Ch 44 Liver/gallbladder/pancreas

Front 1

What is the largest internal organ?

Back 1

Liver

Front 2

Where is the liver in the body?

Back 2

Right epigastric region

Front 3

About ______ of the blood supply comes from the hepatic artery

Back 3

one fourth

Front 4

______ of the blood supply comes from the portal vein

Back 4

three fourths

Front 5

Where does the portal circulatory system bring blood from?

Back 5

The stomach, intestines, spleen, and pancreas

Front 6

Where does blood enter the liver?

Back 6

portal vein

Front 7

What are the seven major functions of the liver?

Back 7

Carbohydrate metabolism
Fat metabolism
Bile production
Storage
Protein metabolism
Steriod metabolism
Bile excretion

Front 8

What does the liver store?

Back 8

Glucose in the form of glycogen
Vitamins (fat and water soluble)
Fatty acids
Minerals
Amino Acids (Albumin and B-globulins)

Front 9

What is the Mononuclear phagocyte system?

Back 9

Kupffer cells
- breakdown old WBCs, RBCs, bacteria, and other particles
- breakdown of hemoglobin from old RBCs to bilirubin and biliverdin

Front 10

What usually happens when the liver metabolizes drugs?

Back 10

Results in loss of activity

Front 11

Total bilirubin normal limits

Back 11

0.2- 1.2 mg/dL

Front 12

Albuminm normal limits

Back 12

3.5-5 g/dL

Front 13

Globulin normal limits

Back 13

2.0- 3.5 g/dL

Front 14

Total protein normal limits

Back 14

6.4- 8.3 g/dL

Front 15

A/G ration normal limits

Back 15

1.5:1- 2.5:1

Front 16

Ammonia normal limits

Back 16

15-45 mcg N/dL

Front 17

AST normal limits

Back 17

10-30 U/L

Front 18

ALT normal limits

Back 18

10-40 U/L

Front 19

Serum cholesterol normal limits

Back 19

<200 mg/dL

Front 20

What is a liver biopsy used for?

Back 20

Obtaining a specimen of liver tissue

Front 21

What are the possible complications of a liver biopsy?

Back 21

Pneumothorax
Peritonitis
Hemorrhage

Front 22

What is cirrhosis?

Back 22

A chronic progressive disease of the liver with extensive degeneration and destruction of liver cells.

Front 23

What is the etiology of cirrhosis?

Back 23

- long term liver disease
- excessive alcohol intake
- primary biliary cirrhosis
- primary sclerosing cholangitis

Front 24

What are the early S/S of cirrhosis?

Back 24

-N/V
- Anorexia
- Dyspepia
- Flatulence
- Diarrhea or constipation
- Abdominal pain
- Fever
- Slight weight loss
- Enlargement of liver and spleen

Front 25

What are the late S/S of cirrhosis?

Back 25

- Jaundice
- Peripheral edema
- Ascites
- Skin lesions
- Hematologic disorders
- Endocrine disturbances
- Peripheral neuropathies
- Liver size decreased and nodular

Front 26

What is jaundice?

Back 26

A yellowish discoloration of body tissue resulting from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct system.

Front 27

What are the 3 kinds of jaundice?

Back 27

- Hemolytic (increased breakdown of RBCs, producing an increase in the amt of unconjugated bilirubin in the blood)
- Hepatocellular (liver's inability to take up bilirubin from the blood or to conjugate or to excrete it)
- Obstructive (due to the decrease or obstructed flow of bile through the liver or biliary duct system)

Front 28

What are two skin lesions seen in cirrhosis?
What are they due to?

Back 28

- Spider angiomas (small dilated blood vessels)
- Palmar erythema (red area on palms)
Due to the increase in circulating estrogen as a result of the liver's inability to metabolize steroid hormones.

Front 29

What are some hematologic problems associated with cirrhosis?

Back 29

- Thrombocytopenia (decreased platelets)
- Leukopenia (decreased WBCs)
- Anemia
- Coagulation disorders
- Splenomegaly (increased spleen)

Front 30

What are some endocrine problems associated with cirrhosis?

Back 30

- inactivation of adrenocortical hormones, estrogen, and testosterone
- Hyperaldosteronism
- Men: gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence, loss of libio
- Women: amenorrhea, vaginal bleeding

Front 31

What is peripheral neuropathy related to?

Back 31

- dietary deficiency
- folic acid
- cobalamin

Front 32

What are some complications of cirrhosis?

Back 32

- Portal hypertension
- Esophageal and gastric varices
- Peripheral edema (ankle and presacral)
- Ascites
- Hepatic encephalopathy (coma)
- Hepatorenal syndrome

Front 33

Portal hypertension is from?
leads to?

Back 33

It is from the portal vein becoming engorged because of blood backup from scarring and nodular changes in the liver causing compression of the veins and sinusoids.
Leads to esophageal and gastric varices

Front 34

Esophageal and gastric varices are?
what causes them?

Back 34

Blood vessels that rupture and bleed excessively.
Causes: development of collateral channels of circulation in inelastic, fragile esophageal veins

Front 35

What is compensated cirrhosis?

Back 35

Patients without complications

Front 36

What is decompensated cirrhosis?

Back 36

Patients that have one or more complications of their disease.

Front 37

Peripheral edema results from?

Back 37

Decreased colloidal oncotic pressure from impaired liver synthesis of albumin and increased portacaval pressure from portal hypertension.

Front 38

Ascites is? results from?

Back 38

Is the accumulation of serous fluid in the peritoneal or abdominal cavity.
Results from the lymphatic system is unable to carry off the excess proteins and water, hypoalbuminemia, hyperaldosteronism, increase in ADH.

Front 39

What are the S/S of ascites?

Back 39

Patient has S/S of dehydration bc of fluid volume deficit systemically from 3rd spacing.
- dry tongue and skin
- sunken eyeballs
- muscle weakness
- decrease in urinary output
- hypokalemia

Front 40

What is asterixis and fetor hepaticus? when are they sometimes seen?

Back 40

Asterixis- flapping temors
Fetor hepaticus- musty, sweet odor of the pt's breath
Only seen in severe cases of hepatic encephalopathy.

Front 41

Explain hepatorenal syndrome

Back 41

- Functional renal failure with azotemia, oliguria, and intractable ascities.
- no structural changes to the kidneys
- can be reversed by liver transplant because kidneys are not usually damaged

Front 42

What are the usual lab findings in cirrhosis?

Back 42

- Enzyme levels (AST, ALT, and GGT) are initially elevated
- In compensated or end stage AST and ALT levels may be normal. Decreased protein, decreased albumin, increased serum bilirubin, increased globulin levels
- decreased cholesterol levels
- Prothrombin time is prolonged

Front 43

Nursin Care for Ascites
diet?
meds?
procedures?

Back 43

Diet- Na restriction
Meds- Diuretics
Procedure- Fluid removal: Paracentesis, Peritoneovenous Shunt

Front 44

Nursing Care for Varices
Goal?
avoid?
Procedures?

Back 44

Goal- avoid bleeding/hemorrhage
Avoid- alcohol, aspirin, irritating foods
Procedures:
- Endoscopic ligation: banding of varices
- Ballon tamponade: controls hemorrhage by compression of varices

Front 45

Nursing Care for Hepatic Encephalopathy
treatment?

Back 45

- restrict protein intake in early stages
- give lactulose
- d/c sedatives, tranquilizers, analgestics

Front 46

What is Laennec's cirrhosis?

Back 46

associated with alcohol abuse

Front 47

What is Postnecrotic cirrhosis?

Back 47

A complication of viral, toxic, or idiopathic hepatitis. Scar tissue form in the liver.

Front 48

What is Biliary cirrhosis?

Back 48

Chronic biliary obstruction and infection.

Front 49

What is Cardiac cirrhosis?

Back 49

Results from severe right sided heart failure in clients with cor pulmonale.

Front 50

What to look for in an assessment for cirrhosis?

Back 50

- Past history of alcoholism, viral hepatitis
- weight loss
- jaundice
- abd distension
- n/v
- altered mentation
- RUQ pain
- abnormal lab values

Front 51

Main points in nursing implementation of cirrhosis

Back 51

- treat alcoholism
- identify hepatitis early and treat
- stress importance of adequate nutriton
- identify biliary disease early and treat

Front 52

What is viral hepatitis?

Back 52

Inflammation and necrosis of hepatic cells.
- bile flow is impaired
- necrosis occurs in spotty pattern
- liver cells may regenerate during recovery period

Front 53

What drugs should be avoided with cirrhosis?

Back 53

-Aspirin
- Acetaminphen
- NSAIDs

Front 54

5 types of hepatitis

Back 54

- HAV
- HBV
- HCV
- HDV
- HEV

Front 55

HAV
also known as?
mode of transmission?

Back 55

"Infectious hepatitis"
Fecal- oral route, poor sanitation

Front 56

HAV
Incubation period?
S/S?

Back 56

15-50 days
Can occur with or without symptoms and only show after incubation
Flu like
-headache, anorexia, fever in early stage
- dark urine, jaundice in later stage

Front 57

HAV
vaccine?
high risk groups?
outcome?

Back 57

Vaccine: 2 doses that be given up to 2 weeks of contact
High risk group: homosexual men, IV drug users, day care workers
Outcome:
- usually mild with recovery
- fatality rate less than 1%
- no carrier state
- no increased risk of chronic hepatitis, cirrhosis or hepatic cancer

Front 58

HAV
Nursing management includes?

Back 58

- stressing good hygiene
- enviromental saniation

Front 59

True or false
HAV increases your risk of chronic hepatitis, cirrhosis, and hepatic cancer.

Back 59

False

Front 60

HAV
When is the person infectious?

Back 60

2 weeks before onset of symptoms and until 1-2 weeks after symptoms start

Front 61

HBV
also known as?
Transmission?

Back 61

"Blood hepatitis"
Transmission- blood and body fluids, through mucous membranes and breaks in skin

Front 62

HBV
At risk groups?
What profession is at great risk for this disease?

Back 62

IV drug users and homosexual activity, tattoos, piercing
Health care workers at great risk

Front 63

HBV
Incubation?
S/S

Back 63

1-6 months
May occur without symptoms, may develop arthralgias, rash

Front 64

True or False
HBV is more infectious than HIV and can stay on surface for up to 7 days.

Back 64

True

Front 65

HBV
vaccine?

Back 65

- 3 doses
- recommended for all health care workers
- passive immunity provided by hepatitis B immune globulin
- recommended for people exposed to HBV who have not recieved the vaccine or never had HBV

Front 66

HBV
Nursing management?

Back 66

- teaching patient proper nutrition, rest, and prevention of spread

Front 67

HBV
carrier state?
increased risk?

Back 67

Carrier state possible
Increased risk for cirrhosis, chronic hepatitis and hepatic cancer

Front 68

HBV
Types of meds given?

Back 68

- a- interferon
- nucleoside and nucleotide analogs

Front 69

HCV
also known as?
transmission?

Back 69

"Non A, Non B hepatitis"
Transmission through blood transfusion, exposure to blood contaminated equipment or drug paraphernalia (most common), or sexual contact

Front 70

HCV
incubation?
who is at risk?

Back 70

15-160 days
Dialysis patients are at risk

Front 71

HCV has a similar clinical course to which other hepatitis?

Back 71

HBV

Front 72

HCV
carrier state?
Increase risk for?

Back 72

Chronic carrier state occurs frequently
Increase risk for chronic liver disease and cancer

Front 73

HCV
treatment?

Back 73

- interferon
- ribavirin

Front 74

True or False
HCV accounts for 30% of liver transplants in US.

Back 74

True

Front 75

HDV
who is at risk?
tranmission?

Back 75

ONLY individuals with HBV are at risk
Transmission through sexual contact and IV drug use

Front 76

HDV
S/S?
treatment?

Back 76

S/S similar to HBV, more likely to progress to chronic active hepatitis and cirrhosis
Investigation into interferon as treatment

Front 77

HEV
transmission?
similar to?

Back 77

Transmitted through fecal- oral route
Similar to HAV

Front 78

HEV
main S/S?

Back 78

Jaundice

Front 79

True or False
HEV is common in the USA.

Back 79

False

Front 80

Acute hepatitis S/S
6 main ones

Back 80

- malaise
- anorexia
- fatigue
- nausea
- occasional vomiting
- RUQ discomfort

Front 81

Chronic hepatitis S/S

Back 81

- malaise
- easy fatigability
- hepatomegaly
- myalgias and/or arthralgias
- elevated liver enzymes AST, ALT

Front 82

Cholelithiasis is?

Back 82

- stones in the gallbladder
- most common disorder of biliary system

Front 83

Cholecystitis is?

Back 83

- inflammation of the gallbladder
- usually associated with cholelithiasis

Front 84

Risk factors of gallbladder disease

Back 84

- higher in women, multiparous women, and persons over 40 years
- estrogen therapy increases risk
- sedentary lfestyle
- familial tendency
- obesity

Front 85

Cholecystitis is most commonly caused by?
other causes?

Back 85

obstruction with gallstone or biliary sludge
Other causes:
- older adults
- trauma
- extensive burns
- recent surgery
- lose alot of weight quickly

Front 86

Due to the inflammation of cholecystitis what duct may become occulded?

Back 86

Cystic duct

Front 87

What are the most common form of gallstones?

Back 87

Stones that are primarily cholesterol

Front 88

What components precipitate into gallstones?

Back 88

- cholesterol
- bile salts
- bilirubin
- calcium
- protein

Front 89

Where do the stones go?

Back 89

Stones can remain in the gallbladder or migrate to the cystic or common bile duct

Front 90

What happens if a blockage occurs due to a gallstone?

Back 90

- bile can continue to flow into the dupdenum directly from the liver
- statis of bile can occur

Front 91

Gallbladder disease
S/S?
In general

Back 91

Varies from
- indigestion
- moderate to severe pain
- fever
- jaundice
- increased WBCs

Front 92

Initial symptoms of acute cholecystitis

Back 92

- indigestion
- RUQ pain
- possible shoulder pain
- N/V
- restlessness
- diaphoresis

Front 93

Acute cholecystitis
when do attacks occur after meals?

Back 93

Usually 3-6 hours after meal

Front 94

Chronic cholecystitis
patient have a history of?

Back 94

- fat intolerance
- dyspepsia
- heartburn
- flatulence

Front 95

For cholelithiasis what does severity depend on?

Back 95

- presence of obstruction
- whether stones move or not

Front 96

True or False
Cholelithiasis can have no symptoms at all.

Back 96

True

Front 97

What is biliary colic?

Back 97

When stones get lodged in the ducts or are moving spasms occur that produce severe pain. The pain is more steady than colicky though.

Front 98

Total obstruction symptoms of cholelithiasis

Back 98

- jaundice
- dark color urine (bilirubin)
- clay color stool
- pruritis (bile salts in the skin)
- intolerance to fatty foods
- bleeding tendencies
- steatorrhea (fatty stools, "floater")
- no urobilinogen in urine

Front 99

Complications of cholecystitis

Back 99

- Gangrenous cholecystitits
- Subphrenic abscess
- Pancreatitis
- Cholangitis
- Biliary cirrhosis
- Fistulas
- Gallbladder rupture

Front 100

Complications of cholelithiasis

Back 100

- Cholangitis (inflammation of biliary ducts)
- Biliary cirrhosis
- Carcinoma
- Peritonitis
- Choledocholithiasis (gallstones in common bile duct)

Front 101

Gallbladder disease
Lab test abnormalities

Back 101

- elevated WBCs
- elevated serum bilirubin (direct and indirect)
- blockage: elevated urinary bilirubin, ALT
- Pancreatic involvement: elevated serum amalyse

Front 102

What does a transhepatic biliary catheter do?

Back 102

Opens things up, not curing anything but making patient comfortable.
Used before surgery or when it is inoperable.
Connected to a drainage bag.

Front 103

Most common meds used for gallbladder disease

Back 103

- Analgesics
- Anticholinergics
- Fat soluble vitamins
- bile salts
Also have dissolution therapy, takes 6months to 12 yrs

Front 104

What are the dietary therapy of a patient with gallbladder disease?

Back 104

- low fat diet (avoid diary products, fried foods, rich pastries, gravy, nuts
- reduced calorie diet if obese
- eat small more frequent meals
-

Front 105

What is the best position to put the patient in if they are experiencing shoulder or abdominal pain after surgery for cholecystectomy?

Back 105

Sim's position, lies on one side with the under arm behind the back and the upper thigh flexed

Front 106

What are the three parts of the pancreas?

Back 106

Head, body, tail

Front 107

The pancreatic duct enters the duodenum through the ?

Back 107

Common bile duct (CBD)

Front 108

Pancreatic enzymes are the exocrine function of the pancreas. What are these 4 enzymes?

Back 108

- trypsinogen
- chymotrypsin
- amylase
- lipase

Front 109

What is the function of pancreatic enzymes?

Back 109

aid in digestion

Front 110

What is the endocrine function of the pancreas?

Back 110

Insulin

Front 111

What are the main causes of acute pancreatitis?

Back 111

- alcoholism (most common in males, decreased blood flow and poor nutrition
- gallbladder disease (gallstones # 1 cause)

Front 112

What happens to the pancreas when it becomes inflammed?

Back 112

- autodigestion of pancreas, enzymes are activated in pancreas instead of duodenum

Front 113

Acute Pancreatitis
S/S?

Back 113

- abdominal pain, severe LUQ or midgastric region, sudden, deep, peircing, steady, can radiate to pt's back
- N/V
- fever
- leukocytosis
- hypotension
- tachycardia
- jaundice
- Grey Turner sign (blue flank)
- Cullen's sign (blue belly button)

Front 114

Acute Pancreatitis
Complications?

Back 114

- Hypovolemia from 3rd space shifting
- Pseudocyst
- Abscess
- Pulmonary
- CV
- Tetany, hypocalcemia
- Hyperglycemia
- Hyperlipidemia

Front 115

Acute Pancreatitis
Lab studies

Back 115

- Serum amylase, increased (< 200 U/L (1-130 normal))
- Serum lipase, increased (1-160 normal)
- Urinary amylase elevated

Front 116

Acute Pancreatitis
Treatment?

Back 116

- pain relief
- F & E replacement
- Bowel and pancreatic rest (may see NG tube used for decompression)
- Sometimes antibiotics
- Surgical therapy

Front 117

What is the dietary teaching for someone with acute pancreatitis?

Back 117

Low fat
encourage carbohydrates

Front 118

Chronic pancreatitis
what is happening to the pancreas?
S/S?

Back 118

- structural changes from so many flare ups
- functional capabilites decline- especially exocrine, weight loss and unable to ingest and absorb food
- possible development of diabetes mellitus from damage to pancreas
S/S: similar to acute but more gradual, cramping, burning pain

Front 119

Chronic Pancreatitis
Management?

Back 119

- AVOIDANCE OF ALCOHOL
- dietary changes: high carbs, low fat
- meds to digest food, given with food

Front 120

Pancreatic Cancer
what kind of cancer is it?
where do half of cases occur?
what can get obstructed?

Back 120

- Adenocarcinoma
- In the head
- CBD can become obstructed from tumor growth

Front 121

Is the care for pancreatic cancer more about curing it or more pallative?
How long do most patients have to live after dx?

Back 121

- Pallative
- 5-12 months

Front 122

Pancreatic Cancer
Risk factors?

Back 122

- cigarette smoking
- high fat diet
- diabetes
- exposure to chemicals

Front 123

Pancreatic Cancer
S/S?

Back 123

Similar to pancreatitis
- abdominal pain
- anorexia
- weight loss
- nausea
- jaundice

Front 124

Pancreatic Cancer
When is it usually dx?
By what tests?

Back 124

- Dx in the advanced stages
- abdominal ultrasound
- CT scan
- ERCP
- Tumor markers: CA19-9 increased and GB CEA, also seen in gallbladder cancer

Front 125

What is the Whipple procedure?

Back 125

Remove entire pancreas and certain other structures and then reattached.