The document summarizes key aspects of the accessory organs of the digestive system including the liver, gallbladder and bile ducts, and pancreas. It describes the anatomy, functions, common diseases, and nursing care considerations for conditions that can affect each organ system.

1. ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM

2. REVIEW OF ANATOMY AND PHYSIOLOGY ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM: Liver Gall bladder and ductal system Pancreas

3. 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.

4. 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

5. 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

6. 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

7. 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

8. CASE STUDY Sirius, 54 y.o., was brought by his family because of vomiting of blood. He’s drowsy, with VS of : 36 o , 110, 28, 80/60. He’s a chronic alcoholic; jaundiced & with big abdomen

9. CASE STUDY What other assessment findings would you expect? What are your plans?

10. NURSING ASSESSMENT MANIFESTATIONS OF LIVER DISORDERS Jaundice Hemorrhage / bleeding problems Pruritus and itching Ascites Generalized Edema Intolerance of Sedation

11. MANIFESTATIONS OF LIVER DISORDERS JAUNDICE CAUSES: Prehepatic – hemolysis Intrahepatic – liver parenchymal dse Poshepatic – obstruction of bile ducts

12. 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.

13. 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

14. MANIFESTATIONS OF LIVER DISORDERS ASCITES Causes : portal hypertension decreased plasma colloid osmotic pressure hyperaldosteronism

15. 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

16. MANIFESTATIONS OF LIVER DISORDERS GENERALIZED EDEMA Insufficient albumin INTOLERANCE OF SEDATION Most sedatives are metabolized in the liver except phenobarbital

17. DISEASES OF THE LIVER HEPATITIS CIRRHOSIS CANCER OF THE LIVER

18. HEPATITIS TYPES: Viral Hepatitis Toxic Hepatitis – exposure to hepatotoxin : carbon tetrachloride. Morphine, barbiturates

19. HEPATITIS Hepatitis A Infectious Fecal-oral route Hepatitis B Serum hepatitis Blood & body fluid transmission

20. HEPATITIS DIAGNOSIS: Screening test for Hepatitis Liver function tests: SGOT Alkaline Phosphatase SGPT Imaging: Ultrasound

21. 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.

22. 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

23. 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

24. HEPATITIS PLANNING & IMPLEMENTATION 3. Nutrition : Well- balanced, high P, high C 4. Providing comfort measures 5. Administer medications : Antivirals Liver supplements

25. 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

26. 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

27. 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.

28. 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.

29. 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

30. 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

31. 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

32. CIRRHOSIS COMPLICATONS: HEPATIC COMA PORTAL HPN ESOPHAGEAL VARICES

33. 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.

34. 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.

35. 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

36. 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

37. 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

38. CANCER OF THE LIVER Primary Secondary – liver is the most common site of CA mets

39. 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.

40. 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

42. DISEASES OF THE GALLBLADDER CHOLELITHIASIS CHOLECYSTITIS

43. CHOLELITHIASIS FORMATION OF GALLSTONES RISK FACTORS : 4 F’s : female, fat, forty, fertile Multiparous Oral contraceptives Cirrhosis Obesity Hyperlipidemia Total parenteral nutrition Bile stasis

44. CHOLELITHIASIS PRECIPITANTS: Alteration in the concentration of lecithin, cholesterol, and bile salts Metabolic changes Cholecystitis Biliary stasis

45. PATHOPHYSIOLOGY Bile acids and lecithin decrease in bile The capacity to dissolve cholesterol is reduced Excess cholesterol precipitate as crystals GALLSTONES

46. 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

47. 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

48. 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

49. GALLBLADDER SURGERY PRE-OP NURSING CARE: Assure optimal health Instruct client over pre-operative plan

50. 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

51. GALLBLADDER SURGERY COMPLICATIONS: Bleeding Cardiorespiratory Thrombophlebitis Wound Evisceration and Dehiscence

52. 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

53. 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

54. 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.

55. 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

56. GALLBLADDER SURGERY PREVENTING DISTENTION: NGT until peristalsis returns Rectal tube – expulsion of flatus Enema – 3 rd day – peristalsis and release of flatus

57. 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

58. 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

59. CHOLECYSTITIS LABS: Increased WBC Increased serum amylase DIAGNOSIS: Utltrasound COMPLICATIONS: Abscess Perforation choledocholithiasis

60. CHOLECYSTITIS MANAGEMENT IVF Antibiotic NG tube decompression Cholecystectomy

62. DISEASES OF THE PANCREAS PANCREATITIS ACUTE CHRONIC CANCER OF THE PANCREAS

63. INFLAMMATION EDEMA OBSTRUCTION OF PANCREATIC DUCT RUPTURE & RELEASE OF DIGESTIVE ENZYMES AUTOLYSIS OF PANCREATIC TISSUE NECROSIS PANCREATITIS

64. ACUTE PANCREATITIS PREDISPOSING FACTORS: Binge alcohol drinking Biliary tract disease Duodenal obstruction Infection Trauma Nutritional deficiency

65. CHRONIC PANCREATITIS PREDISPOSING FACTORS: Alcohol ingestion Gallbladder disease Autoimmune factors

66. 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

67. 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

68. 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

69. God Bless