hepatobiliary disorders 1
TRANSCRIPT
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DISCUSSION OUTLINE
DAY 1I. Review of the Anatomy and Physiology of the
Biliary system-(Liver)
II. AssessmentA. chief complaints
B. Past Medical History
C. Physical Examination
III. Laboratories/ Diagnostic Procedures/ Studies
IV. Common Disorders
A. Liver Cirrhosis
B. Hepatitis
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DISCUSSION OUTLINE
DAY 2I. Review of the Anatomy and Physiology of
the Pancreas and Gallbladder
II. Assessment
III. Common disorders
A. Cholelithiasis
B. Cholecystitis
C. Acute and Chronic Pancreatitis
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I. REVIEW ON THE ANATOMY AND
PHYSIOLOGY (BILIARY SYSTEM)
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MAJOR FUNCTIONS OF THE
LIVER1. Metabolism
2. Production of bile salts
3. Bilirubin metabolism
4. Detoxification of endogenous and exogenous
substances
5. Storage of minerals and vitamins
6. Blood reservoir
7. Excretion of the adrenal cortex hormones
8. Phagocytosis
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ASSESSMENT
PAST MEDICAL HISTORY
Recent skin/mucous membrane
disruption
Major illness/hospitalization
Medications
Family historyPsychosocial History and lifestyle
Habits
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ASSESSMENT
PHYSICAL EXAMINATIONINSPECTION
Skin color
Abdominal size and contour
symmetry
Skin characteristics
Jugular vein
AUSCULTATION
Bowel sounds
PERCUSSION
Liver dullness
Spleen Dullness
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ASSESSMENT
PHYSICAL EXAMINATIONSpider Angioma PALMAR ERYTHEMA
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ASSESSMENT
PHYSICAL EXAMINATIONPALPATION
Light palpation
Deep palpation
Palpate specific organs
SPECIAL PROCEDURES:
Fluid wave test
Shifting Dulllness
Abdominal assment.movie
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ASSESSMENT
CHIEF COMPLAINTSAbdominal pain
Anorexia
Nausea and vomiting
Weight loss
Stool changes
Food intolerance
Altered level of
consciousness
Urine changes
Jaundice, pruritus
Bleeding tendencies
Ascites
Edema of the limbs
Fatigue
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LABORATORY AND
DIAGNOSTIC TESTSFat Metabolism
indicators
Increase: biliary obstruction
Decrease: hepatocellular
damage
Examples:
Serum Total Cholesterol &
Cholesterol Esters
Normal value: 140-200 mg/dl
Serum phospholipids
Normal value: 150-250 mg/dl
Protein Metabolism
Indicators
Total Serum Protein- dec
Immunoglobulins
IgA- inc in Liver cirrhosis
IgG- inc in chronic active
hepatits
IgM- inc in Hepatitis A
BUN- inc in hepatocelluar dse
Protime, PTT, PT- inc
Blood Ammonia Levels- Inc
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LABORATORY AND
DIAGNOSTIC TESTBilirubin Metabolism
Indicators Total Serum Bilirubin
inc- hepatocellualr damage
nv: 0.1- 1 mg/dl
Unconjugated/ Indirect
Bilirubin
inc- hepatocellular damage
nv: 0.1- 1 mg/dl
Conjugated bilirubin
Inc- bilirary obstruction
Urine Bilirubin/ Foam Test
inc- hepatocelluar
damage
Fecal Urobilinogen
(stercobilin)
- alcohol stool (pale or
gray colored stool)
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LABORATORY AND
DIAGNOSTIC TESTInc Serum Enzymes
Alanine transaminase (ALT), also called Serum Glutamic PyruvateTransaminase
Normal value:
Aspartate transaminase (AST) also called Serum Glutamic OxaloaceticTransaminase (SGOT)
Normal value:
Alkaline phosphatase (ALP)
Normal value
Gamma glutamyl transpeptidase (GGT)
Normal value:
LDH (Lactic Dehydrogenase)
Normal Value
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LABORATORY AND
DIAGNOSTIC PROCEDURESLIVER BIOPSY
Nsg intervention before andDuring the procedure:
1. consent
2. NPO: 2-4 hrs
3. Pre-op meds: Vitamin K ifprolonged Prothromin Time
4.
Monitor Pro-time : BLEEDI
NG most commoncomplication
5. Position: LEFT LATERAL
6. HOLD breath 5-10 secondsduring the needle insertion
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LABORATORY AND
DIAGNOSTIC PROCEDURESLIVER BIOPSY
Nsg intervention after the
procedure:
1. POSITION: RIGHT SIDE
for the four hours
2. BED REST for 24 hours
3.Monitor
V
/s: changes mayindicate internal
hemorrhage
4. Observe for signs of
Peritonitis
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LABORATORY AND
DIAGNOSTIC PROCEDURESPARACENTESIS
Nsg intervention BEFORE ANDDURING the procedure:
1. Consent
2. V/S prior
3. Empty the bladder
4. Check serumproteins
5. POSITION: sitting/upright
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LABORATORY AND
DIAGNOSTIC PROCEDURESPARACENTESIS
Nsg intervention after theprocedure:
1. V/s monitoring
2. Urine output
3. Rigidity of the
abdomen
4. Sx and symptoms ofhypovolemic shockand peritonitis
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LABORATORY AND
DIAGNOSTIC PROCEDURESPeritoneoscopy
Nsg intervention before the
procedure:
1. Consent
2. Clotting fx
3. Hypersensitive tolocal anesthesia
4. NPO
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LABORATORY AND
DIAGNOSTIC PROCEDURESPeritoneoscopy
Nsg intervention after the
procedure:
1. V/s and site
monitoring
2. Watch out for
complications:
Bile peritonitis
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HEPATITIS
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HEPATITIS
Inflammation of the liver
Causes: virus, exposure tomedications, hepatotoxins
3 subtypes:
1. Viral Hepatitis
2. Toxic Hepatitis
3. Alcoholic Hepatitis
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A. VIRAL HEPATITIS
Virus HEP A HEP B HEP C HEP D HEP E HEP F HEP G
MOT Fecal-
oral
Blood and
body
fluids,perinatal
Blood
and body
fluids,intranasa
l
Blood and
body
fluids,perinatal
Fecal- oral Fecal- oral Blood and
body
fluids
INCUBATION 2-6 wks 6-24 wks 5-12 wks 3-13 wks 3-6 wks asympto
ONSET abrupt slow Slow Abrupt abrupt
COMP rare Cirrhosis,
Liver CA,
Chronic
Hepatitis
Cirrhosis,
Liver CA,
Chronic
Hepatitis
Liver CA,
Chronic
Hepatitis
Fulminant
H.
No
evidence
on
chronicity
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A. VIRAL HEPATITIS
TREATMENTS AND PREVENTION
Hepatitis A
formerly called Infectious hepatitis, Epidemichepatitis, Epidemic jaundice, Catarrhaljaundice,
Type A hepatitis,
1. Self limiting with only few long termconsequences
2. Txtment of H20 supplies and proper sanitation
3. Hepatitis Vaccine A (Havrix)- 2 doses
4. Immunoglobulin (Gammar) before and afterexposure
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A. VIRAL HEPATITIS
TREATMENTS AND PREVENTION
Hepatitis B
1. Strict handwashing
2. Screening blood donors
3. Testing pregnant women (HBsAg)
4. Hepatitis b Vaccine ( Engerix- B, Recombivax
HB)- 3 dose
5. Immunoglobulin : for post exposure
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A. VIRAL HEPATITIS
TREATMENTS AND PREVENTION
Hepatitis C
1. Major cause of POST TRANSFUSION
HEPATITIS
2. Treatment: Interferon and Oral Ribavirin
Hepatitis D
1. Co-infection of Hepa B
Hepatitis E, F, G
1. General hygiene precautions
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A. VIRAL HEPATITIS
MANIFESTATIONS Preicteric phase
1. Flulike symptoms: malaise, fever, fatigue
2. GI: anorexia, N/V, diarrhea & constipation
3. Muscle aches, polyarthritis
4. Mild RU abdominal pain and tenderness
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A. VIRAL HEPATITIS
MANIFESTATIONSIcteric phase
1. Jaundice
2. Pruritus
3. Clay colored stools
4. Brown urine
5. Decrease in
preicteric phase
symptons
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A. VIRAL HEPATITIS
MANIFESTATIONSNsg. Diagnosis and Intervention for
JAUNDICE
1. Impaired Skin Integrity
NPI: Loose fitting clothes
Tepid Sponge bath
Cool room and clean linens
Pharma: Oral Cholestyramine bind with bile
salts for excretion
antihistamines, and phenobarbitals
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A. VIRAL HEPATITIS
MANIFESTATIONSNsg. Diagnosis and Intervention for
JAUNDICE
1. Disturbed Body Self image
- verbalize concerns or feelings toward condition
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A. VIRAL HEPATITIS
MANIFESTATIONSPost icteric phase
1. Serum bilirubin and
enzymes return tonormal levels
2. Energy level
increases
3. Pain subsides
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A. VIRAL HEPATITIS
COMPLICATIONSFulminant Hepatitis
Massive hepatic
necrosis
Seen primarily in HEP
A, B, D and E
Progression of:
Jaundice
Hepatic
encepalopathy
ascites
Chronic Hepatitis
Liver inflammation
beyond 3-6 months
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HEPATITIS
MANAGEMENTSMedical Management
Glucose water/
dextrose
Bile Acid Sequestrants
(Cholestyramine (
Questran) or Colestipol
( colestid)
Interferon Treatment
Milk thistle
Licorice roots
Nursing Management
Imbalanced Nutrition,
Less thanRisk for infection
(Transmission)
Fatigue
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LIVER CIRRHOSIS
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LIVER CIRRHOSIS
End stage of chronic liver disease
progressive, irreversible
TYPES OF LIVER CIRRHOSIS
1. Laennec s Cirrhosis / Alcoholic Cirrhosis
2. Postnecrotic cirrhosis
3. Primary biliary cirrhosis
4. Secondary biliary cirrhosis
5. Cardiac Cirrhosis
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LIVER CIRRHOSIS
PORTAL HYPERTENSION
increase in the blood
pressure within a system
of veins called the portal
venous systemBlood backs up and find
other ways to the heart
Esophagus
Skin on the abdomen
Veins in the rectum
spleen
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LIVER CIRRHOSIS
BLEEDING ESOPHAGEAL
VARICES Fragile, thin walled, distended
esophageal veins that may
become irritated and ruptured
Note for this sx:
Blod pressure less than or
equal 90/60mmhg
Heart rate: more than 100
beats/min
Cool, clammy skin
Slow capillary refill
restlessness
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LIVER CIRRHOSIS
BLEEDING ESOPHAGEAL
VARICESSENGSTAKEN BLAKEMORE
TUBE
-oro- or nasogastric tube used
occasionally in the management
of upper gastrointestinal
hemorrhage due to bleeding
from esophageal varices
HOW TO PREVENT :
Avoid screaming, shouting
straining at stool
coughing and sneezing
REMEMBER---SCI
SSORS @ bedside
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LIVER CIRRHOSIS
HEPATIC ENCEPALOPATHY
Results from the accumulation
of ammonia in the blood and
other neurotoxins
ASTERIXIS- earliest sign
Other manifestations:
1. Confusion/disorientation
2. Delirium/hallucination
3. FETOR HEPATICUS
4. HEPATIC COMA
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LIVER CIRRHOSIS
MANAGEMENTS
A. Medications
1. Diuretics- Spironolacotone ( Aldactone)
2. Lactulose and neomycin
3. Nadolol (Cogard) & Isosorbide mononitrate (Imdur)
4. Oxazepam (Serax)
5. Ferrous sulfate
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LIVER CIRRHOSIS
MANAGEMENTS
B. DIETARY AND FLUID MANAGEMENT
1. Fluids : 1500 ml/ day with Sodium restriction
2. Diet:
Low protein ( 60- 80 g/ day if with hepatic
encepalopathy)
Adequate protein (75- 100 g/ day if wihout)
3. Vitamin and Mineral Supplements
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LIVER CIRRHOSIS
MANAGEMENTS
C. COMPLICATION MANAGEMENT
1. PARACENTESIS
2. TI
PS ( TRANSJUGULARI
NTRAHEPATI
CPORTOSYSTEMIC SHUNT)
Insertion of expandable stent to allow the
blood flow the portal vein to drain direclty
into the hepatic vein and bypassing the
cirrhotic liver
- Common complication: stenosis and
occlusion of the stent
3. SCLEROTHERAPY (Morrhuate sodium)
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LIVER CIRRHOSIS
MANAGEMENTS
D. NURSING DIAGNOSIS AND INTERVENTIONS
1. Ineffective perfusion
2. Excess Fluid volume
3. Disturbed thought process
4. Imbalanced Nutrition: Less than Body requirements
5. Ineffective protection