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Small Bowel, Biliary & Hepatic

Dysfunction

Prepared by Gabrielle Metelli – 2009


Gabrielle Metelli & Kathleen Dixon - 2008
University of Western Sydney

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Objectives
¾ Identify common dysfunctions of the small bowel.
¾ Describe the risk factors that can lead to the development of these
dysfunctions.
¾ Identify causes, mechanism and treatment of small bowel dysfunctions.
¾ Describe the pathophysiology, clinical manifestations and treatment for
small bowel dysfunctions upper GIT dysfunctions.
¾ Describe the pathophysiology of common disorders of the liver and
gallbladder.
¾ Understand the pharmacological interventions related to the liver and
gallbladder.

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PYLORIC STENOSIS

¾ A hypertrophic obstruction of the circular muscle of the pyloric canal.


¾ Clinical Manifestations :
¾ occurs 2-4 weeks after birth,
¾ seen as projectile vomiting
¾ child is irritable and losses weight – dehydration.
¾ Cause – unknown
¾ Diagnosis
¾ physical examination - olive-shaped mass in right upper quadrant of the
abdomen.

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Illustration copyright 2000 by Nucleus Communications, Inc. All rights reserved. http://www.nucleusinc.com

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MANAGEMENT PAEDIATRIC FLUID REQUIREMNTS
¾ Stabilize child ¾ 1st week –80-100 ml/kg/day
¾ IV fluids, ¾ 2nd week – 125-150 mls/kg/day
¾ NG tube. ¾ 3 months - 140-160 mls/kg/day
¾ Assessment of hydration ¾ 6months - 130-155 mls/kg/day
¾ Surgery – pyloromyotomy. ¾ 9months – 125-145 mls/kg/day
¾ Discharged in 72 hours. ¾ 1 year – 120-135 mls/kg/day
¾ 2 years – 115-125 mls/kg/day
¾ Premature infants will require slightly
INTRAVENOUS FLUIDS more/hour
¾ N/2 saline and 2.5% dextrose
¾ commonly used to rehydrate children.
¾ N/4 Saline and 3.75% dextrose
¾ used for maintenance – not as common
¾ N/Saline – seen more commonly these days for general IV fluids
¾ All fluids in 500mls bags.
¾ Other fluids not really used in paediatrics
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Coeliac Disease Symptoms

¾ a condition that affects the small ¾ tiredness; weakness and lethargy


bowel. ¾ diarrhoea, sometimes constipation
¾ caused by a genetically based, (often both)
abnormal immune response, or ¾ abdominal pain or cramping;
sensitivity to a dietary protein known
as gluten. ¾ indigestion; nausea and vomiting;
¾ sensitivity to gluten causes ¾ flatulence; bloating; weight loss;
inflammation and damage to the small ¾ anaemia – iron and/or folic acid deficiencies;
intestine.
¾ deficiency of vitamins A, D, E, K & B12;
¾ untreated it can result in
¾ mouth ulcers; easy bruising of the skin;
¾ malabsorption leading to malnutrition.
¾ A predisposition to GIT malignancy ¾ bone and joint pain; low blood calcium
¾ cancer of oropharynx.oesophagus levels with muscle spasms
¾ lymphoma of small bowel ¾ Additional Symptoms in Children
¾ affects about one per cent of
¾ Dental abnormalities
Australians.
¾ has been diagnosed more frequently in ¾ Retarded growth
recent years. ¾ Delayed puberty
¾ it is seen in both children and adults ¾ Irritability

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What causes coeliac disease?
¾ the cells of the small bowel (intestine) are damaged (villous atrophy).
¾ This causes a flattening of the tiny, finger like projections, called villi,
which line the inside of the bowel
¾ The function of the cells on normal villi is to break down and absorb nutrients in food.
¾ In coeliac disease, these cells become
¾ flat and inflamed and
¾ the surface area, which enables the absorption of nutrients and minerals from food, is
seriously depleted.

Risk Factors
¾ a family history of the disease
¾ being of European descent; and
¾ having another medical condition that is related to problems with the
immune system,
¾ such as certain types of thyroid disease, type 1 diabetes, lupus erythematosus, or
rheumatoid arthritis.

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DIAGNOSIS TREATMENT
¾ Relies on proving that the small bowel ,
lining shows the typical damage ¾ No Cure
(villous atrophy).

¾ A strict, gluten free diet


¾ Blood tests - antibodies
¾ By specifically removing the cause of the
¾ anti-endomysial antibodies; disease, this treatment allows all
¾ anti-gliadin antibodies and abnormalities, including that of the
¾ anti-tissue transglutaminase antibodies. bowel lining, to recover and will reduce
the risk of developing other associated
diseases.
¾ Biopsy – endoscopy
¾ preferable with multiple biopsies of the
¾ Corticosteriods
distal duodenum and proximal
jejunum.
¾ Vitamin & mineral supplements
¾ Further blood tests – nutritional
deficiencies
¾ Iron
¾ Folate
¾ Vit. B12
¾ Calcium or Vit. D University of Western Sydney 9
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Liver disorders - Hepatitis


¾Viral hepatitis A, B, C, D, E & G
¾Hepatobiliary hepatitis
¾Toxic hepatitis
¾Alcoholic hepatitis
¾Fulminant hepatitis

Diagnostic Tests

Liver function tests include:

¾AST – increased in acute phase


¾ALT – increased in acute phase
¾GGT - increased

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(Brown and Edwards, 2005, p.1111)

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Hepatitis Prevention

¾There is no specific treatment for viral hepatitis.

¾HAV
¾Vaccine
¾NHIG
¾HBV
¾Vaccine
¾Post exposure HBIG & vaccination
¾HCV
¾No vaccine
¾Drug therapy
¾Antivirals
¾Interferons

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Liver Disorders - Cirrhosis
¾ End stage chronic liver disease that results in extensive hepatocellular
damage leading to liver failure.
¾ Laennec’s cirrhosis
¾ Cardiac cirrhosis
¾ Post necrotic cirrhosis
¾ Biliary cirrhosis

Laennec’s Cirrhosis

¾ Also known as alcoholic cirrhosis


¾ The stages are:-
¾ Initially fat accumulation in the liver (steatosis)
¾ Followed by hepatitis, leading to
¾ Cirrhosis

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Cirrhosis - Manifestations Liver Disorders - Cancer

¾ Hepatomegaly ¾ Primary site is rare,


¾ more commonly secondary
¾ Jaundice (metastases) from gastrointestinal,
pulmonary and breast
¾ Portal hypertension
¾ HBV & HCV and alcohol are
¾ Oesophageal varices common causes of primary liver
cancer.

¾ Ascites
¾ Signs and symptoms are somewhat
non-specific and tend to be the
¾ Hepatic failure same as those that occur for
cirrhosis and hepatitis.

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Gallbladder Disorders
Risk Factors
* Cholecystitis
¾ Family history

* Cholelithiasis ¾ Diseases or conditions

¾ Hyperalimination

¾ Race or ethnicity

¾ Female

¾ Age

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Signs and Symptoms - Signs and Symptoms -


Cholelithiasis Cholecystitis

¾ Epigastric pain ¾ Fever

¾ RUQ abdominal pain ¾ Raised WCC

¾ Heartburn ¾ RUQ tenderness and rigidity

¾ Belching ¾ Elevated serum bilirubin

¾ Jaundice ¾ Raised serum levels of alkaline


phosphatase, amylase and
bilirubin.
¾ Intolerance to fat containing
food

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Diagnosis and Treatment
Pancreatitis
Cholecystitis and Chloelithiasis

¾ Upper Abdominal Ultrasound ¾ Acute


¾ Pharmacology
¾ Chronic
¾ Diet therapy

¾ Surgery

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Acute pancreatitis - manifestations Pancreatitis - Treatment

¾ Pain ( epigastric and abdominal) ¾ Narcotic analgesia


¾ N&V
¾ Abdominal distension and rigidity
¾ Dietary management
¾ Decreased bowel sounds
¾ Fever
¾ Turner’s sign ¾ Surgery
¾ Cullen’s sign.
¾ Tachycardia
¾ Hypotension
¾ Cold clammy skin
¾ Jaundice may appear
¾ Elevated serum amylase.

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Pancreatic Cancer
Clinical manifestations
¾ 10th most common cancer.
¾ Slow onset

¾ More common in adults 65 - 80


¾ Anorexia
years of age

¾ Nausea weight loss


¾ More men than women

¾ Flatulence
¾ Mostly adenocarcinomas

¾ Dull epigastric pain


¾ Death in 1 - 3 years after diagnosis

¾ Increase in severity of pain as


the tumour grows

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Diagnosis and Treatment

¾ Ultrasound

¾ CT Scan

¾ ERCP

¾ CA19-9

¾ Whipples procedure

¾ Palliative care

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Bibliography
¾ Black, J. M., Hawks, J., & Keene, A. M. (2004). Medical-surgical nursing: Clinical
management. (7th ed.). Philadelphia: W. B. Saunders.
¾ Brown, D., & Edwards, H. (Eds.). (2008). Lewis’s medical-surgical nursing
assessment and management of clinical problems. (2nd ed.). Sydney: Elsevier.
¾ Crisp, J., & Taylor, C. (Eds.). (2005). Potter and Perry’s fundamentals of nursing.
Sydney: Elsevier.
¾ Lehne, R. A .(2007). Pharmacology for nursing care. (6th ed.). St. Louis: Saunders
Elsevier.
¾ Lemone, P., & Burke, K. (2008). Medical surgical nursing. Critical thinking
in client care. (4th ed.). Upper Saddle River, New Jersey: Prentice Hall.
¾ Marieb, E. N. (2007). Human anatomy and physiology (7th ed.). California: Pearson
Education.
¾ Porth, C. M. (2005). Pathophysiology: Concepts of altered health states. (7th
ed). Philadelphia:Lippincott.
¾ Sarikas, S. N. (2007). Laboratory investigations in anatomy and physiology. San
Francisco: Pearson.

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