HEPATOBILIARY AND PANCREATIC                                          common bile duct, stones within the bile ducts,
DISORDERS                                                             or sclerosing cholangitis.
                                                                     Informed consent
Laboratory and Diagnostic Tests                                      Assess for allergies to iodine, seafood, or
Hepatobiliary Scan                                                    contrast agent
     Noninvasive nuclear medicine study ( also                      NPO for at least 4 hours before the procedure
         referred to as HIDA scan based on the isotopes              Monitor PT or INR
         use)                                                        Report frank blood and blood clots
     Aids in the diagnoses of hepatobiliary disorders               Monitor V/S and assess puncture site
         such as common bile duct obstruction, acute
         and chronic cholecystitis, bile leak, biliary       Biopsy of the Liver
         atresia, and liver transplant function              Preparation
     A radioactive agent is administered I.V. It is              Secure written consent
         taken up by the hepatocytes and excreted                 NPO 2-4 hrs
         rapidly through the biliary tract.                       Vit K injection
     NPO for 4 hours before the test                             Monitor Protime, initial VS
     If possible no opiates should be administered               LLP or supine with pillow under the right
         for at least 4 hours before the test                         shoulder
     Tell the patient that the scan time may be up to            Instruct to exhale deeply, hold breath during
         4 hours                                                      needle insertion
Endoscopic Retrograde Cholangiopancreatography                    Care after liver biopsy
(ERCP)                                                            Turn to R side for 4 hrs to apply pressure
     Direct visualization with radiographic                      Bed rest for 24 hrs
         examination of the liver, gallbladder and                Monitor VS every 30 min – q hr for the 1st 24 hr
     Contrast medium introduced via the endoscope,          Fat metabolism
         as x ray are taken simultaneously.                  •Serum total cholesterol and cholesterol esters
Preparation                                                                    NV: 140-200 mg/dl
     Secure written consent                                 •Serum phospholipids
     NPO 10-12 hrs                                                            NV: 150-200 mg/dl
     Check for allergy to iodine/seafoods
     Take initial VS                                        Protein metabolism
     AtropineSO4, valium, local anesthetic                  Total Serum Protein – NV- 6-8 gm/dL
     Place in left side                                     Immunoglobulins
     Care after ERCP                                        BUN
     NPO til gag reflex return                              Protime, PTT, APTT
     Turn to sides                                          Blood NH3 levels
     Monitor VS
     Monitor signs & symptoms of sepsis,                    Bilirubin metabolism
         perforation, pancreatitis                           •Total serum bilirubin – N - 0.4 – 1.0
Endoscopic Ultrasound (EUS)                                  •Conjugated/direct bilirubin- N- 0-0.4
     A high-frequency ultrasound probe is placed at         •Unconjugated/indirect bilirubin – N- 0.2- 0.8
         the tip of an endoscope to assess the pancreas      •Urine bilirubin/foam test
         through the GI lumen.                               •Urine urobilinogen
     It is useful in staging pancreatic tumors;                      NV- random- <0.25 mg/dL
         establishing the size of the tumor, its extension                       24-hr urine test – up to 4 mg /24
         into adjacent structures, local, and regional       •Fecal urobilinogen/stercobilin
         nodal involvement, and any blood vessels that
         may be involved                                     AST/SGOT- NV- M- 10-40 U/L
     Tissue maybe obtained by fine-needle                                   F- 8-35 U/L
         aspiration through EUS.                             ALT/SGPT –NV- M- 10-40 U/L
     Care same as ERCP                                                      F – 8-35 U/L
                                                                           most specific indicator of liver
Percutaneous Transhepatic Cholangiography (PTC)              function
     Helps distinguish obstructive jaundice caused          LDH –NV- 90-176 mU/L
       by liver disease from jaundice caused by biliary      ALKALINE PHOSPHATASE- NV – 50-120 U/L
       obstruction such as tumor, injury to the
Paracentesis (peritoneal tap)                                         Monitor wt, I & O, abdominal girth
Preparation                                                           Restrict Na and fluid intake
 Secure written consent                                              Administer diuretics as ordered
 Check initial VS                                                         o Initially K-sparing diuretic
 Ask to empty bladder to prevent puncture                                 o Later, K-wasting diuretic
 Check serum protein studies                                         Administer albumin/IV as ordered
 Place in sitting/upright position                                   Assist in paracentesis

Care after paracentesis                                  Esophageal Varices
 Assess VS, UO                                             • Avoid the following to prevent rupture of the
 Check for rigidity of abdomen                                 varices
 Check for signs & symptoms of hypovolemic shock            Shouting., yelling, screaming
                                                             Straining at stool
Liver Cirrhosis                                              Bending, stooping
Characterized by scarring. It is a chronic disease in       Lifting heavy objects
which there has been diffuse destruction and fibrotic        Hot, spicy foods
regeneration of hepatic cells.
                                                         If bleeding esophageal varices occurs:
Assessment                                                Semi fowler’s position
 anorexia                                                Suction mouth
 Weakness                                                Administer IVF, blood, plasma expanders as orderd
 wt loss                                                 Vasopressin as ordered
 fever                                                   Gastric lavage with tap water as ordered
 Jaundice                                                Sclerotherappy, variceal band ligation, ballon
 Pruritus                                                    tamponade
 tea-colored urine                                       Portosystemic shunting: portocaval, splenorenal,
 bleeding tendencies                                         mesocaval
 decrease resistance to infection
 ascites                                                Hepatic Encephalopathy
 portal HPN                                                 Life-threatening complication of liver disease,
 edema                                                          occurs with profound liver failure and may
 asterexis                                                      result from the accumulation of ammonia and
 hepatic encephalopathy                                         other toxic metabolites in the blood
 Males                                                      Restrict protein in the diet
    • Gynecomastia                                           Laxative
    • Decreased libido                                       NeomycinSO4
    • Impotence                                              Tap water or NSS enema
    • Fall of body hair
    • Atrophy of testicle                                Hepatitis
Females                                                       Acute inflammatory disease of the liver
     Hirsutism                                               Can be caused by virus, bacteria or any toxin
     Acne                                                    Types are:
     Deepening of voice                                              • Toxic hepatitis
     Virilism                                                        • Viral hepatitis
General Consideration                                                          • Hepatitis A
    • Rest                                                                     • Hepatitis B
    • Diet: early stage – high calorie, high CHO,                              • Hepatitis C
        high protein, low fat                                                  • Hepatitis D
         late stage – high calorie, high CHO, low                              • Hepatitis E
                      protein, low fat                                         • Hepatitis G
    • Skin care                                          Preventive Measures in Person Infected with Hepa
    • Avoid trauma/injury                                Virus
    • Prevent infection                                       In Hep A & E, enteric precaution should be
    • Avoid sedatives                                         implemented
    • Avoid aspirin                                           For clients with HepaType B,C,D body fluid
    • Eliminate alcohol                                           precaution should be observed
                                                              Instruct client with hepatitis not to donate
    blood                                                      5.  Provision of comfort measures
     Advise client with Hepa B, C, D not to have                       Relieve pruritus
        intimate sexual contact                                         Provide comfortable environment
                                                           Viral Hepatitis
Viral Hepatitis                                            General Consideration
Preicteric phase (prodromal phase)                          Hand washing by all person
• last for 1 week                                           Feces, urine, blood and other body fluid precaution
Assessment:                                                 Contaminated needles and other instruments that
 Fever                                                     came in contact with infected body fluids should
 chills,                                                   be handled with great care and properly discarded
 N/V                                                       Practice “Universal Precaution” in all clients
 ANOREXIA                                                  Do not recap needles
 headache,                                                       Proper sterilization of equipments
 arthralgia,
 body malaise                                             Toxic Hepatitis
 RUQ tenderness                                           Etiology
 Hepatomegaly                                             • Drugs, alcohol, industrial toxin, poisonous
 lymphadenopathy                                              chemicals
Icteric phase                                              Assessment
 Starts with onset of jaundice                                 anorexia, N/V
 Reaches intensity in 2 wks, last from 4-6 weeks               lethargy
 Assessment: progression of symptoms                           icterus
Posticteric phase                                               hepatomegaly
 Disappearance of jaundice                                Collaborative management
 Last for several weeks up to 4 months                              Patient education
                                                                     Rest
Management                                                           Maintain FE balance
1. Promote rest                                                      Promote well-balance diet
2. Maintenance of food and fluid intake                              Identify toxic agent and eliminate it
             • 3,000 ml/day of fluids, I & O and wt                  Gastric lavage
             • Well-balance diet, fruit juices and         Diagnostic Tests for GB Function
                  carbonated        beverage               1. Ultrasound of the gall bladder
             • Fat restriction                             2. Cholecystography
             • Avoid alcoholic beverage                    • Oral cholecystography
3. Medical Management                                      • IV cholecystography
    1. Interferon (Intron-A) –anti-neoplastic,                  Preparation for oral cholecystography
    immunoregulator                                             Fat free dinner, then NPO for 2 hrs
          Administered by injection                            Contrast medium/oral, take 1 tab q 5 min x 6 or
          S/E- fever, chills, anorexia, nausea,                    12       tabs
             myalgias, fatugue                                  1 glass of water only for entire tablets
    2. Lamivudine (Epivir)- oral nucleoside analogue            NPO for 10 hrs, then X ray is taken in AM
    3. Adefovir (Hersera) –oral nucleoside analogue             High fat meal to stimulate contraction
          Have been approved for use in chronic                Series of x rays are taken
             hepatitis in the U.S.                              Poor visualization of GB indicates obstruction
          Studies have revealed improved
             seroconvertion rates, loss of detectable      Cholangiography
             virus, improved liver function, and reduced       X ray visualization of the bile ducts following
             progression to cirrhosis.                                     administration of contrast medium
    4. Ribavirin (Rebetol, Virazole) - Antiviral               Preparation
                                                                   Assess for iodine allergy
4. Prevention of injury/bleeding precaution                        Drink ample fluids after dye administration
              Monitor PT, hct, hgb                                IVF if client is unable to drink fluids
              Avoid parenteral injections                        • Care after the procedure
              Apply pressure on injection sites for 5         Assess for delayed hypersensitivity reaction
                  min                                          Burning sensation on voiding is felt due to
              Monitor urine, stool, skin petechiae,              excretion of dye
                  administer Vit K as      ordered
        Poor x ray visualization indicates biliary             DBCT
         obstruction                                            Vit K injection
Cholelithiais/Cholecystitis                                Postop Care
                                                                Low or semi-fowler’s position
Cholelithiasis is stone formation in the GB                     NGT for decompression
Cholecystitis is inflammation of the GB                         DBCT
          Cause: unknown                                        Diet: low fat for 2-3 months
Predisposing factors                                            Ambulation after 24 hrs post op
      female,                                                  T tube if with CBD exploration
      fat                                                         • Purpose is to drain bile
      forty                                                       • Drainage:
      fair complexion                                                   Brownish red for 1st 24 hrs
      fertile                                                           300-500 ml of bile drainage for 1st 24
Theories                                                                   hrs
      Metabolic factors                                                 Drainage bottle should be placed in
      Biliary stasis                                                      bed at level of incision to drain excess
      Inflammation                                                        but not all of the bile
Composition of Gall stone                                  Pancreatitis
      Cholesterol                                             • Inflammation of the pancreas
      bile salts                                              • Can be acute or chronic
      Ca                                                      • Causes:
      bilirubin                                                         alcohol
      protein                                                           drugs
Assessment                                                               biliary obstruction
      Decreased fat emulsification                                      intestinal diseases
      fat intolerance                                                   autoimmune
      anorexia, N/V                                                     idiopathic
      flatulence                                          Assessment
      steatorrhea                                          pain (LUQ)
      Inflammation                                         fever
      pain (RUQ)                                           anorexia
      fever,                                               N/V severe dehydration
      leukocytosis                                         Steatorrhea
      Decreased bile flow in colon                         wt loss
      acholic stool, poor absorption of fat soluble vit    jaundice
      Increased serum bilirubin                            hyperglycemia
      jaundice, pruritus, tea-colored urine                hypocalcemia
      Infection                                            Serum amylase, serum lipase, urine lipase is
      cholecystitis, pancreatitis                             elevated
Management                                                  Post hemorrhagic necrosis/purplish discoloration
1.Relief of pain - Morphine                                 Cullen sign (preiumbilical area)
     Note: The use of morphine has traditionally been       Grey-Turner sign (flanks)
     avoided because of the concern that it could cause
     spasm of the Sphincter of Oddi, and meperidine has    Management
     been used instead. This is controversial because          Relieve pain: the current recommendation for
     morphine is the preferred analgesic agent for                pain management is the use of Morphine and
     management of acute pain, and meperidine has                 Dilaudid
     metabolites that re toxic to the CNS that can cause       Diet: NPO in acute phase, then bland, low fat
     seiziure. Furthermore, all opiods stimulate the              diet
     sphincter of Oddi to some degree. (Brunner 2008           TPN for nutritional supplement
     edition)                                                  IVF to replenish deficit
2.Diet: low fat diet                                           NGT – remove gastrin and secretion from
3.Bile salts: chenodeoxycholic acid, ursodioxycholic              intestines to give rest to pancreas
acid given after meals                                         Digestive enzymes after meals
4.Surgery: cholecystectomy                                     Antimicrobials
                                                               Ca supplement
Preop care:                                                    Vit D to promote Ca absorption
     IVF to replace loss in vomiting                          Insulin to manage hyperglycemia

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