Disorder of Biliary Tract

to concentrate and store bile....constantly filling and emptying

stones migrating and lodging in the neck of the gall bladder, cystic duct or common bile duct

any condition in which the flow of bile from the liver is slowed or blocked.

• S/S-clay or white colored stools
• dark urine
• cant digest certain foods
• itching
• nause
• vomit
• PAIN in right upper abdomen
• YELLOW skin or eyes

bile is an irritant, causes inflammation and this inflammation can spread to other organs...pancrease=pancreatitis

bile and impaired circulation from swelling causes ischemia, leading to abscess formation and then necrosis of the GB wall and gangrene

Perforation then occurrs and you have peritonitis

infection of the common bile duct by bacteria from other parts of the body....got there by lymph channels

• E Coli
• Strep
• Samonella

Cholelithiasis

Cholecystitis

Cholestasis

Biliary Colic

Choledocholithiasis

filter blood

inflammation of liver cells

it is caused by drugs, alcohol, industrial toxins, medications and plan poisons

There are 6 types...ABCDEG

• Virus replicates and attacks hepatocytes
• liver becomes enlarged and congested with inflammatory cells, lymphocytes and edema
• Swelling causes obstruction to the portal circulation with interference to the blood flow in to the hepatic lobules
• edema of liver bile channels results in intrahepatic obstructive jaundice

Increasing inflammation, necrosis and regneration of cells causes this

• active phagocytosis
• removal of damaged liver cells
• regeneration of liver cells

Takes 2-3 months

death

Causes acute Hepatitis

From fecal oral route....must be ingested, but NOT caused by kissing or sharing utensils

• 1. water, especially during epidemics
• 2. From hands not being washed by food preparers

1 month

• custodians
• day care worker
• travelers in developing countries
• long term care facility workers

No jaundice!!!

99% recover and it confers life long immunity

• BLOOD
• Primarily a STD, but passed via skin thru:
• mucous membrane
• parenteral routes
• contact with infected blood or serous fluid

blood, semen, saliva, NG secretions

Dont want a break in your skin or mucous membrane!!

later confirmed by presence of HAV-IgM antibodies in the blood

• malaise
• nausea
• vomit
• fever

• presence of HbsAg(surface ag) and HbcAg(core ag) in the blood
• later the anti-HBcIgM antibodies appear

carriers can harbor this virus in their bodies without manifesting symptoms and can distrubute the infection

have HbsAg after 6 months

Presence of HbeAg

• kissing(low risk)
• sharing tooth brush or water picks
• razor blades
• cigarettes
• contaminated tattoing/body piercing
• acupuncture equip
• NAIL CLIPPERS!
• hemodialysis
• tampons/sanitary napkins or dressings

• dried blood on skin and clothing can infect you as a FOMITE!
• Rarely trnasmitted by blood transfusion

2-3 months after exposure

presence of antibodies HbsAg

• Iv drug users (parenteral)
• fetuses of infected moms
• sexual partners with
• Permiscuous or anal sex
• male prisoners
• healthcare workers with frequent blood contact

Cirrhosis and Hepatocellular Cancer (HCC)

liver transplant....but only extends life by a max of 5 years

Tylenol

IgG

• presence of HCV antibody
• PLUS
• increased ALT (ALT is supposed to be in the liver, not the blood)

• Most common chronic blood borne infection in the US
• Typical in males 29-49

NEEDLES AND COKE

It is both....

acute can go chronic, but chronic doesnt necessarily start as acute

Usually 50 days

its asymptomatic

• frequent blood transfusion prior to 1992
• veterans injured
• IV drug users
• Been in bar fights

Very low

75-85% of people....but can have it for 10-40 years before you know.

Growing concern with baby boomers.

Will show up with increase in liver enzymes in your physical

• Seen in Mediterranean basin
• Middle East
• Central Africa
• Amazonian basin
• Asia

It is only active in the presence of HBV...so get HBV vaccine, and you cant get it

• same as HBV
• but most common in drug addict and those receiving blood transfusions

high risk for hepatic failure!

• spread by fecal oral route 
• acute infection

• transmitted through blood 
• co infection with B or C

G is Benign....but B and C will kill you!!

• Mono
• yellow fever
• Systemic Herpes simplex

"A" has a very sudden onset

• Pre-icteric Phase/Prodromal Phase
• Icteric Phase
• Post Icteric Phase

jaundice

ANOREXIA & FATIGUE

starts in 2 weeks and lasts 4-6 weeks

Worsening of anorexia, nausea, starts vomiting, weakness and maliaise, liver tenderness NOW JAUNDICE

Increased amt of bilirubin in serum

when the liver's bile channels are obstructed, the concentration of bilirubin in the blood becomes abnormally high, excess bilirubin collects in the dermis and epidermis and in the connective tissue of the sclera creating yellow of jaundice

• yellow sclera and skin
• elevated total bilirubin in serum
• dark amber, foamy urine
• light brown to clay colored stools
• pruritis and burning skin

irritation of bile salts on the skin

• Liver function tests.....look at:
• Elevated ALT and AST enzymes
• Elevated Alkaline Phosphate

it is made in the bones, kidney, liver and intestines and is excreted thru the biliary tract.  When it is blocked, levels rise

will prolong PT first and cause clotting time to increase.

PTT will increase with severe liver damage

Clotting factors are synthesized in the liver and will be decreased with liver damage causing few clotting factors therefore prolonged clotting times and high risk bleeding

it is made in the liver too...so will have decreased levels of this which means a potential for drug problems

during any condition that obstructs blood flow.

• Such as:
• hepatitis
• cirrhosis
• gallstones
• tumor
• Anything that damages liver cells

Only when the person is having a problem with destruction of RBC's.  Like in Anemia or Rh problems in newborn.

NOT with Hepatitis

WBC

Lasts several weeks to months and is when complications of Hepatitis occurs....cuz it is when chronic forms develop

• Liver inflammation that lasts longer than 6  months. 
• Mile or no symptoms, no further destruction after initial insult

• Likelihood:
• HBV 1-10% adults or 15-80% in newborns
• HCV 75-85% chance of all cases to become chronic

• increased physical exertion
• Alcohol intake

is liver damage that can lead to hepatic necrosis and cirrhosis (fibrotic liver disease)

• Fulminant Hepatitis-it is the failure of liver cells to regenerate
• Progressive necrosis and damage leads to liver failure.
• Fatal form is rate....but once develop fatal form-1 yr to live

• rapid weight gain from fluid collection with ascites
• dark urine
• scleral icterus
• hepaic encephalopathy-mental status change
• edema in legs
• cardiac damage

accumulation of fluid in peritoneal cavity

cuz the fluid has lots of albumin in it....will drain it if they cant breathe.

Push on beer belly, get a fluid wave...ascites

Hepatitis B and C

toxins in the blood go to the brain....

• Activity intolerance
• Risk for fluid volume imbalance
• Risk for injury: bleeding (no clotting)
• Imbalanced nutrition
• Risk for impairment of skin integrity(pruritis)
• Risk for social isolation (Hep A....cant work in restaurant)

• No cure!!
• Fluid and elctrolyte replacement
• Vitamin K-for clotting
• Antihistamines-pruritis

• Hepatitis B and C
•  by stopping viral replication

antiviral drug used to treat HBV

Used in conjunction with Interferon

Stops replication, which decreases viral load which decreases liver damage

Treats HCV

prego test done before

Decrease RBC

• REST with BRP only
• comfort measures for pruritis
• Maintenance of food and fluids
• Daily wt (watch for ascites)
• Prevent Injury...especially if PT is prolonged
• use soft tooth brushes
• Vit K

• 3000 calories/day
• 3000 mL/day of fluid

No special diet....just smaller and frequent meals.  Lots of them!!

• urine
• stool
• skin for petachie

• use electric razors
• soft toothbrush
• no contact sports
• no subcutaneous or IM injections

If have to give Subcutaneous or IM injection...apply pressure for 5 minutes

Watch OTC's that are known to cause liver damage

• Tylenol
• aspirin
• sedatives
• medications with alcohol (cough meds)
• Must avoid for 3-12 months

NO ALCOHOL EVER IF HAVE CHRONIC HEPATITIS

• Standard Precautions and Contact Isolation
• Wear gloves/gown
• Private toilet with daily cleaning
• Bag, label and clean contaminated linens
• Isolation of tools (thermometers)
• Careful handwashing

• Standard precautions
• Careful disposal of needles and items exposed to patients blood or body fluids
• Avoidance of contamination of open cuts and mucous membranes (MINE)
• Teach pt. to avoid sex until liver fxn test is normal...then USE A CONDOM
• Dont share razors or tooth brushes
• DONT donate blood, plasma, organs, tissues or semen!!

Havris-provides immunization for 1 year old and above

Initial dose followed by a booster 6-12 months later

• HIG must be given within 7-14 days of exposure
• 48 hours from the first exposure is best

Recombivax HB

• admin in deltoid, may cause flu like symptoms
• requires a series of 3 shots with 2nd and 3rd dose being given 1 and 6 months after the initial dose

have an antibody titer drawn 1-2 months after the 3rd injection.  If ok you are protected for life, if not, booster is needed

HBIG within 7 days then get Recombivax series

1st and 2nd doses should be separated by at least 1 month and final dose 24 weeks

• HBIG given at 1 and 6 months
• 4 doses of combo vaccine
• Test pt for HBsAg and antibody to Hepatitis B surface antigen at 12 and 15 months of age to see if have antibodies

1999

NONE

flapping hands

• Stops viral replication
• Is better cuz has a longer 1/2 life and so it is given less often

B&C