Gallbladder, Liver, Biliary Tract, OR Exocrine Pancreatic Disorder PDF

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CARE OF THE PATIENT WITH A GALLBLADDER, LIVER, BILIARY TRACT, OREXOCRINE PANCREATIC DISORDERI. Laboratory and diagnostic examinations in the assessment of the hepatobiliary and pancreatic systemsA. Serum bilirubin test a) Bilirubin is the pigment that gives bile its yellow-orange color.b) Unconjugat...

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CARE OF THE PATIENT WITH A GALLBLADDER, LIVER, BILIARY TRACT, OR EXOCRINE PANCREATIC DISORDER

I.

Laboratory and diagnostic examinations in the assessment of the hepatobiliary and pancreatic systems A. Serum bilirubin test a) Bilirubin is the pigment that gives bile its yellow-orange color. b) Unconjugated bilirubin is a water-insoluble; also called indirect bilirubin, that passes through the bloodstream to the liver, where it is converted into conjugated (water-soluble; also called direct) bilirubin. c) Normal bilirubin levels: (1) Direct bilirubin: 0.1 to 0.4 mg/dL (2) Indirect bilirubin: 0.2 to 0.8 mg/dL (3) Total bilirubin: 0.3 to 1.2 mg/dL (a) Rationale: (i) Testing for bilirubin in the blood provides valuable information for the diagnosis and evaluation of liver disease, biliary obstruction, and hemolytic anemia. Jaundice, the discoloration of body tissues caused by abnormally high blood levels of bilirubin, is visible when the total serum bilirubin exceeds 2.5 mg/dL. (b) Nursing intervention (i) Keep the patient on NPO (nothing by mouth) status until after the blood specimen is drawn. (ii)

Inform the patient regarding blood draws and what test is being performed.

(iii)

Monitor the venipuncture site for bleeding.

B. Liver Enzyme Tests Tests include: a) AST: 0 to 35 units/L. The AST level is elevated in myocardial infarction, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, and acute hemolytic anemia. b) ALT: Adult or child: 4 to 36 units/L. The ALT level is elevated in hepatitis, cirrhosis, hepatic necrosis, and hepatic tumors and by hepatotoxic drugs. c) LHD: Adult: 100 to 190 units/L. Values are increased in myocardial infarction, pulmonary infarction, hepatic disease (e.g., hepatitis, active cirrhosis, neoplasm), pancreatitis, and skeletal muscle disease. d) Alkaline phosphatase: Adult: 30 to 120 units/L. Elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, hepatitis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones, and healing fractures. e) GGT: Males and females older than age 45 years: 8 to 38 units/L; females younger than age 45 years: 5 to 27 units/L. Levels are elevated in liver cell dysfunction such as hepatitis and cirrhosis; in hepatic tumors; with the use of hepatotoxic drugs; in jaundice; and in myocardial infarction (4 to 10 days after), heart failure, alcohol ingestion, pancreatitis, and cancer of the pancreas. (a) Rationale: (i) The liver is a storehouse of many enzymes. Injury or diseases affecting the liver cause release of these intracellular enzymes into the bloodstream, and their levels become elevated. (b) Nursing intervention:

(i)

Provide information to the patient regarding blood draws and what test is being performed.

(ii)

Monitor the venipuncture site for bleeding.

C. Serum protein test a) normal lab values : i. Total protein: 6.4 to 8.3 g/dL ii. Albumin: 3.5 to 5 g/dL iii. Globulin: 2.3 to 3.4 g/dL iv. Albumin/globulin (A/G ratio): 1.2 to 2.2 g/dL (a) Rationale: (i) One way to assess the liver's functional status is to measure the products it synthesizes. One of these products is protein, especially albumin. (ii)

A low serum albumin level may also result from excessive loss of albumin into urine (as in nephrotic syndrome) or into third-space volumes (as in ascites), as well as in liver disease, increased capillary permeability, or protein-calorie malnutrition.

(b) Nursing intervention: (i) Provide information to the patient regarding blood draws and what tests are being performed. Monitor the venipuncture site for bleeding. D. Cholecystography a) Rationale: i) The oral cholecystogram (OCG) provides roentgenographic visualization of the gallbladder after the oral ingestion of a radiopaque, iodinated dye.

ii)

An OCG (also called a gallbladder [or GB] series) is less accurate than gallbladder ultrasound imaging and is less commonly used to visualize the biliary tree.

iii)

An OCG will not be able to visualize the biliary tree in the patient with jaundice.

b) Nursing interventions: i) Determines whether the patient is allergic to iodine because the dye typically used for this test is iodine-based. ii)

If the patient is not allergic to iodine, administer six tablets orally (e.g., iopanoic acid [Telepaque], iodalphionic acid [Priodax], or ipodate [Oragrafin]), one every 5 minutes, beginning after the evening meal.

iii)

The patient is put on an NPO status.

iv)

The patient may be given a high-fat meal or beverage to stimulate emptying of the gallbladder after the test has begun.

E. Intravenous Cholangiography a) Rationale: i) The intravenous cholangiogram (IVC) allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent. ii)

Used to demonstrate stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder.

iii)

It should not be used in the jaundiced patient unless it is determined that there are no blocked ducts.

F. Operative Cholangiography: a) Rationale: i) In operative cholangiography the common bile duct is directly injected with radiopaque dye.

ii)

Stones appear as radiolucent shadows, and the presence of tumors will cause partial or total obstruction of the flow of dye into the duodenum.

iii)

A CDE is performed only on those with positive cholangiograms.

G. T-Tube Cholangiography a) Rationale: i) Performed to diagnose retained ductal stones postoperatively in the patient who has undergone a cholecystectomy and a common bile duct (CBD) exploration to demonstrate good flow of contrast into the duodenum. b) Nursing intervention: i) During the preoperative phase ensure that the patient is not allergic to iodine. ii)

Preparation of the patient also includes maintaining NPO status after midnight and until the examination is completed.

iii)

Administer a cleansing enema on the morning of the examination, if ordered.

H. Ultrasound of the liver, the gallbladder, and the biliary system: a) Rationale: i) This diagnostic test is not effective in examining all tissue because ultrasound waves do not pass through structures that contain air, such as the lungs, the colon, or the stomach. ii)

Gallstones are easily detected with ultrasound.

b) Nursing intervention: i) The patient is on NPO status from midnight prior to the test. ii)

I.

If the patient has had recent barium contrast studies, request an order for laxatives because ultrasound cannot penetrate barium, and the study will not be adequate.

Gallbladder Scanning:

a) Rationale: i) The primary use of this study is in the diagnosis of acute cholecystitis. b) Nursing intervention: i) Reassuring the patient that exposure to radioactivity is minimal, because only a trace dose of the radioisotope is used. ii)

The patient is on NPO status from midnight until the examination is complete.

J. Needle Liver Biopsy: a) Rationale: i) Used in the diagnosis of various liver disorders, such as cirrhosis, hepatitis, drug-related reactions, granuloma, and tumor. ii)

A needle is inserted between the sixth and seventh or eighth and ninth intercostal space, and into the liver. The patient lies supine with the right arm over the head. The patient is instructed to exhale fully and not breathe while the needle is inserted. This procedure is often done using ultrasound or CT guidance.

b) Nursing intervention: i) The nurse verifies that the patient has signed the consent form. ii)

Ensure that measurements of platelets, clotting or bleeding time, prothrombin time, and International Normalized Ratio (INR) have been ordered; report any abnormal values to the health care provider.

iii)

After the procedure observe the patient for symptoms of bleeding.

iv)

Monitor the patient's vital signs every 15 minutes (two times), then every 30 minutes (four times), and then every hour (four times).

v)

The nurse keeps the patient lying on the right side for at least 2 hours to splint the puncture site. In this position, the liver capsule (a connective tissue layer covering the liver) is compressed against the chest wall, decreasing the risk of hemorrhage or bile leak.

K. Radioisotope Liver a) Rationale: i) Used to outline and detect structural changes of the liver. ii)

A radioisotope (also called a radionuclide) is given intravenously.

b) Nursing intervention: i) The patient is on NPO status from midnight before the test. ii)

Assure patients that they will not be exposed to a large amount of radioactivity, since only trace doses of isotopes are used.

L. Serum Ammonia Test a) The normal serum ammonia test value is 10 to 80 mcg/dL. (a) Rationale: i) Ammonia is a by-product of protein metabolism. ii)

Most of the ammonia is made by bacteria acting on proteins in the intestine.

iii)

By way of the portal vein, ammonia goes to the liver, where it is normally converted into urea and then excreted by the kidneys.

iv)

The serum ammonia level is primarily used as an aid in diagnosing hepatic encephalopathy and hepatic coma.

b) Nursing intervention: i) Notifying the laboratory of any antibiotics the patient is currently taking. ii)

Certain broad-spectrum antibiotics such as neomycin can cause a decreased ammonia level, thus giving inaccurate test results.

M. Hepatitis Virus Studies: a) Normal laboratory test result: i) Negative for hepatitis associated antigen.

(a) Rationale: (i) Hepatitis is an inflammation of the liver caused by viruses, bacteria, and noninfectious causes of liver inflammation. (ii)

(iii)

Hepatitis A, B, and C viruses are the most common hepatitis viruses. Hepatitis D virus is carried by the hepatitis B virus (HBV). Individual hepatitis viruses can be detected by: (1) Different antigen and antibody levels (2) Different incubation periods must be considered

(b) Nursing interventions: (i) Use standard precautions and handle the serum specimen as if it were capable of transmitting viral hepatitis. (ii)

Don gloves when handling any blood or body fluids, and wash hands carefully after handling equipment.

N. Serum Amylase test: a) Normal value: i) 60- 120 Somogyi units/dL ii) or 30 to 220 units/ L (SI units) (a) Rationale: (i) The serum amylase test can aid in quickly diagnosing pancreatitis in its early stages. (ii)

Damage to pancreatic cells (as in pancreatitis) or obstruction to the pancreatic ductal flow (as in pancreatic carcinoma) causes an outpouring of this enzyme into the intrapancreatic lymph system and the free peritoneum.

(iii)

Blood vessels draining the free peritoneum and absorbing the lymph pick up this excess amylase.

(iv)

Persistent pancreatitis, duct obstruction, or pancreatic duct leak (e.g., pseudocysts) cause persistent elevated serum amylase levels.

(b) Nursing intervention: (i) Note on the laboratory order whether the patient is receiving intravenous dextrose or any medications, since these can cause a false-negative result. O. Urine Amylase Test: a) Normal values: i) up to 5000 Somogyi units/24 hours, ii) or 6.5 to 48.1 units/hour. (a) Rationale: (i) Levels of amylase in the urine remain elevated for 7 to 10 days after the onset of pancreatitis. (ii)

Useful in detecting pancreatitis late in the disease course.

(b) Nursing intervention: (i) Record the exact time at the beginning and end of the collection period. (ii)

A 2-hour spot urine or 6-hour, 12-hour, or 24-hour collection can be performed, depending on the health care provider's order.

(iii)

Keep the specimen on ice or refrigerated until it is sent to the laboratory.

P. Serum Lipase Test: a) Normal value: i) 10 to 140 units/L. (a) Rationale: (i) Like serum amylase, serum lipase is elevated in acute pancreatitis and is a helpful complementary test because other disorders (e.g., mumps, cerebral trauma, and renal transplantation) may also cause an increase in serum amylase. (ii)

Lipase appears in the bloodstream after damage to the pancreas.

(b) Nursing intervention: (i) Instruct the patient to remain on NPO status from midnight, except for water Q. Ultrasonography of the pancreas a) Rationale: i) With the use of reflected sound waves, ultrasonography of the pancreas provides diagnostic info for inaccessible abdominal organs. ii)

Ultrasound examination of the pancreas is mainly used to diagnose: 1) Carcinoma 2) Pseudocyst 3) Pancreatitis 4) Pancreatic abscess

iii)

Follow up ultrasound study is used to monitor the resolution of pancreatic inflammation and tumor response to therapy. b) Nursing intervention: i) Foods and fluids withheld 8 hours before examination. ii)

Postpone this study when patient is distended with gas or had a recent barium exam because gas or barium interfere with sound wave transmission.

R. Computed Tomography of the abdomen: a) Rationale: i) Noninvasive ii)

Accurate radiographic procedure

iii)

Diagnose pancreatic conditions such as: 1) inflammation 2) tumors 3) pseudocyst formation 4) ascites 5) aneurysms 6) cirrhosis

7) abscesses 8) trauma 9) cysts 10) anatomical abnormalities b) Nursing intervention: i) Foods and fluid are withheld from midnight until the examination is complete, although this procedure can be done on an emergency basis on patients who have eaten recently. ii) Claustrophobia is the common fear that some have when enclosed in a machine and make sure to show patient a picture of the machine and encourage the patient to verbalize any fears. S. Endoscopic Retrograde Cholangiopancreatography of the pancreatic duct. a) Rationale: i) Endoscopic retrograde cholangiopancreatography (ERCP) enables visualization not only of the biliary system but also of the pancreatic duct. ii)

Dye is injected for radiographic visualization of the common bile duct and pancreatic duct.

iii)

Used to evaluate obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstruction.

b) Nursing intervention: i) Withhold food and fluids for 8 hours before the examination, and obtain the patient's signature on a consent form. ii)

Assess prothrombin time and INR before the procedure.

iii)

After the procedure, keep the patient on NPO status until the gag reflex returns; assess for abdominal pain, tenderness, and guarding, which could be signs of perforation.

iv)

Assess for signs and symptoms of pancreatitis (the most common ERCP complication), including increasingly intense abdominal

pain, nausea, fever, chills, vomiting, and diminished or absent bowel sounds. v)

Assess for signs of hypovolemic shock, including decreased blood pressure, increased pulse and respirations, shortness of breath, cool and clammy skin, and decreased urine output.

II. Disorders of the Liver, Biliary Tract, Gallbladder, and Exocrine Pancreas. A. Cirrhosis a. Etiology and Pathophysiology i. Cirrhosis is a chronic, degenerative disease of the liver in which the lobes become covered with fibrous (scar) tissue, the parenchyma (i.e., the functional tissue of an organ, as opposed to supporting or connective tissue) degenerates, and the lobules are infiltrated with fat. The overgrowth of new and fibrous tissue restricts the flow of blood to the organ, which contributes to its destruction. ii.

Primary biliary cirrhosis occurs more often in women and results from destruction of the bile ducts due to inflammation. The resulting damage to the ducts leads to bile backing up into the liver.

iii.

Secondary biliary cirrhosis is caused by chronic biliary tree obstruction from gallstones, chronic pancreatitis, a tumor, cystic fibrosis, or biliary atresia (the absence of or underdevelopment of biliary structures that is congenital in nature) in children.

iv.

Cardiac cirrhosis results from longstanding, severe right-sided heart failure in patients with cor pulmonale, constrictive pericarditis, and tricuspid insufficiency.

v.

Nonalcoholic fatty liver disease (NAFLD) results from fat building up in the liver. NAFLD is also associated with diabetes, coronary artery disease, and use of corticosteroids.

vi.

Although liver cells have great potential for regeneration, repeated scarring decreases their ability to replace themselves. As the blood supply continues to diminish and scar tissue increases, the organ atrophies.

vii.

With cirrhosis of the liver, the liver's ability to synthesize albumin is reduced as a result of liver cell damage. Obstruction of the portal vein as it enters the liver results in portal hypertension—increased venous pressure in the portal circulation caused by compression or occlusion of the portal or hepatic vascular system. In most instances, portal hypertension that is caused by cirrhosis is irreversible. This increased pressure causes ascites (an accumulation of fluid and albumin in the peritoneal cavity). The damaged liver cannot metabolize protein in the usual manner; therefore protein intake may result in an elevation of blood ammonia levels.

viii.

What is the function of the protein in the liver disease? Protein must be present in adequate amounts to create colloidal osmotic pressure and "attract" the fluid to pass back into the blood vessels after it escapes in the capillaries.

ix.

when ascites in cirrhosis occurs there will be a retention of fluid and sodium results in increased pressure in blood vessels and lymphatic channels, resulting in portal hypertension. Ascites is thus a result of portal hypertension, hypoalbuminemia, and hyperaldosteronism.

x.

hepatic insufficiency causes distention of veins in the upper part of the body, including the esophageal vein. Esophageal varices develop and may rupture, causing severe hemorrhage.

b. Clinical manifestation: i. In the early stages the liver is firm and therefore easier to palpate, and abdominal pain may be present because rapid enlargement produces tension on the organ's fibrous covering. ii.

Later stages of cirrhosis: 1. dyspepsia 2. changes in bowel habits 3. gradual weight loss 4. ascites 5. enlarged spleen 6. malaise 7. nausea 8. jaundice 9. ecchymoses 10. spider telangiectases (small, dilated blood vessels with a bright red center point and spider like branches)

iii.

When enough cells of the liver in cirrhosis become involved and interfere with its function and obstruct its circulation, GI organs and the spleen become congested and cannot function properly. Anemia occurs because of the body's decreased ability to produce red blood cells (RBCs). The cirrhotic liver cannot absorb vitamin K or produce the clotting factors VII, IX, and X. These factors cause the patient with cirrhosis to develop bleeding tendencies.

c. Assessment: i. Subjective data: 1. Early stages: a. Flu like symptoms (loss of appetite, nausea and vomiting, general weakness, and fatigue b. Indigestion c. Abnormal bowel function (either constipation or diarrhea) d. Flatulence

e. Abdominal discomfort 2. Late stages: a. Dyspnea, pruritus, and severe fatigue that interfere with the ability to ca...