NP03L036

Introduction to the
Gallbladder, Liver, and
Exocrine Pancreas
 ENABLING LEARNING
OBJECTIVES
 A. Define key terms related to the
hepatobiliary system.
 B. Identify the structures and function of
the organs in the hepatobiliary system
 C. Identify laboratory and diagnostic
examinations used in the diagnosis of the
liver, gallbladder and exocrine pancreas
disorders and the appropriate nursing
interventions related to these tests.
Key Terms
 Key Terms
 Cholang - Pertaining to bile ducts
 Cholangiography - X-ray examination of
the bile duct
 Choledocho - Pertaining to common bile
duct
 Choledocholithiasis - Stones in the
common bile duct
 Key Terms
 Cirrhosis - A chronic degenerative disease
of the liver
 Hepatitis - Inflammation of the liver
 Hepatomegaly - Enlargement of the liver
 Asterixis - A hand flapping tremor
 Esophageal varices - A complex of
longitudinal, tortuous veins at the lower end
of the esophagus
 Key Terms
 Hepatic Encephalopathy - A type of brain
damage caused by liver disease and
consequent ammonia intoxication
 Paracentesis - A procedure in which fluid is
withdrawn from the abdominal cavity
 Parenchyma - Tissue of an organ as
distinguished from supporting or connective
tissue
 Key Terms
 Flatulence - Excess formation of gases in
the stomach
 Ascites - Abnormal intraperitoneal
accumulation of fluid and albumin
 Pruritus - The symptom of itching
Biliary System
 Biliary System
 The biliary system is comprised of the
organs and duct system that create,
transport, store and release bile into the
duodenum for digestion. It includes the
liver, gallbladder and bile ducts (named the
cystic, hepatic, common, and pancreatic
duct).
Liver
 Liver
 Largest and one of the most complex
glandular organs in the body
 Located just inferior to the diaphragm,
covering most of the right upper quadrant
and extending into the left epigastrium
 Liver
 Divided into two lobes
 Receives approximately 1500ml/minute via
the portal vein and hepatic artery
 Hepatocytes (cells of the liver) produce bile
– Bile is necessary for the metabolism of fats
– Bile travels through the hepatic duct to the gall
bladder for storage
 Liver
 Functions
– Metabolizes fats
– Manages blood coagulation and produces most
of the clotting factors (in the presence of
Vitamin K)
– Manufactures cholesterol
– Manufactures albumin (maintains normal blood
volume)
 Liver
 Functions
– Filters out old red blood cells and bacteria
– Detoxifies poisons (alcohol, nicotine, drugs)
– Converts ammonia to urea
– Provides the main source of body heat
– Stores glycogen for later use
– Activates Vitamin D
– Breaks down nitrogenous wastes to urea
Gall bladder
 Gall bladder
 Sac about 3 to 4 inches long located on the
right inferior surface of the liver
 Stores bile needed for fat digestion
Pancreas
 Pancreas
 Elongated gland that lies posterior to the
stomach
 Involved in both exocrine and endocrine
function
 Produces 1000 to 1500ml of pancreatic
juice daily to aid in digestion
 Digests the three major components of
chyme: proteins, fats and carbohydrates
 Pancreas
 Contents of pancreatic juice
– Protease (Trypsin)
– Lipase (Steapsin)
– Amylase (Amylopsin)
 Enzymes are transported to the duodenum
via the pancreatic duct to the common bile
duct and out to the duodenum via the
papilla of Vater
 Also contains sodium bicarbonate
Laboratory Studies:
 Laboratory Studies:

 Serum bilirubin test. Normal values

– Direct bilirubin: 0.1-0.3 mg/dl
– Indirect bilirubin: 0.2-0.8 mg/dl
– Total bilirubin 0.1-1.0 mg/dl
 Elevated levels will cause jaundice, which is the
most common sign of a liver disorder
 Testing for bilirubin in the blood provides
information for diagnosis and evaluation of liver
disease, biliary obstruction and hemolytic anemia
 Serum bilirubin test.
 Old red blood cells are broken down by the
spleen and bone marrow.
 The hemoglobin which is released is
converted into indirect bilirubin.
 Indirect bilirubin is converted to direct
bilirubin by the liver.
 Serum bilirubin test
 Nursing interventions:
– Keep patient NPO until blood specimen is
drawn.
– Monitor venipuncture site for bleeding.
 Liver enzymes tests
 The liver is a storehouse of enzymes.
Injury or disease will cause release of these
intracellular enzymes into the bloodstream
and their levels will be elevated. Some of
these enzymes are produced in other organs
so elevations may not be specific to the
liver.
 Liver enzymes tests
 AST (Aspartate aminotransferase)
formerly serum SGOT
– Normal value: Adult 5 to 40 IU/L
– Elevated in myocardial infarction, hepatitis,
cirrhosis, hepatic necrosis, hepatic tumor, acute
pancreatitis, acute renal disease, and acute
hemolytic anemia
 Liver enzymes tests
 ALT (Alanine aminotransferase) formerly
SGPT
– Normal value: Adults/child 5 to 35 IU/L
– Elevated in hepatitis, cirrhosis, hepatic
necrosis, and hepatic tumors and by hepatotoxic
drugs
 Liver enzymes tests
 LDH (Lactic dehydrogenase)
– Normal value: 45 to 90 U/L, 115 to 225 IU/L
– Elevated in myocardial infarction, pulmonary
infarction, hepatic disease, pancreatitis,
hemolytic anemia and skeletal muscle disease
 Liver enzymes tests
 Alkaline phosphatase
– Normal value: Adult 30 to 85 ImU/ml
– Elevated in obstructive disorders of the biliary
tract, hepatic tumors, cirrhosis, primary and
metastatic tumors, hyperparathyroidism,
metastatic tumor in bones, and healing fractures
 Liver enzymes tests
 Gamma GT (Gamma glutamyltransferase)
– Normal value: Male/female over 45: 8 to 8
U/L; female under 45: 5-27 U/L
– Elevated in liver cell dysfunction: hepatitis,
cirrhosis, hepatic tumors, hepatotoxic drugs,
myocardial infarction, congestive heart
 Liver enzymes tests
 Nursing interventions:
– Patient teaching,
– Assess site for bleeding
 Prothrombin time:

 Normal value: 11.0-12.6 sec

 Rationale: Detects increased clotting time
that can occur from liver disease (inability
to synthesize clotting factors) or vitamin K
deficiency
 Nursing interventions: Same as for
bilirubin
 Serum Protein Test:
 Normal values
– Total protein: 6 to 8 g/dl
– Albumin: 3.2 to 4.5 g/dl
– Albumin globulin (A/G ration) 1.2 to 2.2 g/dl
– Globulin: 2.3 to 3.4 g/dl
 Can assess functional status of liver by
measuring the products that are
synthesized there: protein, especially
albumin
 Serum Protein Test:
 Low levels may also result from
nephrotic ,ascites), or protein deplete
nutrition.
 Nursing interventions: Patient
education. Assess site for bleeding
 Serum ammonia

 Normal value 15-110 ug/dl

 Rationale: In liver dysfunction, serum
ammonia level increases and BUN level
decreases. Used in diagnosis of hepatic
encephalopathy or coma
 Nursing interventions: List antibiotics
patient is taking on lab request as they may
affect results
 Cholecystography
 Provides visualization of the gallbladder
after ingestion of radiopaque contrast.
Requires concentration of the dye within the
gallbladder. Patient must take dye tablets
evening prior to test. Vomiting or diarrhea
will cause decreased absorption and affect
results
 Oral Cholecystography
 Provides visualization of the
gallbladder after ingestion of
radiopaque contrast. Requires
concentration of the dye within the
gallbladder. Patient must take dye
tablets evening prior to test. Vomiting
or diarrhea will cause decreased
absorption and affect results
 Oral Cholecystography
 Nursing interventions
– rule out allergy to iodine/contrast medium
– Administer radiopaque tablets as ordered
– NPO after midnigh
– May be given high fat diet after test has started
to stimulate emptying of the gallbladder
Intravenous cholangiography (IVC)
 Radiographic dye, injected intravenously, is
concentrated by the liver and secreted into the bile
duct. IVC allows visualization of hepatic and
common bile ducts and gallbladder if cystic duct is
patent. Used to identify stones, stricture, or tumor
of the hepatic duct, common bile duct, and
gallbladder
 Nursing interventions: Same as above, except
tablets are not given
 Operative Cholangiography

 Common bile duct is injected with dye.

Allows surgeon to view this anatomically
difficult area before interventions to
decrease chance of injuring common bile
duct.
 Nursing interventions: Same as above
 T-tube Cholangiography
(Postoperative cholangiography)
 Performed to identify retained stones in the
postoperative cholecystectomy patient
 Performed via a T-tube placed by the
surgeon intra-operatively
 Contrast is injected to ensure adequate flow
of bile into the duodenum
 Nursing interventions
– Protect the patient from infection
– NPO after midnight
 Gallbladder scanning
 Nuclear medicine scan with radioactive isotope
used for the diagnosis of acute cholecystitis
 Nursing interventions
– Educate patient that the small dose of radiation used is
harmless
– NPO after midnight
– Encourage patient to drink fluids after test
– Nursing staff should wear gloves when handling urine
 Radioisotope Liver Scanning

 Used to outline and detect structural

changes in liver. After contrast is injected,
gamma-ray device passed over abdomen.
Records distribution of the radioactive
particles in the liver
 Nursing interventions: Same as above
 Needle Liver Biopsy

 Safe, simple and valuable method to

diagnose pathological liver conditions.
Needle is inserted through the skin, into
intercostal space and into liver where tissue
is removed. Used in the diagnosis of
cirrhosis, hepatitis, drug-related reactions,
granuloma and tumor
 Needle Liver Biopsy
 Nursing interventions
– Explain procedure to patient and obtain informed
consent
– Check lab values for coagulation studies
– Observe for bleeding after procedure. Monitor
VS
– Assess for pain, provide analgesics as ordered
– Assess for pneumothorax
– Keep patient lying on right side for 2 hours and
flat for 12 to 14 hours
 Endosopic Retrograde
Cholangiopancreatography (ERCP)
Fiberoptic duodenoscope inserted through
GI tract into duodenum. Common bile duct
and pancreatic duct are visualized after dye
is injected. Used to diagnose pancreatic
dysfunction. Also used to evaluate
obstructive jaundice, remove common bile
duct stones, and place biliary and pancreatic
duct stents to bypass obstruction
 Endosopic Retrograde
Cholangiopancreatography (ERCP)
 Nursing interventions
– NPO after midnight
– Educate patient and sign permit
– Test takes 1-2 hours to complete. Patient must
lie completely motionless on a hard X-ray table
– NPO post-procedure until gag reflex returns,
assess for abdominal pain, tenderness and
guarding
– Assess for signs and symptoms of pancreatitis-
increased abdominal pain, nausea, vomiting,
diminished or absent bowel sounds
 Laboratory tests related to the
Pancreas
 Amylase Test: Normal 25 to 125 U/L
 Test for pancreatitis. Abnormal serum rise
occurs 12 hours after onset of pancreatic
disease. May return to normal within 48 to
72 hours. (Amylase is cleared efficiently by
the kidneys)
 Nursing interventions:
– List medications on lab request due to false-
positive results
 Laboratory tests related to the
Pancreas
 Serum Lipase Test: Normal 0 to 110U/L
 Elevated in acute pancreatitis. (More
specific than amylase for pancreatitis)
 Nursing interventions
– Keep patient NPO after midnight
 Imaging procedures for the
pancreas
 Ultrasonography of Pancreas
– Used to establish the diagnosis of pseudocyst,
pancreatitis, and pancreatic abscess
 Nursing interventions
– NPO after midnight
– Assess abdomen for distention or gas that may
interfere with sound waves
 Imaging procedures for the
pancreas
 (Computed Tomography (CT) of Abdomen
– Noninvasive accurate test used to diagnose
pathological pancreatic conditions such as
inflammation, tumor, cyst formation, ascites,
aneurysm, and cirrhosis of liver
 Nursing interventions
– NPO after midnight
– Decrease patient's anxiety to claustrophobia
from machine
 Question: The following laboratory values which
are often abnormal in a patient with liver
pathology, include all of the following except:
 PT
 AST/ALT
 Alkaline phosphatase
 Total bilirubin
 Albumin
 CA125
–Answer: CA 125
 Review of Main Points

 Key terms
 Structure and function of the hepatobiliary
system.
 Diagnostic tests
ANY QUESTIONS??