1
Q
Name the vocab:
Lines sinusoids and carry out phagocytic activity to remove bacteria and toxins from the blood
A
Kupffer cells
2
Q
Name the vocab:
A pigment derived from the breakdown of hemoglobin
A
Bilirubin
3
Q
Name the vocab:
Fatty, frothy, foul-smelling stool
A
Steatorrhea
4
Q
What does a serum bilirubin measure?
A
Degree of RBC hemolysis or liver’s inability to excrete normal quantities of bilirubin
5
Q
What is indirect bilirubin (unconjugated) increased with?
A
Hemolysis
6
Q
What is direct bilirubin (conjugated) increased with?
A
Obstructive problems (gallstones, liver tumor)
7
Q
What does urinary bilirubin measure?
A
Urinary excretion of conjugated bili
8
Q
What is alpha-fetoprotein a sign of?
A
Hepatocellular cancer
9
Q
What can an increase in ammonia result in?
A
Hepatic encephalopathy secondary to liver cirrhosis
10
Q
What does a acetaminophen blood level of > 200 mcg/mL 4 hrs after ingestion mean?
A
Risk for liver damage
11
Q
True or False:
Vitamin K is an essential cofactor for many clotting factors
A
True
12
Q
What are the enzymes secreted by the pancreas?
A
Amylase & lipase
13
Q
What is the mechanism of action of furosemide?
A
Acts on distal tubule and loop of Henle to decrease Na+ & H2O reabsorption
14
Q
What is the mechanism of action of spirinolactone?
A
Blocks action of aldosterone, K+ sparing
15
Q
What is the mechanism of action of lactulose?
A
Acidifies feces in bowel and traps ammonia, causing its elimination in feces
16
Q
What is the mechanism of action of magnesium sulfate?
A
Corrects hypomagnesemia from liver dysfunction
17
Q
What is the mechanism of action of nadolol/propanolol?
A
Decreases portal venous pressure and esophageal variceal bleeding
18
Q
What is the mechanism of action of neomycin sulfate & rifaximin?
A
Decrease bacterial flora, thus reducing ammonia formation
19
Q
What is the mechanism of action of Octreotide & Vasopressin?
A
Hemostasis and control of bleeding in esophageal and gastric varicies, constricts splanchnic arterial bed
20
Q
What is the mechanism of action of PPIs (pantoprazole)?
A
Decrease gastric acidity
21
Q
What is the mechanism of action of Vitamin K?
A
Corrects clotting problems from decreased Vitamin K levels
22
Q
Where does the liver sit?
A
RUQ
23
Q
What separates the R & L lobes of the liver?
A
Ligamentum teres
24
Q
What are the functional units of the liver & what do they produce?
A
Hepatocytes –> produce bile
25
What does the liver store?
1) Glucose (in form of glycogen)
2) Vitamins
3) Fatty acids
4) Minerals
5) Amino acids
26
What vitamins does the liver store?
1) ADEK (fat-soluble)
2) B1 & B2
3) Cobalamin
4) Folic acid
27
What minerals does the liver store?
Iron & copper
**Iron needed for Hgb production
28
What amino acids does the liver store?
Albumin & beta globulins
29
What are the 4 functions of the liver?
1) Secretory functions
2) Storage functions
3) Vascular functions
4) Metabolic functions
30
What are the secretory functions of the liver?
1) Bile production & excretion
2) Bilirubin conjugation
31
What kind of liver is needed to conjugate bilirubin?
Mature liver
32
True or False:
Bilirubin helps to make bile
True
33
What is unconjugated bilirubin bound to that makes it NOT water-soluble?
Albumin
34
What are the metabolic functions of the liver?
1) Blood clotting
2) Carb metabolism
3) Detoxification
4) Fat metabolism
5) Protein metabolism
6) Bile production
35
What is essential for fat emulsification & digestion?
Bile production
36
What happens during carb metabolism at the liver?
Glucose is converted to glycogen for storage
37
What waste products does bile contain?
1) Water
2) Cholesterol
3) Bile salts
4) Electrolytes
5) Fatty acids
6) bilirubin
38
When you percuss the liver, what kind of sound should you hear?
Dull
39
Where do you look for signs of jaundice in an adult?
Sclera
40
What happens to the liver as you age (esp > 50)?
1) Decreases in size
2) Lower position (easier to palpate)
3) Decreased protein synthesis
4) Decreased ability to regenerate
5) Decreased drug & hormone metabolism
6) More susceptible to drug-induce liver disease
41
What position should the pt be lying in for easiest liver palpation
Supine
42
What factors affect the liver?
1) Alcohol, drugs, chemicals
2) Autoimmune
3) Stones
4) Heart and blood vessel disorders
5) DM
6) Malnutrition
7) Hereditary
8) Congenital
9) Viruses
43
How many drinks/day is considered moderate consumption for women?
1
44
How many drinks/day is considered moderate consumption for men?
2
45
What is considered binge drinking for women?
4+ drinks on same occasion at least once per month
46
What is considered binge drinking for men?
5+ drinks on same occasion at least once per month
47
What mediation in combination of alcohol consumption can increase the risk of liver damage?
Acetaminophen
48
What are the alcohol screening tools used?
AUDIT & 2-Question test
49
What AUDIT score indicates harmful alcohol consumption?
9 or more
50
What questions do you ask in the 2-Question test for alcohol consumption?
1) In the past year, have you ever drank or used drugs more than you meant to?
2) Have you felt you wanted or needed to cut ddown on your drinking or drug use in the past year?
51
What population is most susceptible of getting Hep B?
Immigrants --> Asian & African
52
What race is most likely to develop alcohol-associated liver disease?
Black
53
How is Hep A transmitted?
Fecal/oral --> don't share bathrooms or wash hands/wipe it down after use
54
True or False:
Hep B is "one and done"
False --> Hep A is
55
What types of Hepatitis is there a vaccine available for?
Hep A & B
56
When are you considered infectious after the start of sx for Hep A?
1-2 weeks
57
What are sx of Hep A?
1) Flu-like (for 2-4 wks)
2) Potentially jaundiced
3) Acute liver failure --> if severe
58
How is Hep B transmitted?
Blood & Secretions --> ex: stuck with a contaminated needle or vomit
59
What can Hep B cause?
Acute or chronic hepatitis
60
True or False:
Hep B is irreversible
False -- it can resolve
61
What can a chronic Hep B infection cause?
1) Severe inflammation
2) Scarring
3) Liver CA
62
Who are most at risk of developing Hep B?
1) Healthcare workers
2) Drug users
3) Sex workers
63
How is Hep C transmitted?
Blood & secretion borne
64
What is the most common cause of chronic liver disease & liver failure?
Hep C
65
What is the time frame between infection & clinical S&S of Hep C?
1 - 2 wks
66
True or False:
High-risk sexual behavior or IV drug use are associated with increased risk of Hep C
True
67
What co-infection with Hep C is common?
HIV
68
True or False:
Hep C can be both acute or chronic
True
69
What form of Hepatitis is uncommon in the US?
Hep D
70
What does Hep D co-exist with?
Hep B
71
How does someone acquire a Hep D infection?
Need to have been exposed or have had Hep B prior to be infected with Hep D
72
How can you prevent Hep D?
Hep B vaccine
73
Which Hepatitis' account for 80% of chronic liver disease and failure?
Hep B & C
73
True or False:
Women can transmit Hep C to their unborn child
True
74
Name the disease:
1) Fecal/oral transmission
2) Contaminated drinking water
3) Developing countries
4) Rare in US
Hep E
75
What is the patho of an acute hepatitis infection?
Virus attacks hepatocytes & destroys them
**Target cell = hepatocytes
76
Can hepatocytes possibly regenerate after an acute hepatitis infection?
Yes
77
What can an acute hepatitis infection result in if severe enough?
Liver failure
78
What can the development of scar tissue and fibrosis in chronic hepatitis infection lead to?
1) Cirrhosis
2) Liver failure
**Irreversible
79
What are sx of hepatitis infection?
1) Asymptomatic
2) Intermittent or ongoing anorexia (lack of appetite)
3) Lethargy
4) Malaise
5) N/V
6) Low-grade fever
7) RUQ/abdominal tenderness
8) Hepatomegaly
9) Jaundiced
10) Dark urine
11) Rashes
12) Pruritus
80
What happens to the liver labs in acute hepatitis?
They increase
81
True or False:
Liver enzymes are only released from cells when hepatocytes are injured
True
82
What is the tx for acute hepatitis infection?
1) Supportive
2) Nutrition
3) Rest
4) Avoid alcohol
83
What is the tx for chronic hepatitis?
1) Supportive
2) Anti-emetics
3) Antihistamines
4) Hep B & C may have some drug therapies
84
What are the dx studies for hepatitis?
1) Serum labs --> viral loads & antibodies
2) Liver biopsy (only if waranted) --> gives extent of damage
85
What are preventative measures for Hep A?
1) Hand washing
2) Proper personal hygiene
3) Environmental sanitation
4) Control & screening of food handlers
5) Active immunization
6) Infection control precautions
86
What are preventative measure for Hep B & C?
1) Screening of donated blood
2) Use of disposable needles & syringes
3) HBV vaccine
4) Condoms
5) Handwashing
6) Avoid sharing toothbrushes & razors
7) Reduce contact with blood or blood-containing secretions
8) Universal precautions
9) Proper needle disposal
87
What is cirrhosis?
The end stage of liver disease characterized by:
1) Extensive degeneration & destruction of liver cells
2) Replacement of liver tissue by fibrous scar tissue & nodules (disrupt blood flow)
**Insidious process
88
What may cause cirrhosis?
1) Any chronic liver disease
2) Nonalcoholic fatty liver disease (NAFLD)
3) Nonalcoholic steatohepatitis (NASH)
4) Excessive alcohol intake
5) Hep C
6) Cardiac cirrhosis
7) Wilson's disease
8) Autoimmune hepatitis
89
What is nonalcoholic steatohepatitis (NASH)?
Fatty accumulation with inflammation
90
Who is NASH most prevalent in?
Pts with metabolic disease & obesity (hard time losing wt, bariatric range)
91
What is cardiac cirrhosis a result of?
Long-standing, severe, right-sided HF
**End up w/ non-functioning liver tissue
92
What does cirrhosis impair?
1) Gluconeogenesis
2) Detoxification of drugs & alcohol
3) Bilirubin metabolism (can't conjugate it)
4) GI function (& nutrition status)
5) Steroid & hormone metabolism
93
What is gluconeogenesis?
Creation of glucose from stored glycogen
**if this is impaired, amino acids and fatty acids cannot be converted to glucose
94
What steroids & hormones does the liver metabolize?
Testosterone, aldosterone, estrogen & progesterone
95
What are the early manifestations of cirrhosis?
Fatigue & enlarged liver
**LFTs may still be normal (compensated cirrhosis)
96
True or False:
Cirrhosis has an insidious onset, so we usually don't know it's happening until the disease is further advanced
True
97
What are the late manifestations of cirrhosis (6 categories)?
1) Jaundice
2) Skin lesions
3) Hematologic problems
4) Endocrine problems
5) Peripheral neuropathy
6) GI problems
98
What are the skin manifestations of cirrhosis?
Spider angiomas & palmar erythema
99
What are the hematologic manifestations of cirrhosis?
1) Bleeding tendency
2) Decreased Vit K absorption
3) Anemia/thrombocytopenia/leukopenia
100
What are the endocrine manifestations of cirrhosis?
1) Gynecomastia (men)
2) Amenorrhea (women)
3) Hyperaldosteronism
101
What is a result of hyperaldosteronism?
Na+ & H2O retention, K+ loss
102
What is peripheral neuropathy in cirrhosis r/t?
Dietary deficiencies with:
1) Alcoholsim
2) Thiamine
3) Folic acid
4) Cobalamin
103
What are the GI sx of cirrhosis?
1) Feator hepaticus
2) Anorexia
3) N/V
4) Dyspepsia
5) Gastritis
6) Change in bowel habits
104
What is fetor hepaticus?
Smelly breath (d/t a lack of digestion)
105
What are the 3 types of jaundice?
1) Hemolytic (pre-hepatic)
2) Hepatocellular (hepatic)
3) Obstructive (post-hepatic)
106
What is hemolytic (pre) jaundice caused by?
Increased breakdown of RBCs
**Can be resolved
107
What is the patho of hepatocellular jaundice?
Liver cannot take up bilirubin from the blood to conjugate or excrete it
108
What are causes of hepatocellular jaundice?
1) Cirrhosis
2) Hepatitis
3) Liver cancer
**Damage within the liver
109
What is the patho of obstructive jaundice?
Results from a decreased or obstructed flow of bile through the liver
***EX: common bile duct obstruction & pancreatic CA
110
What are the dx studies for cirrhosis?
1) Labs
2) Liver biopsy
3) Liver US
4) Ultrasound elastography (Fibroscan)
111
What is the gold standard dx tool for cirrhosis?
Liver biopsy
112
What labs do you analyze for cirrhosis?
1) Enzymes --> AST, ALT, GGT
2) Total protein & albumin
3) Ammonia
4) Bilirubin (direct, indirect, total)
5) Clotting factors --> INR, PT, PTT
113
What are comps of cirrhosis?
1) Portal HTN
2) Peripheral edema & ascites
3) Hepatic encephalopathy
4) Hepatorenal syndrome
114
What are comps of portal HTN?
Esophageal & gastric varicies
115
What is the patho of portal HTN?
1) Obstruction of blood flow through the liver
2) Leads to increased pressure within liver's circulatory system (portal)
3) Development of collateral circulation/channels
4) Varicosities (d/t engorgement of portal vein)
116
What is the most life-threatening comp of portal HTN?
Esophageal varicies
117
What may someone with esophageal varicies present with?
1) Melena (from digested blood/GI bleeds)
2) Hematemesis (coffee ground-like)
118
True or False:
If someone has esophageal varicies, an NG tube is required to decompress the stomach
False --> NO NG tubes (increased risk of rupture)
119
What do patients with esophageal varicies need to avoid?
ASA (aspirin), ETOH, and NSAIDs
120
What are the goals of tx for esophageal varicies?
1) Slow progression of cirrhosis*
2) Reduce portal pressure
3) Prevent bleeding and rupture
121
What medication therapy is used to tx both esophageal and gastric varicies?
Non-selective Beta Blockers
Ex: Propranolol & Nadaolol
122
What do non-selective beta blockers do in treatment of esophageal and gastric varicies?
Work to decrease portal pressure
123
What screening is used for varicies?
EGD --> done by GI providers to check the extent
124
What medications are given if they have a varicie and it ruptures?
1) Octreotide
2) Vasopressin
3) Vitamin K
4) PPIs
125
What does vasopressin do in the treatment of variceal bleeding?
Vasoconstrict blood flow to the gut
126
If the pt has variceal bleeding, what do you do?
1) Stabilize pt & manage airway
2) IV access
3) Stop bleeding at source
4) Blood products
5) Give meds
127
True or False:
A unit of PRBCs does not have clotting factors
True
128
Why do you need to give blood products to someone who has variceal bleeding?
Because they need to replace their clotting factors & RBCs (help increase O2 carrying capacity)
129
What is the procedural tx of esophageal varices?
Balloon tamponade --> placed by provider
Ex: Sengstaken-Blakemore Tube
130
What does a balloon tamponade do in the tx of esophageal varices?
Places direct pressure on the varices to stop bleeding
131
What is the care needed for a balloon tamponade?
1) Explain procedure
2) Check tube patency
3) Verify balloon position with x-ray
4) Secure tube to prevent movement
5) Deflate balloon for 5 min q8-12h
6) Label lumens
7) Saline lavage/NG suction to remove blood
8) Monitor for comps
9) Oral/nasal care
132
What needs to be kept at the bedside of a pt who has a balloon tamponade for esophageal varices & why?
Scissors --> to deflate tube PRN (especially if it moves)
133
What id the biggest concern if a balloon tamponade moves?
Blocking the epiglottis/trachea --> results in airway blockage
134
What is the most common comp of a balloon tamponade?
Aspiration pneumonia
135
What position does a pt need to be in if they have a balloon tamponade for esophageal varices
Semi-fowler's
136
In addition to a balloon tamponade, what other procedure can be performed to tx esophageal varices?
TIPS
137
What happens in a TIPS procedure?
1) Shunt is created between the systemic and portal venous systems
2) Some blood flow is redirected from the liver directly into the hepatic vein and back into the IVC
138
What is there an increased risk of with a TIPS procedure & why?
Hepatic encephalopathy --> d/t decreased conversion of ammonia to urea
139
What is ascites?
Accumulation of serous fluid in the peritoneal or abdominal cavity
140
What factors can contribute to the development of ascites?
1) Protein shift from vessels into lymph space d/t portal HTN
2) Hypoalbuminemia
3) Hyperaldosteronism
4) Impaired water excretion
141
What is the patho of how hypoalbuminemia leads to ascites?
1) Liver can't synthesize proteins (albumin)
2) Decrease in colloidal osmotic pressure
3) Lack of proteins cause less water in the vasculature
4) Leads to 3rd spacing
142
What is the patho of how impaired water excretion leads to ascites?
An increase in ADH secretion stimulated by a decrease in renal blood flow
143
What is the tx of ascites?
1) Na+ restriction
2) Diuretics
3) Albumin infusion
4) Fluid removal via paracentesis
144
Why are diuretics not always effective in treating ascites?
Fluid is not in the vasculature & the fluid in the abdomen does not touch the kidneys, and diuretics work on the kidneys
145
Which diuretics are usually given to tx ascites?
Spirnolactone & furosemide
146
What does an albumin infusion do in the tx of ascites?
Helps maintain intravascular volume
147
Why can a combo of diuretics & albumin be given in tx of ascites?
Once fluid is in the vasculature (d/t albumin), then the kidneys can filter the fluid (diuretics)
148
If pt is receiving a paracentesis, what actions need to be taken?
1) Pt voids first
2) Monitor for hypovolemia
3) Monitor for electrolyte imbalances
149
How does hepatic encephalopathy occur?
When ammonia cannot be converted or blood is shunted past the liver, ammonia levels get high & crosses the BBB which produces neuro changes
150
What are the clinical manifestations of hepatic encephalopathy?
1) Asterixis
2) Apraxia
3) Hyperventilation
4) Hypothermia
5) Fetor hepaticus
151
What is asterixis?
Flapping tremors
152
What is apraxia?
Inability to construct simple figures
153
What are neuro S&S d/t ammonia toxicity?
1) Confusion
2) Changes in mental responsiveness
3) Impaired consciousness
4) Inappropriate behavior
5) Lethargy to deep coma
154
What meds can be given to tx hepatic encephalopathy?
1) Lactulose
2) Rifaximin
3) Neomycin sulfate
155
What does lactulose do in the tx of hepatic encephalopathy?
Traps ammonia in the gut
**Prevent constipation
156
What does rifaximin do in the tx of hepatic encephalopathy?
Antibiotics prevent bacteria from breaking down food & decreasing the normal gut flora (helps prevent protein breakdown)
157
What dietary restriction is required for someone who has hepatic encephalopathy?
Decreased protein intake
158
What is the nursing care required for a pt with hepatic encephalopathy?
1) Maintain safe environment
2) Frequent assessments (neuro q2h)
3) Fluid & electrolytes
4) Monitor reflexes for tremors
5) Avoid constipation
6) Watch for GI bleeds
7) Control factors that precipitate encephalopathy
159
What is hepatorenal syndrome?
1) Comp of cirrhosis
2) Type of renal failure
3) Occurs d/t a decrease in arterial blood volume (kidneys being ignored)
**Can be reversed with liver transplant potentially, but not in the cards for most**
160
When does hepatorenal syndrome occur?
In terminal stages of liver failure with portal HTN & ascites
161
What sx are seen in pts with hepatorenal syndrome?
1) Progressive azotemia
2) Increased serum creatinine
3) Oliguria
162
What is azotemia?
Build up of waste products in the blood v/d the kidneys are shut down and not filtering urea or other products
163
What are indications for a liver transplant?
1) Chronic viral hepatitis (most common)
2) Congenital abnormalities
3) Acute liver failure
4) End stage liver disease
164
What are contraindications of liver transplants?
1) Hepatocellular cancer (d/t need for immunosuppressives)
2) Ongoing drug & alcohol abuse
165
True or False:
High doses of acetaminophen taken with the intention of fatality can lead to liver failure
True
166
What is the most common cause of acute liver failure?
Drugs with alcohol OR ...
1) Chemicals
2) Drugs
3) Alcohol
167
What do pts with acute liver failure present with?
Hepatic encephalopathy
168
What is acute liver failure?
Severe impairment of liver function
169
What can cause a rapid onset of acute liver failure?
Hep B
170
What labs needs to be monitored in a pt with acute liver failure?
1) Ammonia
2) Liver enzymes
3) Chem panel
4) CBC
5) PT
6) Bilirubin
171
What is the tx of acute liver failure?
1) Liver transplant
2) Nutrition & rest
3) Vitamin K/FFP
4) Albumin
172
What is given to pts who try to OD on tylenol?
1) Acetylcysteine (Mucomist)
2) Activated charcoal
173
What does acetylcysteine do?
Helps to try to neutralize ingested tylenol to help preserve some liver function (if given early)
174
What is the most common cause of death in cirrhosis pts?
Liver cancer
175
What is the most common cause of hepatocellular cancer?
Hep C
176
What are the sx of liver cancer?
1) Dull abdominal pain
2) Pain in epigastric or RUQ
3) Anorexia, N/V
**No true tell-tale sign
177
True or False:
Metastatic liver CA is more common
True
178
What is the best way to dx liver CA?
Percutaneous biopsy
179
What are the dx studies of liver CA?
1) US
2) CT
3) MRI
4) Percutaneous biopsy
180
What is the prognosis for those with liver CA?
Poor --> 6 - 12 mos
181
What is the tx for liver CA?
1) Prevention (avoid hepatitis)
2) Surgical excision (depending on size & location)
3) Radiofrequency ablation
4) Embolization
182
What are the 3 functions of the biliary system?
1) Drain waste from liver to duodenum
2) Storage and concentration of bile
3) Aid digestion with controlled release of bile
183
What helps with fat emulsification (breakdown) so that we can absorb and use the fatty acids?
Bilirubin
184
What regulates the flow of bile & pancreatic enzymes into the duodenum?
Sphincter of Odi
185
What is the only entrance that scopes can use to look and the common bile and pancreatic ducts?
Ampulla of Vater
186
True or False:
Problems with the gallbladder can affect the pancreas
True
187
What is a majority of cholelithiasis caused by, especially in Americans?
Diet (salty, fatty foods)
188
What are risk factors for developing gallbladder disease?
1) Sedentary lifestyle
2) Familial tendency
3) Obesity
4) Culture
189
What population is gallbladder disease high in?
Native Americans
190
Are males or females more likely to develop cholelithiasis?
Females
191
True or False:
Cholelithiasis and cholecystitis never occur concurrently
False --> it is common for them to occur together
192
What are risk factors for women that can cause cholelithiasis?
1) Pregnancy
2) Post-menopausal on estrogen replacement (OCs)
3) Obesity
4) > 40 yrs old
193
What are gallstones caused by?
1) Stasis of bile
2) Abnormality of bile composition
194
What are the two types of gallstones?
1) Cholesterol
2) Mixed
195
What is choledocholithiasis?
Gallstones that are stuck in duct
196
Where can gallstones migrate to from the gallbladder?
Cystic or common bile duct
197
What are the S&S of obstruction r/t gallstones?
1) Cholecystitis
2) Jaundice (post-hepatic)
3) Clay-colored stools --> those not getting bile in their stools
4) Dark, amber urine
198
What can migration of a gallstone cause?
1) Pain, usually RUQ (biliary colic) with N/V
2) Obstruction --> impairs flow of bile & digestion
199
What is the gallbladder's response to someone eating a fatty meal?
It is stimulated to make bile in response to fatty acids
200
What are sx of cholecystitis/cholelithiasis?
1) Intolerance to fatty foods
2) Pruritis
3) Clay-colored stools
4) Steatorrhea
4) Dark-colored urine
5) Abdominal guarding & distention
6) Wt loss/anorexia
7) Indigestion
8) Moderate to sevre pain
9) Fever (severe cholecystitis)
10) Jaundice
11) RUQ tenderness --> referred to R shoulder & scapula
12) N/V
13) Restlessness
14) Diaphoresis (esp. w biliary colic)
201
What are RFs for developing cholecystitis?
1) Prolonged immobility
2) Prolonged fasting
3) Prolonged parenteral nutrition
4) DM
5) Bile stasis r/t infection, fever, and dehydration
6) Adhesions (surgical)
7) Neoplasms (tumor)
8) Anesthesia (slow biliary tract)
9) Opioids (slow biliary tract)
202
What is cholecystitis?
Diffuse inflammation usually d/t obstruction of the gallbladder outlet (b/c of stones or biliary sludge)
203
How do secondary infections occur from cholecystitis?
Gallbladder can perforate & cause bile to leak into the peritoneal cavity
204
What are the internal manifestations of cholecystitis?
1) Gallbladder is edematous
2) Hyperemic (lot of blood flow)
3) Distended --> bile or pus filled
4) Occlusion of cystic duct
5) Possible decrease in function (secondary to scaring)
205
What does pain r/t cholecystitis depend on?
1) Site of obstruction
2) Severity of obstruction
3) Severity of inflammation
4) Presence or absence of spasm (biliary colic)
206
What are the pain characteristics of cholecystitis?
**Can be asymptomatic
1) Acute pain & RUQ tenderness that refers to right shoulder & scapula
2) 3-6 hrs after a fatty meal, abdomen is rigid & tender (with N/V & restlessness)
3) Indigestion --> gas, heartburn, flatulence
4) Fever with chills and diaphoresis
207
What are comps of gallstones?
1) Cholecystitis
2) Gangrenous cholecystitis
3) Sub-phrenic abscess
4) Pancreatitis
5) Cholangitis
6) Biliary cirrhosis
7) Fistulas
8) Rupture of gallbladder (bile peritonitis)
9) Choledocholithiasis
208
What is gangrenous cholecystitis?
Pressure on gallbladder causes it to swell & die
209
Why can pancreatitis result from gallstones?
Stone can obstruct the pancreatic duct
210
What is cholangitis?
Inflammation of the biliary ducts
211
What are the dx labs for cholecystitis/cholelithiasis?
1) LFTs
2) WBC
3) Serum bilirubin
4) Serum amylase (specific to pancreas)
212
What are the dx studies for cholecystitis/choleliathiasis?
1) US
2) CT scan
3) ERCP
4) HIDA scan
213
What assessment questions should you ask a patient who may have cholecystitis or cholelithiasis?
1) What meal typically causes pain?
2) Where is the pain located? Does it migrate?
3) Stool characteristics
4) How soon after eating are you in the bathroom?
214
What should be taken into consideration when a pt comes back from an ERCP?
Since general anesthesia is used, verify return of gag reflex before allowing pt to eat
215
What is the post ERCP care?
1) Monitor VS
2) Watch for S&S of pancreatitis
3) Bed rest for several hrs
4) NPO until gag reflex returns
216
What are S&S of pancreatitis?
1) Abdominal pain
2) Fever
3) Increasing amylase & lipase
217
What is the conservative tx for cholelithiasis & cholecystitis?`
1) NPO w/ NG tube --> progress to low fat diet
2) IVFs
3) Anti-emetics
4) Analgesics
5) Vit ADEK
6) Anticholinergics/antispasmodics
218
What do Anticholinergics/antispasmodics do in the tx of cholelithiasis & cholecystitis?
Help with biliary colic
219
What needs to be done during an acute attack of cholecystitis & cholelithiasis?
1) Pain control
2) Infection control
3) F/E balance
220
What is needed for a ERCP?
1) Consent
2) IV
3) NPO pre-procedure
221
What are the surgical interventions for cholecystitis & cholelithiasis?
1) Laparoscopic cholecystectomy
2) Incisional (open) cholecystectomy
222
What does lithotripsy need to have in combination with for cholelithiasis?
Oral dissolution therapy
223
What are contraindications for a laparoscopic cholecystectomy?
1) Peritonitis
2) Bleeding disorders
3) Perforated gallbladder
224
What is the abdomen inflated with in a laparoscopic cholecystectomy?
CO2
225
What can free air in the abdomen cause from a laparoscopic cholecystectomy?
Referred right shoulder pain (Kehr's sign) b/c air irritates the diaphragm
226
True or False:
A laparoscopic cholecystectomy is done inpatient
False --> it is done outpatient
227
What is the post op care for a lap chole?
1) Manage pain & nausea
2) Monitor for bleeding
3) Turn, cough, deep breathing
4) Movement & progressive ambulation
5) Discharge teaching
6) Diet --> no to low fat diet initially
228
What is the tx for Kehr's sign?
Place pt is sims position
229
What is the post-op care for an open cholecystectomy?
1) Focus on ventilation/prevention of pneumonia
2) T-tube care
3) Decreased activity for 4-6 wkes
4) General post-op nursing care
230
What is the purpose of a t-tube?
1) Keep common bile duct open after surgery
2) Tx obstruction
231
What should the drainage from a t-tube look like (normal)?
Brownish/green with a decent amount of drainage
232
What happens to the amount of drainage from a t-tube as the swelling of the common bile duct decreases?
Drainage should decrease
233
What is an important assessment for pt that has a t-tube?
Skin --> make sure there is no leaking around site
234
What weight changes can promote gallstone formation?
Rapid weight loss
235
What nutritional therapy should a pt with gallbladder problems have?
1) Eat smaller, more frequent meals
2) Eat some fat to promote gallbladder emptying (slow introduction)
236
What is gallbladder CA r/t?
Cholecystitis & cholelithiasis
237
What kind of onset does gallbladder CA have?
Insidious
238
Where can gallbladder Ca metastasize to?
Liver
239
True or False:
Gallbladder CA is difficult to dx d/t its vague sx
True
240
What are the dx studies of gallbladder CA?
1) Abdominal US
2) Endoscopic US
3) CT
4) MRI
5) MRCP
241
True or False:
Chemo and radiation may not be effective in treating biliary CA
True
242
What are S&S of duct obstruction?
1) Clay colored stools
2) Jaundice
3) Dark, foamy urine
4) Steatorrhea
5) Fever
6) Increased WBCs
243
What diet changes may be needed post-op of biliary tract problems?
1) Low fat
2) May need fat soluble vitamins
244
Where does the pancreas sit?
LUQ behind stomach (technically in retroperitoneal space)
245
What are the 3 parts of the pancreas?
1) Head
2) Body
3) Tail (touches spleen)
246
What is the pancreas innervated by?
The parasympathetic nervous system (rest & digestion)
247
What kind of enzymes does the pancreas secrete?
Digestive
248
What is the pancreas made of?
Acinar cells
249
What do acinar cells do?
Produce enzymes that drain into the pancreatic duct & duodenum to help with digestion
250
What enzymes are secreted by the pancreas?
1) Amylase
2) Lipase
3) Trypsinogen
4) Chymotrypsin
251
What are the 2 things that the pancreas secretes (exocrine functions)?
Enzymes & bicarbonate
252
What does bicarb do in digestion?
Neutralizes contents of the duodenum
**What leaves the stomach & enters the duodenum is acidic, and bicarb is secreted to neutralize contents/make them more basic
253
What form are pancreatic enzymes in when they are in the pancreas?
Inactive
**Only active when they leave the pancreas
254
What factors affect the pancreas?
1) Biliary tract disease (gallstones)
2) Chronic alcohol intake
3) Drug rxns
4) Pancreatic CA
5) Hypertriglyceridemia
6) Smoking
7) Trauma
8) Viral infections
9) After GI surgical procedures
10) Idiopathic
255
What is impaired at the pancreas with age?
Fat absorption & glucose tolerance
256
What is pancreatitis?
Acute inflammation of the pancreas
***Mild edema to severe hemorrhagic necrosis
257
What causes pancreatitis?
1) Premature activation of pancreatic enzymes
2) Autodigestion (causes injury to pancreatic cells)
3) Inflammatory response
258
What percentage of people with severe pancreatitis will die?
10-30%
259
What causes account for a majority of pancreatitis cases?
Alcohol abuse & gallstones
260
What does plasminogen help with?
Breakdown of clots
261
What are manifestations of pancreatitis?
1) Pain
2) N/V
3) Bloating
4) Low-grade fever
5) HypoTN
6) Jaundice
7) Tachycardia
8) Abdominal distention/tenderness/guarding
9) Decreased bowel sounds
10) Crackles in lungs
11) Steatorrhea
12) Cullen's sign
13) Grey-Turner's sign
262
Why may someone with pancreatitis present with jaundice?
D/t the interconnection between the pancreas and biliary tract & there is an obstruction of bile flow
263
Why may someone with pancreatitis have tachycardia?
D/t hypoTN & increased vascular permeability
264
Why might someone with pancreatitis have crackles in the lungs?
D/t the increase in vascular permeability
265
What is Grey-Turner's Sign?
Ecchymotic spots on the flank --> appears as bruising without injury
266
What causes Grey-Turner's sign?
Intravascular damage from circulating trypsin (proteolytic enzyme that breaks down proteins)
267
What is Cullen's signs?
Discoloration or appearance of bruising around the abdomen without evidence of injury (& distended abdomen)
268
What labs would be elevated in pancreatitis?
1) Amylase
2) Lipase
3) Urinary amylase
4) Blood glucose
5) Serum triglycerides
6) Liver enzymes
7) WBCs
269
What labs would be decreased in pancreatitis?
Calcium
270
When does serum amylase peak & when does it return to normal?
Peaks within 24 hrs, returns to normal in 48-72 hrs
271
When does serum lipase peak & when does it return to normal?
Peaks within 48 hrs & returns to normal within 5-7 days
272
Between serum amylase & serum lipase, which is more specific to the pancreas?
Serum lipase
Amylase is non-specific
273
Why would someone with pancreatitis have increased blood glucose?
Pancreas function impaired --> not releasing enough insulin
274
What are the dx tests for pancreatitis?
1) Abdominal US
2) Abdominal X-Ray
3) Abdominal CT w/ contrast
4) ERCP
5) Endoscopic US
6) MRCP
7) Angiography
8) Chest X-Ray
275
What imaging is best for comps of pancreatitis?
Abdominal CT w/ contrast
276
What does an angiography look at in pancreatitis?
Patency of blood vessels
277
What is a chest x-ray good for r/t pancreatitis?
Tertiary findings r/t comps of pancreatitis
278
Why would an ERCP be done for someone with pancreatitis?
Stones may cause pancreatitis, so it can help to visualize & remove the obstruction
279
What are comps of acute pancreatitis?
Pseudocyst & pancreatic abscess (infected pseudocyst)
280
What is a pseudocyst?
Accumulation of fluid & pancreatic enzymes
**Can perforate and lead to peritonitis
281
What are S&S of a pseudocyst?
1) Abdominal pain/mass
2) N/V
3) Anorexia
282
What is the tx for pseudocyst?
1) Spontaneous resolution?
2) Surgical drainage
3) Percutaneous catheter placement for drainage
283
What is a pancreatic abscess?
1) Collection of pus
2) Extensive necrosis in the pancreas
3) Infection
284
What are S&S of pancreatic abscess?
1) Pain/mass
2) High fever
3) Leukocytosis
285
What is the tx pancreatic abscess?
Prompt surgical drainage to prevent sepsis
286
What is the best way to visualize a pancreatic abscess?
CT
287
What are the systemic pulmonary complications of pancreatitis?
1) Pleural effusion
2) Atelectasis
3) Pneumonia
4) ARDs
288
What are the systemic cardiac complications of pancreatitis?
1) HypoTN
2) Hypovolemia
3) Shock
4) Myocardial insufficiency
289
What is a sign of severe pancreatitis?
Hypocalcemia (S&S = tetany)
290
What are systemic comps of pancreatitis?
1) Pulmonary comps
2) Cardiovascular comps
3) Hypocalcemia
4) Intravascular thrombi
5) Pulmonary emboli
6) DIC
7) Abdominal compartment syndrome
291
True or False:
Serum total calcium is bound to albumin
True
292
What is the drug therapy for pancreatitis?
1) Morphine
2) Antispasmodics
3) Carbonic anhydrase inhibitor
4) Anatacids
5) PPIs
6) Insulin
7) Pancreatic enzyme products
293
What do we worry about when giving a pt with pancreatitis morphine for pain relief?
GI & resp function (d/t resp depression & constipation)
294
What is an example of an antispasmodic given for pancreatitis?
Dicyclomine
295
What does dicyclomine do in the tx of pancreatitis?
Helps with some discomfort by decreasing pancreatic outflow & decreasing volume and concentration of pancreatic secretion
296
What is an example of a carbonic anhydrase inhibitor given for pancreatitis?
Acetazolamide
297
What does acetazolamide do in the tx of pancreatitis?
Decreases volume & bicarb concentration of pancreatic secretions
***Need a neutral environment for pancreatic enzymes to work
298
What do PPIs do in the tx of pancreatitis?
Decrease hydrochloric acid secretion which stimulates pancreatic activity
299
What is insulin used for in pancreatitis?
Used as a supplement depending on how ill the pt is
300
What is the nutritional therapy for pancreatitis?
1) NPO -- initially
2) Entero-jejunal feedings (or TPN if enteral feedings not tolerated)
3) Small, frequent, high carb meals when they can eat again
4) May need extra fat-soluble vitamins d/t decreased dietary intake
301
What carb-containing foods should patients with pancreatitis have?
Bland, high carb, low fat:
1) Toast
2) Bread
3) Rice
4) Pasta
302
What should patients with pancreatitis abstain from?
Alcohol
303
Why is entero-jejunum feeds considered for pancreatitis?
It surpasses the duodenum, resulting in no secretion of pancreatic enzymes
304
What is the nursing management for pancreatitis?
Health Promotion:
1) No alcohol
2) Healthy lifestyle
3) Early dx & tx of biliary tract disease (gallstones main contributor)
4) Assess for pre-disposing factors
305
Where do systemic manifestations of pancreatitis begin?
In the lungs (crackles)
306
What are the acute interventions for pancreatitis?
1) Monitor VS
2) Watch for response to IV fluids
3) F/e balances r/t vomiting
4) Assess lung sounds/respiratory effort, O2 sats
5) S&S of hypocalcemia (tetany)
6) Patient positiong -- for comfort
7) Oral care
8) Watch for S&S of paralytic ileus, renal failure, AMS, blood glucose
9) Post-surgical skin care
307
How do you tx hypocalcemia in patients with pancreatitis?
IV calcium gluconate
308
What are S&S of hyperglycemia to tell pts with pancreatitis to watch for?
1) Polyphagia (increased hunger)
2) Polyuria
3) Polydipsia (excessive thirst)
309
Why is it important for pts with pancreatitis to avoid smoking?
Causes vasoconstriction & we do not want to restrict bloodflow to organs that are trying to heal
310
What is chronic pancreatitis?
Continuous. prolonged, inflammatory and fibrosing process
**Pancreas is progressively destroyed d/t recurrent attacks
311
What are the most common causes of chronic pancreatitis?
1) Chronic alcohol abuse
2) Inflammation associated with gallstones
312
What are other causes of chronic pancreatitis?
1) Tumors
2) Pseudocysts
3) Trauma
4) Systemic disease (autommune, CF)
313
What is the patho of chronic obstructive pancreatitis?
Inflammation of the sphincter of Odi with cholelithiasis
314
What causes chronic obstructive pancreatitis?
CA of the...
1) Ampulla of Vater
2) Duodenum
3) Pancreas
315
What is the patho of non-obstructive chronic pancreatitis?
Inflammation in the head of the pancreas & around the pancreatic duct
316
What pt population typically develops non-obstructive chronic pancreatitis?
Alcoholics
317
What are the CMs of chronic pancreatitis?
1) Abdominal pain (LUQ radiating to the back)
2) Chronic dull pain
3) Malabsorption & wt loss
4) Constipation
5) Mild jaundice
6) Dark urine
7) Steatorrhea
8) DM
***Pain unrelieved with food or antacids
318
Why would a pt with chronic pancreatitis have constipation?
Not eating so gut isn't working properly
319
Why would a pt with chronic pancreatitis have steatorrhea?
If they have fatty foods & the stomahc tries to process this
320
Why would someone with chronic pancreatitis have malabsorption & wt loss?
They can't absorb nutrients d/t the dysfunction with releasing pancreatic enzymes
321
What does amylase digest?
Starches and sugars
322
What does lipase digest?
Fats
323
What do trypsinogen & chymotrypsin digest?
Proteins
324
What is the interprofessional care for chronic pancreatitis?
1) Tx flare-ups as acute attacks
2) Pain control
3) Diet
4) Control diabetes
325
What nutritional support may be needed for a pt with chronic pancreatitis?
1) Avoid smoking & alcohol
2) Pancreatic enzyme replacement
3) Bile salts
4) Low fat diet
326
Why does a pt with chronic pancreatitis need a low fat diet?
There is a dysfunction in secreting lipase which helps digest fats
327
What do bile salts do in chronic pancreatitis?
Helps with fat-soluble vitamin absorption
328
True or False:
Pancreatic CA has silent growth until it is well-advanced & metastisized
True
329
What is the peak incidence of pancreatic CA?
65-80 yrs old (risk increases w/ age)
330
What are the RFs of pancreatic CA?
1) Chronic pancreatitis
2) DM
3) Age
4) Cigarette smoking
5) Family hx
5) High-fat diet
6) Chemical exposure
7) AA > whites
331
What are the CMs of pancreatic CA?
1) Dull, aching abdominal pain
2) Anorexia
3) Rapid & progressive wt loss (w/o trying = red flag!)
4) Nausea
5) Jaundice
332
What are the characteristics of the abdominal pain experienced in pancreatic CA?
1) May occur in upper abdomen & radiate to the back
2) Occurs with eating
3) Occurs at nighttime
333
What are the dx tools for pancreatic cancer?
1) CT
2) Abdominal or EUS (need to f-up with a CT then)
3) ERCP
4) MRI
5) MRCP
6) Tumor markers
334
True or False:
A whipple is the removal of the entire pancreas
False --> only remove portion of pancreas b/c we still need pancreatic enzymes
335
What is anastomosed in a whipple?
1) Pancreatic duct
2) Common bile duct
3) Stomach to jejunum
336
What are the therapies for pancreatic CA?
1) Radiation --> pain relief only
2) Chemo --> limited
**By time of dx, don't necessarily have a lot of tx options
337
What is the nursing management for pancreatic CA?
1) Symptomatic support
2) Pain relief
3) Promotion of comfort
4) Psychological support (pt & family)
5) Nutrition promotion
6) Check for bleeding
7) Post-op care (whipple)
8) Palliative/Hospice care
338
How does a t-tube help with bile post-op of a cholecystectomy?
Helps with flow of bile from liver to duodenum/drainage bag
**As drainage slows --> tube will be removed
339
Besides hepatocytes, what helps to make bile?
Bilirubin
340
What lines the sinusoids?
Kupffer cells
341
What do kupffer cells breakdown?
1) Old RBCs
2) WBCs
3) Bacteria
4) Other products
342
What gives bile its color?
Bilirubin
343
What causes hepatitis?
1) Viruses
2) Substances
3) Autoimmune diseases
4) Metabolic abnormalities
344
NUR 408
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