Liver and Pancreas: Pathophysiology, Diagnostics, and Management, Slides of Nursing

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GI Part 1

Liver and Pancreas

GI System Review

Diagnostics

• (^) Laboratory studies
  • (^) CBC – RBC, H&H  concern for GI bleed
  • (^) PT/INR problem with clotting, bleeding risk
  • (^) Electrolytes
  • (^) AST/ALT  elevated with liver damage
  • Amylase & Lipase  elevated with pancreas damage
  • Bilirubin  elevated with liver dysfunction & other GI issues
• (^) EGD– esophagogastroduodenoscopy
  • (^) Need sedation, consider airway protection
  • Assess for ulcers, polyps, & bleeds
• (^) CT Abdomen
  • (^) NPO 4 hours prior; assess allergies to contrast
• (^) ERCP (endoscopic retrograde cholangiopancreatography)
  • (^) Assess liver, gallbladder, & pancreas
  • (^) Assess allergies to contrast
• (^) Liver Biopsy
  • (^) Check for liver issues, done in IR; post-op risk is bleeding

Liver

Cirrhosis

• (^) Irreversible scaring of the liver; more liver damage = more symptoms
• (^) Causes/Types
  • (^) Alcoholic, cholestatic/biliary, viral hepatitis (B, C, D), compensated & decompensated
  • (^) Drug induced: acetaminophen, antibiotics, seizure meds, etc.
• (^) Widespread scar tissue spread across connective tissue of liver
• (^) Inflammation r/t toxins that liver normally filters out that now build up, nodules form, block bile ducts and blood flow
• (^) Patients asymptomatic initially
  • (^) Start to have complications when we see symptoms

Cirrhosis Presentation

• (^) Early S/Sx
  • (^) Fatigue, anorexia, abdominal pain, n/v, subtle weight change
• (^) Late S/Sx
  • (^) Jaundice, sclera yellow, rash, ecchymosis, petechiae, palmar erythema, spider angiomas, vitamin deficiency, pruritis, ascites, peripheral edema, factor hepaticus, asterixis, respiratory sx, neuro changes
• (^) Labs
  • (^) Elevated LFTs (AST/ALT)
  • (^) Elevated bilirubin & PT/INR
  • (^) Low protein, albumin, H&H

Portal Hypertension

• (^) Complication of cirrhosis
• (^) Increase in pressure within portal vein  blood back flow into spleen  causes veins in esophagus, stomach, intestine, abdomen and rectum to dilate - (^) Major risk for BLEEDING!
• (^) Eventually causes ascites, bleeding varices, caput medusae, decreased liver function, & enlarged spleen

Ascites

• (^) Collection of fluid in peritoneal cavity
• (^) Massive ascites leads to renal vasoconstriction, resulting in salt and water retention
• (^) Risk for bacterial peritonitis (infection)
• (^) Sx – fever, loss appetite, abd pain, LOC changes
• (^) Tx – paracentesis
  • (^) Remove fluid from abdomen; often repeated
  • (^) Make sure pt voids prior to procedure
• (^) Other Tx
  • (^) Sodium & fluid restriction
  • (^) Can give Lasix, Bumex, or spironolactone
  • (^) Albumin
  • (^) I&O, daily weights

Esophageal Varices – Treatment

• (^) O2, fluids, monitor H&H, platelets – replace as needed
• (^) EGD with banding
• (^) Blakemore tube placement
  • (^) Done if EGD unsuccessful and still crazy bleeding
  • (^) Inflate balloon to restrict blood flow to varices
  • (^) Complications: aspiration & esophageal perforation
  • (^) MUST HAVE SECURE AIRWAY (will be intubated)
  • (^) Pt to wear football helmet to secure tube
• (^) Meds/Other Tx:
  • (^) Long term propranolol
  • (^) Vasopressin, octreotide, norepinephrine
  • (^) Pantoprazole
  • (^) PRBC, FFP, Cryo, platelets

Hepatic Encephalopathy

• (^) Neuro changes brought on by severe liver disease
  • (^) Toxins build up in blood and travel to brain
  • (^) Elevated ammonia
• (^) Early Sx – sleep/mood disturbance, minor confusion, mental status changes
• (^) Late Sx – severe altered LOC, neuromuscular issues, asterixis, impulsive, lethargic, major confusion
• (^) Tx – Lactulose
  • (^) Decrease ammonia via stool
  • (^) Goal: 3-4 stool per day
  • (^) Titrate based on stool & sx, not ammonia level
• (^) Other Tx
  • (^) Flagyl, vanco, neomycin, rifaximin – decrease protein & ammonia
  • (^) Safety interventions!!

Liver Transplant

• (^) Use live donor or cadaver liver
• (^) Can give part of lobe and regenerate
• (^) Post-op: look for s/sx complications
• (^) Complications:
  • (^) Infection
  • (^) Rejection
    • (^) Anti-rejection meds

Pancreas

Acute Pancreatitis - Treatment

• (^) NPO!!!  Need to rest the pancreas!!!
  • (^) Prevents release of enzymes
• (^) IV hydration as needed
• Supplement Ca, Mg, & K as needed
• (^) NG tube to suction
• (^) Pain management – dilaudid or morphine are choice
• (^) Nausea meds
  • (^) Zofran, Reglan
• (^) GI drugs to decrease gastric acid secretion
  • (^) Ranitidine, famotidine, omeprazole, pantoprazole
• Antibiotics if concern for infection
• Surgery – if related to gallstones
• (^) Nutrition consideration
  • (^) If NPO for 3+ days – consider TPN
• (^) Once Sx improve & pain controlled & enzymes normalize, slowly start food  ice chips/clears/full, then bland solid foods & progress as tolerated - (^) NO caffeine, NO spicy, NO alcohol, NO smoking

Acute Pancreatitis - Complications

• (^) Hypovolemic Shock
  • (^) r/t dehydration
• (^) Septic Shock
  • (^) r/t infection/inflammation
• (^) ARDS
  • (^) Acute pancreatitis  left lung pleural effusion  atelectasis  pneumonia  ARDS  death
• (^) Paralytic ileus
• (^) Acute kidney injury
  • Multisystem organ failure
    • (^) r/t necrotizing hemorrhagic pancreatitis
  • (^) DIC
    • (^) Changes in pancreas cause release of necrotic tissue & enzymes into bloodstream
  • (^) Type 1 DM
    • (^) r/t increased glucagon and decreased insulin release
    • (^) Check BG and treat w/ insulin as needed
    • (^) Temporary or permanent
  • (^) Jaundice
    • (^) r/t bile duct obstruction