Liver Lengkap

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ACCESSORY ORGANS

OF
THE DIGESTIVE
SYSTEM

REVIEW OF ANATOMY AND
PHYSIOLOGY
ACCESSORY ORGANS OF THE
DIGESTIVE SYSTEM:

Liver

Gall bladder and du!al "#"!e$

Panrea"

This is an in-situ photograph
of the chest and abdominal
contents. As can be seen,
the liver is the largest
parenchymal organ, lying
just below the diaphragm.
The right lobe (at the left in
the photograph) is larger
than the left lobe. The
falciform ligament is the
rough dividing line between
the two lobes.

REVIEW OF ANATOMY AND
PHYSIOLOGY
LIVER

Liver l%bule"

He&a!i "inu"%id" 'a&illarie"( lined )i!*


+u&,,er ell"

P%r!al irula!i%n - brin." bl%%d !% !*e


liver ,r%$ : "!%$a*/ "&leen/ &anrea" 0
in!e"!ine"

REVIEW OF ANATOMY AND
PHYSIOLOGY
F1NCTIONS OF THE
LIVER:

Carb%*#dra!e
$e!ab%li"$

Gl#%.ene"i"

Gl#%.en%l#"i"

Glu%ne%.ene"i"

Fa! $e!ab%li"$ 2
3e!%.ene"i"

Pr%!ein $e!ab%li"$

anab%li"$

dea$ina!i%n

urea ,%r$a!i%n

Sere!i%n %, bile

De!%4i,ia!i%n

Me!ab%li"$ %,
vi!a$in" A/D/+/5 0

Cl%!!in. ,a!%r"/ e"&


&r%!*r%$bin

REVIEW OF ANATOMY AND
PHYSIOLOGY
F1NCTIONS OF THE 5ILIARY SYSTEM:
67 Gallbladder - %nen!ra!e 0 "!%re bile
87 Du!al "#"!e$ - r%u!e ,%r bile !% rea* !*e
in!e"!ine"
67 5ile i" ,%r$ed in !*e liver 0 e4re!ed in!% !*e
hepatic duct
87 C#"!i du! drain" !*e .allbladder
97 He&a!i du! :%in" *e cystic duct !% ,%r$
common bile duct.
4. Sphincter of Oddi : rela4ed/ bile en!er"
du%denu$; %n!ra!ed/ bile "!%red in !*e .all
bladder; %n!r%lled b# *%le#"!%3inin ,r%$ du%denal
$u%"a

REVIEW OF ANATOMY AND
PHYSIOLOGY
PACREAS:

Head/

5%d#

Tail

Panrea!i du!
F1NCTIONS OF THE PANCREAS:

E4%rine : !r#&"in%.en/ *#$%!r#&"in/ a$#la"e/


li&a"e

End%rine : i"le!" %, Lan.er*an": in"ulin and


.lua.%n

CASE ST1DY

Siriu"/ <= #7%7/ )a" br%u.*! b# *i"


,a$il# beau"e %, v%$i!in. %, bl%%d7

He>" dr%)"#/ )i!* VS %, : 9?


%
/ 66@/ 8A/
A@B?@7

He>" a *r%ni al%*%li; :aundied 0


)i!* bi. abd%$en

CASE ST1DY

W*a! %!*er a""e""$en! ,indin." )%uld


#%u e4&e!C

W*a! are #%ur &lan"C



N1RSING ASSESSMENT
MANIFESTATIONS OF LIVER
DISORDERS

Daundie

He$%rr*a.e B bleedin. &r%ble$"

Pruri!u" and i!*in.

A"i!e"

GeneraliEed Ede$a

In!%lerane %, Seda!i%n

MANIFESTATIONS OF LIVER
DISORDERS
DA1NDICE
CA1SES:

Pre*e&a!i - *e$%l#"i"

In!ra*e&a!i - liver &aren*#$al d"e

P%"*e&a!i - %b"!ru!i%n %, bile du!"



MANIFESTATIONS OF LIVER
DISORDERS
HEMORRHAGE

Due !% inadeFua!e &r%!*r%$bin 0 %!*er


l%!!in. ,a!%r"

Mana.e$en! :

5ile "al!" &7%7/

Vi! +/ &7%7 0 &aren!eral/

u"e %, "$all needle )i!* in:e!i%n/

u"e %, "%,! !%%!*bru"*/

*e3 urine and "!%%l ,%r bl%%d7



MANIFESTATIONS OF LIVER
DISORDERS
PR1RIT1S 0 ITCHING

Cau"ed b# bile &i.$en! de&%"i!ed !%


"3in

Mana.e$en!:

ba!*in. )i!* !e&id )a!er 0 u"e %, %il2ba"ed


l%!i%n

*%le"!#ra$ine - bind" )i!* bile "al!" and


,aili!a!e" e4re!i%n )i!*,ee"

1"e "%,! linen

S*%r! ,in.ernail"

MANIFESTATIONS OF LIVER
DISORDERS
ASCITES

Cau"e" :

&%r!al *#&er!en"i%n

derea"ed &la"$a %ll%id %"$%!i &re""ure

*#&erald%"!er%ni"$

MANIFESTATIONS OF LIVER
DISORDERS
ASCITES

Mana.e$en! :

dail# )ei.*! 0 abd%$inal .ir!*

l%) Na die!/ ,luid re"!ri!i%n/ diure!i"

relieve "#$&!%$" ,r%$ &re""ure %, a"i!e" :

*i.* ,%)ler>"

!urnin. 0 &%"i!i%nin.

IV albu$in/

Paraen!e"i"

Peri!%ne%ven%u" S*un!

MANIFESTATIONS OF LIVER
DISORDERS
GENERALIGED EDEMA

In"u,,iien! albu$in
INTOLERANCE OF SEDATION

M%"! "eda!ive" are $e!ab%liEed in !*e


liver e4e&! phenobarbital

DISEASES OF THE
LIVER

HEPATITIS

CIRRHOSIS

CANCER OF THE LIVER



HEPATITIS
TYPES:

Viral He&a!i!i"

T%4i He&a!i!i" - e4&%"ure !%


*e&a!%!%4in : arb%n !e!ra*l%ride7
M%r&*ine/ barbi!ura!e"

HEPATITIS
He&a!i!i" A

In,e!i%u"

Feal2%ral r%u!e
He&a!i!i" 5

Seru$ *e&a!i!i"

5l%%d 0 b%d# ,luid !ran"$i""i%n



HEPATITIS
DIAGNOSIS:
Sreenin. !e"! ,%r He&a!i!i"
Liver ,un!i%n !e"!":

SGOT

Al3aline P*%"&*a!a"e

SGPT
I$a.in.: 1l!ra"%und

Grossly, there are areas of necrosis and
collapse of liver lobules seen here as ill-
defined areas that are pale yellow. uch
necrosis occurs with hepatitis.

HEPATITIS
PLANNING 0 IMPLEMENTATION
67 Preven! "&read %, !*e di"ea"e7
He&a!i!i" A

Tran"$i""i%n : ,eal2%ral r%u!e

Inuba!i%n &eri%d : 82H )3" 'viru" in !*e bl%%d 0


,ee"(

M%"! in,e!ive 8 )3" be,%re %n"e! %, "B"4

En!eri &reau!i%n"

Gl%ve" )*en *andlin. "!%%l"

Hand)a"*in.

HEPATITIS
PLANNING 0 IMPLEMENTATION
67 Preven! "&read %, !*e di"ea"e7
He&a!i!i" 5

Tran"$i""i%n : 5l%%d 0 b%d# ,luid

E4&%"ed individual" : He& 5 i$$un%.l%bulin/


&r%vide" &a""ive i$$uni!#

Hi.* Ri"3 Individual" : He& 5 vaine

T*%"e )*% *andle bl%%d

H%$%"e4ual $ale"

IV dru. u"er"

He$%dial#"i" &a!ien!"
87 Ob!ain re"! !% &r%$%!e liver
re.enera!i%n

HEPATITIS
PLANNING 0 IMPLEMENTATION
97 Nu!ri!i%n : Well2 balaned/ *i.* P/
*i.* C
=7 Pr%vidin. %$,%r! $ea"ure"
<7 Ad$ini"!er $edia!i%n" :

An!iviral"

Liver "u&&le$en!"

CIRRHOSIS
END RESULT OF E!"TO#$ELLUL"R %N&UR'

Paren*#$al ell dea!*

Re.enera!i%n 0 "arrin.

Di$ini"*ed bl%%d ,l%) ,ibr%"i"

Fa!!# de.enera!i%n

P%r!al vein %b"!ru!i%n


TYPES:
67 P%"!ner%!i - &%"! He& 5; $ar%n%dular
87 P%r!al 'Laene>"( - al%*%li"$; $ir%n%dular
97 5iliar# - %b"!ru!i%n
=7 Cardia - ,r%$ &%r!al *#&er!en"i%n

CIRRHOSIS
ASSESSMENT:
Ga"!r%in!e"!inal S#"!e$

D1E TO META5OLIC CHANGES IN THE LIVER


'P/C/F(

An%re4ia

Nau"ea 0 v%$i!in.

Wei.*! l%""

Fla!ulene

Fa!i.ue

A5DOMINAL PAIN

HEPATOMEGALY

ASCITES

Ongoing liver damage with liver cell necrosis followed by
fibrosis and hepatocyte regeneration results in cirrhosis.
This produces a nodular, firm liver. The nodules seen
here are larger than 3 mm and, hence, this is an example
of "macronodular" cirrhosis.

Mall%r#I" *#aline i" "een *ere/ bu! !*ere are al"% neu!r%&*il"/ ner%"i"
%, *e&a!%#!e"/ %lla.en de&%"i!i%n/ and ,a!!# *an.e7 T*e"e ,indin."
are !#&ial ,%r au!e al%*%li *e&a!i!i"7 Su* in,la$$a!i%n an %ur in
a &er"%n )i!* a *i"!%r# %, al%*%li"$ )*% .%e" %n a drin3in. Jbin.eJ
and %n"u$e" lar.e Fuan!i!ie" %, al%*%l %ver a "*%r! !i$e7

CIRRHOSIS
ASSESSMENT:
End%rine S#"!e$
TE L%(ER %S UN")LE TO *ET")OL%+E OR*ONES
OF TE "DREN"L $ORTE,- O("R%ES- ESTRO.EN "ND
TESTES

AMENORRHEA

GYNECOMASTIA

LOSS OF P15IC HAIR

IMPOTENCE
He&a!%2Renal S#ndr%$e
REN"L F"%LURE /%TOUT D%SE"SE

CIRRHOSIS
ASSESSMENT:
O!*er:

DA1NDICE

ICTERIC SCLERAE

PR1RIT1S

SPIDER ANGIOMA

PALMAR ERYTHEMA

M1SCLE ATROPHY

PROLONGED

EASY 5R1ISING
LA5S:

LIVER FKN TESTS

S7 5ILIR15IN

PROLONGED
Pr%!*r%$bin !i$e

DECREASED Seru$
Albu$in

DECREASED H.b 0
H!

CIRRHOSIS 2 $ana.e$en!

Su,,iien! re"! 0 %$,%r!

Mea"ure" !% relieve &ruri!u"

Nu!ri!i%n: *i.* al%rie/ l%) !% $%dera!e


P/ *i.* C/ l%) ,a!/Vi! A/ 5 %$&/ C/ D
and +

M%ni!%r/ &reven! bleedin.7

Diure!i" i, )i!* a"i!e"

Clien! !ea*in. : av%id *e&a!%!%4i


dru." : %&ia!e" 0 "eda!ive"/ av%id
al%*%l

CIRRHOSIS
COMPLICATONS:
67 HEPATIC COMA
87 PORTAL HPN
ESOPHAGEAL VARICES

ubmucosal veins in the esophagus become dilated. These are
!nown as esophageal varices. "arices are seen here in the
lower esophagus as linear blue dilated veins. There is
hemorrhage around one of them. uch varices are easily
eroded, leading to massive gastrointestinal hemorrhage.

#ne of the most common
findings with portal
hypertension is
splenomegaly, as seen here.
The spleen is enlarged from
the normal $%% grams or less
to between &%% and '%%% gm.
Another finding here is the
irregular pale tan pla(ues of
collagen over the purple
capsule !nown as )sugar
icing) or )hyaline perisplenitis)
which follows the
splenomegaly and*or multiple
episodes of peritonitis that
are a common
accompaniment to cirrhosis of
the liver.

HEPATIC COMA
DE.ENER"T%(E D%SE"SE OF TE )R"%N FRO* L%(ER F"%LURE
DUE TO %N")%L%T' OF TE L%(ER TO $ON(ERT "**ON%" TO
URE"

CHANGES IN PERSONALITY AND 5EHAVIOR

LETHARGY

CONF1SION

TREMORS

ST1POR

DIGGINESS

COMA

FETOR HEPATIC1S - FR1ITY ODOR 5REATH

SPIDER TELANGIECTASIA

ELEVATED SER1M AMMONIA LEVELS



HEPATIC COMA
MANAGEMENT:
67 Neur% $%ni!%rin.
87 Die! : Re"!ri! P/ *i.* C/ )i!* Vi! +
97 Ad$ini"!er:

ene$a/

a!*ar!i"

LACT1LOSE - %nver"i%n %, a$$%nia !%


n%nab"%rbable a$$%niu$

in!e"!inal an!ibi%!i" - NEOMYCIN


67 Mana.e$en! ,%r irr*%"i"

ESOPHAGEAL VARICES
D%L"T%ON OF TE (E%NS OF TE ESO!".US FRO* !ORT"L
'!ERTENS%ON
PORTAL HYPERTENSION - re"i"!ane !% n%r$al ven%u"
draina.e %, !*e liver in!% !*e &%r!al vein
MANAGEMENT:
67 Ied n%r$al "aline lava.e
87 5l%%d !ran",u"i%n"
97 Vi!a$in +
=7 Sen."!a3en 5la3e$%re 2 9 lu$en

+ee& "i""%r" a! bed"ide

Label ea* lu$en


67 IV va"%&re""in
87 Sur.er# - "*un!in. %, bl%%d !% de%$&re"" varie"
97 Sler%!*era&#
=7 Peru!ane%u" e$b%liEa!i%n

CANCER OF THE LIVER

Pri$ar#

Se%ndar# - liver i" !*e $%"!


%$$%n "i!e %, CA $e!"

+ere is an hepatocellular
carcinoma. uch liver
cancers arise in the setting
of cirrhosis. ,orldwide, viral
hepatitis is the most common
cause, but in the -..,
chronic alcoholism is the
most common cause.
The neoplasm is large and bul!y and has a
greenish cast because it contains bile. To the
right of the main mass are smaller satellite
nodules.

CANCER OF THE LIVER

SBSK :

An%re4ia

Wei.*! l%""

Wea3ne""

abd%$inal ,ullne"" and bl%a!in.

Abd%$inal &ain

MANAGEMENT - T%!al He&a!i L%be!%$#

RESE$T%ON %S U! TO 012 OF TE OR."N




DISEASES OF THE
GALL5LADDER

CHOLELITHIASIS

CHOLECYSTITIS

CHOLELITHIASIS
FORMATION OF GALLSTONES

R%S3 F"$TORS 4 = F>" : ,e$ale/ ,a!/ ,%r!#/


,er!ile

Mul!i&ar%u"

Oral %n!rae&!ive"

Cirr*%"i"

Obe"i!#

H#&erli&ide$ia

T%!al &aren!eral nu!ri!i%n

5ile "!a"i"

CHOLELITHIASIS
PRECIPITANTS:
67 Al!era!i%n in !*e %nen!ra!i%n %,
lei!*in/ *%le"!er%l/ and bile "al!"
87 Me!ab%li *an.e"
97 C*%le#"!i!i"
=7 5iliar# "!a"i"

5ile aid" and lei!*in derea"e in bile
T*e a&ai!# !% di""%lve *%le"!er%l i" redued
E4e"" *%le"!er%l &rei&i!a!e a" r#"!al"
GALLSTONES
PATHOPHYSIOLOGY

CHOLELITHIASIS
ASSESSMENT:
67 5iliar# %li:

R1L &ain/ u"uall# &%"!&randiall#

Re,erred &ain: R "ub"a&ular


'5OA>S SIGN(

E&i.a"!ri &ain

Nau"ea 0 v%$i!in.
67 Evidene %, *%led%*%li!*ia"i":

Daundie

Cla#2%l%red "!%%l"

H#&erbilirubine$ia

Eleva!ed al3aline &*%"&*a!a"e


DIAGNOSIS :
1l!ra"%und

CHOLELITHIASIS
PLANNING 0 IMPLEMENTATION:
MEDICAL INTERVENTION
67 L%) ,a! die!
87 Preven! de*#dra!i%n
97 Media!i%n":
67 S$%%!* Mu"le rela4an!": redue "&a"$ %, !*e
du! 0 &er$i! bile &a""a.e

Pa&averine

Ni!r%.l#erine

NO M%r&*ineM
67 5ile aid" - C*en%de%4#*%li aid 'CHENIK(
and 1r"%de%4#*%li aid 'ACTIGALL( :,%r
lien!" )*% are &%%r ri"3 ,%r "ur.er#; T%4i !% !*e
liver

CHOLELITHIASIS
S1RGICAL INTERVENTION
67 C*%le#"!%"!%$# - drainin. %, !*e
.allbladder
87 C*%le#"!e!%$# - re$%val %, !*e
.allbladder
97 C*%led%*%li!*%!%$# - re$%val %,
"!%ne" ,r%$ !*e %$$%n bile du!
=7 In!ra%&era!ive C*%lan.i%.ra$ - d#e in
!*e bile du! !*ru !*e #"!i du!/ i, )i!*
*%led%*%li!*ia"i"

GALL5LADDER S1RGERY
PRE2OP N1RSING CARE:

A""ure %&!i$al *eal!*

In"!ru! lien! %ver &re2%&era!ive &lan



GALL5LADDER S1RGERY
POST2OP N1RSING CARE:

Preven! %$&lia!i%n"

Pr%vidin. biliar# draina.e

Preven!in. di"!en!i%n

Mana.e &ain - F%)ler>" &%"i!i%n

Main!ain nu!ri!i%n

Di"*ar.e &lannin. 0 *%$eare - dB


a,!er H26@ da#"

GALL5LADDER S1RGERY
COMPLICATIONS:
67 5leedin.
87 Cardi%re"&ira!%r#
97 T*r%$b%&*lebi!i"
=7 W%und Evi"era!i%n and De*i"ene

GALL5LADDER S1RGERY
POST2OP N1RSING CARE:

Preven! %$&lia!i%n"

Pr%vidin. biliar# draina.e

Preven!in. di"!en!i%n

Mana.e &ain - F%)ler>" &%"i!i%n

Main!ain nu!ri!i%n

Di"*ar.e &lannin. 0 *%$eare - dB


a,!er H26@ da#"

GALL5LADDER S1RGERY
5ILIARY DRAINAGE:

5l%%d# draina.e - n%r$al durin. 6


"!
8 *r"

Greeni"* br%)n draina.e 2 a,!er 8 *r"

=@@ $l in 6
"!
8= *r"/ 8@@ $lB8= *r" !*erea,!er

Plaed ab%ve !*e bile du! !% %lle! %ver,l%)


draina.e

GALL5LADDER S1RGERY
5ILIARY DRAINAGE:

T !ube "!a#" ,%r ? )3" !% ? $%" be,%re i! i"


re$%ved

C%l%r !% urine 0 "!%%l "*%uld be %b"erved a,!er


re$%val %, !*e !ube

C*ill" and ,ever i" n%r$al )i!* la$&in. %, T


!ube durin. *ealin. &eri%d7

GALL5LADDER S1RGERY
POST2OP N1RSING CARE:

Preven! %$&lia!i%n"

Pr%vidin. biliar# draina.e

Preven!in. di"!en!i%n

Mana.e &ain - F%)ler>" &%"i!i%n

Nu!ri!i%n 2 )*en biliar# draina.e i"


ree"!abli"*ed:

Fa! -re"!ri!ed die!

Di"*ar.e &lannin. 0 *%$eare - dB


a,!er H26@ da#"

GALL5LADDER S1RGERY
PREVENTING DISTENTION:

NGT un!il &eri"!al"i" re!urn"

Re!al !ube - e4&ul"i%n %, ,la!u"

Ene$a - 9
rd
da# - &eri"!al"i" and
relea"e %, ,la!u"

GALL5LADDER S1RGERY
POST2OP N1RSING CARE:

Preven! %$&lia!i%n"

Pr%vidin. biliar# draina.e

Preven!in. di"!en!i%n

Mana.e &ain - F%)ler>" &%"i!i%n

Nu!ri!i%n 2 )*en biliar# draina.e i"


ree"!abli"*ed:

Fa! -re"!ri!ed die!

Di"*ar.e &lannin. 0 *%$eare - dB


a,!er H26@ da#"

CHOLECYSTITIS
CA1SES:

In,e!i%n: S!re&/ S!a&*/ E7 %li/ T#&*%id

Gall "!%ne"

Slud.e

5iliar# "!a"i"
SBSK:

In!%lerane !% ,a!!# ,%%d"

1nrelen!in. R1L &ain 0 !enderne""

Re,erred &ain : ri.*! "ub"a&ular/ e&i.a"!ri

Nau"ea 0 v%$i!in.

M1RPHY>S SIGN

CHOLECYSTITIS
LA5S:
67 Inrea"ed W5C
87 Inrea"ed "eru$ a$#la"e
DIAGNOSIS:
1!l!ra"%und
COMPLICATIONS:
67 Ab"e""
87 Per,%ra!i%n
97 *%led%*%li!*ia"i"

CHOLECYSTITIS
MANAGEMENT

IVF

An!ibi%!i

NG !ube de%$&re""i%n

C*%le#"!e!%$#


DISEASES OF THE
PANCREAS

PANCREATITIS

AC1TE

CHRONIC

CANCER OF THE PANCREAS




INFLAMMATION
EDEMA
OBSTRUCTION OF PANCREATIC DUCT
RUPTURE & RELEASE OF DIGESTIVE ENZYMES
AUTOLYSIS OF PANCREATIC TISSUE
NECROSIS
PANCREATITIS

AC1TE PANCREATITIS
PREDISPOSING FACTORS:

5in.e al%*%l drin3in.

5iliar# !ra! di"ea"e

Du%denal %b"!ru!i%n

In,e!i%n

Trau$a

Nu!ri!i%nal de,iien#

CHRONIC PANCREATITIS
PREDISPOSING FACTORS:

Al%*%l in.e"!i%n

Gallbladder di"ea"e

Au!%i$$une ,a!%r"

PANCREATITIS

RELIEF OF PAIN:

De$er%l

NO MORPHINEM

DIET

Av%id a,,eine and al%*%l

S$all ,reFuen! ,eedin. %, 5LAND/ ea"#


di.e"!able ,%%d

PANCREATIC EKTRACTS

Vi%3a"eB C%!aE#$ - ,aili!a!e di.e"!i%n %,


,a!2"%luble vi!a$in"

CANCER OF THE
PANCREAS
SBSK:

An%re4ia

Wei.*! l%""

Wea3ne""

Nau"ea

La!e "i.n": &ain/ :aundie a"i!e"/ &al&able


$a""
S1RGERY:

W*i&&le" Pr%edure: re$%val %, !*e *ead %, !*e


&anrea"/ di"!al "!%$a*/ C5D 0 du%denu$

W*i* lab%ra!%r# value )%uld !*e


nur"e e4&e! !% ,ind in a lien! a" a
re"ul! %, liver ,ailureC
a7 Derea"ed "eru$ rea!inine
b7 Derea"ed "%diu$
7 Inrea"ed a$$%nia
d7 Inrea"ed aliu$

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