liver cirrhosis

1. Cirrhosis of the Liver
Prepared by: Dr. ahlam Said.
Be a Good Doctor

2. Description
• A chronic, progressive disease of the liver
–Extensive parenchymal cell
degeneration
–Destruction of parenchymal cells

3. Description
• Regenerative process is disorganized,
resulting in abnormal blood vessel and
bile duct relationships from fibrosis

4. Description
• Normal lobular structure distorted by
fibrotic connective tissue
• Lobules are irregular in size and shape
with impaired vascular flow
• Insidious, prolonged course

5. Statistics
• > 50% of liver disease in the US is directly
related to alcohol consumption
• Of the estimated 15 million alcoholics in the
USA 10-20% have or will develop cirrhosis

6. Statistics
• Growing number of cases related to chronic
hepatitis C
• 4th leading cause of death in people between
35 and 54 years of age

7. Statistics
• Direct correlation between alcohol
consumption in any geographic area and the
death rate from cirrhosis in that area

8. Etiology and Pathophysiology
• Cell necrosis occurs
• Destroyed liver cells are replaced by
scar tissue
• Normal architecture becomes nodular

9. Etiology and Pathophysiology
• Four types of cirrhosis:
– Alcoholic (Laennec’s) cirrhosis
– Postnecrotic cirrhosis
– Biliary cirrhosis
– Cardiac cirrhosis

10. Etiology and Pathophysiology
• Alcoholic (Laennec’s) Cirrhosis
– Associated with alcohol abuse
– Preceded by a theoretically reversible
fatty infiltration of the liver cells
– Widespread scar formation

11. Etiology and Pathophysiology
• Postnecrotic Cirrhosis
– Complication of toxic or viral hepatitis
– Accounts for 20% of the cases of
cirrhosis
– Broad bands of scar tissue form within
the liver

12. Etiology and Pathophysiology
• Biliary Cirrhosis
– Associated with chronic biliary
obstruction and infection
– Accounts for 15% of all cases of
cirrhosis

13. Etiology and Pathophysiology
• Cardiac Cirrhosis
– Results from longstanding severe
right-sided heart failure

14. Manifestations of Liver Cirrhosis
Fig. 42-5

15. Clinical Manifestations
Early Manifestations
• Onset usually insidious
• GI disturbances:
– Anorexia
– Dyspepsia
– Flatulence
– N-V, change in bowel habits

16. Clinical Manifestations
Early Manifestations
• Abdominal pain
• Fever
• Lassitude
• Weight loss
• Enlarged liver or spleen

17. Clinical Manifestations
Late Manifestations
• Two causative mechanisms
– Hepatocellular failure
– Portal hypertension

18. Clinical Manifestations
Jaundice
• Occurs because of insufficient
conjugation of bilirubin by the liver cells,
and local obstruction of biliary ducts by
scarring and regenerating tissue

19. Clinical Manifestations
Jaundice
• Intermittent jaundice is characteristic of
biliary cirrhosis
• Late stages of cirrhosis the patient will
usually be jaundiced

20. Clinical Manifestations
Skin
• Spider angiomas (telangiectasia, spider
nevi)
• Palmar erythema

21. Clinical Manifestations
Endocrine Disturbances
• Steroid hormones of the adrenal cortex
(aldosterone), testes, and ovaries are
metabolized and inactivated by the
normal liver

22. Clinical Manifestations
Endocrine Disturbances
• Alteration in hair distribution
– Decreased amount of pubic hair
– Axillary and pectoral alopecia

23. Clinical Manifestations
Hematologic Disorders
• Bleeding tendencies as a result of
decreased production of hepatic clotting
factors (II, VII, IX, and X)

24. Clinical Manifestations
Hematologic Disorders
• Anemia, leukopenia, and
thrombocytopenia are believed to be
result of hypersplenism

25. Clinical Manifestations
Peripheral Neuropathy
• Dietary deficiencies of thiamine, folic
acid, and vitamin B12

26. Complications
• Portal hypertension and esophageal
varices
• Peripheral edema and ascites
• Hepatic encephalopathy
• Fetor hepaticus

27. Complications
Portal Hypertension
• Characterized by:
– Increased venous pressure in portal
circulation
– Splenomegaly
– Esophageal varices
– Systemic hypertension

28. Complications
Portal Hypertension
• Primary mechanism is the increased
resistance to blood flow through the liver

29. Complications
Portal Hypertension
Splenomegaly
• Back pressure caused by portal
hypertension → chronic passive congestion
as a result of increased pressure in the
splenic vein

30. Complications
Portal Hypertension
Esophageal Varices
• Increased blood flow through the
portal system results in dilation
and enlargement of the plexus
veins of the esophagus and
produces varices

31. Complications
Portal Hypertension
Esophageal Varices
• Varices have fragile vessel walls
which bleed easily

32. Complications
Portal Hypertension
Internal Hemorrhoids
• Occurs because of the dilation of
the mesenteric veins and rectal
veins

33. Complications
Portal Hypertension
Caput Medusae
• Collateral circulation involves the
superficial veins of the abdominal wall
leading to the development of dilated
veins around the umbilicus

34. Complications
Peripheral Edema and Ascites
• Ascites:
-- Intraperitoneal accumulation of
watery fluid containing small
amounts of protein

35. Complications
Peripheral Edema and Ascites
• Factors involved in the pathogenesis of
ascites:
- Hypoalbuminemia
−↑ Levels of aldosterone
−↑ Portal hypertension

36. Complications
Hepatic Encephalopathy
• Liver damage causes blood to enter
systemic circulation without liver
detoxification

37. Complications
Hepatic Encephalopathy
• Main pathogenic toxin is NH3 although
other etiological factors have been
identified
• Frequently a terminal complication

38. Complications
Fetor Hepaticus
• Musty, sweetish odor detected on the
patient’s breath
• From accumulation of digested by-
products

39. Development of Ascites
Fig. 42-6

40. Diagnostic Studies
• Liver function tests
• Liver biopsy
• Liver scan
• Liver ultrasound

41. Diagnostic Studies
• Esophagogastroduodenoscopy
• Prothrombin time
• Testing of stool for occult blood

42. Collaborative Care
• Rest
• Avoidance of alcohol and anticoagulants
• Management of ascites

43. Collaborative Care
• Prevention and management of
esophageal variceal bleeding
• Management of encephalopathy

44. Collaborative Care
Ascites
• High carbohydrate, low protein, low Na+
diet
• Diuretics
• Paracentesis

45. Collaborative Care
Ascites
• Peritoneovenous shunt
– Provides for continuous reinfusion of
ascitic fluid from the abdomen to the
vena cava

46. Peritoneovenous Shunt
Fig. 42-8

47. Collaborative Care
Esophageal Varices
• Avoid alcohol, aspirin, and irritating
foods
• If bleeding occurs, stabilize patient and
manage the airway, administer
vasopressin (Pitressin)

48. Collaborative Care
Esophageal Varices
• Endoscopic sclerotherapy or ligation
• Balloon tamponade
• Surgical shunting procedures (e.g.,
portacaval shunt, TIPS)

49. Sengstaken-Blakemore Tube
Fig. 42-9

50. Portosystemic Shunts
Fig. 42-11

51. Collaborative Care
Hepatic Encephalopathy
• Goal: reduce NH3 formation
– Protein restriction (0-40g/day)
– Sterilization of GI tract with antibiotics
(e.g., neomycin)
– lactulose (Cephulac) – traps NH3 in gut
– levodopa

52. Drug Therapy
• There is no specific drug therapy for
cirrhosis
• Drugs are used to treat symptoms and
complications of advanced liver disease

53. Nutritional Therapy
• Diet for patient without complications:
– High in calories
↑ CHO
– Moderate to low fat
– Amount of protein varies with degree
of liver damage

54. Nutritional Therapy
• Patient with hepatic encephalopathy
– Very low to no-protein diet
• Low sodium diet for patient with ascites
and edema

55. Nursing Management
Nursing Assessment
• Past health history
• Medications
• Chronic alcoholism
• Weight loss

56. Nursing Management
Nursing Diagnoses
• Imbalanced nutrition: less than body
requirements
• Impaired skin integrity
• Ineffective breathing pattern
• Risk for injury

57. Nursing Management
Planning
• Overall goals:
– Relief of discomfort
– Minimal to no complications
– Return to as normal a lifestyle as
possible

58. Nursing Management
Nursing Implementation
• Health Promotion
– Treat alcoholism
– Identify hepatitis early and treat
– Identify biliary disease early and treat

59. Nursing Management
Nursing Implementation
• Acute Intervention
– Rest
– Edema and ascites
– Paracentesis
– Skin care
– Dyspnea
– Nutrition

60. Nursing Management
Nursing Implementation
• Acute Intervention
– Bleeding problems
– Balloon tamponade
– Altered body image
– Hepatic encephalopathy

61. Nursing Management
Nursing Implementation
• Ambulatory and Home Care
– Symptoms of complications
– When to seek medical attention
– Remission maintenance
– Abstinence from alcohol

62. Nursing Management
Evaluation
• Maintenance of normal body weight
• Maintenance of skin integrity
• Effective breathing pattern
• No injury
• No signs of infection