Chapter 44: Liver, Pancreas, and Biliary Tract Problems
Jaundice, a yellowish discoloration of body tissues, results from an alteration in normal bilirubin
metabolism or flow of bile into the hepatic or biliary duct systems.
The three types of jaundice are hemolytic, hepatocellular, and obstructive.
o Hemolytic (prehepatic) jaundice is due to an increased breakdown of red blood cells
(RBCs), which produces an increased amount of unconjugated bilirubin in the blood.
o Hepatocellular (hepatic) jaundice results from the liver’s altered ability to take up
bilirubin from the blood or to conjugate or excrete it.
o Obstructive (posthepatic) jaundice is due to decreased or obstructed flow of bile
through the liver or biliary duct system.
Hepatitis is an inflammation of the liver. Viral hepatitis is the most common cause of hepatitis.
The types of viral hepatitis are A, B, C, D, E, and G.
o HAV is an RNA virus that is transmitted through the fecal-oral route.
o The mode of transmission of HAV is mainly transmitted by ingestion of food or liquid
infected with the virus and rarely parenteral.
o HBV is a DNA virus that is transmitted perinatally by mothers infected with HBV;
percutaneously (e.g., IV drug use); or horizontally by mucosal exposure to infectious
blood, blood products, or other body fluids.
o HBV is a complex structure with three distinct antigens: the surface antigen (HBsAg), the
core antigen (HBcAg), and the e antigen (HBeAg).
o Approximately 6% of those infected when older than age 5 develop chronic HBV.
o HCV is an RNA virus that is primarily transmitted percutaneously.
o The most common mode of HCV transmission is the sharing of contaminated needles
and paraphernalia among IV drug users.
o There are 6 genotypes and more than 50 subtypes of HCV.
Hepatitis D, E, G o Hepatitis D virus (HDV) is an RNA virus that cannot survive on its own. It requires HBV to
o Hepatitis E virus (HEV) is an RNA virus that is transmitted by the fecal-oral route.
o Hepatitis G virus (HGV) is a sexually transmitted virus. HGV coexists with other viral
infections, including HBV, HCV, and HIV.
o Many patients with hepatitis have no symptoms.
o Symptoms of the acute phase include malaise, anorexia, fatigue, nausea, occasional
vomiting, and abdominal (right upper quadrant) discomfort. Physical examination may
reveal hepatomegaly, lymphadenopathy, and sometimes splenomegaly.
Many HBV infections and the majority of HCV infections result in chronic (lifelong) viral
Most patients with acute viral hepatitis recover completely with no complications.
Approximately 75% to 85% of patients who acquire HCV will go on to develop chronic infection.
Fulminant viral hepatitis results in severe impairment or necrosis of liver cells and potential liver
There is no specific treatment or therapy for acute viral hepatitis.
Drug therapy for chronic HBV and HBC is focused on decreasing the viral load, aspartate
aminotransferase (AST) and aspartate aminotransferase (ALT) levels, and the rate of disease
o Chronic HBV drugs include interferon, lamivudine (Epivir), adefovir (Hepsera), entecavir
(Baraclude), and telbivudine (Tyzeka).
o Treatment for HCV includes pegylated -interferon (Peg-Intron, Pegasys) given with
ribavirin (Rebetol, Copegus).
Both hepatitis A vaccine and immune globulin (IG) are used for prevention of hepatitis A.
Immunization with HBV vaccine is the most effective method of preventing HBV infection. For
postexposure prophylaxis, the vaccine and hepatitis B immune globulin (HBIG) are used.
Currently there is no vaccine to prevent HCV. Most patients with viral hepatitis will be cared for at home, so the nurse must assess the
patient’s knowledge of nutrition and provide the necessary dietary teaching.
Autoimmune hepatitis is a chronic inflammatory disorder of unknown cause. It is characterized
by the presence of autoantibodies, high levels of serum immunoglobulins, and frequent
association with other autoimmune diseases.
Autoimmune hepatitis (in which there is evidence of necrosis and cirrhosis) is treated with
corticosteroids or other immunosuppressive agents.
Wilson’s disease is a progressive, familial, terminal neurologic disease accompanied by chronic
liver disease leading to cirrhosis.
It is associated with increased storage of copper.
PRIMARY BILIARY CIRRHOSIS
Primary biliary cirrhosis (PBC) is characterized by generalized pruritus, hepatomegaly, and
hyperpigmentation of the skin.
NONALCOHOLIC FATTY LIVER DISEASE
Nonalcoholic fatty liver disease (NAFLD) is a group of disorders that is characterized by hepatic
steatosis (accumulation of fat in the liver) that is not associated with other causes such as
hepatitis, autoimmune disease, or alcohol.
The risk for developing NAFLD is a major complication of obesity. NAFLD can progress to liver
NAFLD should be considered in patients with risk factors such as obesity, diabetes,
hypertriglyceridemia, severe weight loss (especially in those whose weight loss was recent), and
syndromes associated with insulin resistance.
CIRRHOSIS Cirrhosis is a chronic progressive disease characterized by extensive degeneration and
destruction of the liver parenchymal cells.
Common causes of cirrhosis include alcohol, malnutrition, hepatitis, biliary obstruction, and
right-sided heart failure. Excessive alcohol ingestion is the single most common cause of
cirrhosis followed by chronic hepatitis (B and C).
Manifestations of cirrhosis include jaundice, skin lesions (spider angiomas), hematologic