GI Accessory Disorder 1

Diagnostic and Laboratory Tests

• Indirect bilirubin normal range: 0.2 to 0.8.
• Direct bilirubin normal range: 0.1 to 0.4.
• Total bilirubin normal range: 0.3 to 1.2.
• Elevated bilirubin levels indicate altered liver function, bile duct obstruction, or other hepatobiliary disorders.
• A bilirubin level greater than 2.5 mg/dL results in jaundice.
• Patients need to be NPO for bilirubin tests.
• Liver enzymes (liver function tests) reveal conditions and monitor hepatotoxic medications.
• Alkaline phosphatase normal range: 30 to 120; elevated levels indicate liver damage.
• Aspartate aminotransferase (AST) normal range: 0 to 35; elevated levels suggest hepatitis or cirrhosis.
• Alanine aminotransferase (ALT) normal range: 4 to 36; elevated levels suggest hepatitis, cirrhosis, or hepatotoxic drugs.
• Lactic dehydrogenase normal range: 100 to 190; elevations signify myocardial infarction, pulmonary embolism, hepatic disease, pancreatitis, and skeletal muscle disease.
• Ammonia normal range: 10 to 80; elevated levels suggest liver dysfunction, potentially leading to hepatic encephalopathy.
• The liver typically converts ammonia to urea for kidney excretion, but this process is impaired with liver dysfunction.
• Albumin normal range: 3.5 to 5; decreased levels are seen in hepatic diseases, leading to decreased colloid osmotic pressure.
• Low albumin causes fluid to remain in tissues, resulting in third spacing or edema, notably ascites.
• Albumin deficits also occur in states of malnutrition.
• Oral cholecystogram (OCG) visualizes the gallbladder using oral radiopaque dye to diagnose gallstones or inflammation.
• Patients undergoing OCG need to be NPO after midnight and checked for iodine/shellfish allergies.
• Cholangiogram visualizes the hepatic and common bile ducts and the gallbladder.
• Cholangiograms can be IV, operative, or T-tube types.
• Cholangiograms are used to look for stones, strictures, and tumors of the hepatic duct, common bile duct, and gallbladder.
• Contrast dye is used; patients must be NPO past midnight, allergy checks are performed, and consent is needed.
• Liver ultrasounds use high-frequency sound waves.
• Patients need to be NPO past midnight unless it's an emergency.
• The test takes 15–30 minutes and is non-invasive.
• If barium was administered, bowel must be cleared first.
• CT scans of the abdomen can detect abscesses, ascites, cirrhosis, aneurysms, or tumors.
• Patients need to be NPO past midnight, and contrast dye allergies need to be assessed.
• BUN and creatinine levels must be checked before contrast administration.

Liver Biopsy

• Requires a consent form, teaching, and NPO status past midnight.
• Patient is placed in a supine position with the right arm over their head.
• Ultrasound or CT guidance is used for needle insertion.
• Platelet count, clotting and bleeding times, PT, and INR must be checked prior.
• During the procedure, the patient lies supine, inhales, and holds their breath.
• Post-procedure care includes frequent vital signs.
• Patients are placed on their right side with a rolled towel against the puncture site for two hours.
• Assess for pneumothorax and hemorrhage.
• Serum amylase normal range: 30 to 220; highest in early acute pancreatitis, returning to normal after 36 hours.
• Serum lipase normal range: 10 to 140; remains elevated longer than amylase, about 14 days.
• The patient needs to be NPO except for water for these tests.
• Endoscopic retrograde cholangiopancreatography (ERCP) involves using a scope and injecting dye into bile and pancreatic ducts.
• ERCP can identify pancreatic dysfunction or obstructions and retrieve stones or place stents.
• Patients need to be NPO eight hours before and have a consent form, PT, and INR pre-test.
• NPO until gag reflex and swallowing ability return post-test.
• Monitor for GI system perforation which is abdominal pain or guarding.
• Assess for pancreatitis, indicated by abdominal pain, nausea, vomiting, fever, chills, and decreased bowel sounds.
• Also assess for hypovolemic shock.

Cirrhosis

• Chronic, degenerative liver disease where liver cells are destroyed and replaced by scar tissue or fat, including the functional tissue of the liver: the parenchyma
• Hepatomegaly (enlarged liver) occurs.
• Slightly more common in men.
• Causes include alcohol-related liver disease, post-necrosis from hepatitis B, C, or D, hepatotoxins, biliary cirrhosis, cardiac cirrhosis, and non-alcoholic fatty liver disease.
• Non-alcoholic fatty liver disease risk factors: obesity, diabetes, coronary artery disease, and corticosteroids.
• Decreases the ability of the body to make albumin.
• Ascites develops from portal hypertension and decreased albumin.
• Esophageal varices, dilated esophageal vessels, can rupture and cause hemorrhage.
• Increased ammonia levels due to impaired protein breakdown in the liver can occur.

Signs and Symptoms of Cirrhosis

• Early signs: abdominal pain, anorexia, nausea, vomiting, and fatigue.
• Later signs: dyspepsia, changes in bowel habits, weight loss, malaise, and fever.
• Splenomegaly, ascites, and jaundice develop.
• Pruritus due to bile salt accumulation under the skin.
• Telangiectasis: dilated blood vessels on the face, trunk, and neck.
• Anemia and thrombocytopenia (bruising and petechiae).
• Inability to absorb vitamin K or produce clotting factors, leading to bleeding risks.
• High ammonia levels, causing confusion and potential coma.
• Low blood glucose, leading to hypoglycemia.
• Electrolyte abnormalities.

Diagnostic Tests and Treatment for Cirrhosis

• Diagnostic tests: ERCP, esophageal scope, liver biopsy, ultrasounds, paracentesis.
• Treatment focuses on removing causes, preventing further damage, and treating symptoms.
• Early stages: moderately high protein intake(75 grams), 2500-3000 kcal.
• With hepatic encephalopathy exacerbations: salt restriction, low fat, additional vitamins (folic acid, K, C).
• Medications: aldactone for edema, neomycin (oral or rectal) to reduce ammonia levels, lactulose to trap and expel ammonia.
• LeVeen shunt: drains ascitic fluid back into the vascular system.

Complications of Cirrhosis

• Ascites: accumulation of fluid in the peritoneal cavity.
  • Ensure bladder is emptied, obtain consent, measure girth before and after paracentesis, and document fluid characteristics.
• Esophageal varices: dilated vessels that can rupture.
  • If ruptured, it's an emergency treated with vasopressin.
  • Saline and ice can be used to vasoconstrict.
  • Sengstaken-Blakemore tube: has an esophageal balloon, gastric balloon, and gastric lavage port.
  • Elevate head of bed 30-45 degrees, deflate balloon per orders to prevent necrosis.
  • NG tube may be needed to drain saliva.
• Hepatorenal syndrome: renal failure due to low blood flow to kidneys.
• Hepatic encephalopathy: inappropriate behavior, disorientation, asterixis, coma.
  • Treated with LeVeen shunt, Blakemore tube, or liver transplant.
  • Partial or complete liver transplants are possible.

Nursing Interventions for Cirrhosis

• Avoid hepatotoxic drugs and alcohol.
• High risk for skin impairment; use low air loss mattress, turn frequently, provide back rubs and lotion.
• Monitor mental status, edema in ankles and abdomen, daily weight, and abdominal girth.
• Encourage rest, avoid infections, implement bleeding precautions, and monitor I/O.
• Monitor vital signs every four hours.
• Administer fluid and salt restrictions as prescribed.
• Complete bed rest until strength returns; perform range of motion exercises.
• Avoid soap, perfumed lotions, or alcohol on the skin.
• Liver cancer, primarily palliative, often metastatic, and with poor prognosis.

Liver Cancer

• Metastatic carcinoma is more common than primary.
• Diagnostic tests: liver scan, ultrasound, CT, MRI, ERCP, liver biopsy, liver function tests, alpha-fetoprotein levels.
• Early stages: weight loss, hepatomegaly, edema, ascites, portal hypertension, dull epigastric or right upper quadrant pain, nausea, vomiting, anorexia, extreme weakness, and jaundice.
• Treatment is primarily palliative.
• If found early, a lobe resection or liver transplant may be possible.
• Chemotherapy is not typically successful.
• Nursing care focuses on comfort, similar to cirrhosis care.

Viral Hepatitis

• Hepatitis A: transmitted via the fecal-oral route.
  • Incubation period: 10-40 days.
  • Risk factors: contaminated food and water.
  • Good hand hygiene is crucial.
  • Two-dose vaccine available.
  • Immunoglobulins can be given post-exposure.
  • Common in areas where there is sewage leakage.
  • Common with homosexually active men, illicit drug users, the homeless, HIV positive individuals, occupations with related risks, and those participating in international travel.
• Hepatitis B: transmitted via blood.
  • Incubation period: 28 to 160 days.
  • Risk factors: contaminated needles, body fluids, sexual contact, mother to infant, substance use disorder.
  • May progress to chronic liver problems.
  • Three-dose vaccine exists.
  • Vaccines are given at birth, and offered to healthcare workers.
• Hepatitis C: transmitted via blood.
  • Incubation period: Two weeks-Six months.
  • Risk factors: needle sticks, substance abuse disorder such as IV drugs, unsanitary tattoo needles, and sexual contact.
  • Often leads to chronic liver problems.
• Hepatitis D: co-infection with hepatitis B.
  • Typically acquired through substance abuse and unprotected sex.
• Hepatitis is a reportable disease.

Hepatitis Prevention

• Hepatitis prevention is through vaccinations, recommended for those at risk.
• Hepatitis B vaccines are given at birth, and healthcare workers are offered them too.
• It is a three-dose vaccine.
• The adult dosing schedule includes administering the first dose, administering the second dose one to two months after the first, and administering the third dose four to six months later.
• The infant dosing schedule includes administering the first dose at birth, administering the second dose at one to two months of age, and administering the third dose between six and fifteen months of age.
• Cells try to regenerate and congestion occurs in the portal vein areas.
• Viral hepatitis's effects are mild to severe and can include: malaise, anorexia, muscle aches, photophobia, diarrhea or constipation, abdominal pain, dyspepsia, joint pain, fatigue, chills, headache, and temperature.
• Indicative of a worsened condition, signs will also include: jaundice, dark urine, and clay-colored stools.
• Additional symptoms may include: weight loss and enlarged lymph nodes; however, some may not have any signs initially.
• Labs showing elevated ALT and LFT (liver function Test) will need assessment.
• Severe patients may have lowered albumin.
• Diagnosis is confirmed via labs and liver biopsy.

Viral Hepatitis Treatment

• There is no cure.
• Disease spread must be prevented via:
  • Good hygiene
  • Vaccination
  • Handling secretions while following contact protocols
  • Avoiding sexual activity and sharing needles
  • Avoiding food preparation while sick
  • Use of separate bathrooms.
  • Avoiding sharing personal items and drinking after others
• Clothing items should be washed separately.
• A symptomatic treatment plan will need to be formed, including: bed rest, antiemetics, and a high-calorie and carbohydrate diet.
• Elevated ALT and AST, liver function tests, PT/INR, bilirubin, LDH, alkaline phosphatase can occur in hepatitis.

Liver Transplants

• People exposed to hepatitis can get immune globulins to help combat it.
• Nutritional plans should include calories, vitamins C, B, and K.
• Antibiotics can combat secondary infections.
• Antihistamines for pruritus.
• IV fluids for dehydration.
• Staying clear of alcohol for at least a year.
• Complications like infections and rejections may arise during the screening for a liver transplant.
• Patients will receive anti-rejection and immunosuppressive medicines such as cyclosporin.

Nursing interventions

• Universal precautions used for every patient.
• Maintain a quiet resting state.
• Ensure small, frequent meals.
• Monitor daily weight before breakfast.
• Lotions baths, tepid to avoid irritation, keep nails short to avoid further infections.
• Divert their minds because of consistent discomfort.
• Separate cloths in a hot washer.
• Cells try to regenerate and congestion occurs in the portal vein areas.