‫كلية المنارة للعلوم الطبية‬

‫قسم تقنيات التخدير‬

‫المرحلة الثانية‬

‫‪Liver Cirrhosis‬‬
‫المصطلحات الطبية‬
‫‪By‬‬
‫مسلم عبدالزهرة عزيز‬ ‫‪-1‬‬
‫مخلد عبدالكريم سلمان‬ ‫‪-2‬‬
‫مالك جاسم مشعل‬ ‫‪-3‬‬
‫اسعد دعيم حمدان‬ ‫‪-4‬‬
‫سعد نعيم داود‬ ‫‪-5‬‬
‫مهند عبداالمير‬ ‫‪-6‬‬
‫مجاهد محمد جبار‬ ‫‪-7‬‬
‫كرار غازي‬ ‫‪-8‬‬
‫‪Introduction‬‬
• The term cirrhosis was first used by Rene Laennec (1781-1826) to
describe the abnormal liver color of individuals with alcohol induced
liver disease.
• Derived from Greek word Kirrhos means Yellowish brown color.
Definition:
• Cirrhosis is a chronic progressive disease of the liver characterized by
extensive degeneration and destruction of the liver parenchymal cells.
• The liver cells attempt to regenerate, but the regenerative process is
disorganized, resulting in abnormal blood vessels and bile duct
architecture.
Scarring also impairs the liver's ability to:
• control infections
• remove bacteria and toxins from the blood
• process nutrients, hormones, and drugs
• make proteins that regulate blood clotting
• produce bile to help absorb fats—including cholesterol—and fat-
soluble vitamins

Etiology:
1- Not clearly defined
2- Alcohol.
• Heavy alcohol for several years can cause chronic injury to the liver and
damages.
• For women, consuming two to three drinks—including beer and wine
per day and for men, three to four drinks per day, can lead to liver
damage and cirrhosis.
• A common problem in alcoholic is protein malnutrition.
3- Obesity: WHO ,2008, estimated that more than 200 million men and
close to 300 million women were obese, obesity is a common cause of
chronic liver disease , 17% of liver cirrhosis is attributable to excess
body weight.
4- Chronic hepatitis .
- Chronic hepatitis C causes inflammation and damage to the
liver over time that can lead to cirrhosis and approximately
20% patient will develop cirrhosis.
- Chronic hepatitis B and D. Hepatitis B and D is virus that
infects the liver and can lead to cirrhosis, but it occurs only
in people who already have hepatitis B. approximate 10%-
20% will develop cirrhosis.
- Nonalcoholic fatty liver disease (NAFLD). This is associated
with obesity, diabetes, protein malnutrition, coronary artery
disease, and corticosteroid medications.
- Autoimmune hepatitis. It is caused by the body's immune
system attacking liver cells and causing inflammation,
damage, and eventually cirrhosis.
- genetic factors -About 70 percent of those with autoimmune
hepatitis are female.
- Diseases that damage or destroy bile ducts. Several
different diseases( cholangitis) can damage or destroy the
 ducts that carry bile from the liver, causing bile to back up in
the liver and leading to cirrhosis.
- Inherited diseases. Cystic fibrosis, alpha-1 antitrypsin
deficiency, hemochromatosis, Wilson disease, galactosemia,
and glycogen storage diseases are inherited diseases that
interfere the liver function properly, cirrhosis can result.
- Drugs, toxins, and infections. drug
reactions( Acetaminophen, isonazide, methotrexate)
prolonged exposure to toxic chemicals, parasitic infections,
and repeated bouts of heart failure with liver congestion.
Types of cirrhosis :
1- Alcoholic (historically called Laennec’s cirrhosis) cirrhosis:
- also called micro nodular or portal cirrhosis and usually
associated with alcohol abuse.
- The first change in the liver from excessive intake is an
accumulation of fat in the liver cells; uncomplicated fatty
changes in the liver are potentially reversible if the person
stops drinking alcohol.
- If the alcohol abuse continues, widespread scar formation
occurs throughout the liver.
2- Post necrotic cirrhosis( macro nodular):most common world wide,
massive loss of liver cells with irregular patterns of regenerating cells
due to complication of viral, toxic or idiopathic (autoimmune) hepatitis.
3- Billiary cirrhosis: is associated with chronic billiary obstruction and
infection. There is diffuse fibrosis of the liver with jaundice.
4- Cardiac cirrhosis: chronic liver disease results from long-standing,
severe right side heart failure with corpulmonale, constrictive
pericarditis, and tricuspid insufficiency. 

Pathophsiology :
Liver insult due to alcohol ingestion, viral hepatitis,
exposure to toxin
 Hepatocyte damage

Liver necrosis →liver fibrosis and scarring → portal hypertension

- Ascities, edema,
- Spleenomegaly ( thrombocytopenia, leucopenia)
- Varices (esophageal varices, hemorrhoids, anemia)

↓ billirubin metabolism – hyperbilirubinemia, jaundice

• ↓ bile in gastrointestinal tract – light colored stool

• ↑ urobilinogen – Dark Urine
• ↓ vit K absorption- bleeding tendency
• ↓ metabolism of protein, carbohydrate, fats→
hypoglycemia,
• ↓ plasma protein- ascites and edema
• ↓androgen and estrogen detoxification(↓ hormone
metabolism)- ↑ estrogen and androgens hormone –
• ↓ Aldosterone metabolism so ↑ levels – sodium and
water retention-- edema
• Biochemical alteration - ↑ AST, ALT levels, ↑
bilirubin, low serum albumin, prolong prothrombin
time, elevated alkaline phosphatase.
• Liver failure
• Hepatic encephalopathy
• Hepatic coma
• Death

Clinical manifestations:
Early manifestations
• No symptoms
• GI disturbances: anorexia, dyspepsia, flatulence, weakness,
fatigue, nausea, vomiting, weight loss, abdominal pain,
bloating, diarrhea, constipation
• Abdominal pain, dull and heavy feeling
• Fever, lassitude, weight loss, enlargement of liver and spleen.
Later manifestations:
• Results from liver failure and portal hypertension
• Jaundice
• Peripheral edema
• Ascites
• Others: Skin lesion, hematological disorders, endocrine
disturbances, and peripheral neuropathy
• Advanced stage: small and nodular liver

Clinical Manifestations:
Complication:
1- Portal hypertension:
The nodules and scar tissue can compress hepatic veins within the liver. This
causes the blood pressure within the liver to be high, a condition known as portal
hypertension.
Portal venous pressure is more than 15mmHg or 20 cm of water (normal 5-10mm
Hg

2- Esophageal Varices:
Esophageal Varices are a complex of tortuous veins at the lower end of the
esophageal enlarged and swollen as a result of portal hypertension.
10-30% of UGI bleeding due to rupture of varices.
80% bleeding due to esophageal Varices.
20% due to gastric varices.
3- Peripheral edema and Ascites:
- Edema results from decreased colloidal oncotic pressure
from impaired liver synthesis of albumin (hypoalbuminia)
- Ascites is the accumulation of serous fluid in the peritoneal
cavity.
- Protein move from the blood vessels via the larger pore of
sinusoids into the lymph space.
 - When the lymphatic system is unable to carry off the excess
protein and water, they leak through the liver capsule into
the peritoneal cavity.
4- Hepatic encephalopathy/Coma:
- Hepatic encephalopathy is a neuropsychiatric
manifestation of liver damage.
- It can occur in any condition in which liver damage
causes ammonia to enter the systemic circulation
without liver detoxification.
- Liver is unable to convert ammonia to urea. The
ammonia crosses the blood brain barrier and
produces neurologic toxic manifestations.
5- Hepatorenal syndrome:
- Hepatorenal syndrome is a serious complication of
cirrhosis characterized by functional renal failure with
advancing azotemia, oliguria, and ascites.

Diagnosis:
 • Liver function test : ↑alkaline phosphate, ALT,AST and y –
glutamyl transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and
globulin, ↑serum ammonia
• Prothombin time is prolonged (normal: 10-14sec)
• Liver cell biopsy to identify liver cell changes
• Ascites fluid test
• Liver ultrasound
• CT Scan: enlarged or atrophied, characteristics
• Stool for occult blood
• Endoscopy
Management:
Medical management
• Dietary modification: table salt, salted butter, margarine,
ordinary can and frozen foods should be avoided.
• The diet should be adequate calories and protein (75- 100
gm/day) unless hepatic encephalopathy is present, in which
case protein is limited.
• Restrict fluid
• Diuretics: spironolactone, aldosterone blocking agents.
• Vitamins B and fat soluble vitamins (A, D, E, K).
• Corticosteroids drugs to improve liver function in post necrotic
cirrhosis.
• Daily weight loss should not exceed 1 to 2 kg (2.2 to 4.4 lb) in
patients with ascites and peripheral edema or 0.5 to 0.75 kg
(1.1 to 1.65 lb) in patients without edema.
• Bed Rest: useful therapy
upright position activation of the renin-angiotensin-
aldosterone system and sympathetic nervous systemresults
in reduced renal glomerular filtration and sodium excretion and
a decreased response to loop diureticsavoid
• Paracentesis: removal of fluid (ascites)
from the peritoneal cavity through a small
surgical incision or puncture made
through the abdominal wall under sterile
conditions (upto 5-6l removal is safe)
• Insertion of a peritoneovenous shunt to redirect ascitic fluid
• Replace Fluid and Electrolytes: intravenous fluids with
electrolytes and volume expanders are provided to restore fluid
volume and replace electrolytes
• Transfusion of blood components also may be required
• An indwelling urinary catheter to monitor urine output
• Pharcological therapy:
• Vasopressin (↓portal pressure)
 • Vasopressin +Nitroglycerine (↓ portal pressure)
• Somatostatin and octreotide (↓ bleeding)
• Balloon Temponade: used for controlling hemorrhage
- Use of double ballon teamponade Isengstaken
Blakemore tube)
- Used to to exert pressure on the cardia (upper orifice
of the stomach) and against the bleeding varices
- The balloon in the stomach is inflated with 100 to 200
mL of air.
- An x-ray is done to confirm proper positioning of the
gastric balloon
Slerotherapy:
• In endoscopic sclerotherapy , a sclerosing agent is injected
through a fiberoptic endoscope into the bleeding esophageal
varices to promote thrombosis and eventual sclerosis.
• The procedure has been used successfully to treat acute GI
hemorrhage
•
Surgical management
• Liver transplantation
• Removing the liver and replacing it with a healthy donor organ
is another way to treat liver cancer or liver cirrhosis
• About 80-90 percent of people who undergo liver
transplantation, survive.
Direct surgical ligation of varices
splenorenal, mesocaval,
and portacaval venous
shunts

Treat underlying cause: if

cirrhosis is from heavy
alcohol use, the treatment is
to completely stop drinking
alcohol.
• If cirrhosis is caused by hepatitis C, then treatment of hepatitis
C
• Avoidance of hepatotoxic substances.
References
• Brunner And Siddhartha's (2004).Medical- Surgical Nursing (12 th
Ed)
• Chintamani .Lewis’s Medical Surgical Nursing, Mosby .2011
• Cirrhosis of Liver, emedicine, Available from:
www.emedicinehealth.com/cirrhosis/page8_em.htm
• M. Joycee Black, Hokanson Jane Hawks. Medical –Surgical
Nursing. Clinical management for positive outcomes. 7 th ed.
2005.