Nursing Management: Liver, Pancreas, and Biliary Tract Problems JAUNDICE Jaundice, a yellowish discoloration of body tissues, results

from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct systems. The three types of jaundice are hemolytic, hepatocellular, and obstructive. Hemolytic (prehepatic) jaundice is due to an increased breakdown of red bloodcells (RBCs), which produces an increased amount of unconjugated bilirubin in the blood. Hepatocellular (hepatic) jaundice results from the livers altered ability to take up bilirubin from the blood or to conjugate or excrete it. Obstructive (posthepatic) jaundice is due to decreased or obstructed flow of bile through the liver or biliary duct system. HEPATITIS Hepatitis is an inflammation of the liver. Viral hepatitis is the most common cause of hepatitis. The types of viral hepatitis are A, B, C, D, E, and G. Hepatitis A HAV is an RNA virus that is transmitted through the fecal-oral route. The mode of transmission of HAV is mainly transmitted by ingestion of food or liquid infected with the virus and rarely parenteral. Hepatitis B HBV is a DNA virus that is transmitted perinatally by mothers infected withHBV; percutaneously (e.g., IV drug use); or horizontally by mucosal exposure to infectious blood, blood products, or other body fluids. HBV is a complex structure with three distinct antigens: the surface antigen(HBsAg), the core antigen (HBcAg), and the e antigen (HBeAg). Approximately 6% of those infected when older than age 5 develop chronic HBV. Hepatitis C HCV is an RNA virus that is primarily transmitted percutaneously. The most common mode of HCV transmission is the sharing of contaminated needles and paraphernalia among IV drug users. There are 6 genotypes and more than 50 subtypes of HCV Hepatitis D, E, G Hepatitis D virus (HDV) is an RNA virus that cannot survive on its own. It requires HBV to replicate. Hepatitis E virus (HEV) is an RNA virus that is transmitted by the fecal-oral route. Hepatitis G virus (HGV) is a sexually transmitted virus. HGV coexists with other viral infections, including HBV, HCV, and HIV.

Clinical manifestations: Many patients with hepatitis have no symptoms. Symptoms of the acute phase include malaise, anorexia, fatigue, nausea,occasional vomiting, and abdominal (right upper quadrant) discomfort. Physical examination may reveal hepatomegaly, lymphadenopathy, and sometimes splenomegaly. Many HBV infections and the majority of HCV infections result in chronic (lifelong)viral infection. Most patients with acute viral hepatitis recover completely with no complications. Approximately 75% to 85% of patients who acquire HCV will go on to develop chronic infection. Fulminant viral hepatitis results in severe impairment or necrosis of liver cells and potential liver failure. There is no specific treatment or therapy for acute viral hepatitis. Drug therapy for chronic HBV and HBC is focused on decreasing the viral load, aspartateaminotransferase (AST) and aspartate aminotransferase (ALT) levels, and the rate of disease progression. Chronic HBV drugs include interferon, lamivudine (Epivir), adefovir (Hepsera),entecavir (Baraclude), and telbivudine (Tyzeka). Treatment for HCV includes pegylated-interferon (Peg-Intron, Pegasys) given with ribavirin (Rebetol, Copegus). Both hepatitis A vaccine and immune globulin (IG) are used for prevention of hepatitis A. Immunization with HBV vaccine is the most effective method of preventing HBV infection. For post exposure prophylaxis, the vaccine and hepatitis B immune globulin(HBIG) are used. Currently there is no vaccine to prevent HCV. Most patients with viral hepatitis will be cared for at home, so the nurse must assess the patients knowledge of nutrition and provide the necessary dietary teaching. AUTOIMMUNE HEPATITIS Autoimmune hepatitis is a chronic inflammatory disorder of unknown cause. It is characterized by the presence of autoantibodies, high levels of serum immunoglobulins,and frequent association with other autoimmune diseases.

Autoimmune hepatitis (in which there is evidence of necrosis and cirrhosis) is treated with corticosteroids or other immunosuppressive agents. WILSONS DISEASE Wilsons disease is a progressive, familial, terminal neurologic disease accompanied by chronic liver disease leading to cirrhosis. It is associated with increased storage of copper. PRIMARY BILIARY CIRRHOSIS Primary biliary cirrhosis (PBC) is characterized by generalized pruritus, hepatomegaly,and hyperpigmentation of the skin. NONALCOHOLIC FATTY LIVER DISEASE Nonalcoholic fatty liver disease (NAFLD) is a group of disorders that is characterized by hepatic steatosis (accumulation of fat in the liver) that is not associated with other causes such as hepatitis, autoimmune disease, or alcohol. The risk for developing NAFLD is a major complication of obesity. NAFLD can progress to liver cirrhosis. NAFLD should be considered in patients with risk factors such as obesity, diabetes,hypertriglyceridemia, severe weight loss (especially in those whose weight loss was recent), and syndromes associated with insulin resistance. CIRRHOSIS Cirrhosisis a chronic progressive disease characterized by extensive degeneration and destruction of the liver parenchymal cells. Common causes of cirrhosis include alcohol, malnutrition, hepatitis, biliary obstruction,and right-sided heart failure. Excessive alcohol ingestion is the single most common cause of cirrhosis followed by chronic hepatitis (B and C). Manifestations of cirrhosis include jaundice, skin lesions (spider angiomas),hematologic problems (thrombocytopenia, leucopenia, anemia, coagulation disorders),endocrine problems, and peripheral neuropathy. Major complications of cirrhosis include portal hypertension, esophageal and gastricvarices,peripheral edema andascites,hepatic encephalopathy, andhepatorenalsyndrome.oHepatic encephalopathyis a neuropsychiatric manifestation of liver damage. Its considered a terminal complication in liver disease. A characteristic symptom of hepatic encephalopathy isasterixis(flappingtremors). Diagnostic tests for cirrhosis include elevations in liver enzymes, decreased total protein,fat metabolism abnormalities, and liver biopsy.

There is no specific therapy for cirrhosis. Management of ascites is focused on sodium restriction, diuretics, and fluid removal. Peritoneovenous shunt is a surgical procedure that provides continuous reinfusion of ascitic fluid into the venous system. The main therapeutic goal for esophageal and gastric varices is avoidance of bleeding and hemorrhage. Transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical procedure in which a tract (shunt) between the systemic and portal venous systems is created to redirect portal blood flow. Management of hepatic encephalopathy is focused on reducing ammonia formation and treating precipitating causes.

An important nursing focus is the prevention and early treatment of cirrhosis. If the patient has esophageal and/or gastric varices in addition to cirrhosis, the nurse observes for any signs of bleeding from the varices (e.g., hematemesis, melena). The focus of nursing care of the patient with hepatic encephalopathy is on maintaining a safe environment, sustaining life, and assisting with measures to reduce the formation of ammonia. Fulminant hepatic failure, or acute liver failure, is a clinical syndrome characterized by severe impairment of liver function associated with hepatic encephalopathy LIVER TRANSPLANTATION Indications for liver transplant include chronic viral hepatitis, congenital biliary abnormalities (biliary atresia), inborn errors of metabolism, hepatic malignancy (confined to the liver), sclerosing cholangitis, fulminant hepatic failure, and chronic end-stage liver disease. Postoperative complications of liver transplant include rejection and infection. The patient who has had a liver transplant requires highly skilled nursing care. ACUTE PANCREATITIS Acute pancreatitisis an acute inflammatory process of the pancreas. The primaryetiologic factors are biliary tract disease (most common cause in women) and alcoholism(most common cause in men). Abdominal pain usually located in the left upper quadrant is the predominant symptom of acute pancreatitis. Other manifestations include nausea, vomiting, hypotension, tachycardia, and jaundice.

Two significant local complications of acute pancreatitis are pseudocyst and abscess. A pancreaticpseudocystis a cavity continuous with or surrounding the outside of the pancreas. The primary diagnostic tests for acute pancreatitis are serum amylase and lipase. Objectives of collaborative care for acute pancreatitis include relief of pain; prevention or alleviation of shock; reduction of pancreatic secretions; control of fluid and electrolyte imbalances; prevention or treatment of infections; and removal of the precipitating cause. Because hypocalcemia can also occur, the nurse must observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. CHRONIC PANCREATITIS Chronic pancreatitisis a continuous, prolonged, inflammatory, and fibrosing process of the pancreas. The pancreas becomes progressively destroyed as it is replaced with fibrotictissue. Strictures and calcifications may also occur in the pancreas. Clinical manifestations of chronic pancreatitis include abdominal pain, symptoms of pancreatic insufficiency, including malabsorption with weight loss, constipation, mild jaundice with dark urine, steatorrhea, and diabetes mellitus. Measures used to control the pancreatic insufficiency include diet, pancreatic enzyme replacement, and control of the diabetes. PANCREATIC CANCER The majority of pancreatic cancers have metastasized at the time of diagnosis. The signs and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis. Transabdominal ultrasound and CT scan are the most commonly used diagnostic imaging techniques for pancreatic diseases, including cancer. Surgery provides the most effective treatment of cancer of the pancreas; however, only15% to 20% of patients have resectable tumors. GALLBLADDER DISORDERS The most common disorder of the biliary system is cholelithiasis(stones in the gallbladder).Cholecystitis(inflammation of the gallbladder) is usually associated with cholelithiasis. Ultrasonography is commonly used to diagnose gallstones. Medical dissolution therapy is recommended for patients with small radiolucent stones who are mildly symptomatic and are poor surgical risks.

Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered and precipitation occurs. Ultrasonography is commonly used to diagnose gallstones. Initial symptoms of acute cholecystitis include indigestion and pain and tenderness in the right upper quadrant. Complications of cholecystitis include gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis. Postoperative nursing care following a laparoscopic cholecystectomy includes monitoring for complications such as bleeding, making the patient comfortable, and preparing the patient for discharge. The nurse should assume responsibility for recognition of predisposing factors of gallbladder disease in general health screening.