1. 2.

Caring for the Patient with Hepatic and Biliary Disorders Types of Hepatitis Viruses All except HBV are RNA viruses HAV a small RNA virus with nonspecific symptoms HBV replicates in the liver Concentrated in blood/blood products Components HBsAG, HBcAG, HbeAG Types of Hepatitis Viruses All except HBV are RNA viruses HCV a large RNA virus Replicates at a high rate Causes a high rate of chronic infections Three genotypes prevalent in US HDV a defective RNA virus Requires coinfection with HBV Types of Hepatitis Viruses All except HBV are RNA viruses HEV symptoms similar to HAV HGV Infection associated with chronic anemia Modes of Transmission HAV Fecal-oral route Sexual contact HBV Direct contact with blood and blood contacts Sexual contact Modes of Transmission HCV IV drug use Sexual contact HDV Same as HBV High rate found in IV drug users Modes of Transmission HEV Fecal-oral route Uncommon in the U.S. HGV Percutaneous Sexual contact Hepatitis Clinical Manifestations Different types of hepatitis have similar symptoms Severity of symptoms can range from asymptomatic to fulminating disease progressing to liver failure and death Phases of Hepatitis

Prodromal Phase Starts about two weeks after exposure Depending on the incubation period Onset can be insidious or rapid Phases of Hepatitis Prodromal Phase Vague, flulike symptoms include: Anorexia Nausea Vomiting Myalgia Arthalgia Fatigue Abdominal pain in right upper quadrant Fever less than 103F Phases of Hepatitis Icteric Phase Begins with the onset of jaundice Worsening of prodromal symptoms Dark urine due to increased conjugated bilirubin Phases of Hepatitis Convalescent Phase Begins after 2 to 3 weeks of acute illness Symptoms subside; appetite, energy increase Jaundice and abdominal pain disappear Duration of illness varies with different types of hepatitis Pathophysiology of Cirrhosis Prolonged injury liver cell damage, death Cells replaced by fibrous tissue Regenerate abnormally, creating nodules Liver repair causes microcirculation distortion Clinical Manifestations May be asymptomatic until severe liver impact Gradual onset Early symptoms nonspecific: Fatigue, weakness, anorexia, weight loss Deficiency of fat soluble vitamins, especially vitamin K Complications of Cirrhosis Portal hypertension Related symptoms: Varices distended veins in esophagus and rectum Splenomegaly Ascites protein-rich fluid in the abdominal cavity

Complications of Cirrhosis

Hepatic encephalopathy excess ammonia in blood affects mentation Hepatorenal syndrome intense renal vasoconstriction Nursing Assessment Evaluate risk factors and causes Thorough health, social, sexual history Previous exposure to blood products Employment history Nursing Assessment Physical assessment Vital signs Level of consciousness Skin color and condition Generalized urticaria Bruising or caput medusae Thorough abdominal assessment Treatment and Nursing Care Treatment can relieve symptoms; cannot reverse cirrhosis Administer medications to treat complications Give vitamin K as ordered Provide high-calorie, low-protein, low-sodium diet Weigh daily, measure abdominal girth Follow-up Care Provide instructions for the treatment plan, follow-up care and nutritional and fluid needs Provide information on resources to treat alcoholism: local support groups and counseling services Prevention Most cases of cirrhosis are preventable Provide education about high-risk behaviors: Dangers of alcohol abuse Prevention of risk factors hepatitis B and hepatitis C Sexual abstinence

 Safe sex practices Avoidance of injection drug use Exposure to blood and bodily fluids Hepatic Encephalopathy A complication of cirrhosis resulting from increased levels of ammonia that causes a disturbance in mental status Hepatic Encephalopathy Symptoms Agitation Combativeness Confusion Exaggerated reflexes Hepatic Encephalopathy Treatment Medications Lactulose: reduces ammonia levels of the blood Oxazepam (Serax): a benzodiazepine not metabolized by the liver used to treat agitation Diet protein restricted Nursing Care Administer MMSE Provide protein-restricted diet Help patient reintroduce protein when indicated Administer lactulose to lower ammonia level Monitor deep tendon reflexes Liver Cancer Primary liver cancer is rare Accounts for < 2% of cancer deaths in US Liver is a common site of metastasis from other cancers Liver Cancer Risk Factors Chronic hepatitis B and C Heavy smoking Heavy drinking

 Prolonged use of anabolic steroids Drinking arsenic-contaminated water Pancreatitis Inflammation of the pancreas Can be acute or chronic Mostly associated with biliary tract obstruction or heavy alcohol use High mortality when there are cardiac, pulmonary, or renal complications Predisposing factors
Chronic alcoholism Hepatobilary disease Obesity Hyperlipidemia Hyperparathyroidism Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam) Diet increase saturated fats

Clinical Manifestations Acute Pancreatitis Sudden, severe, steady epigastric pain Nausea and vomiting Abdominal distention, decreased bowel sounds, rigidity Turners sign Cullens sign Transient hyperglycemia In small number of patients: Tachypnea Tachycardia Hypoxia

Clinical Manifestations Chronic Pancreatitis Irreversible, gradual destruction of pancreatic tissue Recurrent epigastric and left upper quadrant pain

May be referred to the left lumbar region

Pain less severe than acute pancreatitis Tender abdomen with mild muscle guarding over the pancreas Other symptoms can include: Anorexia Nausea Vomiting Weight loss Flatulence Constipation Steatorrhea bulky, fatty, and foul stools

Medical Management Acute Pancreatitis Treatment focus is resting the pancreas Patient is kept NPO Frequent insertion of a nasogastric tube Prevents release of pancreatic enzymes Bed rest Large amounts of IV fluids may be required Medical Management Acute Pancreatitis Clear liquid diet After pain subsides and bowel sounds return Slow transition to low-fat diet Pain management with narcotic analgesics Surgery for infected necrotizing pancreatitis Pancreas and surrounding area are debrided Medical Management Chronic Pancreatitis Acute cases same as acute pancreatitis Supplementation with pancreatic enzymes Narcotics not used due to addiction risk Surgery needed with biliary tract disease Lifelong lifestyle changes required: Alcohol abstinence Low-fat diet Pancreatic Cancer Risk Factors Obesity History of abdominal radiation Cigarette smoking High-fat diet and diabetes, particularly in women Age Clinical Manifestations Asymptomatic until the tumor invades the surrounding tissue or obstructs the

common bile duct As the cancer progresses, symptoms can include: Jaundice with light-colored stools and dark urine Vague, diffuse epigastric pain Pruritis Weight loss, steatorrhea, and malnutrition Pancreatic Cancer Treatment Surgery pancreaticoduodenal (Whipple) resection Survival rate is 20% to 25% Most pancreatic cancers are too advanced for surgery Radiation and chemotherapy used after surgery or for palliation Pancreatic Cancer Treatment Nursing Care Focus of nursing care for pancreatic cancer patients is on palliation, comfort, and support Pancreatitis Teaching Plan Nonpharmacologic pain management Lifestyle changes Necessary to prevent recurrence, improve health Alcohol abstinence Dietary guidelines and nutritional support Nonpharmacologic Pain Management Explore attitudes and beliefs about pain Include religious and cultural practices Alternative methods of easing pain Meditation Visualization Breathing exercises Include evidence of effectiveness Alcohol Abstinence Teaching Plan Relationship between excessive drinking and pancreatitis and liver problems Effects of continued drinking on the pancreas and overall health Referral information on Alcoholics Anonymous (AA), alcohol treatment programs Nutritional Teaching Plan Why a low-fat diet is essential Examples of low-fat food plans Strategies for following a new food plan, dealing with cravings and avoiding temptation Names of nutritionists for referral purposes