Frank MacDonald RN, MN



UNIT 13

Alterations in Function of the Hepatobiliary System and Exocrine Pancreas

Originally developed by:

Anne Mueller RN, MN

Revised (1993) by:

Dot Hughes RN, Msc, PhD

Updated (2000) by:

Marlene Reimer RN, PhD, CNN (C)

Unit 13 Table of Contents

Overview 3

Aim 3

Objectives 3

Resources 3

Web Links 4

Section 1: Disorders of the Liver 5

Learning Activity #1 5

Section 2: Disorders of the Liver—Hepatitis 12

Introduction 12

Learning Activity #2 12

Section 3: Disorders of the Exocrine Pancreas 14

Introduction 14

Pathophysiology 15

Clinical Manifestations 17

Learning Activity #3 18

Evaluation and Treatment 19

Section 4: Disorders of the Gallbladder 22

Introduction 22

Pathophysiology 23

Clinical Manifestations 25

Evaluation and Treatment 26

Final Thoughts 30

References 31

Glossary 32

Acronym List 32

Checklist of Requirements 32

Required Readings 32

Learning Activities 32

Answers to Learning Activities 33

Answers to Learning Activity #2 33

Structure and Function of the Pancreas 33

Answers to Learning Activity #3 34

Answers—Surgical interventions in pancreatitis 35

Disorders of the Gallbladder 36

UNIT 13

Alterations in Function of the Hepatobiliary System and Exocrine Pancreas

The hepatobiliary system may not seem like a very exciting topic, certainly not as stimulating as cardiology or immunology. You may be approaching this section with some dread; however, by the end of this unit you may think differently.

The hepatobiliary system has a profound impact on our very existence. Without an adequately functioning system we would be unable to process and utilize nutrients provided through digestion, and would be unable to rid ourselves of toxic materials. Dysfunction of the hepatobiliary system can lead to a life of discomfort and restrictions, and may ultimately lead to death.

The hepatobiliary system is comprised of the “accessory organs of digestion.” You will come to see shortly that these accessory organs are closely linked, such that disease in one organ can have serious consequences on other organs. Similarly, disease within one portion of the system can have serious and sometimes fatal effects on the whole. The knowledge you will acquire in this section about disorders of the liver, the pancreas and the gallbladder will strengthen your assessment skills and aid in providing complete, competent nursing care.

Overview

This unit contains three parts:

1. Disorders of the liver (cirrhosis, hepatitis).

2. Disorders of the exocrine pancreas.

3. Disorders of the gallbladder.

Aim

The general aim of this unit is to assist you in gaining an understanding of how disorders of the hepatobiliary system and exocrine pancreas affect the individual. By the end of this section you will appreciate the complexity of the hepatobiliary system and its impact on total body functioning. You will accomplish this by integrating knowledge of pathophysiology, clinical manifestations and treatment regimes.

Objectives

Following the completion of this unit you will be able to:

1. Differentiate between different types of hepatitis.

4. Explain the mechanism behind the clinical manifestations of liver disease.

5. Describe the clinical manifestations of acute pancreatitis.

6. Describe the pathogenesis of cholelithiasis and cholecystitis.

Resources

Required

Print Companion: Alterations in Function of the Hepatobiliary System and Exocrine Pancreas

Haicken, B. (1991). Laser laparoscopic cholecystectomy in the ambulatory setting. Journal of Post Anesthesia Nursing, 6(1), 33-39.

Porth, C. M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed). Philadelphia: Lippincott. Chapter 40

Peicher, A., & Schiff, E. R. (1988). Acute viral hepatitis. Hospital Medicine, 24(6), 23-41.

Learning Activities

Activities for this unit include Learning Activities 1, 2, and 3.

Supplemental Materials

Supplemental materials include:

Ambrose, M.S. & Dreher, H.M. (1996). Pancreatitis: Managing a flare-up. Nursing 96, 24 (4), 33-40.

Brown, A. (1991). Acute pancreatitis: Pathophysiology, nursing diagnoses, and collaborative problems. Focus on Critical Care, 18 (2), 121-130.

Covington, H. (1993). Nursing care of patients with alcoholic liver disease. Critical Care Nurse, 13 (3), 47-59.

Doherty, M.M. & Carver, D. (1993). Transjugular intrahepatic portosystemic shunt: New relief for esophageal varices. American Journal of Nursing, 93 (4), 58-63.

.

Web Links

All web links in this unit can be accessed through the Web CT system.

Section 1: Disorders of the Liver

In the unit dealing with disorders of the gastrointestinal system the pathophysiology of specific units was examined by studying representative diseases or disorders. The format used led you through an examination of the disorder’s pathophysiology, clinical manifestations, and treatment. We will depart from this format while examining liver disorders.

While there are numerous liver disorders, many of them share common clinical manifestations. These include portal hypertension, ascites, esophageal varices, hepatic encephalopathy, and jaundice. It is important therefore to understand the underlying mechanisms of these manifestations so that you will appreciate their impact on the patient regardless of their underlying etiology.

Learning Activity #1

Prior to beginning this portion, you are expected to read p. 917-925 in Porth as this will give you an indepth understanding of the functions, anatomy and physiology of the liver. When you complete your reading, work through the following case study and apply your knowledge in answering the case study questions.

Remember that your goal is to work through how the pathophysiology results in certain clinical manifestations, not to simply reproduce those manifestations in your answers.

Disorders of the Liver: Case Study

Patient Name: John Smith

Age: 32

Occupation: house painter

Accommodation: lives alone

Marital Status: single

Presentation to Hospital:

On November 12, 1989, John came to the emergency department complaining of generalized malaise, anorexia, nausea, and vomiting. These symptoms had become progressively worse over the past few days. John was obviously jaundiced in appearance and upon questioning admitted that people had been commenting on his “yellow” appearance. John’s history revealed that he had a ten-year history of alcohol abuse involving 26 ounces of liquor and “a few bottles of beer” daily. He was a nonsmoker, denied the use of street drugs, and his only medication has been 5 or 6 Tylenol per day for headaches. John had no known allergies.

John’s physical exam revealed:

CNS: somnolent but cooperative, oriented

CVS: vital signs T. 38 P. 100 R. 20 BP. 100/60

normal heart sounds, elevated jugular vein pressure 5 cm. above clavicular

bilateral edema to the knees

jaundiced skin and sclera

easy bruising, occasional severe nosebleeds

several spider nevi

CHEST: good air entry, chest clear

GI: protuberant abdomen, tender right upper quadrant

liver palpable 14 cm. below the costal margin

swollen varicose veins draining up from the umbilicus

normal colored stools

GU: dark yellow urine

John was admitted to an acute medical unit where his admitting laboratory work revealed the following (normal values are shown in brackets):

|Hgb 113 (135-180 g/L) |Hct 0.34 (0.40-0.54 L/L) |

|RBC 3.13 (4.5-6.3 X 1012/L) |WBC 16.3 (4-10.0 X 109/L) |

|Platelets 126 (150-400 X 109/L) |

|PT 16.8 (9-11.7 sec.) |PTT 63.9 (24.0-36.5 sec.) |

|INR (International Normalized Ratio) 1.7 (0.8-1.1) |

|ALT 52.3 (5-35 IU/L) |AST 78.7 (8-20 U/L) |

|Electrolytes were found to be normal. |

|Total Bilirubin 25 umol/L ( ................
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