Disease of the liver & gallbladder.pptx.

Disease of the liver & gallbladder.pptx.

1. THE DISEASES OF THE LIVER AND GALLBLADDER

2. Common diseases include   Liver failure Hepatitis Cirrhosis Hepatocellular steatohepatitis Non alcoholic steatohepatitis Hepatic encephalopathy Wilson's disease Cholestasis Gallstonesandcholecysticts Cholangitis Gilbert’s syndrome

3. CIRRHOSIS Cirrhosis is defined histologically as a diffuse hepatic process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules. The progression of liver injury to cirrhosis may occur over weeks to years . Epidemiology Liver diseases results in about 35000 deaths each year in the united states and cirrhosis is the ninth leading cause of death in the united states and is responsible for 1.2 of all US deaths.

4. Causes of Cirrhosis Fatty liver associated with obesity and diabetes Wilson’s disease(excessive copper stored in the liver) Cystic fibrosis (sticky , thick mucus build up in the liver) Hemochromatosis(excessive iron store in the liver Glycogen storage disease(liver can’t store or break down Glycogen) Hepatitis C (26%) Alcoholic liver disease (21%) Hepatitis C and alcoholic liver disease (15%) Cryptogenic causes (18%) Hepatitis B and hepatitis D may be coincident with 15% Autoimmune hepatitis

5. Signs and symptoms Early signs and symptoms of cirrhosis Loss of appetite Feeling weak or Tired Nausea Fever Un expected weight-loss Abdominal pain

6. Signs and symptoms cont… Late symptoms and sign Easy bruising and bleeding Yellow tint to your skin or jaundice of the eye Itchy skin Edema in legs, feet and ankles Ascites of abdomen Brownish or orange color to your urine. Light colored stools.

7. Confusion, difficulty thinking, memory loss, personality changes Blood in stool Redness in the palms of your hands Spider like blood vessels that surround small red spots on your skin majorly on the abdomen (caput medusa) In men, loss of sex drive , shrunken testicles In women , it causes menopause

8. Investigations Physical exam. Doctor will examine looking for signs and symptoms of cirrhosis Blood tests This will indicate lower than normal level of albumin and blood clotting factor High levels of iron Raised bilirubin Imaging test.

9. Investigations cont…. It will show the size, shape and texture of the liver. It will also determine the amount of scanning and amount of fat you have in the liver and fluid in the abdomen. Computerized tomography scan, abdominal ultra sound and magnetic resonance imaging. A transient elastography which measures the fat content and amount of fat stiffness in the liver Biopsy: a sample of liver tissue is removed from your liver and examined under the microscope

10. Management of liver cirrhosis Aims Slow further damage to your liver Present and treat symptoms Prevent and treat complications

11. Management will depend on cause and how much damage exists Alcohol related disease Stop drinking alcohol Hepatitis B or C Several approved antiviral medications so treat hepatitis type B and C

12. Management cont…. Nonalcoholic fatty liver disease Losing weight, physical exercise, eating healthy diet Inherited liver disease Treatment of alpha-1 antitryps indeficiency which includes medicine to reduce swelling ascites and swelling legs Disease that damage or block bile duct in the liver use of ursodisol or surgery to open narrowed or blocked bile.

13. DRUGS Antibiotic to treat SBP quinolones are drugs o choice. Livoline tabs Lactulose Loop diuretics like Lasix and potassium sparing (spironolactone) Non pharmacological advice Diet with plenty of proteins Reduce on the salt intake Avoid hepatotoxic medications Avoid alcohol

14. Complication of liver cirrhosis Liver failure Hepatic encephalopathy. Hepatocellular carcinoma. Ascites Hepato renal syndrome Bleeding tendencies

15. LIVER FAILURE This reflects a loss of liver function 80-90% of liver parenchyma must be destroyed before liver failure manifests Signs of liver failure. Fatigue Nausea Loss of appetite Blood in stool Vomiting blood

16. Advanced stage Jaundice Extreme tiredness Confusion Bleeding Peritonitis Musty or sweet breath odor Alcohol use

17. Investigations Blood test for–liver function test Urine test Abdominal scan

18. Management The most important aspect of treatment in patient with acute liver failure is to provide good intensive care support. Most patient with liver failure tend to develop some degree of respiratory dysfunction, careful attention should be paid to fluid management and hemodynamics. Monitoring of metabolic parameters, surveillance, for infection, maintenance of nutrition and prompt of recognition of gastrointestinal bleeding Bed rest is recommended Coagulation parameters, complete blood cell count and metabolic panel should be checked. Serum aminotransferase and bilirubin are generally measured daily to follow the course of the disease. Protection of the airways in case of coma.

19. Management cont… Acute Set up intravenous fluids, to maintain blood pressure Medications e.g. Laxatives or enemas to help flush toxins Blood glucose monitoring. There may be need for liver transparent as any other treatment modality.

20. Complications Hepatomegaly Splenomegaly Muscle wasting Vasculitis Palmar erythema Spider angiomas

21. Hepatitis This is an injury to the liver parenchyma which is composed mainly of hepatocyte Types of hepatitis Hepatitis A is one of the most causes of acute hepatitis which was isolated by Purcell in 1973. The epidemiology, clinical manifestation and natural history of hepatitis A have become apparent.

22. EPIDEMIOLOGY Persons aged 5-14 years are most likely to acquire hepatitis A before vaccination programs. Over the past 40 years the average of the persons has steadily increased. Evidence of past infection is more prevalent in adults ( approximately 40%) than in children approximately (10%) which supports acquisition school aged years.

23. Etiology Personal contacts Occupation Foreign travel Male homosexual Illicit parental drug use.

24. Clinical manifestation. Prodrome In the prodrome, patients may have mild fluike symptoms of anorexia, nusea, vomiting, malaise, fatigue, low grade fever (ussualy <39.5c), myalagia and mild headache. Icteric phase In this phase, dark urine appears first( bilirubinuria )pale stool follows, jaundice occurs in most (70-85%) adults acute HAV.

25. TREATMENT This is all about supportive care. Ant retro viral drugs may be given. Amantadine and interferon lambda inhibit HAV internal ribosal entry sites and replication . Vaccine with HA vaccine. Immunoglobulin IM

26. Hepatitis B: This is a worldwide healthcare problem especially in the developing countries HBV is commonly transmitted via body fluids such, semen, blood, and viginal secrection .

27. Signs of hepatitis B Anorexia Nausea Vomiting Low grade fever Fatigability Right upper quadrant and epigastric pain (intermittent, mild, to moderate)

28. Signs cont… Disturbance in sleeping pattern Coma Ascites Gastrointestinal bleeding Coagulopathy.

29. Hepatitis C: It is caused by the virus that attacks the liver and liver is flamed. Globally approximately 71 million people have chronic hepatitis c and around 399000 dye from the infection.

30. Signs and symptoms Arthragias Parathesias Myalagias Pruritus Sicca syndrome

31. Investigations Blood test, can detect signs of hepatitis B virus in the body and doctor is able detect if it is a cute or chronic. Liver ultra sound scan: transient electrography can show amount of liver damage. Total and direct serum bilirubin levels Albumin levels LFT’S ASP and ALT levels

32. Investigations cont…. Erythrocyte sedimentation rate. Hematological and coagulation studies ( plate count, CBC, etc.) Liver biopsy, doctor removes a small sample of biopsy from the liver to detect liver damage. Imaging sturdies. Abdominal ultrasonography CT MRIs

33. Treatment of chronic hepatitis B   GOAL is to prevent progression of disease to cirrhosis, liver failure and hepato cellular carcinoma Most people diagnosed with chronic hepatitis B infection need treatment for the rest of their life. It helps to prevent passing the infecting to others. Anti-viral medication is given e.g. tenofovir , telbivudine , adefovir dipivoxil and lamivudine can help fight the virus and slow its ability to damage the liver Interferons (peginterferon Alfa 2a Interferon Alfa 2b Vaccines A and B Other treatment modalities may include Liver transplant

34. HEPATITIS D There are three known genotypes of HDV genotype 1 has a worldwide distribution, genotype 2 exists in Taiwan, japan, and north Asia and genotype 3 is found in south America. Epidemiology Initial sturdies estimated that approximately 15-20million people are coinfected with HDV and HBV.HDV is more common in in adults than in children however children from under developed, HDV endemic countries are more likely to contact the HDV infection through breaks in the skin due to skin lesions. Clinical presentations and management] are similar to those of HBV Clinical presentations and management] are similar to those of HBV

35. HEPATITIS E Hepatitis E is an enteric ally transmitted infection, it is caused by Hep E virus Mode of spread Oral fecal route with contaminated water with endemic areas or through consumption of under cooked meat. Clinical presentation Anorexia (66-100%) Nausea and vomiting (30-100%) Weight loss typically 2.4kg) Dehydration

36. Right upper quadrant pain that increases with physical activity abdominal pain is reported in 35-80% of patients. Between the fifth and eigth week of infection patients may develop Dark urine Light coloured stools Pruritus

37. Management Non pharmacological Management Avoid drinking of contaminated water Vaccination Advice on diet

38. Pharmacological Electrolyte replacement can be both orally or parentally. Potassium chloride Calcium gluconate Potassium phosphate Antiviral agents oral Ribavirin for at least three month Hepatitis B/C agents such peginterferon alfa2a can be used.

39. Gilbert's Syndrome: It occurs due to a defect in the processing of bilirubin by the liver. Gilbert's syndrome is an inherit a mutated gene that affects the liver’s ability to process bilirubin , a waste product that forms during the breakdown of old red blood cells. Jaundice occurs when too much bilirubin builds up in blood.

40. Causes of Gilbert's syndrome A healthy UGT1A1 gene makes liver enzymes that break down bilirubin and remove it from the body. People with a mutated UGT1A1 gene only make about 30% of the enzymes they need. As a result, bilirubin doesn’t move into bile the way it should. The excess bilirubin builds up in blood.

41. symptoms of Gilbert's syndrome Approximately 1 in 3 people with Gilbert's syndrome don’t have symptoms. They learn that they have the disease after getting blood tests to check for a different problem. Among those with symptoms, the most common sign is jaundice, brought on by elevated levels of bilirubin in blood. Jaundice can turn your skin and whites of the eyes yellow, but it isn’t harmful. Occasionally, people who have jaundice or Gilbert's syndrome also experience:

42. Dark-colored urine or clay-colored stool. Difficulty concentrating. Dizziness. Gastrointestinal problems, such as abdominal pain, diarrhea and nausea. Fatigue. Flu-like symptoms, including fever and chills.

43. DIAGNOSIS AND TESTS As a genetic condition, Gilbert's syndrome is present at birth. It often remains undiagnosed until blood tests detect high bilirubin levels. Diagnosis most commonly occurs when people are in their teens or early adulthood and getting blood tests for something else. In addition to blood tests, you may get: Liver function test:  to assess how well your liver is working and measure bilirubin levels. Genetic tests  :to check for the gene mutation that causes Gilbert's syndrome.

44. Management Gilbert's syndrome Jaundice can cause a yellowish appearance that may be unsettling. However, jaundice and Gilbert's syndrome don’t require treatment because it does not cause serious harm to the liver..

45. Cholecystitis. This is the inflammation of the gall bladder Causes It is cause by stones that block the tube cystic duct leading from the gall bladder to the small intestines

46. Signs and symptoms of cholecystitis Severe pain in the upper right or center of abdomen it usually begins in the epigastrium and the localizes to the right upper quadrant. Pain that spreads to right shoulder or scapula Tenderness of the abdomen when. it is touched Nausea Vomiting .

47. Signs cont... Fever above 38 c Signs and symptoms occur after a meal particularly a large or a fat one. On examination fever, tachycardia, and signs of peritoneal irritation e.g. tenderness in the RUQ or epigastric region. Palpable tender gallbladder or fullness in the RUQ 30-40% of the patients. Jaundice 15% of the patients

48. Investigations Imaging modalities Ultra sound scan Hepatobiliary nuclear imaging: This is an imaging test that involves an injected radioactive substance. Magnetic resonance Cholangiopancreatgraphy : it shows details of the liver, gall bladder and bile duct structures. Abdominal computered tomography.

49. Investigations cont…. Laboratory tests ALT and AST levels will be elevated Alkaline phosphate levels may be elevated in 25% patients with cholecysttis . Transient mild CBD obstruction may be caused by inflammatory edema in the calot triangle and the hepatoduodenal ligament. Management.

50. Management. The management of cholecysitis will depend on the severity of the condition and the presence or absence of the complications. In acute phase , Outpatient treatment may be appropriate The initial treatment includes Bowel rest Intravenous hydration Correction of electrolyte abnormalities Intravenous antibiotic. Cholecystectomy is recommended in severe cases.

51. On admission Admit on ward and all admission procedures done. Nasal gastric tube is passed Intravenous line passed and fluids set. observation of temperature, pulse, respiration and blood pressure are taken and recorded. Injection vitamin K is given if patient has jaundice. Jaundiced patients will be given 500mls of 10% mannitol, it serves as a diuresis. Fluid balance chat is monitored Intravenous line is observed for flow and site of canular assessed Assess the nasal gastric aspirates . CCK and this prevents gallbladder sludge in patients receiving total parenteral nutrition.

52. Management cont… The drainage tube in the sub hepatic pouch that will drain oozing blood from the liver bed and that may reveal any internal hemorrhage. AT-tube draining from the common bile duct connected to the outside in to the plastic bag is also observed for drainage and the amount is recorded for at least a week. medication is given i.e. Pethidine 50-100 mg to relieve severe pain Antibiotics to counteract infection are given piperacillin/ tazobactam 3.375g iv 6 hourly or 4.5g iv 8houry, also third class cephalospolins plus metronidazole, levofloxacin, ceftriaxone ,ciprofloxacin, meropenem may be given.

53. Management cont… Diet:at first the patient is on intravenous fluids and later when improves the gastric tube is removed and sips are introduced. Emesis is treated with antiemetics (promethazine) and nasal gastric sunctions Meperidine is a drug of choice that is given to control pain. Daily stimulation of the gallbladder contraction with intravenous

54. Nursing concerns. Excess Fluid Volume. Ineffective Breathing Pattern. Disturbed Body Image. Deficient Knowledge.

55. NURSING DIAGNOSISES. 1.Ineffective Breathing Pattern related to Intra-abdominal fluid collection ( ascites), Decreased lung expansion and accumulated secretions Goal. To Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range in 2days

56. Intervention Monitor respiratory rate, depth and effort. Auscultate breath sounds, noting crackles, wheezes, rhonchi. Rationale Rapid shallow respiration or presence of dyspnea may appear because of hypoxia and/or fluid accumulation in the abdomen May indicate developing complications. Presence of adventitious breath sounds may reflect accumulation of fluids or secretions. Absent or diminished sounds suggests atelectasis

57. Investigate changes in level of consciousness . Keep head of bed elevated. Position on sides . Provide supplemental O 2  as indicated. Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma Facilitates breathing by reducing pressure on the diaphragm and reducing risks of aspiration of secretions. To treat or prevent hypoxia and if respirations and oxygenation is inadequate, mechanical ventilation may be required.

58. Evaluation Patient will have effective respiratory pattern; be free of dyspnea and cyanosis, have vital capacity within acceptable range within two days.

59. 2. Disturbed body image related Biophysical changes/altered physical appearance evidenced by Negative feelings about body/abilities. Goal. Verbalize understanding of changes and acceptance of self in the present situation in 72 hours

60. Interventions . Discuss situation and encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms . Support and encourage patient; provide care with a positive, friendly attitude. Rationale. Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol or other drug use Care givers some times allow judgmental feelings to affect the care of patient and need to make every effort to make patient feel valued as a person.

61. Evaluation Patient will be able to understanding the changes and accept of self in the present situation ,Identify feelings and methods for coping with negative perception of self in 72 hours.

62. 3.Risk for Injury related Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin. Goal. To Maintain homeostasis with absence of bleeding in 4 days.

63. Interventions Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus Use small injection and needles while giving injections. Rationale The esophagus and rectum are the most usual sources of bleeding because of their mucosal fragility and alterations in hemostasis associated with cirrhosis. Minimizes damage to tissues, reducing risk of bleeding and hematoma.

64. Evaluation. patient’s homeostasis will be Maintained with absence of bleeding within 4 days.