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 disease • Inflammation diffuse over the liver • Fibrosis parencymal cells get destroyed and get replaced with: • Nodules and scar tissue (dense scar tissue) bumps in the liver that can’t do anything ; the more you get the less functioning liver tissue you have • Types • Laennec’s = alcoholic MOST COMMON TYPE • Postnecrotic more common in rest of the world • Biliary not common

8. Cirrhosis – types con’t Post necrotic • Follows viral hepatitis • Hepatotoxins ex. acetaminophen and industrial chemicals ( many drugs) take for too long and too much • Metabolic disorders • Wilson disease – copper body hold in copper and deposits it in the liver • Hemochromatosis – iron deposit iron in liver and joints • Both toxic to liver causing cirrhosis

9. Cirrhosis – types con’t Biliary - Stasis of bile • Intrahepatic = primary (not a good prognosis not even with a transplant the same immune response towards your liver will happen to donor liver) • Autoimmune • Extrahepatic = seconday • Prolonged obstruction ex. cancer of bile ducts, stones that are not taken care of (Better Prognosis- can do surgery to relieve obstruction)

10. Alcoholic Cirrhosis Alcohol • Directly Toxic to hepatocytes • causes Metabolites = • Acetaldehyde Both are toxic to the liver • Free radicals • Alcohol dehydrogenase = enzyme that metabolized ETOH (in Caucasian) • Depressed by testosterone possible that women will have more damage to liver than men (the metabolites and alcohol itself are toxic) • Depressed by low protein diet if your malnourished then your also not going to metabolize alcohol efficiently

11. Cirrhosis Stages: • Fatty liver (FIRST) alchol has heptotoxic action and increses fat content in liver leading to : • Increased lipogenesis formation of fat • Decreased oxidation of fatty acids don’t break them well • Mobilization of fat stores bring fat from periphery to liver • (can cause inflammation) • -If you stop drinking at this stage it’s REVERSIBLE • (Non-alcoholic liver disease- high fat diet, w/ sedentary lifestyle) • Non alcoholic • Hepatitis • Inflammation & necrosis of liver cells • This stage can cause Death depending on how bad inflammation is and the necrosis • Cirrhosis • Liver shrunk, hard (has almost no normal tissue left , just nodules and scar tissue) this stage ends with LIVER FAILURE – ther’s not enough functioning celss to make the liver do what it’s supposed to do

12. Manifestations (most types) • Earlyvague symptoms (people don’t pay attention at this stage) • Fatigue, weakness • Anorexia, wt loss • Change in bowel habits • Dull heavy sensation in RUQ • No pain • Late • d/t hepatocellular failure & portal hypertension • LIVER FAILURE

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

14. Manifestations (most types) Manifestation Cause Impaired metabolism of sex hormones because liver is where these hormones are inactivated and can’t control the levels Increased circulating estrogen • Female • Menstrual disorders younger women get ammenorhea in post menopausal they start bleeding again • Male • Testicular atrophy, • Gynecomastia • Impotence; loss of libido • Loss of pectoral, axillary & pubic hair • Vascular spiders (spider angiomas) red dot with lines coming out from it) • Palmar erythema palms of hand get red

15. Manifestations (most types) manifestion Cause Impaired synthesis of plasma proteins Inc. portal pressure blood has a hard time getting through the liver and it backs up into portal system of the stomach etc. hyperaldosterone • Edema & ascites- liver is where you make plasma proteins (decreased oncotic pressure leading to fluid leaking into peritoneum “3rd spacing”

16. Manifestations (most types) Manifestation Cause Dec. synthesis of clotting factors & Vit K absorption Splenomegaly back up of portal pressure causes spleen to enlarge with blood (spleen holds platlets 1/3) so if blood backs up then it holds onto more platelets and therefore fewer platlets in circulation to clot Blood loss, dietary deficiency ETOH toxic to bone marrow and to brain (bone marrow doesn’t make as many new blood cells as you need) • Bleeding- bleed easily ex. gums or epistaxis, bruise easily (liver absorbs vit. K and makes clotting factors) • MAJOR PROBLEM • Thrombocytopenia • Anemia

17. Manifestations (most types) Manifestations Cause Failure to conjugate & remove bilirubin Accumulation of bile salts in skin Unable to convert bilirubin to bile and bile gives stool it’s dark color (bilirubin goes out in your urine) • Jaundice • Pruritus- itching • Dark urine, clay colored stool

20. Manifestations (most types) Manifestation Cause Impaired bile synthesis Inability to store vitamins • Malabsorption of fats & fat soluble vitamins Fat soluble vitamins (A, D, E, K) K- coagulation D-calcium absorbtion • Vit B complex deficiency because liver is where you store the vitmins and this forms blood cells, have correct nerve function

21. Manifestations (most types) Manifestation Cause Impaired gluconeogenesis-beginning formation of new sugar from non sugar sources & glycogenolysis breakdown of sugars that are stored to be used by the body Vit deficiency Decreased ability to convert ammonia to urea if you can’t convert then you build up ammonia and it’s toxic to your brain • Hypoglycemia • Peripheral neuropathy • Elevated blood ammonia levels

22. Manifestations (most types) Manifestation Cause Unknown Decreased hepatic metabolism of methionine • Hepatorenal syndrome renal failure caused by liver failure • Fetor hepaticus musty breath odor because your not metabolizing methionine

26. Portal hypertensionwhen liver fails • 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] build up new blood vessels to take off some of the pressure but these new vessels are weak • (varicose veins inside esophagus) • Ascites because not making plasma proteins you need so oncotic pressure goes down and 3rd space into abdominal cavity • (one you get one these two most patients die within 5 years)

27. PSEportal systemic encapholy • Patho • Elevated ammonia levels comes from breakdown of protein • Ammonia is cerebral toxin • Can get portal-systemic anastomoses – shunting of blood around liver • Allows ammonia to bypass liver • The more protein you take in the more you have to breakdown and more you have to change to urea and excrete and the liver is not functioning so you build up ammonia levels in your blood (build ammonia in blood and get ENCEPHALOPALY- derangement of the brain) • -want to give a diet of low protein • Give them neomycin (antibiotic) kills the bacteria and less ammonia • less time stuff stays in gut = less time it can break down proteins • Brought on by • Hypokalemia • Can be brought on by diuretics • 20% of encephaolopy brought on by diuretics

28. PSE • Constipation more time for flora gut to bring on ammonia • Infection • GI bleeding especially if it’s accolt- blood is a protein and it’s being worked on by bacteria • Narcotic and sedative use • Azotemia nitrogenous waste in the blood • Anesthesia • Hypoxia

29. PSE Manifestations • Subtle personality changes- • Memory loss • Irritability • Lethargy • Sleep disturbances can’t sleep at night only sleep during day • Confusion • Asterixis- particular type of tremor “flapping of the hands” • Convulsions/seizures • Coma then death

31. Collateral Circulation • Bodies Attempt to reduce portal pressure builds new vessels to take the blood • Collateral vessels • In esophagus esophageal varicies • In rectumhemmorhoids • Fragile vessels – bleed easily once you get varices they continue to enlarge and extend the bleeding are the immediate life threatening complication of cirrhosis they can bleed out very quickly • -continue to drink varices get bigger if you stop they get smaller but stay there • Caput Medusae • Around umbilicus dilated veins around belly button

32. Collateral Circulation • Esophageal varices • Risk of bleeding increases: • Intra-abdominal pressure coughing, sneezing, valsalva maneuver • Acid regurgitation acid eats away at the varices and you end up bleeding • Poorly chewed food/ food with sharp edges • Irritation for ETOH, et al. • ASA because it anti-coagulates • Teach pt. not do do these • Manifestations when GI tract is filled with blood • Hematemesis vomit blood • Melena black tarry stools

33. Esophageal Varices • Complications: • Encephalopathy worsens • Hypovolemic shock • Electrolyte imbalance HYPOKALEMIA • Metabolic acidosisbecuae of loss of potassium • Respiratory alkalosisabd distention of ascites makes you breath rapidly and shallowly

35. Ascitesaccumulation of fluid in peritoneal cavity (3rd spacing) • Causes: • Decreased albumin • Increased portal pressure • Increased serum aldosterone • Manifestations: • Abdominal distention • Everted umbilicus pops out • Wt gain • Dyspnea • Percussion dull in bases of the lungs because fluid is pushing up on the lungs

36. Anatomy of the Biliary System

37. Hepatisis is caused by viral insertion into the host cell genoonme resulting in death of the cell? -FALSE Some forms of hepatitis are caused by viruses but not all

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

39. Viral Hepatitis • HAV – fecal/oral Know how it’s spread • Susceptibility: kids & young adults • Immunization: 2 shots 6 months apart • HBV – parenteral(blood)/sex rarely feces • Susceptibility: all age groups, transfusions, injecting drug abuse, sexual contact, health care workers • Immunization: 3 shots – 0, 1, & 6 months

40. Viral Hepatitis • HCV - parenteral can be acute or chronic – sometimes unknown transmission • 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 for several months and it makes you feel like you have the flu • Hepatitis E can only get if you already have B

41. Viral Hepatitis • Patho = inflammation, degeneration, regeneration of liver cells • Stages: • Pre-icteric (prodromal) no jaundice yet - Vague sx’s, but very infectious problem in Hep A. • Fatigue, malaise • Low grade fever • Irritability, HA • RUQ pain, tenderness • Anorexia, wt loss, NVD, dyspepsia • Arthralgia • Aversion to cigarettes

42. Viral Hepatitis • Stages: • Icteric lasts 4-6 weeks • Jaundice • Pruritis • Dark urine, clay colored stool • Splenomegaly • Post cervical lymph node enlargement • Can still have symptoms of preicteric stage • Recovery can last several months • Jaundice disappears you start to feel tired /fatigue and it gradually wears off

43. 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

44. 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

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

46. 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

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

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

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