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Liver, Gallbladder, and Pancreatic Diseases and Disorders 247
Figure 12-5 Caput medusae.
With this condition, the spleen may increase
in size and length by four times its original
size (see Figure 12-4). Splenomegaly often
causes increased blood cell destruction, lead
ing to anemia, leukopenia, and thrombocy
topenia. Thrombocytopenia (thrombo = clot,
cyto = cell, penia = decrease) increases the
risk of bleeding.
3. Gastrointestinal hemorrhage This condition
occurs due to thrombocytopenia and inability
of the liver to secrete blood proteins essential
for clotting. Hematemesis (HEM-ah-TEM-eh-
sis; hema = blood, emesis = vomiting) is often
the first symptom of severe cirrhosis.
4. Ascites (ah-SIGH-teez) This is an accumu
lation of fluid in the abdominal cavity that
develops as a result of liver failure and por
tal hypertension. The increased pressure on
the veins of the portal system causes leaking
of serum into the abdomen. Often, this fluid
enlarges the abdomen to the point of causing
difficult breathing (Figure 12-6). Excessive
abdominal fluid can be drained by piercing
the abdominal wall with a large-bore needle, a
procedure called abdominocentesis (ab-DOM-
ih-no-sen-TEE-sis; abdomino = abdomen,
centesis = puncture). The malnutrition of cir
rhosis leads to spindly arms and legs despite
the bloated abdomen.
Figure 12-6 Ascites.
5. Edema This often develops in the ankles and
feet as a result of liver failure. The normal
liver produces a blood protein called albumin
(AL-byou-men), which is responsible for the
osmotic pressure of blood, the movement of
fluid from the blood through the capillaries to
the tissues and back into the blood. Without
osmotic pressure, blood fluid tends to leak into
the tissues and remain there. A decrease in
albumin allows this to occur, leading to edema
in the feet and ankles.
6. Jaundice This usually results from the obstruc
tion of the bile ducts as normal tissue is replaced
by fibrous scar tissue, a characteristic of cirrho
sis (Figure 12-7).
7. Altered sex hormone metabolism The normal
liver inactivates small amounts of estrogen
secreted by the adrenal glands in both the male
and female. The cirrhotic liver is not capable of
inactivating estrogen; thus, the man develops
Figure 12-7 Jaundice.
248 Chapter 12
Figure 12-8 Gynecomastia.
Figure 12-10 Spider angiomas: facial.
Courtesy of Mark L. Kuss
characteristics related to excessive estrogen. Such
characteristics include:
■ Gynecomastia (GUY-neh-koh-MAS-tee-ah)
An enlargement of the breasts (Figure 12-8)
■ Palmar erythema Palms of the hands become
reddened in color (Figure 12-9)
can lead to hepatic coma and, ultimately, death.
The clinical features of cirrhosis of the liver in a
man are shown in Figure 12-11.
■ Spider angiomas Small dilated blood vessels on
the face and chest (Figure 12-10)
■ Female hair distribution Absent or reduced
chest and pubic hair (see Figure 12-5)
■ Testicular atrophy Decrease in testicle size
8. Hepatic encephalopathy The liver is often unable
to detoxify the blood of nitrogenous waste
products such as ammonia. This waste prod
uct can circulate in the blood and can affect the
brain, causing mental confusion, stupor, and
a characteristic shaking or tremor. This shak
ing, combined with hallucinations, is called
delirium tremens (de-LIR-ee-um TREE-mens)
or DTs. Further depression of the nervous system
Figure 12-9 Palmar erythema.
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Liver, Gallbladder, and Pancreatic Diseases and Disorders 249
■ Diagnosis. An examination revealing the physical
characteristics described in Figure 12-11, along with
blood testing, including elevated liver enzymes, elevated
bilirubin, low serum albumin, and enlarged liver seen
on abdominal X-ray, are all indicative of liver cirrhosis.
A liver biopsy will confirm the diagnosis.
■ Treatment. Treatment of cirrhosis is directed at the
cause in an attempt to prevent further liver damage.
Alcohol is strictly prohibited regardless of the cause of
the cirrhosis. Adequate nutrition and rest are neces
sary. Vitamins, minerals, and diet supplements might
be needed to prevent malnutrition. Diuretics might be
necessary to reduce edema and ascites.
Cirrhosis has an unfavorable prognosis, with most
individuals surviving only 10 to 15 years after diagno
sis. The appearance of ascites is a prognostic indica
tor because a majority of individuals with cirrhosis die
within five years after the onset of ascites. Individuals
usually die of massive bleeding from esophageal varices,
hepatic encephalopathy, and other metabolic disorders.
■ Prevention. Although not all cases of cirrhosis are
preventable, preventive measures include avoiding alco
hol and exposure to all types of hepatitis and obtaining
vaccinations for hepatitis A and B.
Non-Alcoholic Fatty Liver Disease (NAFLD)
■ Description. NAFLD is the buildup of extra fat in the
liver tissue that is not caused by alcohol (Figure 12-12).
A more severe form of NAFLD is called non
alcoholic steatohepatitis (STE-a-toe-hep-ah-TIE-tis) or
NASH. This form of NAFLD causes the liver to swell
and become damaged, and often leads to cirrhosis.
NASH occurs more frequently in women than in men
and is one of the leading causes of cirrhosis.
■ Etiology. The cause of NAFLD is uncertain, but it
tends to develop in people who are overweight, obese or
have had gastric bypass surgery or have diabetes, high
cholesterol, high triglycerides, or underactive thyroid
(hypothyroidism). Poor eating habits and rapid weight
loss may also be contributing factors.
■ Symptoms. NAFLD is often asymptomatic. When
symptoms do occur they may include weakness, fatigue,
nausea, abdominal pain, jaundice, ascites, and mental
confusion.
■ Diagnosis. Testing, which may include CT scan, MRI,
and liver enzyme blood tests. Liver enzymes will be ele
vated. Liver biopsy is the definitive test.
■ Treatment. There are no medical treatments for
NAFLD. Strategies to prevent further liver damage are
aimed at treating the suspected cause and may include
healthy weight loss, controlling diabetes, and lowering
cholesterol and triglycerides.
■ Prevention. Preventive measures include eating a
healthy diet, maintaining a healthy weight, exercising
regularly, controlling diabetes, cholesterol, and tri
glycerides. Avoiding unnecessary medications and con
sumption of alcohol are also beneficial.
Non-alcoholic fatty
liver disease
Figure 12-12 Fatty liver.
Liver Cancer
■ Description. Primary and benign tumors (or those
arising directly from liver tissue) are rare. When pri
mary tumors do develop, they are more likely to occur
in individuals with cirrhosis (Figure 12-13). Men are
Figure 12-13 Liver cancer.
250 Chapter 12
five times more likely to develop liver cancer than
women. Secondary liver tumors (those that metastasize
from other organs) are the most common and usually
are the result of cancers in the breast, digestive system,
and lungs.
■ Etiology. The cause of liver cancer, like most cancers,
is not fully understood.
■ Symptoms. Liver cancer is usually discovered late or
at end stage because symptoms of anorexia, weight loss,
and abdominal discomfort are so nonspecific.
■ Diagnosis. Diagnosis is confirmed by biopsy.
■ Treatment. Treatment of liver cancer can involve sur
gery, chemotherapy, and radiation. Even with aggres
sive treatment, prognosis is very poor, with only 10%
of affected individuals living five years after diagnosis.
■ Prevention. In many cases, avoiding the spread of
cancer from other organs is not possible. The best pre
vention is to avoid hepatitis, cirrhosis, and other liver
diseases by reducing risks for these diseases.
Gallbladder Diseases
Gallbladder disorders usually cause symptoms related
to indigestion when eating fatty foods. Nausea, pain,
and excessive gas are the most common symptoms.
Nutritional changes and a variety of surgical procedures
can be used to treat the disease.
Cholecystitis
■ Description. Cholecystitis (KOH-lee-sis-TYE-tis;
chole = bile or gall, cyst = bladder, itis = inflamma
tion) is inflammation of the gallbladder (Figure 12-14).
Figure 12-14 Cholecystitis.
Courtesy of Mark L. Kuss
■ Etiology. Cholecystitis is usually caused by obstruction
of bile flow due to a gallstone. When bile flow is obstructed,
bile in the gallbladder becomes overly concentrated and
irritates the lining of the gallbladder, leading to inflam
mation. When a fatty meal is eaten, fat in the duodenum
stimulates the gallbladder to contract and release bile.
■ Symptoms. This contraction of the inflamed gall
bladder causes mild to severe pain in the upper-right
quadrant of the abdomen. This pain, combined with a
history of nausea and vomiting after meals, is indicative
of cholecystitis.
■ Diagnosis. Ultrasound and cholecystogram con
firm the diagnosis of cholecystitis. Cholecystogram
involves swallowing a dye that is absorbed by the liver
and excreted into the bile. Radiographic pictures can
confirm the presence of stones.
Complementary and Alternative Therapy
Liver Cancer
Treatment
T
raditional Chinese medicine has long been used to treat liver cancer which is the
third leading cause of cancer deaths in China. Many different traditional Chinese
medicine drugs have been studied for their value in treating liver cancer. Most are from
plants such as milk thistle, corn, or berries. It is generally thought that they have some
benefit in treating these cancers because of their antitoxic, cytotoxic, and health/fitness
qualities. Studies have shown that they do have a role in treating liver cancer through
their unique action in restoring immune balance. Studies have shown they do have a
role in treating liver cancer, though their unique action is restoring immune balance and
enhancing immunity. In late stage cancer, the traditional Chinese medicine could be
used as an adjunct to Western medicine treatments. Further research should be done to
establish which drugs are most effective and the dosage needed.
Source: Jia &Wang (2020)
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Liver, Gallbladder, and Pancreatic Diseases and Disorders 251
Complications of cholecystitis include rupture of
the gallbladder, leading to peritonitis. Chronic chole
cystitis can cause bile to back up into the liver, leading
to liver damage and cirrhosis.
■ Treatment. Treatment for cholecystitis is aimed at
the cause. Gallstones often obstruct the gallbladder or
one of its ducts. Treatment of choice for cholecystitis
caused by stones is surgical removal by a procedure
called cholecystectomy (KOH-lee-sis-TECK-toh-me;
chole = bile or gall, cyst = bladder, ectomy = removal).
Cholecystectomy can be performed using an
abdominal incision or by using a laparoscope (laparo =
abdomen, scope = scope). Removal of the gallbladder
using a laparoscope is called laparoscopic cholecys
tectomy (LAP-ah-row-SKOP-ic KOH-leh-sis-TECK-
toh-me). Laparoscopic cholecystectomy is performed
by passing a small, thin tubular scope through a small
cut made just below the umbilicus (navel), allowing the
surgeon to view the gallbladder during surgery. Three
other small incisions are made in the abdomen to insert
surgical tools. The gallbladder is also removed through
one of these incisions. This type of procedure drasti
cally reduces pain, hospital stay, length of recovery, and
missed workdays compared to surgery with a larger
abdominal incision.
After a cholecystectomy, the bile continues to be
excreted by the liver into the common bile duct and
simply drips into the duodenum as it is produced. As
long as the individual does not take in an excessive
amount of fatty foods, the amount of bile will be suf
ficient to break down the consumed fat, and normal
digestion will occur.
■ Prevention. Preventive measures include maintaining
a healthy body weight and eating a diet high in fiber,
including vegetables and fruit.
Cholelithiasis
■ Description. Cholelithiasis (KOH-lee-lih-THIGH-
ah-sis; chole = bile or gall, lith = stone, iasis = con
dition) is the presence of gallstones in the gallbladder
or bile ducts (Figure 12-15). Gallstones affect women
more often than men and are more common in adults
over the age of 40.
■ Etiology. Gallstones form from bile salts and cho
lesterol and can vary in size, shape, number, color, and
composition. Cholesterol stones are by far the most
common and are formed when a change in the compo
sition of bile occurs. When bile becomes highly satu
rated with cholesterol, it crystallizes and forms a stone.
Liver
Small
bile duct
Hepatic duct
Cystic duct
Gallstones
Common
bile duct
Gallbladder
Duodenum
(A)
Pancreas
Figure 12-15 (A) Location of gallbladder.
(B) Cholelithiasis.
Important risk factors for developing gallstones
include being female, having excessive body weight,
and consuming a diet high in fat and cholesterol and
low in fiber.
■ Symptoms. Gallstones are often asymptomatic. If
symptoms do occur, they are usually related to blocking
the outflow of the gallbladder or of its ducts. Symptoms
can include nausea, vomiting, and upper-right quadrant
pain following meals containing fat. Complications of
cholelithiasis include cholecystitis and jaundice.
■ Diagnosis. A cholecystogram and ultrasound, along
with a positive history, will confirm the diagnosis.
■ Treatment. Extracorporeal shockwave lithotripsy
(litho = stone, tripsy = destruction) (ESWL) can be
252 Chapter 12
performed to break up the stones so they can be passed.
If this procedure is not effective or is not recommended,
cholecystectomy is performed.
■ Prevention. Decreasing fat intake in the diet will not
aid in dissolving stones, but may be helpful in prevention.
Pancreatic Diseases
Diseases of the pancreas are often quite advanced by
the time symptoms appear. Some pancreatic disorders
are associated with alcoholism. Replacement or supple
ments of pancreatic enzymes and insulin might be nec
essary when the pancreas is not functioning properly or
is surgically removed.
Consider This...
Injury to the pancreas can be dangerous
because it is the storage organ for many
strong digestive enzymes.
Pancreatitis
■ Description. Pancreatitis is an inflammation of the
pancreas that can range from mild to fatal. With pan
creatitis, the pancreas becomes inflamed, edematous,
hemorrhagic, and necrotic.
Pancreatitis differs from inflammation of other
organs because of the powerful digestive enzymes the
pancreas produces. As this organ becomes diseased,
these enzymes often escape the pancreatic cells and
ducts, causing digestion of the pancreas (autodigestion)
and the surrounding tissues. If this destruction extends
into blood vessels, hemorrhage occurs, leading to severe
pain and shock. Acute hemorrhagic pancreatitis usu
ally follows an alcohol-drinking spree and is often fatal
despite emergency medical attention.
■ Etiology. This disease is similar to cirrhosis of the liver in
that most cases of severe pancreatitis are due to alcoholism.
Pancreatitis can also be caused by blockage of pan
creatic ducts by gallstones. Many cases of pancreatitis
are idiopathic (of unknown cause).
■ Symptoms. An acute attack of pancreatitis causes
sudden, severe abdominal pain that often radiates to
the back. The individual may find some relief by draw
ing the knees up toward the abdomen. Other symptoms
exhibited during an acute attack are nausea, vomiting,
diaphoresis (sweating), and tachycardia.
Individuals with chronic pancreatitis might com
plain of constant back pain and frequent bouts of mild
symptoms similar to those of an acute attack. As the
disease progresses, the pancreatic tissues are replaced
with fibrous tissues and function is lost. As endocrine
function is lost, the individual exhibits symptoms of
diabetes mellitus. Digestive disorders, including mal
absorption, occur when exocrine function is impaired.
■ Diagnosis. Diagnosis of pancreatitis is often made
based on the individual’s history and is confirmed
by blood testing. A high blood amylase (pancreatic
enzyme) is indicative of pancreatitis.
■ Treatment. Treatment and prognosis of pancreati
tis depend on the cause. If it is caused by gallstones,
it is treated successfully by removing the gallbladder
and the involved stones. Treatment for idiopathic and
alcohol-related pancreatitis is palliative because there
is no cure. Individuals must stop drinking alcohol
and are treated with analgesics and nutritional sup
port. Prognosis for these types of pancreatitis is poor.
■ Prevention. In some cases, pancreatitis might not
be preventable. Actions that reduce risk include the
following:
■ Limit alcohol intake. If any symptoms of pancreatitis
develop, alcohol should be avoided completely.
■ Stop smoking. Tobacco use increases the risk of
pancreatitis.
■ Eat a healthy, low-fat diet. Increased consumption of
fat increases the risk of gallstones and, thus, increases
the risk of pancreatitis.
Pancreatic Cancer
■ Description. Pancreatic cancer is usually an adeno
carcinoma that occurs in the head of the pancreas. This
cancer spreads very rapidly, and its poor prognosis
makes it a leading cause of cancer death (Figure 12-16).
■ Etiology. The cause of this tumor is unknown, but
known carcinogens include cigarette smoking, high cof
fee consumption, chemical exposure, and consumption
of a high-fat diet.
■ Symptoms. Symptoms usually do not occur until
late in the disease process, after metastasis has already
occurred. As pancreatic tissue is destroyed, the individual
can experience abdominal pain, back pain, nausea, vom
iting, loss of appetite, weakness, jaundice, and fatigue.
■ Diagnosis. Ultrasound, CT, and magnetic resonance
imaging (MRI) can be helpful in making a diagnosis. A
biopsy is the definitive test.
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Liver, Gallbladder, and Pancreatic Diseases and Disorders 253
Figure 12-16 Pancreatic cancer.
■ Treatment. Treatment can include surgical resec
tion, chemotherapy, and radiation. This tumor usually
responds poorly to all therapies, and prognosis is very
poor. Supportive care can be provided, including pain
management and nutritional support.
■ Prevention. There is no proven prevention. Activities
to reduce risk include not smoking, maintaining a healthy
weight, eating a healthy diet, and exercising regularly.
Rare Diseases
Primary Biliary Cirrhosis
Primary biliary cirrhosis is a chronic liver disease that
gradually destroys the bile ducts in the liver. The cause is
unknown, but it might be related to immune system dys
function. Destruction of bile ducts decreases bile excretion
from the liver and causes a chronic inflammation, result
ing in cirrhosis. The disease is much more common in
middle-aged women than in men. Signs and symptoms of
the disease include jaundice, edema, itching, and abnor
mal liver function studies. Treatment is directed at reliev
ing the symptoms. A liver transplant might be necessary.
Gilbert’s Syndrome
Gilbert’s syndrome is a congenital liver disorder that
usually has its onset in the teenage or young adult years
and is more common in males. Symptoms include
increased serum bilirubin and jaundice, but it is usually
left untreated because it does not seem to affect liver
function adversely.
Hemochromatosis
Hemochromatosis is a disorder in which the body
absorbs and stores excessive amounts of iron. It is the
most common inherited disease, affecting approxi
mately one in 300 people in the United States (CDC,
2020). Eventually, damage to the liver can occur. It is
diagnosed by blood tests for iron levels, and treatment
requires blood (about one to two units) to be removed
weekly until iron levels return to normal. This regimen
must be continued every four months for life to keep
the iron levels within normal limits.
Effects of Aging on the System
The older adult who develops hepatitis usually under
goes a more severe infection than a younger person does
with the same disease. The mortality rate for hepatitis
increases with age. Older people can be at an increased
risk for developing hepatitis if any of the following fac
tors is present:
■ A depressed immune system
■ Increased contact with a variety of caregivers
■ Poor nutrition
■ Increased intake of medications
■ Poor hygiene
■ Multiple blood transfusions
Cirrhosis in an older person can be of unknown
etiology or due to chronic alcohol intake. It is usually
progressive and severe, and the prognosis is poor. Bile
stones are also seen more frequently in the older adult.
Surgery is usually the treatment of choice but might not
be an option due to the age of the individual and other
complicating disorders. Pancreatic disease is also com
mon in the older adult population, so replacement of
pancreatic enzymes might be needed if the pancreas is
not producing adequate amounts.
Summary
D
iseases of the liver, gallbladder, and pancreas have serious effects on digestion and metabolism. The liver has
many functions in the body, so when it is diseased, a variety of other disorders can result. If the liver fails
completely, a transplant is necessary. Hepatitis is a common liver disorder and is usually viral in nature. Cirrhosis
of the liver is a chronic, progressive disease most commonly related to alcohol ingestion.
254 Chapter 12
Gallbladder disease, most commonly caused by gallstones, affects thousands of individuals annually. Pancreatic
disorders are often not diagnosed until late in the disease process because early symptoms are often not apparent. If
the pancreas is not functioning properly, pancreatic enzymes and hormones might need to be supplemented. The
older adult is at increased risk for developing disorders of the liver, gallbladder, and pancreas.
Review Questions
Short Answer
1. What are the functions of the liver, gallbladder, and pancreas?
2. Which signs and symptoms are associated with common liver, gallbladder, and pancreatic disorders?
3. Which diagnostic tests are most commonly used to determine the type and cause of liver, gallbladder, or pan
creatic disorders?
Multiple Choice
4. Which of the following is the cause of jaundice?
a. Increased levels of amylase in the blood
b. Decreased levels of pancreatase in the blood
c. Increased levels of bilirubin in the blood
d. Decreased levels of lipase in the blood
5. Impaired liver function reveals an elevation in which of the following tests?
a. Bilirubin and alkaline phosphatase
b. Albumin and bilirubin
c. Alkaline phosphatase and amylase
d. Amylase and albumin
6. Diseases of the liver, gallbladder, or pancreas generally have an adverse effect on which of the following?
a. The immune system
b. Digestion and metabolism
c. The inflammatory process
d. The endocrine system
7. Which of the following types of hepatitis is the most common?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
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Liver, Gallbladder, and Pancreatic Diseases and Disorders 255
8. Individuals at high risk for developing HBV include which of the following?
a. Drug addicts
b. Blood recipients
c. Health care workers
d. All of the above
9. Which of the following is the best definition of cirrhosis?
a. A chronic, degenerative disease of the pancreas
b. An acute irreversible disease of the liver
c. An abnormality of the liver caused by alcoholism
d. A chronic, degenerative, irreversible disease of the liver
10. Ascites is an accumulation of fluid in the abdominal cavity, usually due to which of the following conditions?
a. Pancreatic cancer
b. Liver failure and portal hypertension
c. Cholelithiasis
d. Cirrhosis
True or False
11. T F Gallbladder disorders usually cause symptoms related to indigestion when eating high-fat foods.
12. T F A cholecystogram is a radiographic exam used to diagnose cholecystitis.
13. T F Gallstones are most commonly found in obese, middle-aged men.
14. T F A high serum amylase is usually diagnostic for pancreatitis.
15. T F The older adult who develops hepatitis usually experiences a much milder episode of the disease than
does a young person.
16. T F Ascites refers to lymph in the system.
17. T F A cholecystectomy is the removal of the gallbladder.
18. T F Jaundice is often indicative of liver disease.
19. T F Hematemesis means vomiting blood.
Case Studies
■ Ms. Fisher is a 68-year-old woman with the classic symptoms of gallbladder disease. She is diagnosed
with gallstones and is scheduled for surgery in two weeks. She asks you about the cause of gallstones and why
she would develop them. How would you respond to her? What typical factors put an individual at risk for
developing gallstones?
(continued)
256 Chapter 12
Case Studies (continued)
■ Mr. Swicky came to the clinic with complaints of abdominal pain, sweating, fever, and anorexia. His phy
sician sent him to the hospital for an in-depth evaluation. He was diagnosed with viral hepatitis A. Mr. Swicky’s
spouse is very concerned about his condition. What can you tell them about type A hepatitis? Should his spouse
be vaccinated for hepatitis A now? Are there other treatments? What precautions should the family practice to
prevent transmitting hepatitis? Where can they find more information about hepatitis?
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