Hepatic and Biliary System

Hepatic and Biliary System
Learning Objectives:
Upon completion of this unit the learners will be able to:
Identify the metabolic function of the liver and the alterations in these functions that occur with the liver disease.
Explain the liver function tests and the clinical manifestations of liver dysfunction in relation to the pathophysiologic alterations of the liver.
Differentiate among the types of viral hepatitis, including etiology, Pathophysiology, clinical manifestations, complications, and collaborative care.
Describe the nursing management of the patient with viral hepatitis.
Explain the etiology, pathophysiology, clinical manifestation, complications and collaborative care of the patient with cirrhosis of the liver.
Describe the nursing management of the patient with cirrhosis of the liver.
Explain the etiology, Pathophysiology, clinical manifestation, complications and collaborative care of acute and chronic pancreatitis.
Describe the nursing management of the patient with acute and chronic pancreatitis.
Explain the etiology, Pathophysiology, clinical manifestation, complications and collaborative care including surgical therapy of gallbladder disorders.
Describe the nursing management of the patient undergoing conservative or surgical treatment of cholecytitis and cholelithiasis.










Assessment and Management of Patients with Hepatic Disorders
§ Liver is the largest gland in the body, can be considered a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism.
§ The liver is located behind the ribs in the right upper portion of the abdominal cavity
§ The liver is especially important in the regulation of glucose and protein metabolism.
§ The liver manufactures and secretes bile, which has a major role in the digestion and absorption of fat in the GI tract.
§ It removes the waste products from the blood stream and secretes them into the bile.
§ The bile produced by the liver is stored temporarily in the gall bladder until it is needed for digestion, at which time the gall bladder empties and bile enters the intestine.
Functions of the liver


Function
Actions

Digestion
Ø1 Bile salts for digestion/emulsification of fats
Ø2 Processing and storage of fats, carbohydrates and proteins absorbed by the intestine and sent to the liver via the portal circulation
Ø3 Processing and storage of vitamins and minerals
Ø4 Vitamin B 12, A, D, E ,K

Endocrine
Ø1 Metabolism of glucocorticoids, mineralocorticoids and sex hormones
Ø2 Regulation of fat, carbohydrate and protein metabolism
Ø3 Glucose stored as glycogen
Ø4 Main source of body heat

Hematologic
Ø1 Temporary storage of blood
Ø2 Synthesis of bilirubin from breakdown of RBCs
Ø3 Hematopoiesis in certain disease states
Ø4 Synthesis of blood clotting factors (fibrinogen, thrombin, prothrombin)
Ø5 synthesis of albumin, prealbumin,

Excretion
Ø1 Excretion of bile pigment
Ø2 Excretion of cholesterol via bile
Ø3 Urea synthesis as the final step in the excretion of ammonia (protein breakdown)
Ø4 Detoxification of drugs, poisons and other foreign substances





Laboratory Assessment of Liver and Pancreatic Function



Lab test
Significance

Direct bilirubin
Increased with biliary obstruction

Indirect bilirubin
Increased with destruction of RBCs

Serum amylase
Pancreatic digestive enzymes, increased with acinar cells are destroyed. This test also measures salivary amylase (enzyme which converts starches into sugar), so pancreatic isoamylase more accurate

Serum lipase
Pancreatic digestive enzyme, increased with acute pancreatitis

Ammonia
By-product of protein metabolism. Reduced synthesis of urea from body stores of ammonia, elevations seen in severe hepatic failure/injury and lead to encephalopathy (central nervous system dysfunction resulting from liver disease)and coma

Enzymes:
AST
ALT
LDH
ALP
GGT
Cellular enzymes are released from hypoxic or damaged cells.
·1 AST, ALT, and LDH are increased from damaged liver, heart, kidney and muscle cells.
·2 ALP is increased with biliary obstruction
·3 LDH 5 is an isoenzyme from the liver and striated muscle
·4 GGT is more specific to liver disease
AST: Aspartate Amino Transferase, formerly SGOT
ALT: Alanine Amino Transferase, formerly SGPT
LDH: Lactic Dehydrogenase
ALP: Alkaline Phosphate
GGT: Gamma Glutamyl Transpeptide
Assessing People with Hepatic Disorders:
Common Hepatic Manifestations:
1. Abdominal pain or discomfort.
2. Nausea& vomiting.
3. Anorexia.
4. Weight loss.
5. Fluid and electrolytes imbalance.
6. Jaundice: Appear when the liver cannot able to metabolize bilirubin.
7. Altered mental or neurological status (Encephalopathy).
This symptom has been attributed to: increase level of ammonia and other protein by product in the blood because of the inability of the liver to metabolize them into urea.

Increased susceptibility to infection.
This symptom has been attributed to: the decreased ability of the liver to perform phagocytes may result in increased susceptibility to infection.
Altered bleeding tendencies. This symptom has been attributed to: The liver becomes unable to manufacture clotting factors or clear fibrinolysins result in increase the risk for bleeding.

Fatty food intolerance manifested by pain on ingestion of
fat.
Dark, tea-colored urine or clay colored stools.
Altered bowel habit.


Hepatitis
Definition:
Hepatitis is inflammation of the liver caused by viral infection or exposure to toxic chemicals
Clinical Manifestation of the Phases of Hepatitis:

Preicteric
It lasts 1-21 days Icteric
It lasts 2-4 weeks Post Icteric
It persist several months
1. Anorexia.
2. Nausea, vomiting.
3. Right upper quadrant discomfort.
4. Decrease sense of taste and smell.
5. Malaise.
6. Headache.
7. Fever.
8. Arthralgias.
9. Urticaria, rash.
10. Hepatomegaly & tenderness of the liver.
11. Splenomegaly.
12. Weight loss.
1. Jaundice.
2. Pruritus due to accumulation of bile salts under skin.
3. Dark urine.
4. Bilirubinuria.
5. Light or clay colored stool.
6. Fatigue.
7. Continued hepatomegaly with tenderness.
8. Weight loss.
1- Malaise.
2- Easy fatigability.
3- Hepatomegaly.


· Jaundice: A condition characterized by raised bilirubin level in the blood.
· Bilirubin: The pigment gives bile its oranges color; it is a waste product from the break down of hemoglobin.

Characteristics of Viral Hepatitis

Source of infection and spread of disease Mode of transmission Incubation Period Virus Name
Contaminated food, milk, water and selfish; person's with sub clinical infections infected food handler, poor personal hygiene, poor sanitation. Fecal-oral route; poor sanitation, person to person contact. Waterborne; food borne. 15-50 days
( average 30 days) Hepatitis A virus ( HAV)
§ Contaminated needles, syringes, and blood products.
§ Sexual activity with infected partners.
§ Oral-oral contact.
§ Tattoo / body piercing, bites.
§ Occupational hazards for health care personnel, hemodialysis staff, chemotherapy nurses, operating room nurses, dentists, persons at risk needle sticks. §1 Percutaneous (parenteral)/ permucosal exposure to blood or blood products
§2 Sexual contact.
§3 Perinatal transmission 28-160 days
(average 70-80 days) Hepatitis B virus
( HBV)
§ Blood and blood products, needles and syringes.
§ Sexual activity with infected partners. Increased with sexual transmitted disease.
§ Chronic treatment with hemodialysis.
§4 Transfusion of blood and blood products
§5 Exposure to contaminated blood or blood products through equipment
§6 High risk sexual contact.
§7 Perinatal contact. 15-160 days
(average 50 days) Hepatitis C virus
( HCV)
(non A –non-B)
Called post transfusion H.

§ Same as HBV. §1 Can cause infection only together with HBV.
§2 Rotes of transmission same as for HBV.
§3 HBV surface antigen necessary for replication.
21-140 days
(average 35days)
§1 HBV must precede HDV;
§2 Chronic carriers of HBV are always at risk. Hepatitis D virus ( HDV)
§ Contaminated water; poor sanitation
§4 Fecal-oral.
§5 Outbreaks associated with contaminated water supply in developing countries 15-65days
( average 42 days) Hepatitis E virus
( HEV)
Similar to HAV
Nursing Care for a Patient with Hepatitis:
A-) Nursing Assessment:
Subjective Data: Important Health Information:
Past health history:
§ Previous liver disease, hepatitis immunization.
§ Hemophilia.(An inherited bleeding disease)
§ Exposure to infected persons.
§ Ingestion of contaminated food and water.
§ Sexual promiscuity.
§ Exposure to toxins.
§ Exposure to contaminated needles.
§ Recent travel.
§ Organ transplant recipient.
§ Exposure to new drug regimen.
2- Present illness:
Fatigue.
Weight loss.
Weight changes.
Digestive disturbance.
Skin changes.
Feeling of fullness in right upper quadrant.
3- Functional assessment:
Diet,.
Alcohol intake.
Occupation.
Exposure to toxins.
Interpersonal relationship.
Objective Data:
Vital signs: Hypertension, tachypnea, low grade fever.
Skin: Dryness, scratches, jaundice, bruises, angioedema. (Sever form of urticaria which involve skin, face, hands and genital organ)
Eyes: Icteric sclera.
Thorax: Spider angiomas.
Abdomen: Distention, prominent veins, hepatomegaly, Splenomegaly.
Activity-exercise: Fatigue, Arthralgias (pain in joints), myalgias.





Possible findings:
Abnormal liver enzyme studies.
Elevated serum bilirubin.
Hypoalbuminemia.
Anemia.
Bilirubin in urine and increased urobilinogen.
Prolonged prothrombin time.
Serologic test positive for hepatitis, including anti-HAV IgM, anti-HBc IgM, anti-HCV, anti-HDV.
Abnormal liver scan.
Positive liver biopsy.
Management:
All types of hepatitis:
Rest according to patient's level of fatigue.
Therapeutic measures to control dyspeptic symptoms and malaise.
Hospitalization for protracted nausea and vomiting or life-threatening complications.
Small, frequent feedings of a high-caloric, low –fat diet; proteins are restricted when the liver cannot metabolize protein by-products, as demonstrated by the symptoms.
Vitamin K injected subcutaneously if prothrombin time is prolonged.
Intravenous fluid and electrolyte replacement as indicated.
Administration of antiemetic for nausea.
After jaundice has cleared gradual increase in physical activity. This may require many months.
For HCV Patients:
Long-term interferon (Betaseron) therapy may produce at least temporary remission.
Complications:
Dehydration, Hypokalemia.
Chronic "carrier" hepatitis or chronic active hepatitis.
Diminution or arrest of flow of bile.
Fulminant hepatitis (sudden, sever onset of acute liver failure that occurs within 8 weeks of the first symptoms of jaundice).
HBV carriers have a higher risk of developing Hepatocellular carcinoma.

Hepatic and Biliary System

Hepatic and Biliary System
Learning Objectives:
Upon completion of this unit the learners will be able to:
Identify the metabolic function of the liver and the alterations in these functions that occur with the liver disease.
Explain the liver function tests and the clinical manifestations of liver dysfunction in relation to the


الكبدية الصفراوية والنظام
أهداف التعلم :
عند الانتهاء من هذه الوحدة سوف تكون قادرة على المتعلمين :
تحديد وظيفة التمثيل الغذائي في الكبد وتغيرات في هذه الوظائف التي تحدث مع مرض الكبد.
شرح اختبارات وظائف الكبد والمظاهر السريرية للاختلال وظيفي في الكبد يتعلق