Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism

1. By:-
MR.JAGDISH SAMBAD
M.Sc.Nursing-MSN

2. Introduction
• The liver is a large organ that sits in the right
upper abdomen, just under the right lung. It is one
of the body's most "intelligent" organs, in that it
performs so many different functions at the same
time. The liver makes proteins, eliminates waste
material from the body, produces cholesterol,
stores and releases glucose energy and
metabolizes many drugs used in medicine. It also
produces bile that flows through bile ducts into the
intestine where it helps to digest food.
• The liver receives blood from two different
sources, the heart and the intestine.

4. Definition
• “ Cirrhosis is a chronic progressive disease
of the liver characterized by extensive
degeneration and destruction of the liver
paranchymal cells”.
• Cirrhosis is a chronic degenerative disease
in which normal liver cells are damaged and
are then replaced by scar tissue.

5. Incidence
• The highest incidence occurs between the
ages of 40 and 60, and it is twice as
common in men as in women.

6. Causes

7. Causes
• Alcohol-related liver disease. Most people who consume
alcohol do not suffer damage to the liver. But heavy
alcohol use over several years can cause chronic injury to
the liver.
• Chronic Viral Hepatitis -- Type B and Type C hepatitis,
and perhaps other viruses, can infect and damage the
liver over a prolonged time and eventually cause
cirrhosis.
• Chronic Bile Duct Blockage -- This condition can occur
at birth (biliary atresia) or develop later in life (primary
biliary cirrhosis). The cause of the latter remains
unknown. When the bile ducts outside the liver become
narrowed and blocked, the condition is called primary
sclerosing cholangitis. This condition is often associated
with chronic ulceration of the colon (colitis).

8. Causes
• Abnormal Storage of Copper (Wilson's Disease)
or Iron (Hemochromatosis) -- These metals are
present in all body cells. When abnormal amounts
of them accumulate in the liver, scarring and
cirrhosis may develop.
• Drugs and Toxins -- Prolonged exposure to
certain chemicals or drugs can scar the liver.
• Autoimmune Hepatitis -- This chronic
inflammation occurs when the body's protective
antibodies fail to recognize the liver as its own
tissue. The antibodies injure the liver cells as
though they were a foreign protein or bacteria.

9. causes
• Nonalcoholic fatty liver disease (NAFLD). In
NAFLD, fat builds up in the liver and eventually
causes cirrhosis. This increasingly common liver
disease is associated with obesity, diabetes,
protein malnutrition, coronary artery disease, and
corticosteroid medications.

10. Pathophysiology
• Alcohol, drug and Infection
• Synthesis of fatty acid & triglycerides increase
• Formation & release of lipoproteins decreases
• Fat appear in the liver
• Liver cells enlarge of accumulation of lipids
• Enlarge liver cells rupture

11. Pathophysiology
• Fatty contents from ruptured liver cells form fatty
cysts.
• Cell between adjoining veins in the liver are linked
by developing fibrosis.
• Continued scarring & necrosis lead to the liver
shrinking.
• Liver function decrease or ceases.

12. Pathophysiology
• Obstructed flow of blood leads to increased
pressure in the portal vein (Portal Hypertension)
• Blood backs up in the liver & spleen.
• Veins in the abdomen, rectum & esophagus dilate.
• The congestion of blood in the liver leads to
decrease production of albumin.
• Decrease serum albumin levels allow more water
to move in to other body compartments.

13. Pathophysiology
• Renin & aldosterone production level increase,
leading to water and sodium retention.
• Ascites

16. Symptoms
• Yellowing of the skin (jaundice) due to the
accumulation of bilirubin in the blood.
• Fatigue
• Weakness
• Loss of appetite
• Itching
• Easy bruising from decreased production of blood
clotting factors by the diseased liver.
• nausea
• vomiting
• weight loss
• abdominal pain and bloating when fluid
accumulates in the abdomen

18. Diagnostic findings
• History Taking
• Physical Examination
• Blood tests - To check whether the liver is functioning
normally.
• Ultrasound, CT scan, or radioisotope scan - To look for
signs of cirrhosis within or on the surface of the liver.
• Laparoscope - A very tiny camera inserted through a small
slit in the abdomen to view the liver directly.
• Liver biopsy - Removing tissue from the liver and studying
it under a microscope to identify fibrosis and scarring.
Biopsy is the only way diagnosis can be 100% certain.

19. Treatment
• Aim of the treatment :-
1. preventing further damage to the liver,
2. treating the complications of cirrhosis, and
3. liver transplantation.

20. Preventing further damage to the liver
• Consume a balanced diet and one multivitamin
daily.
• Avoid drugs (including alcohol) that cause liver
damage.
• Avoid nonsteroidal antiinflammatory drugs
(NSAIDs, e.g., ibuprofen). Patients with cirrhosis
can experience worsening of liver and kidney
function with NSAIDs.
• Eradicate hepatitis B and hepatitis C virus by using
anti-viral medications. Not all patients with cirrhosis
due to chronic viral hepatitis are candidates for
drug treatment.

21. • Remove blood from patients with hemochromatosis
to reduce the levels of iron and prevent further
damage to the liver.
• Suppress the immune system with drugs such as
prednisone and azathioprine (Imuran) to
decrease inflammation of the liver in autoimmune
hepatitis.
• Immunize patients with cirrhosis against infection
with hepatitis A and B to prevent a serious
deterioration in liver function.

23. Treating the complications of cirrhosis
1) Edema and ascites:-
• Retention of salt and water can lead to swelling of
the ankles and legs (edema) or abdomen (ascites)
in patients with cirrhosis.
• To restrict dietary salt (sodium) and fluid to
decrease edema and ascites.
• Diuretics are medications that work in the kidneys
to promote the elimination of salt and water into the
urine. A combination of the diuretics
spironolactone (Aldactone) and furosemide can
reduce or eliminate the edema and ascites in most
patients.

25. 2) Bleeding from varices:-
• If large varices develop in the esophagus or upper
stomach, patients with cirrhosis are at risk for
serious bleeding due to rupture of these varices.
Once varices have bled, they tend to rebleed and
the probability that a patient will die from each
bleeding episode is high (30%-35%).
• Propranolol (Inderal), a beta blocker, is effective
in lowering pressure in the portal vein and is used
to prevent initial bleeding and rebleeding from
varices in patients with cirrhosis
• Octreotide (Sandostatin) also decreases portal
vein pressure and has been used to treat variceal
bleeding.

27. • Transjugular intrahepatic portosystemic shunt
(TIPS) is a non-surgical procedure to decrease the
pressure in the portal vein. TIPS is performed by a
radiologist who inserts a stent (tube) through a
neck vein, down the inferior vena cava and into the
hepatic vein within the liver. The stent then is
placed so that one end is in the high pressure
portal vein and the other end is in the low pressure
hepatic vein.

28. 3)Hepatic encephalopathy:-
• Patients with an abnormal sleep cycle, impaired thinking,
odd behavior, or other signs of hepatic encephalopathy
usually should be treated with a low protein diet and oral
lactulose.
• Dietary protein is restricted because it is a source of the
toxic compounds that cause hepatic encephalopathy.
• To be sure that adequate lactulose is present in the colon at
all times, the patient should adjust the dose to produce 2-3
semiformed bowel movements a day. (Lactulose is a
laxative, and the adequacy of treatment can be judged by
loosening or increasing frequency of stools.)
• If symptoms of encephalopathy persist, oral antibiotics such
as neomycin or metronidazole (Flagyl), can be added to
the treatment regimen.

30. 4) Spontaneous bacterial peritonitis (SBP):-
• Patients suspected of having spontaneous bacterial
peritonitis usually will undergo paracentesis. Fluid
that is removed is examined for white blood cells
and cultured for bacteria.
• Most patients with spontaneous bacterial peritonitis
are hospitalized and treated with intravenous
antibiotics such as ampicillin, gentamycin, and
one of the newer generation cephalosporin.

31. Liver transplantation
• Cirrhosis is irreversible. Many patients' liver function
will gradually worsen despite treatment and
complications of cirrhosis will increase and become
difficult to treat.
• Therefore, when cirrhosis is far advanced, liver
transplantation often is the only option for
treatment.

32. Nursing Management
• Assessment
• Subjective Data
• Objective Data

33. Nursing Diagnosis
1. Activity intolerance related to fatigue and malaise.
2. Imbalance nutrition less than body requirement related
to increase metabolic demand.
3. Impaired skin integrity related to pruritus from jaundice
and edema.
4. Chronic pain and discomfort related to enlarge tender
liver and Ascites.
5. Fluid volume excess related to ascites and edema
formation.
6. G.I Bleeding and hemorrhage related to portal
hypertension.
7. Knowledge deficit related to disease process and
treatment plan.

34. Study of Alcoholic Liver Cirrhosis in Hospital Based Patients, Bijapur, Northern
Karnataka, India. A . M . Patil et.all
• This study related to the prevalence of alcoholic liver cirrhosis in relation to age, sex, rural
and urban area patients and also prevalence of ALC in literate and illiterate Patients.
Prevalence of morphological types of cirrhosis of liver and complications of alcoholic liver
cirrhosis. Material and Methods: The material for this study is obtained from in-patient and
out-patients attending the Al-Ameen Medical College and Hospital, Bijapur, Karnataka. A total
of 100 cases of Alcoholic liver cirrhosis patients studied over a period of three year of study
from January 2010 to January 2014. Results: The study includes 100 cases of Alcoholic liver
c cirrhosis (ALC). The sex wise distribution of prevalence of ALC cases was highest in males
i.e. 74 cases (74%), as compare to females, prevalence rate is 26 cases (26%). According to
age wise, prevalence of ALC it is highest in age group of 31-40 years i.e. 30 cases (30%)
and next highest in the age group 41-50 years i.e. 28 cases (28%). The prevalence of
Morphological types of cirrhosis in out of 100 cases. 42 cases (42.0%) are micro nodular
cirrhosis and 30 cases (30.0%) macro nodular and 28 cases (28.0%) mixed cirrhosis. The
Prevalence rate is high in the illiterate patients as compare to literate patients. In rural and
urban area wise, highest cases seen in rural area patients i.e., 62 cases (62%) as compared
to urban area patients i.e. 38 cases (38%) were observed in present study.