cirrhosis of liver

1. CIRRHOSIS OF LIVER
M.MALARMATHI,
M.SC NURSING,
KGNC,
SBV.

3. • The liver is located in the upper right-hand portion of the abdominal cavity,
beneath the diaphragm, and on top of the stomach, right kidney, and intestines.
• Shaped like a cone, the liver is a dark reddish-brown organ that weighs about
1.5 kg.
• The liver consists of 2 main lobes. Both are made up of 8 segments that
consist of 1,000 lobules (small lobes). These lobules are connected to small
ducts (tubes) that connect with larger ducts to form the common hepatic duct.
• The common hepatic duct transports the bile made by the liver cells to the
gallbladder and duodenum (the first part of the small intestine) via the
common bile duct.

4. • Production of bile, which helps carry away waste and break down fats in the small
intestine during digestion
• Production of certain proteins for blood plasma
• Production of cholesterol and special proteins to help carry fats through the body
• Conversion of excess glucose into glycogen for storage (glycogen can later be
converted back to glucose for energy) and to balance and make glucose as needed.
• Regulation of blood levels of amino acids, which form the building blocks of
proteins.
• Processing of hemoglobin for use of its iron content (the liver stores iron)
• Conversion of poisonous ammonia to urea (urea is an end product of protein
metabolism and is excreted in the urine)
• Clearing the blood of drugs and other poisonous substances

5. DEFINITION
Cirrhosis of liver is a chronic,
progressive disease characterized by
widespread fibrosis (scaring) &
nodule formation. Cirrhosis occurs
when the normal flow of blood, bile,
& hepatic metabolites is altered by
fibrosis.

6. ETIOLOGY
Chronic
alcohol intake
Hepatitis B
and C
Autoimmune
hepatitis
Wilson’s
disease
Haemochroma
tosis
Alpha 1
antitrypsin.
Glycogen
storage
diseases
cystic fibrosis
Biliary
obstruction
ETIOLOGY

7. TYPES OF CIRRHOSIS OF LIVER
Alcoholic cirrhosis
Postnecrotic cirrhosis
Biliary cirrhosis
Cardiac cirrhosis

8. Alcoholic cirrhosis
(Laennec’s cirrhosis, micronodular, portal cirrhosis)
• Most common, due to chronic alcoholism. First stage alcohol
intake is an accumulation of fat in the liver cells. If the alcohol
abuse continues, widespread scar formation occurs throughout
the liver.

9. Postnecrotic cirrhosis
• There are broad bands of scar tissue due to late results of toxic,
autoimmune or viral hepatitis. Broad bands of scar tissue from
within the liver

10. Biliary cirrhosis
• Scaring occurs around bile duct in liver, Results from chronic
biliary obstruction & infection. There is diffuse fibrosis of the
liver with jaundice main feature.
Cardiac cirrhosis
• Associated with severe right sided long term heart failure,
fairly rare.

11. PATHOPHYSIOLOGY
Due to etiological causes Primary
event is injury to hepatocellular
elements
Initiates inflammatory response
with cytokine release->toxic
substances
Destruction of hepatocytes, bile
duct cells, vascular endothelial cells

12. Repair through cellular
proliferation and regeneration
Formation of fibrous scar
Clinical features

13. STAGES OF LIVER DAMAGE

14. CLINICAL FEATURES

15. DIAGNOSTIC EVALUATION
History
collection
Physcial
examination
Liver biopsy
CT scan
Liver
ultrasound
Gastroscopy

16. History collection.
• History collection findings shows that
previous history of viral, toxic, or idiopathic
hepatitis, chronic biliary obstruction and
infection, severe right sided heart failure
• Functional health patterns any history of
chronic alcoholism, weakness, fatigue.
• Elimination dark urine,decrease urine
output,flatulence, changes in bowel habits.
• Cognitive perceptual Dull, right upper quadrant
or epigastric pain.etc one history reveals
Cirrhosis of liver.

17. Physcial examination
• In the abdomen in chronic liver disease include:
collateral circulation of the abdominal wall
around the umbilicus, bruising, hepatomegaly,
splenomegaly, abdominal distension (particularly
in the flanks) with shifting dullness and fluid
thrill secondary to ascites, hepatic bruit,
• S p i d e r n e v i , p a l m a r e r t h y e m a , c a p u t
medusa,mehrcke nails, terry nails reveals
cirrhosis of liver.

18. Lab findings
• The following findings are typical in cirrhosis:
Aminotransferases - AST and ALT are
moderately elevated, with AST > ALT.
However, normal aminotransferases do not
preclude cirrhosis.
• Alkaline phosphatase - usually slightly
elevated. GGT -- correlates with AP levels.
Typically much higher in chronic liver disease
from alcohol. Bilirubin - may elevate as
cirrhosis progresses.
• Albumin - levels fall as the synthetic function
of the liver declines with worsening cirrhosis
since albumin is exclusively synthesized in the
liver.
• Prothrombin time- increases since the liver
synthesizes clotting factors.
• Globulins - increased due to shunting of
bacterial antigens away from the liver to
lymphoid tissue. Serum sodium -
hyponatremia due to inability to excrete free
water resulting from high levels of ADH and
aldosterone.
• Thrombocytopenia - due to both congestive
splenomegaly as well as decreased
thrombopoietin from the liver. However this
rarely results in platelet count < 50,000/mL.
• Leukopenia and neutropenia- due to
splenomegaly with splenic margination.
• Coagulation defects - the liver produces most
of the coagulation factors and thus
coagulopathy correlates with worsening liver
disease.

19. Liver biopsy
Is a medical procedure in which a small
amount of liver tissue is surgically
removed so it can be analyzed in the
laboratory by a pathologist. Liver biopsies
are usually done to detect the presence of
abnormal cells in the liver, like cancer
cells, or to evaluate disease processes
such as cirrhosis.

20. • CT scan
This procedure combines special x-ray equipment with sophisticated computers to produce
multiple, digital images or pictures of the liver. It can help determine the severity of
cirrhosis as well as other liver diseases. See "Radiation Dose in X-Ray and CT Exams" for
more information.

21. • Liver ultrasound
Is a type of imaging exam that uses sound waves to create pictures of
the inside of the abdomen and/or pelvis, including images of the liver.
Doppler ultrasound allows for evaluation of blood flow to and from the
liver.

22. Gastroscopy
• Endoscopic examination of the esophagus, stomach and duodenum is performed in
patients with established cirrhosis to exclude the possibility of esophageal varices. If
these are found, prophylactic local therapy may be applied (sclerotherapy or banding)
and beta blocker treatment may be commenced. Rarely diseases of the bile ducts, such
as as primary sclerosing, can be causes of cirrhosis. Imaging of the bile ducts, such as
ERCP or MRCP (MRI of biliary tract and pancreas) can show abnormalities in these
patients, and may aid in the diagnosis.

23. Non pharmacological management
Ø Rest
Ø Avoidance of alcohol and anticoagulants management of ascites
Ø Administration of 300 calorie, high carbohydrate, protein, low fat diet,
low sodium diet for ascites.

24. Diuretic therapy is an important part of management.
• Spironolactone
• A high potency loop diuretic.
• Chlorothiazide may be used.

25. Needle puncture of the abdominal
cavity may be performed to remove
ascitic fluid.

26. Peritoneovenous shunt is a surgical
procedure that provides continous
reinfusion of ascitic fluid.

27. Non pharmacological management
• Fist step is initated stabilize the
patient and manage the airway.
• Iv therapy is initated and may
include administration of blood
products.
pharmacological management
• B- Blockers
• Octreotide
• Vasopressin
• Vitamin K

28. BALLOON TAMPONADE:
Balloon tamponade controls the
h e m o r r h a g e b y m e c h a n i c a l
compression of the varices. It may
be used in patients with acute
esophageal or gastric variceal
hemorrhage that can not be
controlled on initial endoscopy.

29. Endoscopic sclerotherapy SCLEROTHERAPY:
It involves injection of a sclerosant
solution into the varices through an
injection needle that is placed
through the endoscope.

30. ENDOSCOPIC BAND LIGATION
Endoscopic variceal ligation or
banding is performed by placing a
small rubber band around the base
of the varix(enlarged vein).

31. • Non Pharmacological
management
• The goal of management of
hepatic encephalopathy is the
reduction of ammonia.
• With improvement of mental
function, dietary protein content
is increased gradually over days.
• Electrolytes and acid imbalance
should as be treatment.

32. • Lactulose
• Antibiotics
• B- Blockers
• Octreotide
• Vasopressin
• Vitamin K
• Spironolactone
• Furosemide
• Chlorothiazide.

33. Liver transplantation may be
considered in patient with recurrent
hepatic encephalopathy and end
stage liver disease.

34. Nursing management
• Monitor the hemodynamic parameter
• Monitor I/O, daily weight
• Monitor prothrombin time, bleeding time
• Provide adequate rest.
• Patient level of conscious
• Restrict fluids & sodium if there is edema or
ascites
• Provide adequate nutrition & hydration
• Fluid and eletrolyte imbalance
• Acid base balance
• Monitor the respiratory status
• Provide adequate intake of nutrients
• Maintenance of normal body weight
• Maintenance of skin integrity
• Advice the patient cessation of alcohol.

35. • Provide comfort measures such as back rubbing &changing position to relieve pain
• Teach the patient relaxation techniques like deep breathing
• Provide quiet and calm environment.
• Give analgesics to relieve form pain and fever.
• Evaluate pt’s current activity tolerance and adjust activity and reduce intensity of task
that may cause undesired physiological changes.
• Help and encourage patients to eat,Feed the patient when fatigue or let someone
nearby to help patients.

36. • Keep head of bed elevated to facilitates breathing by reducing pressure on the
diaphragm
• Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods
to aids in reducing gastric irritation &abdominal discomfort that may impair oral
intake /digestion.
• Protect pt. from bleeding, monitor urine, stool, gums, skin for signs of bleeding/
bruising
• Teach pt. to use soft toothbrush,avoid constipation
• Administer Vit. K as ordered.

37. THANK YOU