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  • Accessory Organs of Digestive System By: Mr. Ranie M. Esponilla
  • REVIEW OF ANATOMY AND PHYSIOLOGY
    • ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM:
    • Liver
    • Gall bladder and ductal system
    • Pancreas
  • This is an in-situ photograph of the chest and abdominal contents. As can be seen, the liver is the largest parenchymal organ, lying just below the diaphragm. The right lobe (at the left in the photograph) is larger than the left lobe. The falciform ligament is the rough dividing line between the two lobes.
  • REVIEW OF ANATOMY AND PHYSIOLOGY
    • LIVER
    • Liver lobules
    • Hepatic sinusoids (capillaries) lined with Kupffer cells
    • Portal circulation – brings blood to the liver from : stomach, spleen, pancreas & intestines
  • REVIEW OF ANATOMY AND PHYSIOLOGY
    • FUNCTIONS OF THE LIVER:
      • Carbohydrate metabolism
        • Glycogenesis
        • Glycogenolysis
        • Gluconeogenesis
      • Fat metabolism - ketogenesis
      • Protein metabolism
        • anabolism
        • deamination
        • urea formation
      • Secretion of bile
      • Detoxification
      • Metabolism of vitamins A,D,K,B &
      • Clotting factors, esp prothrombin
  • REVIEW OF ANATOMY AND PHYSIOLOGY
    • FUNCTIONS OF THE BILIARY SYSTEM:
    • Gallbladder – concentrate & store bile
    • Ductal system – route for bile to reach the intestines
      • Bile is formed in the liver & excreted into the hepatic duct
      • Cystic duct drains the gallbladder
      • Hepatic duct joins he cystic duct to form common bile duct.
      • Sphincter of Oddi : relaxed, bile enters duodenum; contracted, bile stored in the gall bladder; controlled by cholecystokinin from duodenal mucosa
  • REVIEW OF ANATOMY AND PHYSIOLOGY
    • PACREAS:
    • Head,
    • Body
    • Tail
    • Pancreatic duct
    • FUNCTIONS OF THE PANCREAS:
    • Exocrine : trypsinogen, chymotrypsin, amylase, lipase
    • Endocrine : islets of Langerhans: insulin and glucagon
  • CASE STUDY
    • Sirius, 54 y.o., was brought by his family because of vomiting of blood.
    • He’s drowsy, with VS of : 36 o , 80/60.
    • He’s a chronic alcoholic; jaundiced & with big abdomen
  • CASE STUDY
    • What other assessment findings would you expect?
    • What are your plans?
  • NURSING ASSESSMENT
    • MANIFESTATIONS OF LIVER DISORDERS
    • Jaundice
    • Hemorrhage / bleeding problems
    • Pruritus and itching
    • Ascites
    • Generalized Edema
    • Intolerance of Sedation
  • MANIFESTATIONS OF LIVER DISORDERS
    • JAUNDICE
    • CAUSES:
    • Prehepatic – hemolysis
    • Intrahepatic – liver parenchymal dse
    • Poshepatic – obstruction of bile ducts
  • MANIFESTATIONS OF LIVER DISORDERS
    • HEMORRHAGE
    • Due to inadequate prothrombin & other clotting factors
    • Management :
      • Bile salts p.o.,
      • Vit K, p.o. & parenteral,
      • use of small needle with injection,
      • use of soft toothbrush,
      • check urine and stool for blood.
  • MANIFESTATIONS OF LIVER DISORDERS
    • PRURITUS & ITCHING
    • Caused by bile pigment deposited to skin
    • Management:
      • bathing with tepid water & use of oil-based lotion
      • cholestyramine – binds with bile salts and facilitates excretion withfeces
      • Use soft linen
      • Short fingernails
  • MANIFESTATIONS OF LIVER DISORDERS
    • ASCITES
    • Causes :
      • portal hypertension
      • decreased plasma colloid osmotic pressure
      • hyperaldosteronism
  • MANIFESTATIONS OF LIVER DISORDERS
    • ASCITES
    • Management :
      • daily weight & abdominal girth
      • low Na diet, fluid restriction, diuretics
      • relieve symptoms from pressure of ascites :
        • high fowler’s
        • turning & positioning
        • IV albumin,
        • Paracentesis
        • Peritoneovenous Shunt
  • MANIFESTATIONS OF LIVER DISORDERS
    • GENERALIZED EDEMA
    • Insufficient albumin
    • INTOLERANCE OF SEDATION
    • Most sedatives are metabolized in the liver except phenobarbital
  • DISEASES OF THE LIVER
    • HEPATITIS
    • CIRRHOSIS
    • CANCER OF THE LIVER
  • HEPATITIS
    • TYPES:
    • Viral Hepatitis
    • Toxic Hepatitis – exposure to hepatotoxin : carbon tetrachloride. Morphine, barbiturates
  • HEPATITIS
    • Hepatitis A
    • Infectious
    • Fecal-oral route
    • Hepatitis B
    • Serum hepatitis
    • Blood & body fluid transmission
  • HEPATITIS
    • DIAGNOSIS:
    • Screening test for Hepatitis
    • Liver function tests:
    • SGOT
    • Alkaline Phosphatase
    • SGPT
    • Imaging: Ultrasound
  • Grossly, there are areas of necrosis and collapse of liver lobules seen here as ill-defined areas that are pale yellow. Such necrosis occurs with hepatitis.
  • HEPATITIS
    • PLANNING & IMPLEMENTATION
    • 1. Prevent spread of the disease.
    • Hepatitis A
    • Transmission : fecal-oral route
    • Incubation period : 2-7 wks (virus in the blood & feces)
    • Most infective 2 wks before onset of s/sx
    • Enteric precautions
    • Gloves when handling stools
    • Handwashing
  • HEPATITIS
    • PLANNING & IMPLEMENTATION
    • 1. Prevent spread of the disease.
    • Hepatitis B
    • Transmission : Blood & body fluid
    • Exposed individuals : Hep B immunoglobulin, provides passive immunity
    • High Risk Individuals : Hep B vaccine
      • Those who handle blood
      • Homosexual males
      • IV drug users
      • Hemodialysis patients
    • 2. Obtain rest to promote liver regeneration
  • HEPATITIS
    • PLANNING & IMPLEMENTATION
    • 3. Nutrition : Well- balanced, high P,
    • high C
    • 4. Providing comfort measures
    • 5. Administer medications :
      • Antivirals
      • Liver supplements
  • CIRRHOSIS
    • END RESULT OF HEPATO-CELLULAR INJURY
    • Parenchymal cell death
    • Regeneration & scarring
    • Diminished blood flow fibrosis
    • Fatty degeneration
    • Portal vein obstruction
    • TYPES:
    • Postnecrotic – post Hep B; macronodular
    • Portal (Laenec’s) – alcoholism; micronodular
    • Biliary – obstruction
    • Cardiac – from portal hypertension
  • CIRRHOSIS
    • ASSESSMENT:
    • Gastrointestinal System
    • DUE TO METABOLIC CHANGES IN THE LIVER (P,C,F )
      • Anorexia
      • Nausea & vomiting
      • Weight loss
      • Flatulence
      • Fatigue
    • ABDOMINAL PAIN
    • HEPATOMEGALY
    • ASCITES
  • Ongoing liver damage with liver cell necrosis followed by fibrosis and hepatocyte regeneration results in cirrhosis. This produces a nodular, firm liver. The nodules seen here are larger than 3 mm and, hence, this is an example of "macronodular" cirrhosis.
  • Mallory's hyaline is seen here, but there are also neutrophils, necrosis of hepatocytes, collagen deposition, and fatty change. These findings are typical for acute alcoholic hepatitis. Such inflammation can occur in a person with a history of alcoholism who goes on a drinking "binge" and consumes large quantities of alcohol over a short time.
  • CIRRHOSIS
    • ASSESSMENT:
    • Endocrine System
    • THE LIVER IS UNABLE TO METABOLIZE HORMONES OF THE ADRENAL CORTEX, OVARIES, ESTROGEN AND TESTES
    • AMENORRHEA
    • GYNECOMASTIA
    • LOSS OF PUBIC HAIR
    • IMPOTENCE
    • Hepato-Renal Syndrome
    • RENAL FAILURE WITHOUT DISEASE
  • CIRRHOSIS
    • ASSESSMENT:
    • Other:
    • JAUNDICE
    • ICTERIC SCLERAE
    • PRURITUS
    • SPIDER ANGIOMA
    • PALMAR ERYTHEMA
    • MUSCLE ATROPHY
    • PROLONGED
    • EASY BRUISING
    • LABS:
    • LIVER FXN TESTS
    • S. BILIRUBIN
    • PROLONGED Prothrombin time
    • DECREASED Serum Albumin
    • DECREASED Hgb & Hct
  • CIRRHOSIS - management
    • Sufficient rest & comfort
    • Measures to relieve pruritus
    • Nutrition: high calorie, low to moderate P, high C, low fat,Vit A, B comp, C, D and K
    • Monitor, prevent bleeding.
    • Diuretics if with ascites
    • Client teaching : avoid hepatotoxic drugs : opiates & sedatives, avoid alcohol
  • CIRRHOSIS
    • COMPLICATONS:
    • HEPATIC COMA
    • PORTAL HPN
    • ESOPHAGEAL VARICES
  • Submucosal veins in the esophagus become dilated. These are known as esophageal varices. Varices are seen here in the lower esophagus as linear blue dilated veins. There is hemorrhage around one of them. Such varices are easily eroded, leading to massive gastrointestinal hemorrhage.
  • One of the most common findings with portal hypertension is splenomegaly, as seen here. The spleen is enlarged from the normal 300 grams or less to between 500 and 1000 gm. Another finding here is the irregular pale tan plaques of collagen over the purple capsule known as "sugar icing" or "hyaline perisplenitis" which follows the splenomegaly and/or multiple episodes of peritonitis that are a common accompaniment to cirrhosis of the liver.
  • HEPATIC COMA
    • DEGENERATIVE DISEASE OF THE BRAIN FROM LIVER FAILURE
    • DUE TO INABILITY OF THE LIVER TO CONVERT AMMONIA TO UREA
    • CHANGES IN PERSONALITY AND BEHAVIOR
    • LETHARGY
    • CONFUSION
    • TREMORS
    • STUPOR
    • DIZZINESS
    • COMA
    • FETOR HEPATICUS – FRUITY ODOR BREATH
    • SPIDER TELANGIECTASIA
    • ELEVATED SERUM AMMONIA LEVELS
  • HEPATIC COMA
    • MANAGEMENT:
    • Neuro monitoring
    • Diet : Restrict P, high C, with Vit K
    • Administer:
      • enema,
      • cathartics
      • LACTULOSE – conversion of ammonia to nonabsorbable ammonium
      • intestinal antibiotics – NEOMYCIN
    • Management for cirrhosis
  • ESOPHAGEAL VARICES
    • DILATION OF THE VEINS OF THE ESOPHAGUS FROM PORTAL HYPERTENSION
    • PORTAL HYPERTENSION – resistance to normal venous drainage of the liver into the portal vein
    • MANAGEMENT:
    • Iced normal saline lavage
    • Blood transfusions
    • Vitamin K
    • Sengstaken Blakemore - 3 lumen
      • Keep scissors at bedside
      • Label each lumen
    • IV vasopressin
    • Surgery – shunting of blood to decompress varices
    • Sclerotherapy
    • Percutaneous embolization
  • CANCER OF THE LIVER
    • Primary
    • Secondary – liver is the most common site of CA mets
  • Here is an hepatocellular carcinoma. Such liver cancers arise in the setting of cirrhosis. Worldwide, viral hepatitis is the most common cause, but in the U.S., chronic alcoholism is the most common cause. The neoplasm is large and bulky and has a greenish cast because it contains bile. To the right of the main mass are smaller satellite nodules.
  • CANCER OF THE LIVER
    • S/SX :
      • Anorexia
      • Weight loss
      • Weakness
      • abdominal fullness and bloating
      • Abdominal pain
    • MANAGEMENT – Total Hepatic Lobectomy
    • RESECTION IS UP TO 90% OF THE ORGAN
  •  
  • DISEASES OF THE GALLBLADDER
    • CHOLELITHIASIS
    • CHOLECYSTITIS
  • CHOLELITHIASIS
    • FORMATION OF GALLSTONES
    • RISK FACTORS : 4 F’s : female, fat, forty, fertile
    • Multiparous
    • Oral contraceptives
    • Cirrhosis
    • Obesity
    • Hyperlipidemia
    • Total parenteral nutrition
    • Bile stasis
  • CHOLELITHIASIS
    • PRECIPITANTS:
    • Alteration in the concentration of lecithin, cholesterol, and bile salts
    • Metabolic changes
    • Cholecystitis
    • Biliary stasis
  • PATHOPHYSIOLOGY Bile acids and lecithin decrease in bile The capacity to dissolve cholesterol is reduced Excess cholesterol precipitate as crystals GALLSTONES
  • CHOLELITHIASIS
    • ASSESSMENT:
    • Biliary colic:
      • RUQ pain, usually postprandially
      • Referred pain: R subscapular
      • (BOA’S SIGN)
      • Epigastric pain
      • Nausea & vomiting
    • Evidence of choledocholithiasis:
      • Jaundice
      • Clay-colored stools
      • Hyperbilirubinemia
      • Elevated alkaline phosphatase
    • DIAGNOSIS :
    • Ultrasound
  • CHOLELITHIASIS
    • PLANNING & IMPLEMENTATION:
    • MEDICAL INTERVENTION
    • Low fat diet
    • Prevent dehydration
    • Medications:
      • Smooth Muscle relaxants: reduce spasm of the duct & permit bile passage
        • Papaverine
        • Nitroglycerine
        • NO Morphine!
      • Bile acids – Chenodeoxycholic acid (CHENIX) and Ursodeoxycholic acid (ACTIGALL) :for clients who are poor risk for surgery; Toxic to the liver
  • CHOLELITHIASIS
    • SURGICAL INTERVENTION
    • Cholecystostomy – draining of the gallbladder
    • Cholecystectomy – removal of the gallbladder
    • Choledocholithotomy – removal of stones from the common bile duct
    • Intraoperative Cholangiogram – dye in the bile duct thru the cystic duct, if with choledocholithiasis
  • GALLBLADDER SURGERY
    • PRE-OP NURSING CARE:
    • Assure optimal health
    • Instruct client over pre-operative plan
  • GALLBLADDER SURGERY
    • POST-OP NURSING CARE:
    • Prevent complications
    • Providing biliary drainage
    • Preventing distention
    • Manage pain – Fowler’s position
    • Maintain nutrition
    • Discharge planning & homecare – d/c after 7-10 days
  • GALLBLADDER SURGERY
    • COMPLICATIONS:
    • Bleeding
    • Cardiorespiratory
    • Thrombophlebitis
    • Wound Evisceration and Dehiscence
  • GALLBLADDER SURGERY
    • POST-OP NURSING CARE:
    • Prevent complications
    • Providing biliary drainage
    • Preventing distention
    • Manage pain – Fowler’s position
    • Maintain nutrition
    • Discharge planning & homecare – d/c after 7-10 days
  • GALLBLADDER SURGERY
    • BILIARY DRAINAGE:
    • Bloody drainage – normal during 1 st 2 hrs
    • Greenish brown drainage - after 2 hrs
    • 400 ml in 1 st 24 hrs, 200 ml/24 hrs thereafter
    • Placed above the bile duct to collect overflow drainage
  • GALLBLADDER SURGERY
    • BILIARY DRAINAGE:
    • T tube stays for 6 wks to 6 mos before it is removed
    • Color to urine & stool should be observed after removal of the tube
    • Chills and fever is normal with clamping of T tube during healing period.
  • GALLBLADDER SURGERY
    • POST-OP NURSING CARE:
    • Prevent complications
    • Providing biliary drainage
    • Preventing distention
    • Manage pain – Fowler’s position
    • Nutrition - when biliary drainage is reestablished:
      • Fat –restricted diet
    • Discharge planning & homecare – d/c after 7-10 days
  • GALLBLADDER SURGERY
    • PREVENTING DISTENTION:
    • NGT until peristalsis returns
    • Rectal tube – expulsion of flatus
    • Enema – 3 rd day – peristalsis and release of flatus
  • GALLBLADDER SURGERY
    • POST-OP NURSING CARE:
    • Prevent complications
    • Providing biliary drainage
    • Preventing distention
    • Manage pain – Fowler’s position
    • Nutrition - when biliary drainage is reestablished:
      • Fat –restricted diet
    • Discharge planning & homecare – d/c after 7-10 days
  • CHOLECYSTITIS
    • CAUSES:
    • Infection: Strep, Staph, E. coli, Typhoid
    • Gall stones
    • Sludge
    • Biliary stasis
    • S/SX:
    • Intolerance to fatty foods
    • Unrelenting RUQ pain & tenderness
    • Referred pain : right subscapular, epigastric
    • Nausea & vomiting
    • MURPHY’S SIGN
  • CHOLECYSTITIS
    • LABS:
    • Increased WBC
    • Increased serum amylase
    • DIAGNOSIS:
    • Utltrasound
    • COMPLICATIONS:
    • Abscess
    • Perforation
    • choledocholithiasis
  • CHOLECYSTITIS
    • MANAGEMENT
    • IVF
    • Antibiotic
    • NG tube decompression
    • Cholecystectomy
  •  
  • DISEASES OF THE PANCREAS
    • PANCREATITIS
      • ACUTE
      • CHRONIC
    • CANCER OF THE PANCREAS
  • INFLAMMATION EDEMA OBSTRUCTION OF PANCREATIC DUCT RUPTURE & RELEASE OF DIGESTIVE ENZYMES AUTOLYSIS OF PANCREATIC TISSUE NECROSIS PANCREATITIS
  • ACUTE PANCREATITIS
    • PREDISPOSING FACTORS:
    • Binge alcohol drinking
    • Biliary tract disease
    • Duodenal obstruction
    • Infection
    • Trauma
    • Nutritional deficiency
  • CHRONIC PANCREATITIS
    • PREDISPOSING FACTORS:
    • Alcohol ingestion
    • Gallbladder disease
    • Autoimmune factors
  • PANCREATITIS
    • RELIEF OF PAIN:
      • Demerol
      • NO MORPHINE!
    • DIET
      • Avoid caffeine and alcohol
      • Small frequent feeding of BLAND, easy digestable food
    • PANCREATIC EXTRACTS
      • Viokase/ Cotazym – facilitate digestion of fat-soluble vitamins
  • CANCER OF THE PANCREAS
    • S/SX:
    • Anorexia
    • Weight loss
    • Weakness
    • Nausea
    • Late signs: pain, jaundice ascites, palpable mass
    • SURGERY:
    • Whipples Procedure: removal of the head of the pancreas, distal stomach, CBD & duodenum
    • Which laboratory value would the nurse expect to find in a client as a result of liver failure?
    • Decreased serum creatinine
    • Decreased sodium
    • Increased ammonia
    • Increased calcium
  • God Bless