git part 2-run
TRANSCRIPT
GIT part 2GIT part 2Accessory OrgansAccessory Organs
Ruby Ruth T. Roces, R.N., M.D.Ruby Ruth T. Roces, R.N., M.D.
Anatomy and Anatomy and PhysiologyPhysiologyAccessory OrgansAccessory Organs PancreasPancreas LiverLiver Gall bladderGall bladder
Pancreatic secretionsPancreatic secretions
1. Bicarbonate1. Bicarbonate2. Pancreatic amylase2. Pancreatic amylase3. Pancreatic lipase3. Pancreatic lipase4. Trypsin and 4. Trypsin and chymotrypsinchymotrypsin
Liver physiology and PathophysiologyLiver physiology and PathophysiologyNormal Function Normal Function Abnormality in functionAbnormality in function
1. Stores glycogen1. Stores glycogen = Hypoglycemia= Hypoglycemia2. Synthesizes proteins2. Synthesizes proteins = Hypo-proteinemia= Hypo-proteinemia
3. Synthesizes globulins3. Synthesizes globulins =Decreased Antibody =Decreased Antibody formationformation risk for risk for INFECTIONINFECTION
4. Synthesizes Clotting 4. Synthesizes Clotting factorsfactors
= Bleeding tendencies= Bleeding tendencies
5. Secreting bile5. Secreting bile = Jaundice and pruritus= Jaundice and pruritus6. Converts ammonia to 6. Converts ammonia to ureaurea
=Hyper-ammonemia=Hyper-ammonemia
7. Stores Vitamims and 7. Stores Vitamims and mineralsminerals
=Deficiencies of Vit and min=Deficiencies of Vit and min
8. Metabolizes estrogen8. Metabolizes estrogen = Gynecomastia, testes atrophy= Gynecomastia, testes atrophy
DisordersDisorders
CONDITION OF THE CONDITION OF THE LIVERLIVERLiver CirrhosisLiver Cirrhosis A chronic, progressive A chronic, progressive
disease characterized by a disease characterized by a diffuse damage to the diffuse damage to the hepatic cellshepatic cells
CONDITION OF THE CONDITION OF THE LIVERLIVERLiver CirrhosisLiver CirrhosisETIOLOGY: ETIOLOGY:
Post-infection, Alcohol Post-infection, Alcohol (Laennac’s cirrhosis), (Laennac’s cirrhosis), Cardiac diseases, Cardiac diseases, Schisostoma, Biliary Schisostoma, Biliary obstructionobstruction
Pathogenesis: Pathogenesis:
repeated destruction of hepatic cellrepeated destruction of hepatic cell
scar tissue formation (fibrotic) scar tissue formation (fibrotic) regeneration of liver cell follows regeneration of liver cell follows
another destruction will occur another destruction will occur cycle cycle (scarring and regeneration) will be (scarring and regeneration) will be
repeated until hepatocytes becomes repeated until hepatocytes becomes fibrotic and liver function is fibrotic and liver function is
compromised compromised
CONDITION OF THE CONDITION OF THE LIVERLIVERASSESSMENT FINDINGSASSESSMENT FINDINGS1. Anorexia and weight 1. Anorexia and weight lossloss
2. Jaundice2. Jaundice3. Fatigue3. Fatigue
CONDITION OF THE CONDITION OF THE LIVERLIVERASSESSMENT FINDINGSASSESSMENT FINDINGS
4. Early morning nausea and 4. Early morning nausea and vomitingvomiting
5. RUQ abdominal pain5. RUQ abdominal pain6. Ascites6. Ascites7. Signs of Portal hypertension7. Signs of Portal hypertension
Liver function test:Liver function test: Elevated AST aspartate aminotransferase Elevated AST aspartate aminotransferase
formerly SGOTformerly SGOT 4.8 - 19 U/L4.8 - 19 U/L Elevated ALT alanine aminotransferase Elevated ALT alanine aminotransferase
formerly SGPTformerly SGPT 2.4 - 7 U/L2.4 - 7 U/Lhighly specifichighly specific
Elevated Alkaline Phosphatase-30-115 IUElevated Alkaline Phosphatase-30-115 IU Elevated Bilirubin -0.1-1.0 mg/dLElevated Bilirubin -0.1-1.0 mg/dL
COMMON COMMON LABORATORY LABORATORY PROCEDURESPROCEDURESLiver biopsyLiver biopsy IntratestIntratest
– Position: Semi fowler’s LEFT Position: Semi fowler’s LEFT lateral to expose right side of lateral to expose right side of abdomen abdomen
Post-testPost-test: position on : position on RIGHT RIGHT lateral with pillow underneath,lateral with pillow underneath, monitor VS and complications monitor VS and complications like bleeding, perforation. like bleeding, perforation. Instruct to avoid lifting objects Instruct to avoid lifting objects for 1 weekfor 1 week
CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING INTERVENTIONSNURSING INTERVENTIONS 1. Monitor VS, I and O, 1. Monitor VS, I and O,
Abdominal girth, weight, Abdominal girth, weight, LOC and BleedingLOC and Bleeding
2. Promote rest. 2. Promote rest. Elevated the head of the Elevated the head of the bed to minimize dyspneabed to minimize dyspnea
CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING INTERVENTIONSNURSING INTERVENTIONS 3. Provide Moderate to LOW-protein (1 3. Provide Moderate to LOW-protein (1
g/kg/day) and LOW-sodium dietg/kg/day) and LOW-sodium diet 4. Provide supplemental vitamins 4. Provide supplemental vitamins
(especially K) and minerals(especially K) and minerals Administer prescribedAdminister prescribedDiuretics= to reduce ascites and edemaDiuretics= to reduce ascites and edemaLactulose= to reduce NH4 in the bowelLactulose= to reduce NH4 in the bowelAntacids and Neomycin= to kill bacterial Antacids and Neomycin= to kill bacterial
flora that cause NH productionflora that cause NH production
CONDITION OF THE CONDITION OF THE LIVERLIVER
NURSING INTERVENTIONSNURSING INTERVENTIONS6. Avoid hepatotoxic drugs6. Avoid hepatotoxic drugs
–ParacetamolParacetamol–Anti-tubercular drugsAnti-tubercular drugs
7. Reduce the risk of injury 7. Reduce the risk of injury – Side rails reorientationSide rails reorientation– Assistance in ambulationAssistance in ambulation– Use of electric razor and soft-Use of electric razor and soft-
bristled toothbrushbristled toothbrush
CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING NURSING INTERVENTIONSINTERVENTIONS
8. Keep equipments ready 8. Keep equipments ready including Sengstaken-including Sengstaken-Blakemore tube, IV fluids, Blakemore tube, IV fluids, Medications to treat Medications to treat hemorrhagehemorrhage
Wilson’s diseaseWilson’s disease
Rare autosomal-recessive Rare autosomal-recessive disorderdisorder
Excessive deposition of Excessive deposition of copper in the liver & braincopper in the liver & brain
< 30 y.o.< 30 y.o. Defect in chromosome 13- Defect in chromosome 13-
copper transporting proteincopper transporting protein
AssessmentAssessment
Liver abnormalitiesLiver abnormalities JaundiceJaundiceNeurologic Neurologic Loss of coordinationLoss of coordination TremorTremor DysphagiaDysphagia
Psychiatric abnormalitiesPsychiatric abnormalities PsychosisPsychosis Mania Mania depressiondepression AnxietyAnxiety
Kayser-Fleischer rings in the Kayser-Fleischer rings in the corneacornea
DiagnosticsDiagnostics
Decreased serum Decreased serum ceruloplasminceruloplasmin
Elevated urinary copper Elevated urinary copper excretionexcretion
Elevated hepatic copperElevated hepatic copper
ManagementManagement Dietary copper restriction Dietary copper restriction
(shellfish,liver,legumes)(shellfish,liver,legumes) Penicillamine (copper chelator), Penicillamine (copper chelator),
administered w/ pyridoxineadministered w/ pyridoxine Oral zinc ( inc fecal excretion)Oral zinc ( inc fecal excretion)
Gall bladderGall bladder
CholelithiasisCholelithiasis
Formation of Formation of GALLSTONES in the GALLSTONES in the biliary apparatusbiliary apparatus
Predisposing FACTORSPredisposing FACTORS
“ “ 5 F’s”5 F’s”FemaleFemaleFatFatFortyFortyFertileFertileFairFair
Assessment findingsAssessment findings
Asymptomatic in 80%Asymptomatic in 80%PE:PE: RUQ tendernessRUQ tenderness Palpable gallbladderPalpable gallbladder
DiagnosticsDiagnostics Ultrasound may show the Ultrasound may show the
gallstones (95%)gallstones (95%)
ManagementManagement Cholecystectomy- definitive & Cholecystectomy- definitive &
curativecurative Dietary modificationDietary modification Pharmacologic dissolution( w/ bile Pharmacologic dissolution( w/ bile
salts)salts)w/ or w/o lithotripsyw/ or w/o lithotripsy
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERCholecystitisCholecystitis Inflammation of the Inflammation of the
gallbladdergallbladder Can be acute or chronicCan be acute or chronic Can be calculous or Can be calculous or
acalculousacalculous
PathophysiologyPathophysiology
Supersaturated bile, Biliary stasisSupersaturated bile, Biliary stasis
Stone formationStone formation
Blockage of GallbladderBlockage of Gallbladder
Inflammation, Mucosal Damage and Inflammation, Mucosal Damage and WBC infiltration WBC infiltration
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERASSESSMENT findings ASSESSMENT findings for cholecystitisfor cholecystitis
1. Charcot’s triad1. Charcot’s triad2. Indigestion, belching 2. Indigestion, belching and flatulenceand flatulence
3. Fatty food intolerance3. Fatty food intolerance
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERASSESSMENT findings ASSESSMENT findings for cholecystitisfor cholecystitis
4. Mass at the RUQ4. Mass at the RUQ5. Murphy’s sign5. Murphy’s sign
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES1. Ultrasonography- 1. Ultrasonography- can detect the stones can detect the stones
2. Abdominal X-ray2. Abdominal X-ray3. Cholecystography3. Cholecystography
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES 4. WBC count increased4. WBC count increased 5. HIDA scan- cannot 5. HIDA scan- cannot
visualize the gallbladder- +visualize the gallbladder- + 6. ERCP: revels inflamed 6. ERCP: revels inflamed
gallbladder with gallstonegallbladder with gallstone
ERCPERCP
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER
NURSING INTERVENTIONSNURSING INTERVENTIONS 1. NPO in the active phase1. NPO in the active phase 2. Maintain NGT 2. Maintain NGT
decompressiondecompression 3. 3. give pain med- Demerol give pain med- Demerol
(MEPERIDINE)(MEPERIDINE)
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER
4. 4. AVOID HIGH- fat diet and GAS-AVOID HIGH- fat diet and GAS-forming foodsforming foods
5. Assist in surgical and non-5. Assist in surgical and non-surgical measuressurgical measures
6. Surgical procedures- 6. Surgical procedures- Cholecystectomy, Cholecystectomy, Choledochotomy, laparoscopyCholedochotomy, laparoscopy
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER
PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY1.1. Analgesic- MeperidineAnalgesic- Meperidine2.2. Chenodeoxycholic acid= to Chenodeoxycholic acid= to
dissolve the gallstonesdissolve the gallstones3.3. AntacidsAntacids4.4. Anti-emeticsAnti-emetics
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER
Post-operative nursing interventionsPost-operative nursing interventions 1. MONITOR1. MONITOR 2. Post-operative position- 2. Post-operative position- LOW LOW
FOWLER’sFOWLER’s 3. Encourage early ambulation 3. Encourage early ambulation 4. 4. Administer medication before Administer medication before
coughing and deep breathing coughing and deep breathing exercises.exercises.Advise client to splint Advise client to splint during exercise. during exercise.
CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER5. Administer analgesics, 5. Administer analgesics, antiemetics, antacidsantiemetics, antacids
6. Care of the biliary drainage 6. Care of the biliary drainage or T-tube drainage ( 200-300ml)or T-tube drainage ( 200-300ml)
7. Fat restriction is only limited 7. Fat restriction is only limited to 4-6 weeks. Normal diet is to 4-6 weeks. Normal diet is resumedresumed
CholangitisCholangitis Infection/inflammation Infection/inflammation
of biliary tree 2 to of biliary tree 2 to obstruction (stone or obstruction (stone or malignancymalignancy))
AssessmentAssessment Charcot’s triadCharcot’s triad Reynold’s pentad Reynold’s pentad
( charcot’s plus shock ( charcot’s plus shock & altered mental & altered mental status)status)
DiagnosticsDiagnostics
WBCWBC Bilirubin, alk phosphate- incBilirubin, alk phosphate- inc Blood cultures- ( gm – Blood cultures- ( gm –
enterics)enterics) ERCP- diagnostic gold ERCP- diagnostic gold
standardstandard
ManagementManagement Life threatening- ICULife threatening- ICU Iv antibioticsIv antibiotics Bile duct decompression- Bile duct decompression-
endoscopic sphicterotomy, endoscopic sphicterotomy, pecutaneous hepatic drainage pecutaneous hepatic drainage or operative decompressionor operative decompression
ERCP- stone removal, stent ERCP- stone removal, stent placement or sphincterotomyplacement or sphincterotomy
PancreasPancreas
CONDITION OF THE CONDITION OF THE PANCREASPANCREASPancreatitisPancreatitisInflammation of Inflammation of the pancreasthe pancreas
Can be acute or Can be acute or chronicchronic
Etiology & Risk FactorsEtiology & Risk Factors
– AlcoholismAlcoholism– gallstonesgallstones– HypercalcemiaHypercalcemia– TraumaTrauma– Viral infectionsViral infections– Post ERCPPost ERCP–HyperlipidemiaHyperlipidemia–Drugs(thiazideDrugs(thiazide))
CONDITION OF THE CONDITION OF THE PANCREASPANCREASPATHOPHYSIOLOGY of PATHOPHYSIOLOGY of acute pancreatitisacute pancreatitis
Spasm, edema or block in the Spasm, edema or block in the Ampulla of VaterAmpulla of Vater reflux of reflux of proteolytic enzymesproteolytic enzymes auto auto digestion of the pancreasdigestion of the pancreas inflammationinflammation
Autodigestion of pancreatic tissueAutodigestion of pancreatic tissue
Hemorrhage, Necrosis and InflammationHemorrhage, Necrosis and Inflammation
KININ ACTIVATION will result to KININ ACTIVATION will result to increased permeabilityincreased permeability
Loss of Protein-rich fluid into the Loss of Protein-rich fluid into the peritoneumperitoneum
HYPOVOLEMIAHYPOVOLEMIA
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
CONDITION OF THE CONDITION OF THE PANCREASPANCREASASSESSMENT findingsASSESSMENT findings1. Abdominal pain- 1. Abdominal pain- acute onset, occurring acute onset, occurring after a heavy meal or after a heavy meal or alcohol intakealcohol intake
2. Abdominal guarding2. Abdominal guarding
CONDITION OF THE CONDITION OF THE PANCREASPANCREASASSESSMENT findingsASSESSMENT findings 3. Bruising on the flanks 3. Bruising on the flanks and umbilicus and umbilicus Grey turner’s sign-Grey turner’s sign-purplish discoloration of the flank purplish discoloration of the flank (ecchymoses)(ecchymoses)
Cullen’s sign-periumbilical discolorationCullen’s sign-periumbilical discoloration 4. N/V, jaundice4. N/V, jaundice
5. Hypotension and 5. Hypotension and hypovolemiahypovolemia
6. Signs of shock6. Signs of shock 7. Client assumes fetal 7. Client assumes fetal
position to relieve pressure position to relieve pressure (celiac plexus nerve)(celiac plexus nerve)
CONDITION OF THE CONDITION OF THE PANCREASPANCREASDIAGNOSTIC TESTSDIAGNOSTIC TESTS 1. Serum amylase and serum 1. Serum amylase and serum
lipase- inc 3xlipase- inc 3x 2. Ultrasound2. Ultrasound 3. WBC- inc3. WBC- inc 4. Serum calcium-dec.- binds w/ 4. Serum calcium-dec.- binds w/
area of necrosisarea of necrosis 5. CT scan5. CT scan
CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Demerol is givenDemerol is given. Morphine is . Morphine is
AVOIDEDAVOIDED correction of Fluid and Blood losscorrection of Fluid and Blood loss Place patient on NPOPlace patient on NPO to inhibit to inhibit
pancreatic stimulationpancreatic stimulation NGT insertion to decompress NGT insertion to decompress
distention and remove gastric distention and remove gastric secretionssecretions
CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Position patient in Position patient in SEMI-SEMI-
FOWLER’s to decrease FOWLER’s to decrease pressure on the diaphragm pressure on the diaphragm
Deep breathing and coughing Deep breathing and coughing exercisesexercises
Provide parenteral nutritionProvide parenteral nutrition
CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Introduce oral feedings Introduce oral feedings
gradually- HIGH carbo, LOW gradually- HIGH carbo, LOW FATFAT
Maintain skin integrityMaintain skin integrity Manage shock and other Manage shock and other
complicationscomplications
Pancreatic CancerPancreatic Cancer Usually an adenocarcinomaUsually an adenocarcinoma Usually involves the HeadUsually involves the HeadRisk factors:Risk factors: SmokingSmoking High fat dietHigh fat diet MenMen > 60 y.o.> 60 y.o.
AssessmentAssessment Abdominal pain radiating to Abdominal pain radiating to
the backthe back AnorexiaAnorexia N/VN/V Weight lossWeight loss Weakness, fatigueWeakness, fatigue IndigestionIndigestion
Jaundice (obstructs the bile Jaundice (obstructs the bile duct)duct)
Trousseau’s sign- migratory Trousseau’s sign- migratory thrombophlebitis d/t ectopic thrombophlebitis d/t ectopic production of production of procoagulatantsprocoagulatants
Courvoisier’s sign- palpable Courvoisier’s sign- palpable nontender gallbladdernontender gallbladder
DiagnosticsDiagnostics
CT scanCT scan ERCPERCP Transcutaneous Transcutaneous
pancreatic biopsy- risk pancreatic biopsy- risk of spreading tumorof spreading tumor
ManagementManagement
Surgery- whipples Surgery- whipples procedure procedure (pancreaticoduodenecto(pancreaticoduodenectomy)my)
Radio/chemoRadio/chemo