Test 3: Pancreas, Liver, Biliary

HIDA Scan

- Radioactive dye used and traced through the bile ducts which will show obstruction or slow bile flow. - Radioactive imaging procedure that tracks the production and flow of bile from the liver and gallbladder to the intestine

*2 Top serious complications Post-Whipple procedure*

1. Development of fistula (abnormal passageway) 2. Periotonitis (inflammation/infection of peritoneum causing boardlike abdominal rigidity) *Call surgeon immediately if either suspected!*

Cause of pancreatitis pain

-Most common cause: autodigestion of the pancreas. (The pancreatic enzymes stay in the pancreas rather than empting into intestine.)

*Max amount of tylenol/day (to avoid liver damage*

4,000 mg/day

Is pancrease exocrine or endocrine?

Both

Gallbladder cancer Prognosis

Poor

Type of pain w/Acute Pancreatitis

Severe Sharp Radiates to midback Aggravated by eating Begins when recumbent NOT relieved by vomiting

8 Complications of Cholecystitis or cholelithiasis

(*Bil*'s *Gang* took *Sub*way and *Ruptured Bil*s *Fist* with a *Pan* so they *"called Angi"* -Biliary cirrhosis -Gangrenous cholecystitis -Subphrenic abscess -Rupture of the gallbladder leading to > -Bile peritonitis -Fistulas -Pancreatitis -Cholangitis (inflammation of the biliary ducts)

Causes of bile peritonitis

(E BUG) -Extrahepatic bile duct perforation (spontaneous) -Biliary trauma (thoracoabdominal or iatrogenic trauma) -Ulcers (Pepetic) -Gallbladder perforation

S/S Subphrenic abscess

(Hiccup ADDICTS) -Hiccups -Anorexia -Dullness in percussion -Diminished or absent breath sounds -Increased respiratory rate with shallow respiration -*Cough* Tenderness over the 8th-11th ribs -*Shoulder pain* on the affected side. -*Leukocytosis* -*Fever* (swinging) & Chills

5 Diagnostic Tests for diagnosis of gallbladder disease

(Hide ME UP) -HIDA scan -MRCP: (Magnetic resonance cholangiopancreatography) -ERCP- (Endoscopic Retrograde Cholangio-Pancreatography) -Ultrasonography is commonly used to diagnosis gallstones -Percutaneous transhepatic Choangiography

Gallstone Treatment Options

(OLE E) -Oral dissolution therapy (small stones) -Laparoscopic cholectysectomy (surgery of choice!) -ERCP with sphincterotomy -Extracorporeal shock-waves - lithotripsy (ESWL)

Risk factors for gallbladder disease (6 Fs)

*Female* Fat (obese) Forty + Fertile (multiparity) Flatulant Familial tendancy *Also estrogen therapy

Gallbladder Cancer Nursing Management(4)

Supportive care: -Nutrition (low fat) -Hydration -Skin care -Pain relief.

Extracorporeal shock-waves (ESWL)

- lithotripsy used to disintegrate gallstones. Afterward, broken down stones pass through the common bile duct and into the small intestine -use of shock waves as a noninvasive method to break up stones in the gallbladder or biliary ducts

MRCP: (Magnetic resonance cholangiopancreatography)

- non-invasive oral or injected contrast followed by an MRI. -medical imaging technique that uses magnetic resonance imaging to visualize the biliary and pancreatic ducts in a non-invasive manner. This procedure can be used to determine if gallstones are lodged in any of the ducts surrounding the gallbladder.

Causes of Pancreatitis (7)

-#1 Gallbladder disease/gallstones (more common in women) #2 chronic alcohol intake (more common in men) -Smoking (acute) -Hypertriglyceridemia (serum levels >1000 mg/dL) (acute) -Some medications -Some metabolic disorders -Surgical procedures on the pancreas, stomach, duodenum or biliary tract.

Gallstone S/S

-Abdominal Rigidity -Pain (steady) located in the RUQ -Pain can cause: tachycardia, diaphoresis and prostration. -Pain can be referred to the right shoulder and scapula. Usually occurs 3 - 6 hours after a high fat meal or when client lies flat. -Indigestion - fever -Leukocytosis -Jaundice -N/V -Restlessness -Fat intolerance -Dyspepsia/heartburn/flatulence

Pancreatic Psuedocyst

-Accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall. -.Cysts lined with fibrous scar tissue and granulation tissue, and becomes filled with pancreatic enzymes and juice

Acute pancreatitis

-Acute inflammation of the pancreas. -degree of inflammation varies from mild edema to severe hemorrhagic necrosis.

2 Risk factor for acute pancreatitis

-African American (3x higher than white) -Middle aged (men and women equally)

5 Most common types of drugs used in the treatment of gallbladder disease

-Analgesics (Morphine & NSAIDs) -Anticholinergics -Bile salts -Cholestyramine (Questran) for Pruritus -Fat soluble vitamins may be used (KADE)

*Post laparoscopic cholecystectomy interventions*

-Assess patient's O2 stats frequently until anesthesia wears off. -Deep breathe q hr.

*Other Post-Whipple complications*

-Chest pain/MI -PE/SOB -Paralytic Ileus -Renal Failure O/P < 20ml/hrs -Blood loss/Third Spacing/Hypovolemia > Shock (*Interventions for hypovolemia:* Monitor for: -VS: decreased BP, Increased HR -Decreased vascular pressures -Decreased UOP -Pitting edema of extremeties -Dependent edema of sacrum, back -Intake far exceeding O/P -DVT

Pancreatic Abscess

-Collection of pus resulting from extensive necrosis in the pancreas. It may become infected or perforate into adjacent organs. Pancreatic abscesses necessitate prompt surgical drainage to prevent sepsis.

Pancreatic Pseudocyst Diagnosis

-Elevated serum amylase -CT -MRI -EUS (Endoscopic ultrasonography)

Sign of severe pancreatitis & its cause

-Hypocalcemia - Due in part to the combining of calcium and fatty acids during fat necrosis. -Exact mechanisms of how or why hypocalcemia occurs not well understood.

*Signs of Pancreatic Cancer*

-Increased serum amylase & lipase -Increased alkaline phosphatase -Increased bilirubin -Elevated CEA (carcinoembryonic antigen) -CA 19-9 & CA 242 tumor markers

S/S of Total obstruction of gallbladder bile duct

-Jaundice (r/t lack of bile into the duodenum) -Dark amber urine (r/t soluble bilirubin in the urine) -Clay colored stools (r/t no bilirubin reaching small intestine to be eliminated) -Pruritus (r/t deposits of bile salts in the skin) -Intolerance of fatty foods (r/t no bile in the small intestine for fat digestion) -Bleeding tendencies (r/t lack of, or decreased absorption of vitamin K > decreased production of prothrombin) -Steatorrhea (r/t no bile salts in duodenum which prevents fat emulsion and digestion).

*Nutritional interventions for Acute *and* Chronic pancreatitis*

-Limit food intake to avoid increased pain -TPN or TEN (total enteral) -increase calories up to 4000-6000/day to maintain weight -Foods high in carb and protein, low in fat -Avoid alcohol, caffeine, nicotine, spicy foods

*Differences in S/S of cholecystitis in older & DM patients*

-May not have pain or fever -Localized tenderness may be only sign -Older pt. may become acutely confused as first sign of gallbladder disease -Monitor for dehydration in older pts

*Acute pancreatitis Interventions*

-Monitor respiratory status q 4-8hrs -Provid O2 -Monitor for pleural effusions, fluid overload (assess wt. gain, crackles, dyspnea) _Monitor for S/S hypocalcemia: *Chvostek's* & *Trousseau's* signs (cause muscle spasms after stimulation) -Fetal position to reduce pain

*Obstructive Jaundice*

-Most common w/*chronic cholecystitis* -Caused by edema of ducts or gallstones -Normal flow of bile into the duodenum is blocked -allows excess bile salts to accumulate on the skin. This leads to itching, or *pruritus*. -Biliruben doesn't reach large intestines resulting in *clay-colored feces and dark, foamy urine* w/extra biliruben.

Dx/ S/S Gangrenous cholecystitis

-Murphy's sign + (extreme pain upon GB compression) -Sonogram-thickened walls -Non-shadowing echoes within the lumen -Llocal peritoneal fluid

*Risk factors of Pancreatic cancer*

-Mutations of p16 or BRCA2 genes, gene for hereditary nonpolyposis colorectal cancer -DM -Chronic pancreatitis -Cirrhosis _high intake red meat -Chemical exposure: gasoline, pesticides -Obesity - + age -Male -Cigarettes -Fam history -Genetic syndromes

Basic symptoms of Acute Pancreatitis

-N/V -epigastric pain -LUQ pain. Pain is severe, sharp, and radiates to the midback.

*Common GI complication of acute pancreatitis w/interventions*

-Paralytic ileus -May need prolonged nasogastric intubation -Assess for *passage of gas or stool* -Bowel sounds NOT reliable as indicator of peristalsis return!!

2 Local Compications of Acute Pancreatitis

-Pseudocyst -Abscess

Nutritional Therapy/Diet for gallbladder disease

-Smaller, more frequent meals -Some fat at each meal (promotes emptying of gall bladder) -Low in saturated fats (e.g., butter, shortening, lard) -High in fiber -High in calcium -If obesity: Reduced-calorie -Avoid rapid weight lostt (can promote formation of gallstones)

*Problems for pt. with diabetes AND on TPN*

-Susceptible to elevated glucose levels -Usually require regular insulin additives to TPN -Closely monitor bl glucose q *2-4hrs*

*Interventions: Severe Biliary colic*

-Tachycardia -Pallor -Diaphoresis -Prostration (extreme exhaustion) -Assess for shock caused by biliary colic -*Stay w/pt, keep head of bed flat, contact RRT or provider*

*Enzyme Replacement for Chronic Pancreatitis: TEACHING*

-Take w/ meals and snacks, follow w/glass of water -Admin enzymes after antacid or H2 blockers (decreased pH inactivates drug) -Swallow tabs or caps /out chewing to minimize oral irriatation and allow drug to be released slowly -If can't swallow, sprinkle on applesauce DO NOT mix enzyme preps in protein-containing foods -Wipe lips after taking enzymes to avoid skin irritation -Do not crush enteric-coated preps -Follow up on all scheduled lab testing

Clinical Symptoms of acute Pancreatitis

-low-grade fever -leukocytosis -hypotension -tachycardia -jaundice -Abdominal tenderness with muscle guarding -Bowel sounds Decreased/absent -Paralytic ileus may w/marked abdominal distention -Crackles -Cyanosis -Greenish to Yellow-brown discoloration of abdominal wall (damaged by circulating trypsin) -Grey Turner's Sign (spots) -Cullen's Sign -Shock (hemorrhage into pancreas) -Toxemia (from activated pancreatic enzymes -Hypovolemia (fluid shift into retroperiotneal space)

*Post-Op Open Whipple / Radical pancreaticoduodenectomy Interventions*

1. Assess endotrach tube/ 40%FiO2 2. Start/Check IV 3. Foley 4. NG tube to low intermittent suction -Semi-fowler's position -Check BG often -Assess VS frequently (fl/electolyte imbalance) -Monitor for Hemorrhage (pulse, BP, skin color, LOC) -Monitor for wound infection -Check bowel sounds, stools -Monitor for Intra-abdom abscess (temp, svere pain)

Anticholinergic used for tx of gallbladder disease + MOA

Atropine -MOA: Relaxes smooth muscles and decreases ductal tone

Grey Turner's Sign

Bruising of flank indicating pancreatic necrosis & retro peritoneal bleeding

Biliary Cirrhosis

Cirrhosis develops from chronic biliary obstruction, bile stasis, and inflammation, resulting in severe obstructive jaundice.

Hormone that Stimulates contraction of Gallbladder

CCK -Fatty acids in the lumen of the duodenum stimulate endocrine cells to release the hormone cholecystokinin (CCK). CCK stimulates contractions in the smooth muscle of the gallbladder. As well, CCK causes relaxation of the sphincter of Oddi, allowing bile release into the duodenum.

The most common problem of the gallbladder

Cholecystitis

2 Most common disorders of the biliary system

Cholelithiasis (Stones in the gallbladder) Cholecystitis (Inflammation) Cancer

Subphrenic abscess

Disease characterized by an accumulation of infected fluid between the diaphragm, liver, and spleen. This abscess develops after surgical operations like splenectomy. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death. It is also associated with peritonitis. Dx with US

Cullen's Sign

Ecchymosis (edema and bruising) around the umbilicus (may indicate internal bleeding or major organ injury)

How Bile salts are used for tx of gallbladder disease

Facilitate digestion & vitamin absorption

Gallbladder Patho

Gallbladder takes the bile from the liver, concentrates and stores it, and releases in response to chyme passing through the stomach into the duodenum.

Percutaneous Transhepatic Choangiography

Insertion of a needle directly into the gallbladder duct, followed by injection of contrast to find a blockage. -(PTHC or PTC) or percutaneous hepatic cholangiogram is a radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken.

Endocrine functions of Pancreas

Islet of Langerhans: -B cells secrete insulin -A cells secrete glucagon

Cause of obstruction of gallbladder bile duct

Lack of bile flow into the duodenum (???)

Bile peritonitis

Peritoneal inflammation caused by leakage of bile into the peritoneal cavity

4 pulmonary complications of acute pancreatitis

Pleural effusion Atelectasis Pneumonia ARDS (Acute Resp distress syndrome)

Gangrenous cholecystitis

Presence of microabscesses, necrosis, and/or intramural hemorrhage, stones and/or fine gravel in GB without obstruction of the bile duct

What Cholestyramine (Questran) is used for

Pruritis r/t gallbladder disease -binds with bile salts in intestine and increases excretion in feces

3 Main systemic complications of acute pancreatitis

Pulmonary Cardiovascular (hypotension) Tetany (caused by hypocalcemia)

2 Causes of Gallbladder cancer

Relationship b/t Gallbladder cancer and: -Cholecysitits -Cholelithiasis.

ERCP with sphincterotomy

Removes the gallstone and allows the stone to pass out the duodenum.

Exocrine functions of Pancreas

Secretes pancreatic enzymes to break down starch, proteins, and fats.

AST enzyme

Skeletal and cardiac muscle, liver (tissue damage)

Pancreatic Pseudocyst Tx

Surgical drainage procedure Percutaneous catheter placement/drainage Endoscopic drainage

ERCP- (Endoscopic Retrograde Cholangio-Pancreatography)

Test used for visualization of gallbladder, cystic duct, common hepatic duct, common bile duct. -Upper endoscopy + X-ray; Check bile & pancreatic duct problems/tumor; allows investigation& management in same setting

Cause of pulmonary complicationsof acute pancreatitis

The passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels.

Whipple Procedure

The surgical procedure for cancer of the pancreas involves resection of the antrum of the stomach, the gallbladder, the duodenum, and varying amounts of the pancreas. Anastomoses are constructed between the stomach, the common bile and pancreatic ducts, and jejunum.

Trypsinogen > Trypsin Patho

Trypsinogen is an inactive proteolytic enzyme produced by the pancreas. It is released into the small intestine via the pancreatic duct. In the small intestine, it is activated to trypsin by enterokinase. Normally, trypsin inhibitors in the pancreas and plasma bind and inactivate any trypsin that is inadvertently produced. In pancreatitis, activated trypsin is present in the pancreas. This enzyme can digest the pancreas and produce bleeding

Labs that may increase while taking pancrelipase

Uric acid levels

2 Meds used for Oral dissolution therapy

Ursodiol (Actigall) -Chenodeozycholic acid (Chenodial) -used to dissolve small gallstones

Transhepatic biliary catheter

Used preoperatively in biliary obstruction. The catheter is used when endoscopic drainage has been unsuccessful. It drains the bile ducts to relieve pressure and is connected to a drainage bag outside of the body.

ALT enzyme

enzyme that is liver specific, and is released when there is hepatocellular damage/death

Cholecystitis S/S

inflammation of the gallbladder

Alkaline Phosphatase (ALP)

is another enzyme that may be elevated in patients with liver, bone and other diseases

Murphy's sign

pain with palpation of gallbladder seen with cholecystitis

Cause of Grey Turner's and Cullen's Signs

seepage of blood-stained exudate from the pancreas - may occur in severe cases of pancreatitis

Laparoscopic cholectysectomy

surgery of choice removal of the gallbladder -Client may need a stint to keep the bile duct open.

Cholelithiasis

the presence of gallstones in the gallbladder or bile ducts

Enzyme that "digests" pancrease and causes bleeding

trypsin

5 Common Gallbladder Disease Lab findings

↑ WBC count (r/t inflammation) ↑ Serum bilirubin level (r/t obstruction) ↑ Urinary bilirubin level (r/t obstruction) ↑ Liver enzyme levels (including alkaline phosphatase, ALT, & AST) ↑ Serum amylase level (r/t pancreatic involvement)