1 - What you Need to Know
Elimination (Liver, Pancreas, & Gallbladder)Pathophysiology Case Study & Integration Concept Map Case 1L.B. is a 45-year-old Caucasian woman with three children—ages 4, 6, and 10 years. She works long hours as an instructor at a local college to support her three children and husband who is disabled. She has had a 6-month history of severe bouts of abdominal pain associated with indigestion, gas, and steatorrhea. Fatty foods seem to exacerbate the symptoms. L.B. is about 40 pounds overweight. A CT scan of L.B.’s abdomen revealed multiple stones in her gallbladder. She was scheduled for a cholecystectomy.Discussion Questions What risk factors does L.B. have that predispose her to development of gallstones? Risk factors that predisposed L.B. to cholelithiasis are, she is female, Caucasian, & obese.Why are fatty foods often associated with an exacerbation of symptoms? Increase in fatty food intake increases GB to contract & release bile that is saturated with cholesterol that turns into bile salts (crystals) and cause hypomotility or stasis of bile in the bile duct. The stasis of bile crystals then fuses together to form gallstones in the GB.What is the relationship between gallstones and cholecystitis? The relation between gallstones & cholecystitis is the ongoing presence of gallstones in the gallbladder will cause walls of the gallbladder to become inflamed with fibrosis & wall thickening.Case Study 2F.C. is a 54-year-old man with a history of chronic heavy alcohol use. He has frequent bouts of gastrointestinal bleeding for which he has been hospitalized on six separate occasions over the years. He continues to drink and exhibits most of the common manifestations of alcoholic cirrhosis. He was recently hit by a car and was hospitalized for a broken leg. He appeared to be under the influence of alcohol at the time of the accident and had a blood alcohol level of 1.8. F.C.’s family reports that his mental functioning has deteriorated significantly over the past few months.Discussion Questions What are the common manifestations of alcoholic cirrhosis? Which of these are secondary to hepatocellular failure? Which are secondary to portal hypertension? Some common manifestations of cirrhosis are hepatomegaly, fever (due to inflammation of the liver cells), abdominal pain, weight loss (anorexia – d/t multiple failure of liver functions), changes in bowel habits, hypoalbuminemia (causes edema in lower extremities, working its way up), ascites & anemia, Secondary to hepatocellular failure is jaundice.Secondary to portal HTN is gastroesophageal varices.Why is F.C. at particular risk for GI bleeding? F.C. is at risk for GI bleeding because cirrhosis leads to portal HTN that cause gastroesophageal varices. Once formed, patient is at risk for hemorrhage due to rupture of vessel from increased portal pressure. Pt may also be experiencing hypokalemia which reduces clotting factors.What is the probable cause of F.C.’s progressive mental deterioration? F.C.’s mental deterioration is possible caused by an increased level of ammonia in the blood that has not been detoxified in the liver. Hepatic encephalopathy results from severe chronic liver disease.4. Draw a concept map of the development of portal hypertension caused by cirrhosis.See the following pageAlcoholic Cirrhosiscenter42545Alcohol abuseAlcohol abuse2209800850900027432008509000381000104775Accumulation of fat in liver cells0Accumulation of fat in liver cells2895600104775ETOH converts into acetahyde in the liver0ETOH converts into acetahyde in the liver16764005905500411480059055002971800165735Acetahyde causes fibrosis of the liver0Acetahyde causes fibrosis of the liver3733800120015001981200127635Scar tissue & nodules forms0Scar tissue & nodules forms31242008191500198120013335Scarring & thickening of liver wall prevent entry of blood flow into liver00Scarring & thickening of liver wall prevent entry of blood flow into liver312420012001500198120051435Blood flow begins to back up in the portal vein00Blood flow begins to back up in the portal vein31242008191500198120013335Pressure begins to build, leaking out of vessel & into the peritoneal space00Pressure begins to build, leaking out of vessel & into the peritoneal space312420012001500198120051435Portal hypertension0Portal hypertension4114800189230Treatment:Aiming to reduce SxMedication (Actigall, Colchicine, Liver transplantation00Treatment:Aiming to reduce SxMedication (Actigall, Colchicine, Liver transplantation-152400189230Other types of cirrhosis:PostnecroticBiliaryCardiac00Other types of cirrhosis:PostnecroticBiliaryCardiac1219200189230Diagnosis:Liver BxHepatic profileERCP00Diagnosis:Liver BxHepatic profileERCP2514600189230Complications:AscitesGastroesophageal varicesCaput medusaCoagulopathy00Complications:AscitesGastroesophageal varicesCaput medusaCoagulopathyCase 3D.W. is a 47-year-old man being evaluated for complaints of fatigue, anorexia, and abdominal distention. On examination, it skin is noted that the skin is jaundiced and the liver enlarged. D.W. denies significant alcohol or drug use. He denies any known exposure to hepatitis and has never been vaccinated for hepatitis. He is taking no medication. Laboratory tests reveal the following, and a diagnosis of acute hepatitis B is made:?AST (5-40)142 IU/L ??ALT (5-35)120 IU/L ??GGT (10-48)42 IU/L ?Alk Phos (35-15)84 IU/L ?Total bilirubin (<1.0)1.0 mg/dl ?Albumin (3.5-5.5)4.3 g/dl ?HBsAg (negative)positive +?Anti-HBS negative ?Anti-HCV negative ?HIV negative Discussion Questions Review and analyze the laboratory data. Which findings support the diagnosis of acute hepatitis B? Finding that supports the diagnosis of Hepatitis B is the postive Hep B surface antigen.What are the usual modes of hepatitis B transmission? What further risk factor assessment is indicated to identify the source of infection? Hep B usual mode of transmission are prenatally, percutaneous (IV drug use, ACCIDENTAL NEEDLE STICK PUNCTURES), or body fluids and tissue (saliva, organ tissue transplantation, sex-semen and vaginal secretions).Further risk factors to asses is if pt has had any blood transfusion or organ transplants, drug use, and sexually active. History of rash, joint pain, or kidney disease.What precautions should D.W. take to avoid transmitting the disease to others? To avoid transmission, D.W. should use protection during sexual intercourse, to not donate blood or do anything that can expose another person to be in contact with his blood, and no kissing or any other ways that body fluids may be transmitted.Case Study 4BK is a 63-yr-old women who is admitted to the medical-surgical floor from ED with nausea & vomiting and epigastric and LUQ abdominal pain that is severe, sharp, and boring and radiates through to her mid-back. The pain started 24 hours ago and awoke her in the middle of the night. BK is divorced, retired sales manager who smokes a ? pack of cigarettes daily. The ED nurse reports that BK is anxious and demanding. Her VS: 100/70, 97, 30, 100.2o F (tympanic), SaO2 88% on room air and 92% on 2 L of O by N/C. The ED nurse giving you the report states that the admitting diagnosis is acute pancreatitis. Unfortunately the CT scanner is down and won’t be fixed until morning. However, an US of the abdomen was performed, and “no cholelithiasis, gallbladder wall thickening, or choledocholithiasis was seen. The pancreas was not well visualized due to overlying bowel gas.” Admitting labs reveal lipase 3000 units/L ??, amylase 2000 units/L ??, alkaline phosphatase 350 units/L ??, alanine transaminase (ALT) 90 units/L ??, aspartate transaminase (AST) 150 unites/L ??, total bilirubin 2.0 mg/dl ?, albumin 3.0 g/dl, BUN 26 mg/dl ?, creatinine 1.0 mg/dl, WBC 17.5 thou/cmm ?, and Hct 36%. A clean-catch urine sample was just sent to the lab, the urine was dark.What are the possible causes of pancreatitis?Possible causes of pancreatitis are hypertrygliceremia, high estrogen levels, gallstones, post-ERCP, drugs, alcohol, hypercalcemia, biliary sludge & microlithiasis, trauma, pancreas divisium, pregnancy, infections & toxins, vascular disease, post-op pancreatitis, Hereditary pancreatitis, & structural abnormalities.If a CT scan is planned for the morning, what orders would you expect?Orders to expect for a CT scan scheduled for the morning would be to check for pt’s allergies, NPO after midnight, & if CT is w/wo contrast, CKD, pregnancy, medical Hx (asthma).Which labs are the most important to monitor in acute pancreatitis? Why are they significant?Amylase & lipase levels (norm: below 200) are important to monitor.Elevated levels indicates inflammation of the pancreas caused by an immune response. Activation of enzymes in the pancreas (abnormal effect) then starts to damage pancreas. Lipase not able to breakdown fat in the duodenum so in turns also increases cholesterol levelWhat do the BUN and creatinine tell you about her renal function and volume status?A slight increase in the BUN suggests that BK is beginning to have diminished renal function. This is due to the decrease in blood flow to the renal. Vasculature insufficiency is due to interstitial edema causing hypovolemia.Creatinine is WNL or considered borderline. ................
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