Pancreatic & Hepatobiliary Nursing

Las Vegas, Nevada

PANCREATIC AND

HEPATOBILIARY DISORDERS

A Comprehensive Clinical Guide for GI/Endoscopy Nurses

Assessment, Management, and Interventional Procedures

Target Audience: Registered Nurses, GI/Endoscopy Nurses, Medical-Surgical Nurses

Level: Intermediate to Advanced

Release Date: February 2026 | Expiration Date: February 2029

Nevada State Board of Nursing Approved CE Provider

Author Disclosure

The author and planning committee have no relevant financial relationships to disclose.

Evidence-Based Guidelines Referenced

• American College of Gastroenterology (ACG) Guidelines on Acute Pancreatitis, 2024 • AASLD Practice Guidance on Cirrhosis and Portal Hypertension, 2023 • ASGE Guidelines for ERCP and Biliary Disorders • American Gastroenterological Association (AGA) Guidelines

LEARNING OBJECTIVES

Upon completion, the participant will be able to:

Differentiate between acute and chronic pancreatitis in terms of etiology, presentation, and nursing management

Apply evidence-based severity scoring systems (BISAP, Ranson's) to assess patients with acute pancreatitis

Describe the pathophysiology and management of choledocholithiasis, cholangitis, and biliary strictures

Explain the stages of liver cirrhosis and implement nursing care for complications including ascites, hepatic encephalopathy, and variceal bleeding

Outline the nursing role before, during, and after ERCP procedures including complication prevention and recognition

Develop patient education plans for pancreatic enzyme replacement therapy (PERT) and dietary modifications

Recognize indications for liver transplant referral and provide pre/post-transplant nursing care

SECTION 1: ANATOMY AND PHYSIOLOGY REVIEW

1.1 The Pancreas

The pancreas is a retroperitoneal organ approximately 15-20 cm long, lying posterior to the stomach. It has both exocrine and endocrine functions critical to digestion and glucose homeostasis.

EXOCRINE FUNCTION (95% of pancreas): Acinar cells produce digestive enzymes (amylase, lipase, proteases) secreted into the pancreatic duct. These enzymes are secreted as inactive zymogens to prevent autodigestion.

ENDOCRINE FUNCTION (Islets of Langerhans): Beta cells (insulin), alpha cells (glucagon), delta cells (somatostatin). Critical for glucose regulation.

PANCREATIC DUCT ANATOMY: • Main pancreatic duct (Wirsung) - joins common bile duct at ampulla of Vater • Accessory duct (Santorini) - drains via minor papilla in some individuals • Sphincter of Oddi - controls flow into duodenum • Pancreas divisum - anatomic variant where ducts fail to fuse (present in 5-10%)

1.2 The Biliary System

The biliary system transports bile from the liver to the duodenum for fat emulsification and absorption.

• Intrahepatic bile ducts → Right and left hepatic ducts → Common hepatic duct • Cystic duct (from gallbladder) + Common hepatic duct = Common bile duct (CBD) • CBD joins pancreatic duct at ampulla of Vater • Gallbladder stores and concentrates bile between meals

1.3 The Liver

The liver is the largest solid organ, performing over 500 functions including:

• Metabolism: Carbohydrates, proteins, lipids, drugs/toxins • Synthesis: Albumin, clotting factors, bile, cholesterol • Storage: Glycogen, vitamins (A, D, E, K, B12), iron, copper • Detoxification: Ammonia → urea, bilirubin conjugation, drug metabolism • Immune function: Kupffer cells (macrophages)

SECTION 2: ACUTE PANCREATITIS

2.1 Etiology

MNEMONIC - 'I GET SMASHED': Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion stings, Hyperlipidemia/Hypercalcemia/Hypothermia, ERCP, Drugs MOST COMMON: Gallstones (40%) and Alcohol (30%) account for 70% of cases

2.2 Clinical Presentation and Diagnosis

CLASSIC PRESENTATION: Sudden onset severe epigastric pain radiating to the back, worse with eating and lying supine, improved by leaning forward. Associated nausea, vomiting, and abdominal distension.

REVISED ATLANTA CRITERIA - Diagnosis requires 2 of 3: 1. Characteristic abdominal pain (epigastric, radiating to back, acute onset) 2. Serum lipase (or amylase) ≥3x upper limit of normal 3. Imaging findings consistent with acute pancreatitis (CT, MRI, or ultrasound) NOTE: Lipase is preferred over amylase (more specific, stays elevated longer)

2.3 Severity Assessment

Early severity prediction is critical for triage and management intensity.

2.4 Classification by Severity (Revised Atlanta)

2.5 Nursing Management

KEY NURSING INTERVENTIONS: 1. FLUID RESUSCITATION (Priority #1 in first 24 hours) • Goal-directed fluid therapy with lactated Ringer's (preferred) or NS • 250-500 mL/hr boluses initially, titrate to goals: - Urine output ≥0.5 mL/kg/hr - Heart rate <120 - MAP 65-85 mmHg - Decreasing BUN/hematocrit • CAUTION: Avoid fluid overload in elderly/cardiac patients 2. PAIN MANAGEMENT • IV opioids (morphine, hydromorphone, fentanyl) • PCA may be appropriate for severe pain • Positioning: semi-Fowler's, knees flexed 3. NPO STATUS AND NUTRITION • NPO initially; reassess daily • Early enteral nutrition (within 24-48 hrs) if tolerated - reduces infection risk • Oral diet when pain improving, no vomiting, hunger returns • Low-fat diet initially 4. MONITORING • Vital signs, I/O, daily weights • Serial labs: CBC, BMP, lipase, LFTs, calcium • Watch for complications (see below)

SECTION 3: CHRONIC PANCREATITIS

Chronic pancreatitis is characterized by progressive inflammatory changes leading to irreversible structural damage with fibrosis, loss of exocrine and endocrine function.

3.1 Etiology and Risk Factors

TIGAR-O Classification: T - Toxic-metabolic (alcohol most common - 70%, smoking, hypercalcemia, CKD) I - Idiopathic (early onset, late onset, tropical) G - Genetic (PRSS1, SPINK1, CFTR mutations) A - Autoimmune (Type 1 IgG4-related, Type 2) R - Recurrent acute pancreatitis O - Obstructive (pancreas divisum, tumors, strictures)

3.2 Clinical Manifestations

3.3 Pancreatic Enzyme Replacement Therapy (PERT)

PERT ESSENTIALS: INDICATIONS: Steatorrhea, weight loss, documented low fecal elastase (<200 mcg/g) DOSING: • Start: 40,000-50,000 lipase units with meals, 20,000-25,000 with snacks • Titrate based on symptoms (may need up to 90,000 units/meal) • Divide dose: half at start, half during meal ADMINISTRATION: • Take with FIRST bite of food (enzymes need to mix with food) • Swallow capsules whole OR open and sprinkle on acidic food (applesauce) • Do NOT crush enteric-coated microspheres • Take with each meal/snack containing fat MONITORING: • Symptom improvement (stool consistency, weight gain) • Fat-soluble vitamin levels (A, D, E, K) • If not responding: increase dose, add PPI to reduce acid (protects enzymes)

SECTION 4: BILIARY DISORDERS

4.1 Choledocholithiasis (CBD Stones)

Stones in the common bile duct may migrate from the gallbladder or form primarily in the bile duct. They cause obstruction, biliary colic, and can lead to cholangitis or pancreatitis.

CLINICAL FEATURES: RUQ pain, jaundice, dark urine, pale stools. Labs show elevated bilirubin (conjugated/direct), elevated ALP and GGT (cholestatic pattern), may have transaminase elevation.

DIAGNOSIS: Ultrasound (dilated CBD >6mm, stones visible ~50% of time), MRCP (gold standard for CBD stones), EUS (very sensitive, can see small stones).

TREATMENT: ERCP with sphincterotomy and stone extraction; cholecystectomy if gallbladder in situ.

4.2 Acute Cholangitis

ACUTE CHOLANGITIS IS A MEDICAL EMERGENCY Definition: Bacterial infection of the biliary tree due to obstruction CHARCOT'S TRIAD (50-75% of patients): 1. Fever/chills 2. RUQ pain 3. Jaundice REYNOLD'S PENTAD (severe/suppurative cholangitis - poor prognosis): 4. Altered mental status 5. Hypotension/shock TREATMENT: • NPO, IV fluids, IV antibiotics (broad-spectrum: piperacillin-tazobactam, or ciprofloxacin + metronidazole) • URGENT BILIARY DRAINAGE within 24-48 hours (earlier if severe) - ERCP preferred - Percutaneous transhepatic cholangiography (PTC) if ERCP fails - Surgery as last resort

4.3 Primary Sclerosing Cholangitis (PSC)

PSC is a chronic, progressive cholestatic liver disease characterized by inflammation and fibrosis of intra- and extrahepatic bile ducts, leading to multifocal strictures.

ASSOCIATIONS: Strong association with IBD (especially ulcerative colitis - 70-80% of PSC patients have UC). Male predominance. Increases risk of cholangiocarcinoma.

DIAGNOSIS: MRCP shows characteristic 'beaded' appearance of bile ducts. Liver biopsy shows 'onion-skin' fibrosis around ducts.

MANAGEMENT: No proven medical therapy to halt progression. ERCP for dominant strictures. Liver transplant for end-stage disease (recurrence possible). Annual cholangiocarcinoma surveillance.

SECTION 5: LIVER CIRRHOSIS AND COMPLICATIONS

Cirrhosis represents the end stage of chronic liver disease, characterized by diffuse fibrosis and regenerative nodules disrupting normal liver architecture.

5.1 Etiology

• Alcohol-associated liver disease (most common in Western countries) • Non-alcoholic steatohepatitis (NASH) - rapidly increasing • Chronic hepatitis B and C • Autoimmune hepatitis • Primary biliary cholangitis (PBC) • Primary sclerosing cholangitis (PSC) • Hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency

5.2 Compensated vs. Decompensated Cirrhosis

5.3 Complications and Nursing Management

ASCITES

Accumulation of fluid in the peritoneal cavity due to portal hypertension and hypoalbuminemia.

ASCITES MANAGEMENT: • SODIUM RESTRICTION: 2 grams/day (most important dietary intervention) • DIURETICS: Spironolactone (100-400 mg) + Furosemide (40-160 mg) in 100:40 ratio - Monitor: Weight (goal 0.5 kg/day loss, 1 kg if peripheral edema), electrolytes, creatinine - Complications: Hyponatremia, hyperkalemia, renal impairment • PARACENTESIS: Large-volume (>5L) requires albumin replacement (6-8 g/L removed) • AVOID: NSAIDs (reduce renal perfusion), nephrotoxic drugs SPONTANEOUS BACTERIAL PERITONITIS (SBP): • Infection of ascitic fluid; fever, abdominal pain, worsening encephalopathy • Diagnosis: Ascitic fluid PMN ≥250 cells/mm³ • Treatment: IV cefotaxime or ceftriaxone; IV albumin • Prophylaxis: Daily norfloxacin or TMP-SMX for high-risk patients

HEPATIC ENCEPHALOPATHY (HE)

Neuropsychiatric syndrome due to accumulation of neurotoxins (especially ammonia) that the failing liver cannot clear.

HE MANAGEMENT: • IDENTIFY AND TREAT PRECIPITANTS: Infection, GI bleeding, constipation, dehydration, medications (sedatives, opioids), electrolyte disturbances, dietary indiscretion • LACTULOSE (first-line): 15-30 mL PO q1-2h until bowel movement, then titrate to 2-3 soft stools/day - Mechanism: Acidifies colon, traps ammonia, osmotic cathartic - Monitor for dehydration; can give as enema if unable to take PO • RIFAXIMIN (add to lactulose for recurrent HE): 550 mg PO BID - Non-absorbable antibiotic; reduces ammonia-producing bacteria • PROTEIN: Do NOT restrict protein (worsens sarcopenia); maintain 1.2-1.5 g/kg/day • SAFETY: Fall precautions, aspiration precautions, reorient frequently

SECTION 6: PORTAL HYPERTENSION AND VARICEAL BLEEDING

Portal hypertension (HVPG >5 mmHg) develops when blood flow through the cirrhotic liver is impeded. When HVPG exceeds 10-12 mmHg, varices form in areas of portosystemic collaterals.

6.1 Esophageal and Gastric Varices

• 50% of cirrhotics have varices at diagnosis • Risk of first bleed: 5-15% per year for medium/large varices • Variceal bleeding mortality: 15-20% per episode (has improved with modern care) • Risk factors for bleeding: Large varices, red wale marks on endoscopy, Child-Pugh C

6.2 Primary Prophylaxis (Prevention of First Bleed)

SCREENING: All patients with newly diagnosed cirrhosis should undergo EGD to screen for varices. PROPHYLAXIS OPTIONS: • Non-selective beta-blockers (NSBB): Propranolol, nadolol, or carvedilol - Target heart rate reduction of 25% or to 55-60 bpm - Carvedilol 6.25-12.5 mg daily increasingly used (additional alpha-blockade) - CAUTION: Avoid in decompensated cirrhosis with refractory ascites, SBP, or hypotension • Endoscopic variceal ligation (EVL/banding): For patients who cannot tolerate NSBB - Repeat every 2-4 weeks until varices eradicated, then surveillance EGD SMALL VARICES: NSBB can be used; if not, repeat EGD in 2 years MEDIUM/LARGE VARICES: NSBB or EVL required

6.3 Acute Variceal Hemorrhage Management

ACUTE VARICEAL BLEEDING IS A GI EMERGENCY IMMEDIATE ACTIONS: 1. AIRWAY PROTECTION: Intubation for massive bleeding, encephalopathy, or inability to protect airway 2. RESUSCITATION: Large-bore IV access x2, type and crossmatch, conservative transfusion (Hgb goal 7-8 g/dL) 3. VASOACTIVE THERAPY: Start IMMEDIATELY (before endoscopy) • Octreotide 50 mcg IV bolus, then 50 mcg/hr infusion x 3-5 days • OR Terlipressin (not available in US) or somatostatin 4. ANTIBIOTICS: Ceftriaxone 1g IV daily x 7 days (reduces mortality, prevents SBP) 5. PPI: IV PPI (though evidence weak, commonly given) 6. URGENT EGD: Within 12 hours for diagnosis and therapy (EVL, sclerotherapy) 7. LACTULOSE: Prevent HE from blood protein load RESCUE THERAPIES (if endoscopic therapy fails): • Balloon tamponade (Sengstaken-Blakemore, Minnesota tube) - bridge to TIPS • TIPS (Transjugular intrahepatic portosystemic shunt) - very effective but risk of HE • Surgical shunt (rare)

SECTION 7: ERCP - NURSING CONSIDERATIONS

Endoscopic Retrograde Cholangiopancreatography (ERCP) is both a diagnostic and therapeutic procedure for biliary and pancreatic disorders. It carries higher complication rates than standard endoscopy, making nursing vigilance critical.

7.1 Pre-Procedure Nursing Care

PRE-ERCP CHECKLIST: □ NPO status verified (minimum 6-8 hours for solids, 2 hours for clear liquids) □ Informed consent obtained and questions answered □ Labs reviewed: CBC, PT/INR, PTT, BMP, type and screen □ Anticoagulant/antiplatelet management per ASGE guidelines: • Warfarin: Hold 5 days, check INR <1.5 for sphincterotomy • DOACs: Hold 24-48 hours depending on agent and renal function • Aspirin: Usually continue; clopidogrel: hold 5-7 days if high-risk procedure □ Allergies reviewed (especially iodine/contrast, antibiotics) □ IV access confirmed (preferably 20g or larger) □ Antibiotics ordered if indicated (cholangitis, incomplete drainage anticipated) □ Pregnancy test for women of childbearing age (radiation exposure) □ Patient positioned: Prone or left lateral decubitus with left arm behind back □ Dentures, glasses, jewelry removed □ Bite block available □ Monitoring equipment: ECG, pulse oximetry, BP, capnography

7.2 Intra-Procedure Nursing Role

• Monitor sedation depth (usually moderate to deep sedation or general anesthesia) • Position changes as directed by endoscopist • Assist with fluoroscopy and radiation safety (lead aprons, thyroid shields) • Prepare and pass accessories: Sphincterotome, extraction balloons, stents, baskets • Document findings, interventions, fluoroscopy time, contrast volume • Administer rectal indomethacin (100 mg) if ordered for post-ERCP pancreatitis prophylaxis

7.3 Post-ERCP Complications

POST-ERCP PANCREATITIS PREVENTION: • Rectal indomethacin 100 mg (placed immediately before or after ERCP) - REDUCES RISK BY 50% • Aggressive hydration with lactated Ringer's • Prophylactic pancreatic duct stent in high-risk cases (difficult cannulation, sphincter of Oddi dysfunction) • Avoid repeated cannulation attempts; use guidewire-guided technique • Limit contrast injection into pancreatic duct

SECTION 8: LIVER TRANSPLANT CONSIDERATIONS

8.1 Indications for Transplant Referral

WHEN TO REFER: • MELD score ≥15 (expected survival benefit from transplant) • First episode of major decompensation (ascites, HE, variceal bleed) • Hepatocellular carcinoma within Milan criteria (single tumor ≤5cm or up to 3 tumors each ≤3cm) • Hepatopulmonary syndrome, portopulmonary hypertension • Refractory pruritus (PBC, PSC) • Acute liver failure (King's College Criteria)

8.2 MELD Score

MODEL FOR END-STAGE LIVER DISEASE (MELD) VARIABLES: Creatinine, Bilirubin, INR, Sodium (MELD-Na) SCORE INTERPRETATION: • MELD 6-9: 1.9% 3-month mortality • MELD 10-19: 6% 3-month mortality • MELD 20-29: 20% 3-month mortality • MELD 30-39: 52% 3-month mortality • MELD ≥40: 71% 3-month mortality USED FOR: Organ allocation - higher MELD = higher priority on transplant waitlist MELD 3.0 (implemented 2024): Includes sex, albumin - improves prediction accuracy

8.3 Pre-Transplant Nursing Care

• Nutrition optimization (enteral supplements, PERT if needed) • Infection prevention and management • Abstinence support for alcohol-associated liver disease (typically 6 months) • Psychosocial assessment and support • Patient/family education about transplant process, waitlist, expectations • Coordination with transplant center for testing and evaluation • Vaccination updates (before immunosuppression) • HCC surveillance (ultrasound ± AFP every 6 months)

SECTION 9: CASE STUDIES

Case Study 1: Acute Pancreatitis

PATIENT: Thomas R., 48-year-old male PRESENTATION: Severe epigastric pain radiating to back for 8 hours, nausea and vomiting. History of gallstones. VITALS: BP 100/70, HR 112, RR 22, Temp 37.8°C LABS: Lipase 1,850 U/L (normal <60), WBC 14,200, BUN 32, Hct 48%, LFTs elevated IMAGING: RUQ ultrasound shows gallstones, CBD 8mm

QUESTIONS:

1. Calculate the BISAP score. What does it indicate?

2. What is the likely etiology of this patient's pancreatitis?

3. What are the nursing priorities in the first 24 hours?

ANSWERS: 1. BISAP = 2 (BUN >25: 1 point; SIRS present [HR>90, RR>20]: 1 point). This indicates approximately 2% mortality risk - mild-moderate severity. Requires close monitoring but likely not ICU. 2. Gallstone pancreatitis - gallstones present, dilated CBD (8mm), elevated LFTs suggest stone impacted at ampulla or recently passed. This is the most common cause of acute pancreatitis. 3. Nursing priorities: • Aggressive IV fluid resuscitation with LR (250-500 mL/hr, titrate to urine output ≥0.5 mL/kg/hr) • Pain management with IV opioids • NPO status with reassessment for early enteral nutrition • Monitor for organ dysfunction (respiratory, renal, cardiovascular) • Prepare for ERCP if cholangitis develops or stone confirmed in CBD • Monitor labs (lipase trending, LFTs, BUN, electrolytes)

Case Study 2: Hepatic Encephalopathy

PATIENT: Margaret W., 62-year-old female with alcoholic cirrhosis PRESENTATION: Family reports increasing confusion over 2 days, sleep-wake reversal, difficulty remembering names. Was doing well until recent GI bleed requiring transfusion 5 days ago. EXAM: Jaundice, ascites, asterixis present, oriented to person only, follows simple commands

QUESTIONS:

1. What grade of hepatic encephalopathy is this?

2. What likely precipitated this episode?

3. What is the nursing management?

ANSWERS: 1. Grade 2 hepatic encephalopathy - disorientation to time/place, asterixis present, can follow commands but confused. Not somnolent (would be Grade 3). 2. GI bleeding is the precipitant. Blood in the GI tract is a massive protein load that gut bacteria convert to ammonia. This is one of the most common precipitants of HE. 3. Nursing management: • LACTULOSE: 30 mL PO (or NG if aspiration risk) q1-2h until bowel movement, then titrate to 2-3 soft stools/day • Safety precautions: Fall risk, aspiration precautions, frequent reorientation • Monitor mental status using consistent assessment tool • Ensure adequate protein intake (do NOT restrict protein) • Check for other precipitants: infection (SBP, UTI), electrolyte disturbances, medications • May add rifaximin if recurrent episodes • Monitor for worsening to Grade 3-4 requiring ICU

Case Study 3: Post-ERCP Complication

PATIENT: David L., 55-year-old male PROCEDURE: ERCP with sphincterotomy and stone extraction 4 hours ago. Received rectal indomethacin. CURRENT: New onset severe epigastric pain, nausea, requesting pain medication. Vital signs stable.

QUESTIONS:

1. What complication should you suspect?

2. What assessment and tests are needed?

ANSWERS: 1. Post-ERCP pancreatitis (PEP) - most common complication of ERCP. Onset 2-12 hours post-procedure with epigastric pain. Perforation is possible but less common and usually presents with more severe pain, peritonitis, or subcutaneous emphysema. 2. Assessment: • Abdominal exam (tenderness, guarding, rigidity, bowel sounds) • Vital signs monitoring for signs of sepsis or hemorrhage • Labs: Lipase (≥3x ULN confirms PEP), CBC, BMP • If concern for perforation: Upright chest X-ray or CT to look for free air Management of PEP: • NPO, IV fluids (goal-directed resuscitation) • IV pain medication • Admit for observation (most cases are mild and resolve in 2-3 days) • Monitor for severe pancreatitis requiring ICU