LIVER and PANCREAS DYSFUNCTION Valerie Gumangan RN ACNP

LIVER and PANCREAS DYSFUNCTION Valerie Gumangan, RN, ACNP

PANCREAS ¡ Exocrine l l ¡ Secretes digestive enzymes into the small intestines Breakdown of CHO, protein, and fats Endocrine l l l Produces hormones Insulin Glucagon

EXOCRINE FUNCTION ¡ CCK: Cholecystokinin l ¡ Secretin l ¡ ¡ ¡ Stimulus for enzyme secretion Secretion of bicarb and water Lipase: Fats Amylase: Carbohydrates Trypsin: Proteins

EXOCRINE FUNCTION ¡ ¡ ¡ 90% of pancreatic digestive enzymes are proteolytic Trypsin Chymotrypsin l ¡ splits proteins into peptones Elastase l Breakdown elastic tissue

EXOCRINE FUNCTION ¡ Amylolytic l l ¡ Breakdown of carbohydrates Amylase Lipolytic l l l Breakdown of fats Lipase Phospholipase A

ENDOCRINE FUNCTION Islet of Langerhans ¡ Alpha cells l ¡ Beta cells l ¡ Glucagon: ↑ blood glucose Insulin: ↓ blood glucose Delta cells l Somatostatin

PANCREATITIS ¡ ¡ ¡ Inflammation of the pancreas Autodigestion of the pancreas by pancreatic enzymes Cellular destruction and organ damage

ACUTE PANCREATITS ¡ Acute l l l Mild or Nonhemorrhagic Severe or Hemorrhagic Fulminant

EPIDEMIOLOGY ¡ ¡ ¡ 185, 000 cases each year 150, 000 cholelithiasis or sustained alcohol abuse African-Americans are at ↑ risk

CAUSES ¡ ¡ ¡ ¡ Alcohol consumption Gallstones Pancreatic obstruction Drugs and toxins Hyperlipidemia Family history Trauma and iatrogenic factors

SIGNS and SYMPTOMS ¡ Severe abdominal pain l l ¡ ¡ ¡ Epigastrium radiating to midback Not relieved by vomiting Fever, malaise Nausea, vomiting Rigid and distended Rebound tenderness Absent or diminished bowel sounds

SIGNS and SYMPTOMS ¡ Dyspnea and Tachypnea l ¡ Grey Turner’s sign l ¡ Large ecchymosis appearing in the flanks Cullen’s sign l ¡ Pulmonary infiltrates Ecchymosis in umbilical area Hypovolemic Shock

DIAGNOSTIC FINDINGS ¡ Serum Amylase l ¡ Serum Lipase l ¡ ¡ Normal (23 -85 u/L) Normal (0 -160 u/L) Serum trypsinogen: elevated Urinary amylase: elevated

DIAGNOSTIC FINDINGS ¡ ¡ Hematocrit: initially elevated then later decreased WBC: elevated C-reactive protein: elevated Liver function tests: elevated

DIAGNOSTIC FINDINGS ¡ ¡ Sodium and Potassium: decreased Blood glucose: elevated Serum Calcium: decreased Albumin and Magnesium: decreased

DIAGNOSTIC FINDINGS ¡ ¡ ¡ Abdominal and Chest X-ray CT scan, Ultrasound, MRI Endoscopic Retrograde Cholangiopancreatography (ERCP) Aspiration biopsy Stool studies: steatorrhea

COMPLICATIONS ¡ Hypovolemic shock l l 3 rd spacing Hemorrhage Vomiting Decreased protein intake

COMPLICATIONS ¡ Pulmonary complications l l Atelectasis Acute lung injury Pleural effusion ARDS

COMPLICATIONS ¡ Cardiovascular l ¡ Release of myocardial depressant factor Pancreatic pseudocyst l l Cavity next to pancreas Filled with necrotic products

COMPLICATIONS ¡ Pancreatic abscess l l l ¡ 2 -4 weeks after episode Necrosis of tissue Relocation of bacteria Hypocalcaemia can occur with severe disease

COMPLICATIONS ¡ Fluid and electrolytes l l l Vomiting NG suction Redistribution of fluids

TREATMENT ¡ Pain Management l l l ¡ IV opioid analgesics Dilaudid IV PCA Demerol and Morphine IV GI rest l l Decrease stimulation of pancreas Nasogastric tube insertion

TREATMENT ¡ ¡ Fluid and Electrolyte replacement Cessation of alcohol consumption Nutrition: enteral versus parenteral Surgery if there is biliary obstruction

TREATMENT ¡ Respiratory l l Oxygen Monitor oxygen saturation Arterial blood gas Ventilator support

TREATMENT ¡ Fluid volume deficit l l l IV fluids Plasma expanders Vasopressors Blood replacement Strict intake and output

TREATMENT ¡ Fluid and electrolyte imbalance l l ¡ LR or IV maintenance fluid containing K+ Calcium gluconate Hypocalcemia l l Chvostek’s sign Trousseau’s sign

TREATMENT ¡ Pseudocyst, abscess or fistula l l l Monitor for signs and symptoms of shock Prepare patient for surgery Watch for infections post-operatively

TREATMENT ¡ ¡ ¡ Biliary drainage tube Surgical debridement ERCP l l ¡ Sphinceterotomy Gallstone removal Stent placement Balloon dilatation Laparoscopic cholecystectomy with CBDE

MEDICATIONS ¡ Viokase l ¡ Pancrease l ¡ Replace pancreatic enzymes Glucagon l Treat hypoglycemia

NURSING IMPLICATIONS ¡ Vital signs l l ¡ Laboratory values l l ¡ Hypovolemic shock Sepsis Amylase, Lipase BMP Fluid and electrolytes l l l NPO NGT Nutrition

NURSING IMPLICATIONS ¡ ¡ Administer pain medication Monitor blood glucose Monitor intake and output Daily weight

CHRONIC PANCREATITIS ¡ ¡ Persistent inflammation of the pancreas Scarring and calcification of the pancreatic ducts

CAUSES ¡ ¡ 70% is caused by alcohol abuse 20% is caused by obstruction, trauma, metabolic disturbances

SIGNS & SYMPTOMS ¡ 80% of pancreatic destruction causes l l l Malabsorption resulting in nutritional deficits Diarrhea and steatorrhea Impaired glucose regulation

DIAGNOSTIC FINDINGS ¡ ¡ ¡ LFT, CMP, CBC, ESR Stool studies Abdominal CT scan l ¡ Abdominal US l ¡ Images organ, detect inflammation Detect inflammation and calcifications ERCP l looks for stones

TREATMENT ¡ ¡ GI rest Pain control No Alcohol Daily weight

TREATMENT ¡ ¡ ¡ Low fat, protein, and high carbohydrate diet Oral pancreatic enzymes Monitor blood glucose

TREATMENT ¡ ¡ ¡ Replacement of fat soluble vitamins Octreotide (Sandostatin) Celiac plexus block

LIVER FUNCTION ¡ Glucose metabolism l l ¡ Ammonia conversion l l ¡ Glycogenolysis Gluconeogenesis Ammonia to urea Urea excreted in the urine Protein metabolism l Synthesis of plasma proteins

LIVER FUNCTION ¡ Fat metabolism l ¡ Vitamin and iron storage l ¡ ¡ ¡ Fatty acids broken down for energy Vitamin A, B, D, and Bcomplex vitamins Bile formation Bilirubin excretion Drug metabolism

LIVER FUNCTION TESTS ¡ ¡ ¡ ALT: Alanine aminotransferase ALP: Alkaline phosphotase AST: Aspartate aminotransferase Bilirubin Albumin

LIVER PANEL ¡ ¡ Total Protein GGT: Gammaglutamyl transferase LDH: Lactic acid dehydrogenase Prothrombin time

HEPATIC DYSFUNCTION ¡ ¡ Primary liver disease Obstruction of bile flow Altered hepatic circulation Acute or chronic

CAUSES ¡ Toxicities: l ¡ ¡ Chemicals, Plants, Drugs Bacterial invasion Nutritional deficiency Autoimmune Hepatitis Viruses l Hepatitis A, B, C, D, E

CHRONIC LIVER DISEASE ¡ ¡ ¡ 12 th leading cause of death in the United states among young and middle-aged adults 40% associated with alcohol use Cirrhosis

SIGNS & SYMPTOMS ¡ ¡ ¡ Jaundice Portal hypertension Ascites and varices Nutritional deficiencies Hepatic encephalopathy Coma

JAUNDICE ¡ ¡ Bilirubin level >2. 5 mg/d. L All body tissue become tinged yellow Hepatocellular jaundice Obstructive jaundice

PORTAL HYPERTENSION ¡ ¡ ¡ Increased pressure through portal venous system Obstructed blood flow through damaged liver Commonly associated with liver cirrhosis

PORTAL HYPERTENSION ¡ GI bleeding l l ¡ ¡ ¡ Black tarry stool Hematemesis Encephalopathy Coagulopathy Ascites

ASCITES ¡ ¡ Backup of venous blood flow from portal HTN Failure to metabolize aldosterone Movement of fluid from vessels to peritoneal space Accumulation of albumin-rich fluid

HEPATIC ENCEPHALOPATHY ¡ ¡ ¡ Life-threatening complication of liver disease Liver unable to detoxify toxic byproducts of metabolism Ammonia is the major etiologic factor of encephalopathy

HEPATIC ENCEPHALOPATHY ¡ ¡ ¡ Mental changes Motor disturbances Altered mood and sleep patterns Asterixis “liver flap” l Flapping tremor of the hands Constructional apraxia

VIRAL HEPATITIS ¡ ¡ Systemic, viral infection Necrosis and inflammation of liver cells Altered liver function 5 definitive types of viral hepatitis l Hepatitis A, B, C, D, E

HEPATITIS A ¡ ¡ Hepatitis A Virus Fecal-oral transmission l l l ¡ Poor sanitation Person-person contact Water and food borne Incubation l 15 -50 days

SIGNS and SYMPTOMS Hepatitis A Phases ¡ Preicteric l l l Flu-like symptoms Fatigue Loss of appetite Nausea Cough Joint pain

SIGNS and SYMPTOMS ¡ Icteric l l l l Jaundice Dark colored urine RUQ pain Itchy skin Clay-colored stools Poor appetite Some preicteric symptoms subside

SIGNS and SYMPTOMS ¡ Post icteric phase l l Things start to return to normal Fatigue can remain

HEPATITIS A ¡ ¡ ¡ Mild with recovery No carrier state Doesn’t usually lead to chronic state

HEPATITIS A Prevention ¡ Hand washing ¡ Safe water supplies ¡ Proper sanitation ¡ Sewage disposal ¡ HAV vaccination Medical Management ¡ Bed rest during acute stage ¡ Small frequent meals ¡ Supplemental IV with glucose ¡ Gradual progressive ambulation

HEPATITIS B ¡ ¡ ¡ Hepatitis B Virus Parenteral transmission Intimate contact with carriers Perinatal: mother to baby Occupational hazard to health care workers

HEPATITIS B ¡ ¡ ¡ Incubation: 28 -160 days Symptoms: rash and arthralgias Outcome: may be severe Carrier state possible Increased risk of chronic hepatitis

HEPATITIS B Prevention ¡ Hand washing ¡ Wear gloves when handling body fluids ¡ safe sex ¡ HBV vaccination ¡ Hepatitis B Immunoglobulin Medical management ¡ Alpha-interferon ¡ Lamivudine (Epivir) and adefovir (Hepsera) ¡ Bed rest until s/s subside ¡ Restrict activities ¡ Adequate nutrition

HEPATITIS B PANEL ¡ ¡ ¡ HBs. Ag: Hepatitis B surface antigen HBs. Ab or Anti-HBs: Hepatitis B surface antibody HBc. Ab: Hepatitis B core antibody

HEPATITIS C ¡ ¡ ¡ Hepatitis C Virus Blood transfusion transmission Exposure to contaminated blood Intimate contact with infected partner Increased risk for STDs

HEPATITIS C ¡ ¡ ¡ Incubation: 15 -160 days Symptoms: similar to HBV. Less severe and anicteric Chronic carrier state Can lead to chronic liver disease Increased risk for cancer

HEPATITIS C ¡ ¡ No benefit from rest, diet, or vitamin supplements Antiviral agents l l l Interferon (Intron-A) Ribavirin (Rebetol) Side effect: hemolytic anemia

HEPATITIS D ¡ ¡ ¡ Delta agent HBV surface antigen required for replication Incubation: 21 -140 days Symptoms: similar to HBV Can lead to carrier state, chronic active hepatitis, and cirrhosis

HEPATITIS E ¡ ¡ ¡ Hepatitis E Virus Fecal-oral transmission Low risk for person to person contact Incubation: 15 -65 days Symptoms: Similar to HAV Severe in pregnant women

HEPATITIS G and GB VIRUS C ¡ ¡ ¡ Non A-E virus Incubation: 14 -145 days 2 isolates of same virus Autoantibodies are absent Still too many unknowns Persistent infection

TOXIC HEPATITIS ¡ ¡ Resembles viral hepatitis Exposure to toxic chemicals l l ¡ Medications Botanicals Remove causative agent

TOXIC HEPATITIS ¡ ¡ ¡ Anorexia, nausea, vomiting Jaundice Hepatomegaly No effective antidotes Delay in treatment can result in increased severity

DRUG INDUCED HEPATITIS ¡ ¡ ¡ Most common cause of acute liver failure 50% of all cases in the U. S. Acetaminophen has been identified as the leading cause of acute liver failure

DRUG INDUCED HEPATITIS ¡ ¡ Onset is abrupt Early symptoms l ¡ Late symptoms l ¡ Fever, chills, rash, arthralgia, pruritus, anorexia Jaundice, dark urine, enlarged and tender liver Treatment l Short course of high-dose corticosteroids

TREATMENT ¡ ¡ ¡ Rest Small, frequent meals Low protein, fat, and high carbohydrate IV fluid containing dextrose as needed Monitor labs