Hepatobilary disorders

1. Adult
Health
Nursing
Anisa Khadim
BSN Generic (4 year program)

2. Alteration in Hepatobiliary System
• Pancreatitis
• Pancreatic Pseudo Cyst / Abscess
• Pancreatic Carcinoma
• Hepatic Abscess
• Cancer of Liver
• Cirrhosis of Liver
• Cholecystitis
• Cholilithiasis
• Cancer of Gall Bladder

3. Objectives
At the end of the topic , I will be able to understand:
 The particular disease
 Causes
 Signs and symptoms
 Diagnostic tests
 Management
 Nursing intervention

4. Pancreas
Anatomy of Pancreas
 Organ of digestive and endocrine
system
 Located in the abdomen
 Behind the stomach
 Long , Tapered organ
 pancreas is about 6 inches (15
centimeters) long
 Pear shaped
Physiology of Pancreas
Works as both digestive (exocrine)
and endocrine glands
 As a part of Digestive System, it
secretes pancreatic juice that
helps in digestion of food entering
the duodenum
 As a part Endocrine System , it
regulates the blood sugar level
and secretes hormones like
Insulin and Glucagon

5. Pancreatic
Disorders

6. Pancreatitis
Def: It is defined as ;
“ Inflammation of Pancreas”
Causes
Conditions that can lead to pancreatitis include:
• Gallstones
• Alcoholism (main cause of chronic pancreatitis)
• Certain medications
• Pancreatic cancer
• Abdominal surgery
• Cystic fibrosis
• Infection
• Injury to the abdomen
• Obesity
• Trauma

7. Types of Pancreatitis
There are two types of Pancreatitis
1) Acute pancreatitis:
It develops suddenly and lasts for some days (8 to 10 days)
2) Chronic pancreatitis:
when acute phase of pancreatitis do not cure ,it leads to
chronic pancreatitis ( older than 3 month or more)

9. Signs and Symptoms
Acute pancreatitis signs and symptoms include:
• Upper abdominal pain
• Abdominal pain that radiates to your back
• Tenderness when touching the abdomen
• Fever
• Rapid pulse
• Nausea
• Vomiting

10. Signs and Symptoms contd.
Chronic pancreatitis signs and symptoms include:
• Upper abdominal pain
• Abdominal pain that feels worse after eating
• Losing weight without trying
• Oily, smelly stools (steatorrhea)

11. Diagnostic Tests
To diagnose following tests are performed:
 Complete blood count
 Ultrasound
 CT scan
 MRI
 Endoscopy

12. Management
Management for pancreatitis includes;
NPO (As body is unable digest food properly)
Analgesics (To relieve pain)
Antibiotics (To subside infection)
IV Fluids (To overcome dehydration)
For chronic pancreatitis , Pancreatic enzyme supplements are given
that help the body to process and digest food.

13. Complications
Acute pancreatitis can leads to;
• Kidney failure
• Infection
• Diabetes
• Malnutrition
• Pseudo Cyst
• Breathing Problems (due to chemical changes)

14. Nursing Intervention
• Relieve pain
• Oral feeding withheld
• Adequate parenteral fluids
• Oral hygiene
• Complete bed rest
• Relieve dryness of mouth
• Patient education

15. Pancreatic Pseudo Cyst
Def:
It is defined : ‘’Collection of leaked pancreatic fluid’’.
Causes:
Pancreatitis (leakage of enzymes harm the tissue of pancreas
Alcohol intake
Gallstones
Injury / Trauma
Tumor
Auto immune disease

16. Signs and Symptoms
 Stomach pain
 Fever
 Swollen belly
 Nausea and vomiting
 An abdominal mass detected on physical examination
 Dehydration
 Low blood pressure ( due to dehydration)
 Can be asymptomatic

18. Diagnostic tests
 Blood tests to check levels of amylase and lipase
 Serum electrolytes to check sodium ,potassium levels
 USG
 CT scan as confirmatory test
 MRI to check the extent of tissue involvement

19. Management
pseudo cysts are mostly treated symptomatically
 Pain killers
 Antibiotics
 Avoid solid diet
 Anti emetics to control nausea and vomiting
 Surgical management include the drainage of cyst via endoscopy

20. Nursing Intervention
 Relieve pain
 Oral feeding withheld
 Adequate parenteral fluids
 Oral hygiene
 Complete bed rest
 Relieve dryness of mouth
 Patient education

21. Pancreatic Carcinoma
Pancreatic cancer begins in the tissues of your pancreas — an organ in
your abdomen that lies behind the lower part of your stomach.
Most common type of cancer that forms in the pancreas begins in the
cells that line the ducts that carry digestive enzymes out of the
pancreas (pancreatic ductal adenocarcinoma)

23. Causes
Cause of pancreatic cancer is not clearly identified but several risk
factor can increase the incidence of disease, which include;
 Inherited gene mutation
 Smoking
 Trauma
 High nicotine intake
 Chronic inflammation of pancreas

24. Signs and symptoms
 Loss of appetite or unintended weight loss
 Yellowing of your skin and the whites of your eyes (jaundice)
 Light-colored stools
 Dark-colored urine
 Itchy skin (due to high bilirubin)
 New diagnosis of diabetes or existing diabetes that's becoming more
difficult to control
 Fatigue

25. Diagnostic tests
 Blood test (Tumor marker)
 Ultrasound abdomen
 Endoscopic ultrasound (EUS)
 CT scan
 MRI
 Biopsy

26. Management
Management may include medical and surgical.
Medical management:
• Symptomatic treatment
• Chemotherapy (Chemotherapy uses drugs to help kill cancer cells.)
• Radiotherapy (Radiation therapy uses high-energy beams, such as
those made from X-rays and protons, to destroy cancer cells)
• Chemo-radiation ( includes both chemotherapy and radiotherapy )

27. Surgical management
• Whipple procedure (pancreatico duodenectomy)
• Distal pancreatectomy(Surgery to remove the left side (body and tail)
of the pancreas)
• Total pancreatectomy (Life long insulin and enzyme replacement is
needed)

28. Nursing Interventions
• Pain management ( Morphine is drug of choice)
• Glucose monitoring
• Assess Nutritional status
• Monitor for adverse effects of chemo and radiotherapy
• Post op care (in case of surgery)
• Surgical site care
• Daily dressing of wound
• Assess signs of infection on incision site
• Family counselling
• Social support

29. Hepatic
Disorders

30. Liver
Anatomy
• Body's largest solid organ
• Around 3 pounds in adulthood
• Roughly the size of a football
• Left portion above the stomach and
the right portion above the first part of the small intestine.

31. Physiology / Functions of liver
The liver’s major functions are in the metabolic processes of the body.
These include:
• Breaking down or converting substances from food like fats and
proteins
• Extracting energy, vitamins, and minerals
• Making toxins less harmful to the body and removing them from the
bloodstream
• The liver also manufactures an estimated 800 to 1,000 milliliters (mL)
of bile a day

32. Liver Abscess
A liver abscess is a pus-filled cyst found in the liver.
Causes
• Trauma /Injury
• Bacterial infection
• Viral infection
• Diabetes
• GI conditions ( gastritis ,diverticula)

34. Types of Liver Abscess
Pyogenic liver abscess: Bacterial infection causes this abscess.
“Pyogenic” means producing pus. The bloodstream may carry infection
from more distant parts of the body.
Amebic liver abscess: The parasite Entamoeba histolytica causes this
abscess. E. histolytica causes amebic dysentery, an intestinal infection.
From the intestines, the parasite can travel through the bloodstream to
the liver.
Injury-induced liver abscess: Surgery, a diagnostic procedure, or trauma
to the liver may cause an abscess.

35. Signs and Symptoms
• Abdominal pain, especially in the upper right portion of the abdomen
• Dark urine
• Fever or chills leading to Tachycardia
• Malaise or lethargy
• Nausea with or without vomiting
• Clay colored stool

36. Diagnostic Tests
• Complete blood count
• Liver function blood test
• Blood cultures to check for bacterial infections
• Stool sample analysis
• Abdominal ultrasound
• Chest X-ray
• CT scan

37. Treatment
Medical Management:
Oral / IV antibiotics includes
• Aminoglycosides (Gram-negative antibacterial medicine i.e.
Amikacin)
• Combination piperacillin - tanzobactum
Surgical Management:
Surgical management include drainage of abscess via needle or
catheter insertion

38. Complications
• Empyema (pus accumulation in the chest)
• Encephalopathy (a decline in brain function)
• Endocarditis (inflammation of the heart’s inner lining and valves)
• Kidney failure
• Liver failure
• Peritonitis ( inflammation of tissue that lines the abdomen)

39. Nursing care/ Interventions
• Auscultation of breath sounds
• Monitor vital signs continuously
• Observe for pain
• Monitor patient’s level of consciousness
• Medication as prescribe
• Monitor for reaction of medicine
• Mobilization
• Nutritional status assessment
• Check for any signs of Other Organ involvement

40. Hepatic Cancer
Liver cancer is cancer that begins in the cells of live (mainly
Hepatocytes)
Causes:
• Liver cancer mainly caused by Mutation in DNA.
Other Risk Factor may include:
• Infection of liver (Hep B ,Hep C)
• Diabetes
• Fatty liver
• Excessive alcohol consumption

41. Signs and Symptoms
Most people don't have signs and symptoms in the early stages of primary liver
cancer. When signs and symptoms do appear, they may include:
• Losing weight without trying
• Loss of appetite
• Upper abdominal pain
• Nausea and vomiting
• General weakness and fatigue
• Abdominal swelling
• Yellow discoloration of your skin and the whites of your eyes (jaundice)
• White, chalky stools (bilirubin can’t be drained into the intestine)

42. Types of liver cancer
• Hepatocellular carcinoma(HCC) starts in the main type of liver
cells, called hepatocellular cells. Most cases of HCC are the result of
infection with hepatitis B or C, or cirrhosis of the liver caused by
alcoholism.
• Cholangiocarcinoma (bile duct cancer) occurs in the small, tube-
like bile ducts within the liver that carry bile to the gallbladder (about
10 % to 20%).
• Hepatoblastoma ,though rare, is the most common liver cancer in
pediatric patients. It occurs in the lobes of the liver.

43. Stages of Liver Cancer
• The stage of a cancer describes how much cancer is in the body. It
helps determine how serious the cancer is and how best to treat it.
• Liver cancer stages range from stage I (1) through IV (4).
• Stage 1 (less spreading)
• Stage 4 (highly spread)

44. Staging Systems
A variety of staging system can be used to determine spreading of cancer.
Most commonly used staging system is the AJCC (American Joint Committee
on Cancer) TNM system:
• The extent (size) of the Tumor (T): How large has the cancer grown? Is
there more than one tumor in the liver? Has the cancer reached nearby
structures like the veins in the liver?
• The spread to nearby lymph Nodes (N): Has the cancer spread to nearby
lymph nodes?
• The spread (metastasis) to distant sites (M): Has the cancer spread to
distant lymph nodes or distant organs such as the bones or lungs?

45. TNM Staging
Tumor (T):There are 4 main T stages – T1 to T4.
The T stage depends on:
• The size of the tumors
• Whether the cancer has grown into any blood vessels in the liver .
T1 : single tumor in the liver that is 2 cm or less, not involve blood vessels
T2 : single tumor that is more than 2cm and less than 5cm and it has
grown into blood vessels
T3 : several tumors in the liver, and at least one of them is more than 5cm
T4 : the cancer has grown in the close organs of liver , veins i.e. portal
vein

46. TNM Staging contd.
Nodes (N):
There are 2 N stages:
N0: Means that there are no cancer cells in nearby lymph nodes
N1: Means that there are cancer cells in lymph nodes near the liver.
Metastasis (M)
There are 2 M stages:
M0: Means there is no sign that the cancer has spread outside the liver
M1: Means there are cancer cells in other parts of the body such as the lungs
or bones (advanced cancer).

47. Pathophysiology
Etiologic factors
Genomic DNA change
Inflammation/Liver injury/Cirrhosis (initiation)
Loss of cellular growth control (promotion)
Adenomatous hyperplasia/ dysplasia
Genomic alteration
Hepatocellular carcinoma

48. Diagnostic evaluation
• Blood tests
• Imaging tests ( USG,CT,MRI)
• Tissue biopsy

49. Management
Medically , tumors are managed by :
• Radiation therapy
• Chemotherapy
• Combination of both (Radio and chemo therapy)
• Surgically ,tumors can be resected by:
• Lobectomy(Removal of affected lobe)
• Cryosurgery(Removal of tumor via freeze and thaw cycle)
• Liver transplant

50. Nursing Care Interventions
• Give analgesics as ordered and encourage the patient to identify care
measures that promote comfort.
• Provide patient with a special diet that restricts sodium, fluids, and protein
and that prohibits alcohol.
• To increase venous return and prevent edema, elevate the patient’s legs
whenever possible.
• Keep the patient’s fever down.
• Provide meticulous skin care.
• Turn the patient frequently and keep his skin clean to prevent pressure
ulcers.

51. Nursing Care Intervention contd.
• Prepare the patient for surgery, if indicated.
• Provide comprehensive care and emotional assistance.
• Monitor the patient for fluid retention and ascites.
• Monitor respiratory function.
• Explain the treatments to the patient and his family, including adverse
reactions the patient may experience.

52. Liver Cirrhosis/Hepatic Cirrhosis
It is defined as :
"Replacement of normal liver tissues with fibrosed (scarred)
tissues that disrupt structure and function of liver".

53. Types Of Hepatic Cirrhosis
1) Alcoholic Cirrhosis:
Scar tissue involve portal area
Due to chronic alcoholism
Most common type
2) Post-necrotic Cirrhosis:
Due to some viral infections (HCV , HBV)
3) Biliary Cirrhosis:
Around bile ducts
Due to biliary infection like biliary obstruction

54. Pathophysiology
Etiological factors (Alcoholism ,biliary statis)
Disruption of liver cells
Replaced by scarred tissues
Scarred area exceeds than normal
Liver Cirrhosis

55. Signs and Symptoms
Clinical manifestation can be divided in to 2 categories depending on severity of
disease.
Compensated Cirrhosis:
• Intermittent mild fever
• Vascular spiders (can be due to esophageal variceal bleeding)
• Palmar erythema (cause not identified but genetics and hormonal changes play
role)
• Unexplained epistaxis
• Ankle edema
• Vague morning indigestion
• dyspepsia
• Abdominal pain

56. Signs and Symptoms contd.
Decompensated Cirrhosis:
• Ascites
• Jaundice
• Weakness
• Muscle wasting
• Weight loss
• Continuous mild fever
• Clubbing of fingers (inflamed soft tissues at the end of fingers and nails)
• Purpura (due to decreased platelet count)
• Spontaneous bruising
• Epistaxis
• Hypotension

57. Diagnostic Evaluation
• Blood test ( LFTs , S/Albumin)
• USG
• CT Scan
• MRI
• ABGs Analysis ( reveal hypoxia)

58. Management
Liver Cirrhosis is managed syptomatically:
• Antacid (to decrease gastric distress)
• Sandostatin (to decrease inner GI bleeding)
• Diuretics( to overcome ascites)
• Nutritional supplements

59. Nursing Interventions
• Assess vital signs ( keep an eye on BP)
• Assess pain level
• Assess for signs of hypoxia ( difficult breathing , cold skin, sweating)
• Measure abdominal girth daily
• Monitor nutritional status
• Fluid and salt restriction
• Monitoring for any bleed ( from any orifice of body)
• GCS monitoring
• Prevention from pressure ulcers
• Teaching self-care

60. Complications
• Bleeding / Hemorrhage
• Fluid overload
• Hepatic encaphlopathy

62. Biliary
Disorders

63. Gall Bladder
Anatomy
• Pear shaped organ
• Lies in inferior surface of liver
• Hollow ,saclike organ
• 7.5 to 10cm long
• Storage capacity (30ml to 50ml)
Physiology
• Stores bile
• Concentration of bile

64. Cholecystitis
Cholecystitis is “’Acute inflammation of the gallbladder’’.
Causes:
• Surgical procedures
• Trauma
• Ductal problems (cystic duct obstruction)
• Tumor

65. Clinical Manifestations
• Severe pain in right upper quadrant
• Pain radiates toward right shoulder
• Tenderness on physical examination
• Fever
• Nausea and vomiting

66. Diagnostic Evaluation
• Blood tests
• Imaging procedures
• Scanning
Management :
• Medically, we manage cholecystitis Symptomatically.
• Surgical measures include drainage of gall bladder and Removal of gall
bladder

67. complications
• Infection
• Death of gall bladder tissue (due to compromised blood supply)
• Torn gall bladder (tear/perforation)

68. Cholelithiasis
Def:
‘’Formation of stones in the gall bladder’’.
Causes:
• Biliary obstruction
• Diet high in cholesterol
Several risk factor may contribute to cholelithiasis:
• Obesity
• Age ( > 40 years are at higher risk)
• Cystic fibrosis( genetic disorder)
• Estrogen therapy (increases cholesterol level in bile)
• Infection etc.

69. Clinical Manifestations
• Pain
• Jaundice
• Changes in urine and stool color
• Vitamin deficiencies (due to malabsorption)
• Pain radiating to right shoulder
• Intolerance to fatty food
• Signs of dyspepsia

71. Diagnostic Evaluation
• Blood tests
• Imaging test (USG .X-Ray, CT ,MRI)
• Imaging procedures like:
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Cholecystography ( using contrast agent)
• Percutaneous Transhepatic Cholangiography ( dye injected direct into
the biliary tract)

72. Management
Medically , we treat cholelithiasis with:
• Pain relievers
• Anti biotics
• Dietary modifications
Surgical Management:
• Laparoscopic cholecystectomy
• Cholecystectomy
• Choledochostomy (Incision into the common duct)

73. Nursing Care Interventions
• Relieving pain
• Provide skin care
• Check respiratory status frequently
• Check for biliary drain
• Wound care
• Check for any complications
• Teach self-care to the patient

74. Cancer of Gall Bladder
• Gallbladder cancer is an abnormal growth of cells that begins in the
gallbladder.
• Gallbladder cancer may not be discovered in early stages due to its
hidden position.

75. Causes and Risk factors
Exact cause of gall bladder cancer is not known but Gene Mutation
plays role in causing it.
Risk factors include:
• Age ( >years increases the risk)
• Sex ( Females are more prone)
• History of gall stones
• Other gall bladder diseases
• Inflammation of bile duct

77. Clinical Manifestations
Gallbladder cancer signs and symptoms may include:
• Abdominal pain, particularly in the upper right portion of the
abdomen
• Abdominal bloating
• Losing weight without trying
• Yellowing of the skin and whites of the eyes (jaundice)

78. Diagnostic Evaluation
• Blood tests
• Imaging tests
Management:
• Surgery to remove the gallbladder
• Surgery to remove the gallbladder and a portion of the liver
• Chemotherapy
• Radiation Therapy

79. Thank
You!!!