Pp03l036_ Intro To The Gallbladder Liver Or Exocrine Pancreas

NP03L036 Introduction to the

Gallbladder, Liver, and Exocrine Pancreas

ENABLING LEARNING OBJECTIVES A. Define key terms related to the hepatobiliary system.  B. Identify the structures and function of the organs in the hepatobiliary system  C. Identify laboratory and diagnostic examinations used in the diagnosis of the liver, gallbladder and exocrine pancreas disorders and the appropriate nursing interventions related to these tests. 

Key Terms

Key Terms Cholang - Pertaining to bile ducts  Cholangiography - X-ray examination of the bile duct  Choledocho - Pertaining to common bile duct  Choledocholithiasis - Stones in the common bile duct 

Key Terms Cirrhosis - A chronic degenerative disease of the liver  Hepatitis - Inflammation of the liver  Hepatomegaly - Enlargement of the liver  Asterixis - A hand flapping tremor  Esophageal varices - A complex of longitudinal, tortuous veins at the lower end of the esophagus 

Key Terms Hepatic Encephalopathy - A type of brain damage caused by liver disease and consequent ammonia intoxication  Paracentesis - A procedure in which fluid is withdrawn from the abdominal cavity  Parenchyma - Tissue of an organ as distinguished from supporting or connective tissue 

Key Terms Flatulence - Excess formation of gases in the stomach  Ascites - Abnormal intraperitoneal accumulation of fluid and albumin  Pruritus - The symptom of itching 

Biliary System

Biliary System 

The biliary system is comprised of the organs and duct system that create, transport, store and release bile into the duodenum for digestion. It includes the liver, gallbladder and bile ducts (named the cystic, hepatic, common, and pancreatic duct).

Liver

Liver Largest and one of the most complex glandular organs in the body  Located just inferior to the diaphragm, covering most of the right upper quadrant and extending into the left epigastrium 

Liver Divided into two lobes  Receives approximately 1500ml/minute via the portal vein and hepatic artery  Hepatocytes (cells of the liver) produce bile 

– Bile is necessary for the metabolism of fats – Bile travels through the hepatic duct to the gall bladder for storage

Liver 

Functions – Metabolizes fats – Manages blood coagulation and produces most of the clotting factors (in the presence of Vitamin K) – Manufactures cholesterol – Manufactures albumin (maintains normal blood volume)

Liver 

Functions – – – – – – –

Filters out old red blood cells and bacteria Detoxifies poisons (alcohol, nicotine, drugs) Converts ammonia to urea Provides the main source of body heat Stores glycogen for later use Activates Vitamin D Breaks down nitrogenous wastes to urea

Gall bladder

Gall bladder Sac about 3 to 4 inches long located on the right inferior surface of the liver  Stores bile needed for fat digestion 

Pancreas

Pancreas Elongated gland that lies posterior to the stomach  Involved in both exocrine and endocrine function  Produces 1000 to 1500ml of pancreatic juice daily to aid in digestion  Digests the three major components of chyme: proteins, fats and carbohydrates 

Pancreas 

Contents of pancreatic juice – – –

Protease (Trypsin) Lipase (Steapsin) Amylase (Amylopsin)

Enzymes are transported to the duodenum via the pancreatic duct to the common bile duct and out to the duodenum via the papilla of Vater  Also contains sodium bicarbonate 

Laboratory Studies:

Laboratory Studies: 

Serum bilirubin test. Normal values – – –

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Direct bilirubin: 0.1-0.3 mg/dl Indirect bilirubin: 0.2-0.8 mg/dl Total bilirubin 0.1-1.0 mg/dl

Elevated levels will cause jaundice, which is the most common sign of a liver disorder Testing for bilirubin in the blood provides information for diagnosis and evaluation of liver disease, biliary obstruction and hemolytic anemia

Serum bilirubin test. Old red blood cells are broken down by the spleen and bone marrow.  The hemoglobin which is released is converted into indirect bilirubin.  Indirect bilirubin is converted to direct bilirubin by the liver. 

Serum bilirubin test 

Nursing interventions: – Keep patient NPO until blood specimen is drawn. – Monitor venipuncture site for bleeding.

Liver enzymes tests 

The liver is a storehouse of enzymes. Injury or disease will cause release of these intracellular enzymes into the bloodstream and their levels will be elevated. Some of these enzymes are produced in other organs so elevations may not be specific to the liver.

Liver enzymes tests 

AST (Aspartate aminotransferase) formerly serum SGOT – Normal value: Adult 5 to 40 IU/L – Elevated in myocardial infarction, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal disease, and acute hemolytic anemia

Liver enzymes tests 

ALT (Alanine aminotransferase) formerly SGPT – Normal value: Adults/child 5 to 35 IU/L – Elevated in hepatitis, cirrhosis, hepatic necrosis, and hepatic tumors and by hepatotoxic drugs

Liver enzymes tests 

LDH (Lactic dehydrogenase) – Normal value: 45 to 90 U/L, 115 to 225 IU/L – Elevated in myocardial infarction, pulmonary infarction, hepatic disease, pancreatitis, hemolytic anemia and skeletal muscle disease

Liver enzymes tests 

Alkaline phosphatase – Normal value: Adult 30 to 85 ImU/ml – Elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones, and healing fractures

Liver enzymes tests 

Gamma GT (Gamma glutamyltransferase) – Normal value: Male/female over 45: 8 to 8 U/L; female under 45: 5-27 U/L – Elevated in liver cell dysfunction: hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs, myocardial infarction, congestive heart

Liver enzymes tests 

Nursing interventions: – Patient teaching, – Assess site for bleeding

Prothrombin time: Normal value: 11.0-12.6 sec  Rationale: Detects increased clotting time that can occur from liver disease (inability to synthesize clotting factors) or vitamin K deficiency  Nursing interventions: Same as for bilirubin 

Serum Protein Test: 

Normal values – – – –

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Total protein: 6 to 8 g/dl Albumin: 3.2 to 4.5 g/dl Albumin globulin (A/G ration) 1.2 to 2.2 g/dl Globulin: 2.3 to 3.4 g/dl

Can assess functional status of liver by measuring the products that are synthesized there: protein, especially albumin

Serum Protein Test: Low levels may also result from nephrotic ,ascites), or protein deplete nutrition.  Nursing interventions: Patient education. Assess site for bleeding 

Serum ammonia Normal value 15-110 ug/dl  Rationale: In liver dysfunction, serum ammonia level increases and BUN level decreases. Used in diagnosis of hepatic encephalopathy or coma  Nursing interventions: List antibiotics patient is taking on lab request as they may affect results 

Cholecystography 

Provides visualization of the gallbladder after ingestion of radiopaque contrast. Requires concentration of the dye within the gallbladder. Patient must take dye tablets evening prior to test. Vomiting or diarrhea will cause decreased absorption and affect results

Oral Cholecystography  Provides visualization of the

gallbladder after ingestion of radiopaque contrast. Requires concentration of the dye within the gallbladder. Patient must take dye tablets evening prior to test. Vomiting or diarrhea will cause decreased absorption and affect results

Oral Cholecystography 

Nursing interventions – – – –

rule out allergy to iodine/contrast medium Administer radiopaque tablets as ordered NPO after midnigh May be given high fat diet after test has started to stimulate emptying of the gallbladder

Intravenous cholangiography (IVC) 

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Radiographic dye, injected intravenously, is concentrated by the liver and secreted into the bile duct. IVC allows visualization of hepatic and common bile ducts and gallbladder if cystic duct is patent. Used to identify stones, stricture, or tumor of the hepatic duct, common bile duct, and gallbladder Nursing interventions: Same as above, except tablets are not given

Operative Cholangiography Common bile duct is injected with dye. Allows surgeon to view this anatomically difficult area before interventions to decrease chance of injuring common bile duct.  Nursing interventions: Same as above 

T-tube Cholangiography (Postoperative cholangiography) Performed to identify retained stones in the postoperative cholecystectomy patient  Performed via a T-tube placed by the surgeon intra-operatively  Contrast is injected to ensure adequate flow of bile into the duodenum  Nursing interventions 

– Protect the patient from infection – NPO after midnight

Gallbladder scanning 

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Nuclear medicine scan with radioactive isotope used for the diagnosis of acute cholecystitis Nursing interventions – Educate patient that the small dose of radiation used is harmless – NPO after midnight – Encourage patient to drink fluids after test – Nursing staff should wear gloves when handling urine

Radioisotope Liver Scanning Used to outline and detect structural changes in liver. After contrast is injected, gamma-ray device passed over abdomen. Records distribution of the radioactive particles in the liver  Nursing interventions: Same as above 

Needle Liver Biopsy 

Safe, simple and valuable method to diagnose pathological liver conditions. Needle is inserted through the skin, into intercostal space and into liver where tissue is removed. Used in the diagnosis of cirrhosis, hepatitis, drug-related reactions, granuloma and tumor

Needle Liver Biopsy 

Nursing interventions – Explain procedure to patient and obtain informed consent – Check lab values for coagulation studies – Observe for bleeding after procedure. Monitor VS – Assess for pain, provide analgesics as ordered – Assess for pneumothorax – Keep patient lying on right side for 2 hours and flat for 12 to 14 hours

Endosopic Retrograde Cholangiopancreatography (ERCP) Fiberoptic duodenoscope inserted through GI tract into duodenum. Common bile duct and pancreatic duct are visualized after dye is injected. Used to diagnose pancreatic dysfunction. Also used to evaluate obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstruction

Endosopic Retrograde Cholangiopancreatography (ERCP) 

Nursing interventions – – –

NPO after midnight Educate patient and sign permit Test takes 1-2 hours to complete. Patient must lie completely motionless on a hard X-ray table – NPO post-procedure until gag reflex returns, assess for abdominal pain, tenderness and guarding – Assess for signs and symptoms of pancreatitisincreased abdominal pain, nausea, vomiting, diminished or absent bowel sounds

Laboratory tests related to the Pancreas Amylase Test: Normal 25 to 125 U/L  Test for pancreatitis. Abnormal serum rise occurs 12 hours after onset of pancreatic disease. May return to normal within 48 to 72 hours. (Amylase is cleared efficiently by the kidneys)  Nursing interventions: 

– List medications on lab request due to falsepositive results

Laboratory tests related to the Pancreas Serum Lipase Test: Normal 0 to 110U/L  Elevated in acute pancreatitis. (More specific than amylase for pancreatitis)  Nursing interventions 

– Keep patient NPO after midnight

Imaging procedures for the pancreas 

Ultrasonography of Pancreas – Used to establish the diagnosis of pseudocyst, pancreatitis, and pancreatic abscess

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Nursing interventions – –

NPO after midnight Assess abdomen for distention or gas that may interfere with sound waves

Imaging procedures for the pancreas 

(Computed Tomography (CT) of Abdomen – Noninvasive accurate test used to diagnose pathological pancreatic conditions such as inflammation, tumor, cyst formation, ascites, aneurysm, and cirrhosis of liver

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Nursing interventions – NPO after midnight – Decrease patient's anxiety to claustrophobia from machine

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Question: The following laboratory values which are often abnormal in a patient with liver pathology, include all of the following except: PT AST/ALT Alkaline phosphatase Total bilirubin Albumin CA125

–Answer: CA 125

Review of Main Points Key terms  Structure and function of the hepatobiliary system.  Diagnostic tests 

ANY QUESTIONS??