GI and Liver

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tiffanydawnn
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136438
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GI and Liver
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2012-02-20 06:29:25
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GI Liver
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GI and Liver
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  1. irritable bowel syndrome
    • 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
  2. IBS manifestations
    • 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)
  3. IBS dx
    • r/o other causes
    • stool for RBCs, WBCs, ova, parasites
    • sigmoidoscopy
    • colonoscopy
    • small bowel series (upper GI w/small bowel follow through)
    • CBC/ESR
  4. IBS meds
    • goal: manage symptoms
    • bulk forming laxatives
    • anticholinergics
    • antidepressants
    • antidiarrheals
    • herbs/probiotics
  5. bulk forming laxatives
    • reduce spasms, promote regularity
    • encourage H20
    • bran
    • methylcellulose
    • psyllium
  6. anticholinergics
    • 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)
  7. antidepressants
    • tricyclics/SSRIs
    • relieve abd pain/DHR r/t anticholinergic s/e
  8. antidiarrheals
    loperamide (Imodium), diphenoxylate (Lomotil)
  9. IBS nutrition
    • increased fiber
    • limit sugars
    • limit gas forming foods (beans, broccoli, beans, cabbage, nuts, raisins)
    • limit caffeine (GI stimulant)
  10. inflammatory bowel disease
    • 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
  11. ulcerative colitis
    • 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
  12. UC manifestations
    • DHR with blood and mucus
    • --mild: <4/day
    • --severe: up to 20/day
    • anemia
    • hypovolemia
    • malnutrition
    • fecal urgency
    • LLQ cramping
    • fatigue
    • anorexia
    • weakness
  13. UC complications
    • hemorrhage
    • toxic megacolon - colon dilates
    • colon perforation > peritonitis
    • increased r/f colon cancer
  14. Crohn's disease
    • 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
  15. Crohn's manifestations
    • DHR - liquid or semiformed (no blood)
    • abd pain/tenderness - RLQ
    • abscesses
    • malnutrition
    • fever
    • malaise
    • fatigue
    • weight loss
    • anemia
    • fissures
    • ulcers
  16. Crohn's complications
    • scarring
    • strictures
    • adhesions
    • fistula > abscess, chills, fever, abd mass, leukocytosis, DHR, WL, malnutrition
    • obstruction r/t repeated inflammation, scarring
    • perforation > peritonitis
  17. IBD dx
    • 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
  18. IBD meds
    • goal: remission
    • anti-inflammatories
    • corticosteroids
    • immunosuppressants
    • antibiotics
  19. sulfasalazine (Azulfidine)
    • sulfonamide antibiotic/anti-inflammatory
    • poorly absorbed, acts topically to inhibit inflammatory process
    • s/e: HA, N&V, rash
  20. olsalazine (Dipentum)/mesalamine (Asacol Rowasa)
    • non-sulfa form of sulfasalazine
    • fewer side effects
    • rectal or oral
  21. corticosteroids
    • reduce inflammation, induce remission for acute exacerbations
    • hydrocortisone rectally for topical relief
    • IV for severe
    • PO for mild to moderate
  22. immunosuppressants
    • for pt not responding to other therapy
    • maintain remission, facilitate healing
    • azathioprine (Imuran)
    • methotrexate
    • cyclosporine (Sandimmune)
  23. monoclonal antibody
    • infliximab (Remicade)
    • suppresses tumor necrotic factor (inflammatory mediator)
  24. antibiotic
    • metronidazole (Flagyl)
    • antibiotic with anti-inflammatory effects
  25. IBD diet
    • eliminate triggers (milk, gluten)
    • NPO during exacerbation
    • low residue diet
    • TPN
    • elemental (Ensure)
  26. IBD surgery
    • bowel obstruction
    • perforation
    • fistula
    • abscess
    • perianal complications
  27. colectomy
    • surgical resection and removal of colon
    • extensive UC
    • IPPA - ileal pouch anal anastomosis - pouch attached to rectum
  28. liver functions
    • 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)
  29. hepatitis
    • 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
  30. hepatitis variations
    • 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
  31. prodromal/preicteric phase
    • flu-like symptoms
    • GI upset
    • muscle aches
    • polyarthritis
    • RUQ pain
    • tenderness
  32. icteric phase
    • 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
  33. convalescent/post-icteric phase
    • normalization of enzyme, bilirubin levels
    • increased energy
    • decreased pain
  34. hepatitis dx
    • 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
  35. hepatitis meds - prevention
    • vaccines: Hep A, Hep B/D
    • post-exposure prophylaxis: immune globulin (IG)
  36. hepatitis meds - treatment
    • 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)
  37. hepatitis nursing
    • acute: bedrest
    • prevention
    • food safety
    • safe sex
    • vaccination
    • prophylactic treatment
    • infection control
    • rest periods
    • nutrition
    • avoid hepatotoxins (mushrooms, Tylenol)
  38. hepatitis diet
    • high carb diet
    • avoid ETOH, diet drinks
    • nutritional supplements
  39. hepatitis nursing dx
    • 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
  40. cirrhosis
    • 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
  41. types of cirrhosis
    Laennec's - from ETOH use - increased triglyceride, fatty acid synthesis, decreased formation and release of lipoproteins > fatty liver > inflammation > necrosis, fibrosis
  42. posthepatic - chronic Hep B/C > immune response > liver damage (shrunken, nodular)
    biliary - obstructed bile flow > retained bile in liver causes damage, destroys liver cells> inflammation > liver damage
  43. cirrhosis manifestations
    • 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
  44. portal HTN
    • 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
  45. 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
  46. esophageal varices
    • 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)
  47. splenomegaly
    • enlarged spleen caused by portal HTN (causes blood back up into splenic vein)
    • increases rate of blood cell destruction > anemia, leukopenia, thrombocytopenia
  48. hepatic encephalopathy
    • 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
  49. asterixis
    • aka liver flap
    • early sign of hepatic encephalopathy
    • extend arms, dorsiflex wrist - hands would flap down
  50. hepatorenal syndrome
    • 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
  51. spontaneous bacterial peritonitis
    • inflammation of peritoneum
    • inflammatory response worsens ascites (increased capillary permeability)
    • s/s: increased abd discomfort, pain, fever, increased ascites, worsening encephalopathy
  52. cirrhosis dx
    • 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)
  53. bilirubin - elevated direct and indirect
    • 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
  54. cirrhosis meds
    • goal: treat complications
    • avoid ETOH, hepatotoxic drugs
    • diuretics
    • laxatives
    • anti-biotics
    • beta blocker
    • antacids
    • iron/folic acid/Vitamin K
    • oxazepam
    • octreotide
  55. diuretics
    • spironolactone (Aldactone) - reduces ascites by decreasing aldosterone levels
    • furosemide (Lasix) - excrete potassium
  56. laxatives
    • lactulose (Cephulac)
    • reduces ammonia-producing bacteria in colon and converts ammonia to ammonium ion > excreted
  57. antibiotics
    • neomycin (Neo Tabs)
    • decrease ammonia production in bowel
    • ototoxic/nephrotoxic
  58. beta blocker
    • nadolol (Corgard), propanolol (Inderal)
    • reduce portal HTN, prevent esophageal bleed
  59. antianxiety
    • oxazepam (Serax)
    • not metabolized by liver
  60. octreotide
    • vasoconstricts portal vessels
    • esophageal varices
  61. cirrhosis diet
    • restrict sodium/fluids
    • adequate protein
    • ADEKs
    • iron
  62. paracentesis
    • 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
  63. TIPS
    • 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
  64. 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
  65. cirrhosis nursing dx
    • 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)

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