HEPATOBILIARY

DISORDERS
Katrina Saludar Jimenez, R. N
 DISCUSSION OUTLINE
DAY 1
I. Review of the Anatomy and Physiology of the
Biliary system-(Liver)
II. Assessment
A. chief complaints

B. Past Medical History

C. Physical Examination

III. Laboratories/ Diagnostic Procedures/ Studies

IV. Common Disorders
A. Liver Cirrhosis
B. Hepatitis
 DISCUSSION OUTLINE
DAY 2
I. 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
I. REVIEW ON THE ANATOMY
AND PHYSIOLOGY (BILIARY
SYSTEM)
 MAJOR FUNCTIONS OF THE
LIVER
1. 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
 ASSESSMENT
PAST MEDICAL HISTORY

Recent skin/mucous membrane

disruption
Major illness/hospitalization

Medications

Family history

Psychosocial History and lifestyle

Habits
 ASSESSMENT
PHYSICAL EXAMINATION
INSPECTION PERCUSSION

 Skin color Liver dullness

 Abdominal size and

contour
 symmetry

 Skin characteristics
Spleen Dullness
 Jugular vein

AUSCULTATION

 Bowel sounds
 ASSESSMENT
PHYSICAL EXAMINATION
 Spider Angioma PALMAR ERYTHEMA
 ASSESSMENT
PHYSICAL EXAMINATION
PALPATION
 Light palpation

 Deep palpation

 Palpate specific organs

SPECIAL PROCEDURES:
 Fluid wave test

 Shifting Dulllness

 Abdominal assment.movie
 ASSESSMENT
CHIEF COMPLAINTS

 Abdominal pain
Urine changes
 Anorexia
Jaundice, pruritus
 Nausea and vomiting
Bleeding tendencies
 Weight loss
Ascites
 Stool changes

Edema of the limbs

 Food intolerance

 Altered level of Fatigue

consciousness
 LABORATORY AND
DIAGNOSTIC TESTS
Fat Metabolism Protein Metabolism
indicators Indicators
 Total Serum Protein- dec
 Increase: biliary obstruction
 Immunoglobulins
 Decrease: hepatocellular
damage IgA- inc in Liver cirrhosis

Examples: IgG- inc in chronic active

hepatits
 Serum Total Cholesterol &
Cholesterol Esters IgM- inc in Hepatitis A

Normal value: 140-200 mg/dl  BUN- inc in hepatocelluar dse

 Serum phospholipids  Protime, PTT, PT- inc

 Blood Ammonia Levels- Inc

Normal value: 150-250 mg/dl
 LABORATORY AND
DIAGNOSTIC TEST
Bilirubin Metabolism
Indicators
 Total Serum Bilirubin
 Urine Bilirubin/ Foam Test

inc- hepatocellualr damage

inc- hepatocelluar
nv: 0.1- 1 mg/dl damage

 Unconjugated/ Indirect  Fecal Urobilinogen

Bilirubin (stercobilin)

inc- hepatocellular damage - alcohol stool (pale or

gray colored stool)
nv: 0.1- 1 mg/dl
 Conjugated bilirubin

Inc- bilirary obstruction

 LABORATORY AND
DIAGNOSTIC TEST
Inc Serum Enzymes
 Alanine transaminase (ALT), also called Serum Glutamic Pyruvate
Transaminase
Normal value:

 Aspartate transaminase (AST) also called Serum Glutamic Oxaloacetic

Transaminase (SGOT)
Normal value:

 Alkaline phosphatase (ALP)

Normal value

 Gamma glutamyl transpeptidase (GGT)

Normal value:

 LDH (Lactic Dehydrogenase)

Normal Value
 LABORATORY AND
DIAGNOSTIC PROCEDURES

LIVER BIOPSY
 Nsg intervention before and
During the procedure:

1. consent

2. NPO: 2-4 hrs

3. Pre-op meds: Vitamin K if

prolonged Prothromin Time

4. Monitor Pro-time : BLEEDING

– most common complication

5. Position: LEFT LATERAL

6. HOLD breath 5-10 seconds

during the needle insertion
 LABORATORY AND
DIAGNOSTIC PROCEDURES
LIVER 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 may

indicate internal
hemorrhage

4. Observe for signs of

Peritonitis
 LABORATORY AND
DIAGNOSTIC PROCEDURES
PARACENTESIS
 Nsg intervention BEFORE AND
DURING the procedure:

1. Consent
2. V/S prior
3. Empty the bladder
4. Check serum proteins
5. POSITION: sitting/
upright
 LABORATORY AND
DIAGNOSTIC PROCEDURES
PARACENTESIS
 Nsg intervention after the
procedure:

1. V/s monitoring
2. Urine output
3. Rigidity of the
abdomen
4. Sx and symptoms of
hypovolemic shock
and peritonitis
 LABORATORY AND
DIAGNOSTIC PROCEDURES
Peritoneoscopy
 Nsg intervention before the
procedure:

1. Consent
2. Clotting fx
3. Hypersensitive to
local anesthesia
4. NPO
 LABORATORY AND
DIAGNOSTIC PROCEDURES
Peritoneoscopy
 Nsg intervention after the
procedure:

1. V/s and site

monitoring
2. Watch out for
complications:
Bile peritonitis
 HEPATITIS

HEPATOBILIARY

DISORDER 1
 HEPATITIS

 Inflammation of the liver

 Causes: virus, exposure to
medications, hepatotoxins
 3 subtypes:
1. Viral Hepatitis
2. Toxic Hepatitis
3. Alcoholic Hepatitis
 A. VIRAL HEPATITIS
Virus HEP A HEP B HEP C HEP D HEP E HEP F HEP G

MOT Fecal- Blood and Blood Blood and Fecal- oral Fecal- oral Blood and
oral body and body body body
fluids, fluids, fluids, fluids
perinatal intranasa perinatal
l

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, Cirrhosis, Liver CA, No

Liver CA, Liver CA, Chronic evidence
Chronic Chronic Hepatitis on
Hepatitis Hepatitis Fulminant chronicity
H.
 A. VIRAL HEPATITIS
TREATMENTS AND PREVENTION

 Hepatitis A
 formerly called Infectious hepatitis, Epidemic
hepatitis, Epidemic jaundice, Catarrhal
jaundice, Type A hepatitis,
1. Self limiting with only few long term
consequences
2. Txtment of H20 supplies and proper
sanitation
3. Hepatitis Vaccine A (Havrix)- 2 doses
4. Immunoglobulin (Gammar) before and after
exposure
 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
 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
2. General hygiene precautions
 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
 A. VIRAL HEPATITIS
MANIFESTATIONS
Icteric phase

1. Jaundice
2. Pruritus
3. Clay colored stools
4. Brown urine
5. Decrease in
preicteric phase
symptons
 A. VIRAL HEPATITIS
MANIFESTATIONS

Nsg. 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
 A. VIRAL HEPATITIS
MANIFESTATIONS

Nsg. Diagnosis and Intervention for

JAUNDICE
1. Disturbed Body Self image
- verbalize concerns or feelings toward condition
 A. VIRAL HEPATITIS
MANIFESTATIONS

Post icteric phase

1. Serum bilirubin and

enzymes return to
normal levels
2. Energy level
increases
3. Pain subsides
 A. VIRAL HEPATITIS
COMPLICATIONS

Fulminant Hepatitis Chronic Hepatitis

 Massive hepatic
 Liver inflammation
necrosis
beyond 3-6 months
 Seen primarily in HEP
A, B, D and E
 Progression of:

 Jaundice

 Hepatic
encepalopathy
 ascites
 HEPATITIS
MANAGEMENTS

Medical Management Nursing Management

 Glucose water/ Imbalanced Nutrition,
dextrose Less than
 Bile Acid Sequestrants
Risk for infection
(Cholestyramine
( Questran) or (Transmission)
Colestipol ( colestid) Fatigue
 Interferon Treatment

 Milk thistle

 Licorice roots
 LIVER CIRRHOSIS
HEPATOBILIARY

DISORDER 2
 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
 LIVER CIRRHOSIS
PORTAL HYPERTENSION
 increase in the blood
pressure within a system
of veins called the portal
venous system
 Blood backs up and find
other ways to the heart
 Esophagus

 Skin on the abdomen

 Veins in the rectum

 spleen
 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
 LIVER CIRRHOSIS
BLEEDING ESOPHAGEAL VARICES

 SENGSTAKEN BLAKEMORE
TUBE
-oro- or nasogastric tube used
occasionally in the management
of
upper gastrointestinal hemorrhag
e
due to bleeding from
esophageal varices

HOW TO PREVENT :
 Avoid screaming, shouting
 straining at stool
 coughing and sneezing
 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
 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
 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
 LIVER CIRRHOSIS
MANAGEMENTS
 C. COMPLICATION MANAGEMENT

1. PARACENTESIS

2. TIPS ( TRANSJUGULAR
INTRAHEPATIC
PORTOSYSTEMIC 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)
 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