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Questions and Answers
What condition can result from bleeding esophageal varices?
What condition can result from bleeding esophageal varices?
Which of the following is a common symptom of esophageal varices?
Which of the following is a common symptom of esophageal varices?
What is a primary risk factor for the hemorrhage of esophageal varices?
What is a primary risk factor for the hemorrhage of esophageal varices?
Which diagnostic method is NOT typically used to identify the bleeding site in esophageal varices?
Which diagnostic method is NOT typically used to identify the bleeding site in esophageal varices?
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What is an expected outcome of portal hypertension in relation to esophageal varices?
What is an expected outcome of portal hypertension in relation to esophageal varices?
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What characterizes hepatic cirrhosis?
What characterizes hepatic cirrhosis?
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What is the most common cause of hepatic cirrhosis?
What is the most common cause of hepatic cirrhosis?
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Which type of hepatic cirrhosis results from broad bands of scar tissue due to viral hepatitis?
Which type of hepatic cirrhosis results from broad bands of scar tissue due to viral hepatitis?
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What is a common clinical manifestation of hepatic cirrhosis?
What is a common clinical manifestation of hepatic cirrhosis?
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What percentage of hepatic cirrhosis patients are typically between 40 and 60 years old?
What percentage of hepatic cirrhosis patients are typically between 40 and 60 years old?
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Which type of hepatic cirrhosis is associated with chronic biliary obstruction?
Which type of hepatic cirrhosis is associated with chronic biliary obstruction?
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Which symptom is NOT typically associated with hepatic cirrhosis?
Which symptom is NOT typically associated with hepatic cirrhosis?
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Which factor does NOT typically contribute to the development of hepatic cirrhosis?
Which factor does NOT typically contribute to the development of hepatic cirrhosis?
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What is the primary purpose of pharmacological therapy in managing esophageal varices?
What is the primary purpose of pharmacological therapy in managing esophageal varices?
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When using a Sengstaken-Blakemore tube, what is the recommended pressure range for the balloons?
When using a Sengstaken-Blakemore tube, what is the recommended pressure range for the balloons?
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What is a potential complication of overinflating the Sengstaken-Blakemore tube?
What is a potential complication of overinflating the Sengstaken-Blakemore tube?
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Which therapy is considered the treatment of choice for managing esophageal varices?
Which therapy is considered the treatment of choice for managing esophageal varices?
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What is a significant risk associated with surgical management of varices?
What is a significant risk associated with surgical management of varices?
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Which of the following is NOT a common complication of endoscopic sclerotherapy?
Which of the following is NOT a common complication of endoscopic sclerotherapy?
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What is an essential monitoring aspect while using balloon tamponade for esophageal varices?
What is an essential monitoring aspect while using balloon tamponade for esophageal varices?
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What action should be taken after endoscopic therapy to ensure effectiveness?
What action should be taken after endoscopic therapy to ensure effectiveness?
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What primarily causes the formation of cholesterol stones in the gallbladder?
What primarily causes the formation of cholesterol stones in the gallbladder?
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Which demographic is most likely to develop cholesterol stones and gallbladder disease?
Which demographic is most likely to develop cholesterol stones and gallbladder disease?
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Which of the following is NOT a risk factor for developing gallbladder disease?
Which of the following is NOT a risk factor for developing gallbladder disease?
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What is a common clinical manifestation of bile duct obstruction due to gallstones?
What is a common clinical manifestation of bile duct obstruction due to gallstones?
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Which diagnostic test provides direct observation of the bile duct?
Which diagnostic test provides direct observation of the bile duct?
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Which symptom indicates obstruction of the common bile duct due to gallstones?
Which symptom indicates obstruction of the common bile duct due to gallstones?
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What condition can occur as a consequence of fat-soluble vitamin deficiency due to gallbladder disease?
What condition can occur as a consequence of fat-soluble vitamin deficiency due to gallbladder disease?
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Which of the following is true regarding the clinical manifestations of gallbladder disease?
Which of the following is true regarding the clinical manifestations of gallbladder disease?
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What is a primary dietary recommendation for managing acute symptoms of gallbladder disease?
What is a primary dietary recommendation for managing acute symptoms of gallbladder disease?
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Which pharmacological therapy is used to dissolve small cholesterol gallstones?
Which pharmacological therapy is used to dissolve small cholesterol gallstones?
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What is a required condition for a patient to be eligible for extracorporeal shockwave lithotripsy?
What is a required condition for a patient to be eligible for extracorporeal shockwave lithotripsy?
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Which surgical procedure involves opening the gallbladder for drainage before stone removal?
Which surgical procedure involves opening the gallbladder for drainage before stone removal?
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Which of the following is NOT a nursing diagnosis for gallbladder disease management?
Which of the following is NOT a nursing diagnosis for gallbladder disease management?
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What type of complications should a nurse monitor for following gallbladder surgery?
What type of complications should a nurse monitor for following gallbladder surgery?
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Which is an important aspect of patient assessment before gallbladder surgery?
Which is an important aspect of patient assessment before gallbladder surgery?
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Which of the following goals is NOT typically included in the planning phase post-surgery for gallbladder disease?
Which of the following goals is NOT typically included in the planning phase post-surgery for gallbladder disease?
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Study Notes
Esophageal Varices
- Dilated, tortuous veins in the submucosa of the lower esophagus
- Caused by portal hypertension due to portal venous circulation obstruction
- Can lead to hemorrhagic shock, decreased cerebral, hepatic, and renal perfusion
- Increased risk of encephalopathy due to increased nitrogen load in the GI tract from bleeding and increased serum ammonia levels
- Bleeding can be triggered by: lifting heavy objects, straining at stool, coughing, vomiting, poorly chewed food, irritating fluids, reflux of stomach contents, and medication.
- 30-50% mortality rate in the first bleeding episode
- Pathophysiology: blood seeks new routes (collateral circulation) due to obstruction in vessels in the submucosal layer
Clinical Manifestations
- Hematemesis
- Melena
- General deterioration in mental or physical status
- Cold, clammy skin
- Hypotension
- Tachycardia
Assessment & Diagnostic Findings
- Endoscopy: NPO until gag reflex returns
- Barium swallow
- Ultrasonography
- CT scan
- Angiography
Portal Hypertension Measures
- Indirect insertion of fluid-filled balloon catheter into the antecubital or femoral vein to the hepatic vein.
- Reading over 20 ml saline is abnormal.
Laboratory Tests
- Liver function tests
- Blood flow and clearance studies to assess cardiac output and hepatic blood flow
Managing Esophageal Varices
- Monitor vital signs and signs of hypovolemia.
- Administer oxygen.
- Pharmacological therapy to decrease portal pressure (Vasopressin and Beta Blockers).
- Balloon tamponade: Sengstaken-Blakemore tube
Medical Management of Bleeding Esophageal Varices
- Monitor circulating volume with a central line.
- Monitor vital signs.
- Administer oxygen.
- IV fluids: caution for overhydration.
- Balloon tamponade: controls bleeding by applying pressure on the cardiac portion of the stomach and against the bleeding varices using a double-balloon tamponade (Sengstaken-Blakemore tube).
- Has four openings: Gastric aspiration, esophageal aspiration, inflating of the gastric balloon, and inflating of the esophageal balloon.
- The pressure in the balloon should be 25-40 mmHg and checked every 2-4 hours.
- Overinflating or leaving the balloon in place for a long time may cause injury from ulceration and necrosis of the mouth, nose, or stomach mucosa.
- Displacement of the tube may result in airway obstruction and asphyxia from aspiration.
- Overinflating may result in sudden rupture and aspiration of gastric content into the lungs.
- Frequent assessment for bleeding and inflation of balloons are needed to minimize complications.
Endoscopic Therapy (Injection Sclerotherapy)
- Useful in GI bleeding
- Less effective in the first and subsequent variceal bleeding
- Complications: esophageal stricture, perforation, aspiration pneumonia.
- Give antacids post-procedure to control sclerosing and reduce acid reflux
Esophageal Banding Therapy (Band Ligation)
- Treatment of choice
- Can be combined with pharmacologic treatment
- Less risky than sclerosing
- Complications: lacerations, dysphagia, stricture (rare)
TIPS (Transjugular Intrahepatic Portosystemic Shunt)
- Used for cases where other treatments have failed.
- Less risky than surgery
Surgical Management of Varices
- Surgical bypass: to reduce portal pressure
- Devascularization and transection
- Very risky: can cause encephalopathy
- Second-line management if everything else fails
Hepatic Cirrhosis
- Chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.
- An irreversible process.
Types of Hepatic Cirrhosis
- Alcoholic cirrhosis: Scar tissue surrounds the portal areas and is the most common type.
- Postnecrotic cirrhosis: Broad bands of scar tissue occur as a late result of acute viral hepatitis.
- Biliary cirrhosis: Scarring occurs in the liver around the bile ducts, usually due to chronic biliary obstruction and infection (Cholangitis). Less common type.
Pathophysiology of Hepatic Cirrhosis
- Nutritional deficiency with reduced protein intake.
- Excessive alcohol intake (most common cause).
- Exposure to certain chemicals (carbon tetrachloride, chlorinated naphthalene, arsenic, or phosphorus) or exposure to infection.
- Twice as many men as women are affected.
- Most patients are between 40 and 60 years of age.
Clinical Manifestations of Hepatic Cirrhosis
- Liver enlargement: early symptom, liver loaded with fatty tissue (firm and has a sharp edge, producing abdominal pain), later the liver decreases in size due to contraction of scar tissue and the edges become nodular.
- Portal obstruction and ascites.
- Infection and peritonitis.
- Gastrointestinal varices.
- Edema.
- Vitamin deficiency and anemia.
- Mental deterioration.
Gallstones (Cholelithiasis)
- Decreased bile acid and increased cholesterol synthesis in the liver cause bile supersaturation with cholesterol, which precipitates and forms stones.
- Four times more women than men develop cholesterol stones and gallbladder disease (due to estrogen and contraceptive use, which increase cholesterol saturation).
- Risk factors: obesity, multiparous, frequent changes in weight, rapid weight loss, oral contraceptives, estrogens, cystic fibrosis, diabetes mellitus, and increased risk with age due to more cholesterol synthesis and decreased bile acid synthesis.
Clinical Manifestations of Gallstones
- Silent, may produce no pain and only mild GI symptoms (detected accidentally).
- Pain and biliary colic, jaundice, change in urine (dark) and stool color (light), vitamin deficiency (fat-soluble)
- Two types of symptoms (which may be acute or chronic)
- From disease of the gallbladder itself: epigastric distress following fatty meal (fullness, abdominal distention), vague pain in the RUQ
- From obstruction of the bile passage by gallstone: fever, palpable mass, colicky pain (right abdominal pain radiating to the back or right shoulder), nausea and vomiting, Murphy’s sign (inspiratory pain): positive, jaundice (commonly occurs with obstruction of common bile duct), changes in urine color (dark color) and stool color (clay-colored), vitamin deficiency (fat-soluble vitamins)
Diagnostic Tests for Gallstones
- Abdominal X-ray
- Ultrasound
- Radionuclide imaging: intravenous radioactive agent
- Cholecystography: oral iodine contrast agent used 10-12 hours before X-ray, NPO
- Endoscopic retrograde cholangiopancreatography (ERCP): direct observation through fiberoptic scope inserted through esophagus into the duodenum. Discuss nursing implications.
- Percutaneous transhepatic cholangiography: inject the dye directly into the biliary tree.
Medical Management of Gallstones
- Treatment of acute symptoms.
- Nutritional and supportive treatment: low-fat, liquid diet, rest, IV fluids, nasogastric suction, analgesia, and antibiotics.
- Pharmacological therapy to dissolve small, radiolucent gallstones composed primarily of cholesterol: ursodeoxycholic acid and chenodeoxycholic acid.
Nonsurgical Removal of Gallstones
- Dissolving gallstones: infusion of solvent into the gallbladder.
- Extracorporeal shockwave lithotripsy (through water bath): Patient should have < 4 stones, < 3 cm in diameter, and no liver or pancreas disease. Contraindicated in inflammatory diseases of the biliary system.
- Intracorporeal lithotripsy: by ultrasound, pulsed laser
- By instrumentation: such as ERCP
Surgical Management of Gallstones
- Laparoscopic cholecystectomy.
- Cholecystectomy.
- Mini-cholecystectomy.
- Choledochostomy.
- Surgical cholecystostomy: opening the gallbladder to remove the stones or the pus by drainage when severely inflamed before removal.
- Percutaneous cholecystostomy.
Nursing Process: Undergoing Surgery for Gallbladder Disease: Assessment
- Patient history.
- Knowledge and teaching needs.
- Respiratory status and risk factors for postoperative respiratory complications.
- Nutritional status.
- Monitor for potential bleeding.
- GI symptoms: after laparoscopic surgery, assess for loss of appetite, vomiting, pain, distention, fever - potential infection or disruption of the GI tract.
Nursing Diagnoses
- Acute pain.
- Impaired gas exchange.
- Impaired skin integrity.
- Imbalanced nutrition.
- Deficient knowledge.
Collaborative Problems/Potential Complications
- Bleeding.
- Gastrointestinal symptoms.
- Complications as related to surgery in general: atelectasis, thrombophlebitis.
Planning for Gallbladder Disease
- Goals may include relief of pain, adequate ventilation, intact skin, improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self-care routines.
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Description
This quiz covers the critical aspects of esophageal varices, including their causes, clinical manifestations, and diagnostic findings. Understand the pathophysiology behind portal hypertension and recognize the symptoms and risks associated with bleeding. Enhance your clinical knowledge related to this serious condition.
