clay-colored stools

33. Figure 6-5 (From Kamal, A., Brockelhurst, J.C. [1991]. Color atlas of geriatric medicine. [3rd ed.]. St. Louis: Mosby-Year Book—Europe.) Severe jaundice.

34. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Medical management/nursing interventions • Treat symptoms • Small, frequent meals • Low fat, high carbohydrate • IV fluids for dehydration • Vitamin C, vitamin B-complex, vitamin K • Avoid unnecessary medications, especially sedatives

35. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Hepatitis (continued) • Medical management/nursing interventions (continued) • Gamma globulin or immune serum globulin • Hepatitis B immune globulin (HBIG) • Should be given to anyone exposed to hepatitis B • Hepatitis B vaccine • Should be given to people identified as high risk for developing hepatitis B

36. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Liver abscesses • Etiology/pathophysiology • May be single or multiple • Abscess forms in the liver due to an invading bacteria

37. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Liver abscesses (continued) • Clinical manifestations/assessment • Fever • Chills • Abdominal pain and tenderness in the right upper quadrant • Hepatomegaly • Jaundice • Anemia

38. Liver Abcess • Autopsy specimen showing a superior and an inferior surface amoebic liver abscess.(Rt .lobe)

39. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Liver abscesses (continued) • Medical management/nursing interventions • IV antibiotics • Percutaneous drainage of liver abscess • Open surgical drainage

40. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cholecystitis and cholelithiasis • Etiology/pathophysiology • An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder and the trapped bile acts as an irritant causing inflammation • Risk factors • Female; American Indian or white; obesity; pregnancy; diabetes; multiparous women; use of birth control

41. Figure 6-6 (From Phipps, W.J., Monahan, F.D., Sands, J.K., Marek, J.F., Neighbors, M. [2003]. Medical-surgical nursing: health and illness perspectives. [7th ed.]. St. Louis: Mosby.) Common sites of gallstones.

42. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cholecystitis and cholelithiasis (continued) • Clinical manifestations/assessment • Indigestion after eating foods high in fat • Severe, colicky pain in the right upper quadrant • Anorexia • Nausea and vomiting • Flatulence • Increased heart and respiratory rates • Diaphoresis

43. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cholecystitis and cholelithiasis (continued) • Clinical manifestations/assessment (continued) • Low-grade fever • Elevated WBC • Mild jaundice • Steatorrhea (fatty stool) • Dark amber urine

44. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cholecystitis and cholelithiasis (continued) • Medical management/nursing interventions • Mild attacks • Bedrest • NG tube to suction • NPO • IV fluids • Antispasmodic/analgesic • Antibiotics • Avoid spicy foods when allowed PO intake

45. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Cholecystitis and cholelithiasis (continued) • Medical management/nursing interventions (continued) • Lithotripsy • Cholecystectomy • Laparoscopic • Open

46. ESWL: Lithotripsy

47. Cholecystectomy

49. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Pancreatitis • Etiology/pathophysiology • Inflammation of the pancreas • Acute or chronic • Predisposing factors • Alcohol • Trauma • Infectious disease • Certain drugs

50. Disorders of the Liver, Biliary Tract, Gallbladder, and Pancreas • Pancreatitis (continued) • Clinical manifestations/assessment • Abdominal pain • Anorexia; nausea and vomiting • Malaise • Low-grade fever • Jaundice • Weight loss • Steatorrhea • Tachycardia