Liver, Pancreas and Biliary Disorders

1. Liver, Pancreas and Biliary Disorders Dr. L. Saarmann, RN

3. Question • Which of the following is not a cause of jaundice? • Excessive destruction of red blood cells • Impaired uptake of bilirubin by the liver cells • Ingestion of iron supplements • Decreased conjugation of bilirubin • Obstruction of bile flow in the canaliculi of the hepatic lobules or in the intrahepatic or extrahepatic bile ducts

4. Answer • Excessive destruction of red blood cells • Impaired uptake of bilirubin by the liver cells • Ingestion of iron supplements: Iron supplements do not affect the metabolism of RBCs • Decreased conjugation of bilirubin • Obstruction of bile flow in the canaliculi of the hepatic lobules or in the intrahepatic or extrahepatic bile ducts

7. Cirrhosis • Chronic • Inflammation • Fibrosis • Nodules and scar tissue • Types • Laennec’s = alcoholic • Postnecrotic • Biliary

8. Cirrhosis – types con’t • Post necrotic • Follows viral hepatitis • Hepatotoxins • Metabolic disorders • Wilson disease – copper • Hemochromatosis - iron

9. Cirrhosis – types con’t • Biliary - Stasis of bile • Intrahepatic = primary • Autoimmune • Extrahepatic = seconday • Prolonged obstruction

10. Alcoholic Cirrhosis • Alcohol • Toxic to hepatocytes • Metabolites = • Acetaldehyde • Free radicals • Alcohol dehydrogenase = enzyme that metabolized ETOH • Depressed by testosterone • Depressed by low protein diet

11. Cirrhosis • Stages: • Fatty liver • Increased lipogenesis • Decreased oxidation of fatty acids • Mobilization of fat stores • Hepatitis • Inflammation & necrosis of liver cells • Cirrhosis • Liver shrunk, hard

12. Manifestations (most types) • Early • Fatigue, weakness • Anorexia, wt loss • Change in bowel habits • Dull heavy sensation in RUQ

13. Manifestations (most types) • Late – due to hepatocellular failure and portal hypertension

14. Manifestations (most types) Manifestation Cause Impaired metabolism of sex hormones Increased circulating estrogen • Female • Menstrual disorders • Male • Testicular atrophy, • Gynecomastia • Impotence; loss of libido • Loss of pectoral, axillary & pubic hair • Vascular spiders • Palmarerythema

15. Manifestations (most types) manifestion Cause Impaired synthesis of plasma proteins Inc. portal pressure hyperaldosterone • Edema & ascites

16. Manifestations (most types) Manifestation Cause Dec. synthesis of clotting factors & Vit K absorption Splenomegaly Blood loss, dietary deficiency ETOH toxic to bone marrow • Bleeding • Thrombocytopenia • Anemia

17. Manifestations (most types) Manifestations Cause Failure to conjugate & remove bilirubin Accumulation of bile salts Unable to convert bilirubin to bile • Jaundice • Pruritus • Dark urine, clay colored stool

20. Manifestations (most types) Manifestation Cause Impaired bile synthesis Inability to store vitamins • Malabsorption of fats & fat soluble vitamins • Vit B complex deficiency

21. Manifestations (most types) Manifestation Cause Impaired gluconeogenesis & glycogenolysis Vit deficiency Decreased ability to convert ammonia to urea • Hypoglycemia • Peripheral neuropathy • Elevated blood ammonia levels

22. Manifestations (most types) Manifestation Cause Unknown Decreased hepatic metabolism of methionine • Hepatorenal syndrome • Fetor hepaticus

26. Portal hypertension • Due to obstruction of normal blood flow through the portal vascula system • Results in: • Hepatic encephalopathy aka portal-systemic encephalopathy PSE • Collateral circulation [esophageal varices] • ascites

27. PSE • Patho • Elevated ammonia levels • Ammonia is cerebral toxin • Can get portal-systemic anastomoses – shunting of blood around liver • Allows ammonia to bypass liver • Brought on by • Hypokalemia • Can be brought on by diuretics

28. PSE • Constipation • Infection • GI bleeding • Narcotic and sedative use • Azotemia • Anesthesia • Hypoxia

29. PSE Manifestations • Subtle personality changes • Memory loss • Irritability • Lethargy • Sleep disturbances • Confusion • Asterixis • Convulsions • coma

31. Collateral Circulation • Attempt to reduce portal pressure • Collateral vessels • In esophagus • In rectum • Fragile vessels – bleed easily • Caput Medusae • Around umbilicus

32. Collateral Circulation • Esophageal varices • Risk of bleeding increases: • Intra-abdominal pressure • Acid regurgitation • Poorly chewed food • Irritation for ETOH, et al. • ASA • Manifestations • Hematemesis • melena

33. Esophageal Varices • Complications: • Encephalopathy worsens • Hypovolemic shock • Electrolyte imbalance • Metabolic acidosis • Respiratory alkalosis

35. Ascites • Causes: • Decreased albumin • Increased portal pressure • Increased serum aldosterone • Manifestations: • Abdominal distention • Everted umbilicus • Wt gain • Dyspnea • Percussion dull in bases

36. Anatomy of the Biliary System

37. Hepatitis • Inflammation of liver • Types: • Viral • HAV, HBV, HBD, HBE • Toxic • From drug or chemicals • Alcoholic • autoimmune

38. Viral Hepatitis • HAV – fecal/oral • Susceptibility: kids & young adults • Immunization: 2 shots 6 months apart • HBV – parenteral/sex • Susceptibility: all age groups, transfusions, injecting drug abuse, sexual contact, health care workers • Immunization: 3 shots – 0, 1, & 6 months

39. Viral Hepatitis • HCV - parenteral– sometimes unknown • Susceptibility: all age groups, injecting drug abuse, blood transfusions, long-term kidney dialysis, health care workers, unprotected sex with infected person, Injecting drug abuser, received a tattoo or acupuncture with contaminated instruments, solid organs from a donor who has hepatitis C, Share personal items such as toothbrushes and razors with someone who has hepatitis C (less common), born to a hepatitis C-infected mother • No vaccine • Tx with interferon

40. Viral Hepatitis • Patho = inflammation, degeneration, regeneration of liver cells • Stages: • Pre-icteric (prodromal) - Vague sx’s, but very infectious • Fatigue, malaise • Low grade fever • Irritability, HA • RUQ pain, tenderness • Anorexia, wt loss, NVD, dyspepsia • Arthralgia • Aversion to cigarettes

41. Viral Hepatitis • Stages: • Icteric • Jaundice • Pruritis • Dark urine, clay colored stool • Splenomegaly • Post cervical lymph node enlargement • Recovery • Jaundice disappears

42. Lab abnormalities c any liver disease • Increased AST, ALT, LDH, alkaline phosphate • Decreased total serum PRO & albumin • Increased prothrombin time (PT) • Decreased Hct & Hgb • Hyperbilirubinemia • Increased urine bilirubin & excess urobilinogen • Hypoglycemia • Steatorrhea • EEG may show generalized slowing • Thrombocytopenia, leukopenia • Hypokalemia, Hyponatremia

43. Biliary System • Cholelithiasis ‑ presence of stones in the gallbladder. • Cholecystitis ‑ acute or chronic inflammation of the gallbladder usually caused by gallstones obstructing the cystic duct. • Choledocholithiasis ‑ stones in the common bile duct • Cholangitis ‑ inflamed bile ducts secondary to obstruction or bacterial invasion

44. Risk Factors • Female, pregnancy, multiparous women • Estrogen therapy/oral contraceptives • Obesity • Age over 40 • Diabetes Mellitus • Hyperlipidemia • Sedentary life style • Native American

45. Manifestations • Biliary Colic • Murphy’s sign • GI – NV; intolerance for fatty food; bloating, flatulence, dyspepsia • Fever/chills/leukocytosis • Jaundice • Clay colored stools/ dark urine • steatorrhea

47. Pancreatitis • Acute or chronic inflammation – may disrupt endocrine and exocrine function • Edema • Necrosis • hemorrhage

48. Pancreatitis • Acute pancreatitis • Inflammation & autodigestion • Obstruction of pancreatic ducts • Reflux of bile or duodenal contents • Toxic effects of ETOH

49. Acute pancreatitis • Types • Edematous interstitial • Necrotizing • Hemorrhagic necrotizing

50. Acute pancreatitis • Etiology • ETOH • Cholelithiasis • Infections • ABD trauma • Metabolic conditions • PUD • Idiopathic • Drugs • ERCP (endoscopic retrograde cholangiopancreatography)