GI and Liver

• motility disorder of lower GI tract
• chronic disorder
• patho: no identifiable cause, CNS regulation of bowel is altered
• dx: 3 days per month past 3 mos of 2/3 sx

• 1 - abd pain relieved by defecation (spasms or dull/continuous)
• 2 - change in frequency
• 3 - change in form
• **mucus**
• bloating/gas
• N&V
• anorexia
• fatigue
• HA
• dep/anx
• tender abd (sigmoid)

• r/o other causes
• stool for RBCs, WBCs, ova, parasites
• sigmoidoscopy
• colonoscopy
• small bowel series (upper GI w/small bowel follow through)
• CBC/ESR

• goal: manage symptoms
• bulk forming laxatives
• anticholinergics
• antidepressants
• antidiarrheals
• herbs/probiotics

• reduce spasms, promote regularity
• encourage H20
• bran
• methylcellulose
• psyllium

• inhibit bowel motility by interfering with PNS stimulation
• relieves abd pain/cramping
• 30-60 min before meals
• s/e: dry mouth, blurred vision, urinary hesitancy
• monitor bowel sounds, flatus
• dicyclomine (Bentyl), hyoscyamine (Anaspaz)

• tricyclics/SSRIs
• relieve abd pain/DHR r/t anticholinergic s/e

loperamide (Imodium), diphenoxylate (Lomotil)

• increased fiber
• limit sugars
• limit gas forming foods (beans, broccoli, beans, cabbage, nuts, raisins)
• limit caffeine (GI stimulant)

• IBD = ulcerative colitis and Crohn's disease
• closely related
• unknown etiology
• risk factors: genetics, autoimmune, smoking, contraceptives
• UC - large bowel in continuous pattern (distal to proximal)
• CD - small intestine, patchy pattern

• chronic inflammatory bowel disorder
• affects mucosa/submucosa of colon and rectum in a continuous pattern
• mild to moderate ( <6 stools daily)
• distal rectosigmoid colon > progresses proximally > fulminant colitis (entire colon)
• microscopic hemorrhages > crypt abscesses that spread laterally
• mucosa red/edematous/ulcerated > hemorrhage and necrosis

• DHR with blood and mucus
• --mild: <4/day
• --severe: up to 20/day
• anemia
• hypovolemia
• malnutrition
• fecal urgency
• LLQ cramping
• fatigue
• anorexia
• weakness

• hemorrhage
• toxic megacolon - colon dilates
• colon perforation > peritonitis
• increased r/f colon cancer

• chronic inflammatory GI disorder
• can affect mouth to anus
• usually affects terminal ileum/ascending colon
• small patchy lesions of mucosa and submucosa > ulcerations and fistulas

• DHR - liquid or semiformed (no blood)
• abd pain/tenderness - RLQ
• abscesses
• malnutrition
• fever
• malaise
• fatigue
• weight loss
• anemia
• fissures
• ulcers

• scarring
• strictures
• adhesions
• fistula > abscess, chills, fever, abd mass, leukocytosis, DHR, WL, malnutrition
• obstruction r/t repeated inflammation, scarring
• perforation > peritonitis

• sigmoidoscopy
• colonoscopy
• barium upper/lower GI
• stool for WBCs, RBCs, ova, parasites, bacteria, mucus (r/o other causes)
• CBC
• --anemia r/t chronic inflammation, blood loss, malnutrition
• --leukocytosis r/t inflammation, abscesses
• ESR, C-reactive r/t inflammation
• serum albumin decreased r/t malabsorption, malnutrition, protein loss
• folic acid/vitamin levels decreased r/t malabsorption, malnutrition
• LFTs - inflamed duodenum > bile backs up into liver

• goal: remission
• anti-inflammatories
• corticosteroids
• immunosuppressants
• antibiotics

• sulfonamide antibiotic/anti-inflammatory
• poorly absorbed, acts topically to inhibit inflammatory process
• s/e: HA, N&V, rash

• non-sulfa form of sulfasalazine
• fewer side effects
• rectal or oral

• reduce inflammation, induce remission for acute exacerbations
• hydrocortisone rectally for topical relief
• IV for severe
• PO for mild to moderate

• for pt not responding to other therapy
• maintain remission, facilitate healing
• azathioprine (Imuran)
• methotrexate
• cyclosporine (Sandimmune)

• infliximab (Remicade)
• suppresses tumor necrotic factor (inflammatory mediator)

• metronidazole (Flagyl)
• antibiotic with anti-inflammatory effects

• eliminate triggers (milk, gluten)
• NPO during exacerbation
• low residue diet
• TPN
• elemental (Ensure)

• bowel obstruction
• perforation
• fistula
• abscess
• perianal complications

• surgical resection and removal of colon
• extensive UC
• IPPA - ileal pouch anal anastomosis - pouch attached to rectum

• produces albumin - primary plasma protein
• produces cholesterol
• metabolizes carbs, fats, proteins > ammonia > urea > kidney > urine
• metabolizes ETOH, drugs
• stores vitamins ADEK
• stores glycogen
• stores iron (ferritin)
• unconjugated bilirubin > direct bilirubin > bile > GB
• metabolizes aldosterone > aldactone
• stores blood
• synthesizes clotting factors (all except von W)
• produces and secretes bile > break down fats
• breaks down bacteria (Kupffer cells)

• inflammation of the liver
• damages hepatic cells, disrupts liver function
• impaired bile flow > jaundice
• patho: hep virus replicates in liver > damages hepatocytes > immune response > inflammation/necrosis

• A - fecal/oral, abrupt, benign/self-limiting
• B - blood/body, slow onset, vaccine
• C - blood/body, slow onset
• D - blood/body, abrupt, must have B to get it, B vaccine protects against it
• E - fecal/oral, abrupt
• B+D - fulminant hepatitis - fatal in 2 weeks if untreated

• flu-like symptoms
• GI upset
• muscle aches
• polyarthritis
• RUQ pain
• tenderness

• jaundice r/t hyperbilirubinemia s/t inflammation of liver and bile ducts
• pruritus r/t bile salts on skin
• clay-colored stools r/t lack of bile pigment in stool
• brown urine r/t excess bile excreted in urine
• no fever
• increased appetite

• normalization of enzyme, bilirubin levels
• increased energy
• decreased pain

• LFTs
• ALT - enzyme contained in liver cells - released when damaged
• AST - enzyme in heart and liver cells - released when damaged
• ALP - enzyme in liver and bone cells
• GGT - enzyme increase with ETOH use
• LDH
• bilirubin - elevated r/t impaired bilirubin metabolism/biliary duct obstruction
• viral antigen - HAV, HBV, HCV, HDV
• liver biopsy - lay on R side 2 hours post, monitor for bleeding

• vaccines: Hep A, Hep B/D
• post-exposure prophylaxis: immune globulin (IG)

• mild/moderate - not treated
• severe acute B - antiretroviral - lamivudine (Epivir)
• --decreases liver inflammation and fibrosis
• acute C - antiviral - interferon alpha - reduces risk of chronic C
• --also used for chronic B and C
• --s/e: flu-like symptoms, depression
• chronic C - combo antiviral - peginterferon (Pegasys) and ribavirin (Rebetol)
• --s/e: hemolytic anemia
• milk thistle, licorice root (increased r/f HTN)

• acute: bedrest
• prevention
• food safety
• safe sex
• vaccination
• prophylactic treatment
• infection control
• rest periods
• nutrition
• avoid hepatotoxins (mushrooms, Tylenol)

• high carb diet
• avoid ETOH, diet drinks
• nutritional supplements

• risk for infection (transmission)
• fatigue r/t s/e of hepatitis
• imbalanced nutrition - less than body requirements r/t immune function
• disturbed body image r/t jaundice, rash

• fibrosis of liver tissue > decreased mass, impaired liver function, altered blood flow
• caused by ETOH, prolonged biliary obstruction, chronic Hep B/C, severe R HF (liver congestion)
• patho: liver tissue replaced by fibrous tissue > hepatocytes destroyed > liver function declines > disrupted blood flow to IVC > portal HTN

Laennec's - from ETOH use - increased triglyceride, fatty acid synthesis, decreased formation and release of lipoproteins > fatty liver > inflammation > necrosis, fibrosis

biliary - obstructed bile flow > retained bile in liver causes damage, destroys liver cells> inflammation > liver damage

• early
• --few s/s
• --enlarged, tender liver
• --dull epigastric or RUQ pain
• --WL, anorexia
• --weakness
• late
• --impaired metabolism > bleeding, ascites, gynecomastia, infertility, jaundice, neuro changes
• --portal HTN > edema, anemia, low WBC/platelet

• increased pressure in portal system causes blood to be rerouted to adjoining vessels
• congested veins in esophagus, rectum, abdomen
• increased hydrostatic pressure causes fluid to shift into abd cavity > ascites

• accumulation of plasma-rich fluid in abd cavity
• caused by portal HTN
• hypoalbuminemia decreases osmotic pressure of plasma > fluid escapes into extravascular space
• hyperaldosteronism increases Na and H20 retention > contributes to ascites
• s/s: caput medusa

• enlarged veins in esophagus caused by portal HTN (blood backs up into esophageal veins)
• can rupture > massive hemorrhage
• contributing factors: thrombocytopenia, decreased clotting factors
• tx: beta blocker to decrease portal HTN, triple lumen NG (Blakemore/Minnesota) to tamponade vessels (monitor airway)

• enlarged spleen caused by portal HTN (causes blood back up into splenic vein)
• increases rate of blood cell destruction > anemia, leukopenia, thrombocytopenia

• accumulation of neurotoxins (ammonia) in blood, cerebral edema
• liver cannot convert ammonia to urea (lactulose to excrete ammonia, destroy bacteria)
• s/s: asterixis, agitation, restlessness, impaired judgement, slurred speech, confusion, disorientation

• aka liver flap
• early sign of hepatic encephalopathy
• extend arms, dorsiflex wrist - hands would flap down

• rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure
• caused by altered blood flow to kidneys s/t liver failure, portal HTN
• precipitated by GI bleed, diuretics

• inflammation of peritoneum
• inflammatory response worsens ascites (increased capillary permeability)
• s/s: increased abd discomfort, pain, fever, increased ascites, worsening encephalopathy

• LFTs - elevated but not as severe as acute hep
• CBC - low r/t splenomegaly, anemia
• Coag studies - prolonged PT r/t decreased clotting factors, lack of vitamin K (stored in liver)
• electrolytes - hyponatremia (hemodilution), hypokalemia, hypophosphatemia, hypomagnesemia (malnutrition, altered renal function)

• albumin - low r/t impaired production
• ammonia - elevated r/t inability to convert to urea for renal excretion
• glucose - abnormal (high or low)
• abd u/s - liver size, nodules, ascites
• esophagoscopy - varices
• liver biopsy

• goal: treat complications
• avoid ETOH, hepatotoxic drugs
• diuretics
• laxatives
• anti-biotics
• beta blocker
• antacids
• iron/folic acid/Vitamin K
• oxazepam
• octreotide

• spironolactone (Aldactone) - reduces ascites by decreasing aldosterone levels
• furosemide (Lasix) - excrete potassium

• lactulose (Cephulac)
• reduces ammonia-producing bacteria in colon and converts ammonia to ammonium ion > excreted

• neomycin (Neo Tabs)
• decrease ammonia production in bowel
• ototoxic/nephrotoxic

• nadolol (Corgard), propanolol (Inderal)
• reduce portal HTN, prevent esophageal bleed

• oxazepam (Serax)
• not metabolized by liver

• vasoconstricts portal vessels
• esophageal varices

• restrict sodium/fluids
• adequate protein
• ADEKs
• iron

• dx or tx (relieve resp distress)
• can remove large vol of fluid - IV albumin given to maintain fluid volume
• patient voids prior, sits upright to avoid bowl perf

• transjugular intrahepatic portosystemic shunt
• emergent relief of portal HTN
• allows blood flow from portal vein to hepatic vein (bypass liver)
• short term fix until liver transplant

• criteria: irreversible cirrhosis, decline in function, increasing bilirubin, decreasing albumin
• contraindications: malignancy, active ETOH/drug abuse, poor surgical risk
• immunosuppressives or life
• whole liver or individual lobes

• excess fluid volume r/t portal HTN, hypoalbuminemia, hyperaldosteronism
• disturbed thought process r/t encephalopathy
• ineffective protection r/t impaired coagulation
• impaired skin integrity r/t jaundice (pruritus)
• imbalanced nutrition - less than body requirements r/t malnutrition (ETOH, anorexia, impaired vitamin absorption, impaired protein metabolism)