Chronic liver Failure

‫هدير محمد صابر على‬

‫هدير محجوب محمد محجوب الحماقى‬
‫هشام محمد ربيع عبد السالم‬
‫هشام محمد عبدالعاطى السالمونى‬
‫هناء رضا محمد عبد الرشيد‬
‫هناء رفعت سعيد احمد‬
‫هند الشحات محمد ابراهيم السيد‬
‫هند عاطف جالل غريب‬

‫‪Under Supervision‬‬
‫‪Assistant prof / Amal Abdelrazek‬‬
A.L / Seham Nassar

: - Outlines

• Introduction
• Definition
• Pathophysiological
• Causes
• Risk factors
• Signs and Symptoms
• Complications
• Diagnosis
• Medical Managements
• Surgical management
• Nursing Management
• Prevention

Introduction

• The liver is a vital organ that helps your body digests food,
removes toxins, metabolizes drugs and alcohol, produces proteins
important for the blood and clotting, and is crucial for nutrition.

• "Chronic liver disease" refers to disease of the liver which lasts

over a period of six months.

• it is a long-standing irreversible change in the hepatic structure

• It consists of a wide range of liver pathologies which include

inflammation (chronic hepatitis), liver cirrhosis, and
hepatocellular carcinoma.

• Many factors can contribute to the risk of developing chronic

liver disease: lifestyle behaviors, genetics, and medications.
• Hepatic and hepatobiliary diseases are a common cause of
morbidity and mortality in children.

Definition-:

Chronic liver disease is a disease process of the liver that

involves a process of progressive destruction and

regeneration of the liver parenchyma leading to fibrosis

and cirrhosis. "Chronic liver disease" refers to progressive

deterioration of liver functions for more than six months, It

consists of a wide range of liver pathologies which include

inflammation (chronic hepatitis), liver cirrhosis,

and hepatocellular ml carcinoma.

Pathophysiology
Chronic liver disease represents a continuous and progressive process of
hepatic fibrosis. When the liver exposure to any insults such as (biliary
disease, viral infection, toxins and any metabolic disease that led to
degeneration of the liver but when the cause determined and treated the
liver will return healthy that called (reversible). on another hand when the
cause untreated the degeneration will increase and formation of (necrosis)
and when increase the insults the retained healthy cell will proliferation
that called (regeneration nodules) and the spaces between these nodules
the(fibrosis) takes place. in this stage the liver become irreversible and
development of cirrhosis.

Causes

1- Viral causes

Hepatitis B: is an infectious disease caused by the hepatitis B virus

(HBV) that affects the liver.

Hepatitis C :is an infectious disease caused by the hepatitis C virus

(HCV) that primarily affects the liver

2- Cytomegalovirus : is a genus of viruses in the order Herpesvirales,

in the family Herpesviridae, in the subfamily Betaherpesvirinae.
Humans and monkeys serve as natural hosts
 3- Toxic and drugs

Alcoholic liver disease

Rarely drug induced liver disease from methotrexate, amiodarone,

nitrofurantoin and others

Paracetamol (acetaminophen) causes acute liver damage.

4- Metabolic

Non-alcoholic fatty liver disease: also known as metabolic (dysfunction)

associated fatty liver disease (MAFLD), is excessive fat build-up in the
liver without another clear cause such as alcohol use.

Haemochromatosis: indicates accumulation of iron in the body from any

cause. The most important causes are hereditary haemochromatosis
(HHC), a genetic disorder, and transfusional iron overload, which can
result from repeated blood transfusions.

Wilson's disease: is a genetic disorder in which excess copper builds up

in the body. Symptoms are typically related to the brain and liver. Liver-
related symptoms include vomiting, weakness, fluid build up in the
abdomen.
 5- Autoimmune response causes

Primary biliary cholangitis (previously known as primary biliary

cirrhosis): is an autoimmune disease of the liver.It results from a slow,
progressive destruction of the small bile ducts of the liver, causing bile
and other toxins to build up in the liver, a condition called cholestasis.
Further slow damage to the liver tissue can lead to scarring, fibrosis, and
eventually cirrhosis.

Primary sclerosing cholangitis:is a long-term progressive disease of the

liver and gallbladder characterized by inflammation and scarring of the
bile ducts, which normally allow bile to drain from the gallbladder.

Autoimmune Hepatitis : is a chronic, autoimmune disease of the liver that

occurs when the body's immune system attacks liver cells, causing the liver
to be inflamed.

6- Other

Right heart failure: is often caused by pulmonary heart disease (cor

pulmonale), which is typically caused by difficulties of the pulmonary
circulation, such as pulmonary hypertension or pulmonic
stenosis.Physical examination may reveal pitting peripheral edema,
ascites, liver enlargement, and spleen enlargement.

Risk factors: -

•
Heavy alcohol use.
•
Obesity Type 2 diabetes.
•
Tattoos or body piercings injecting drugs.
•
Using shared needles.
•
Exposure to other people's blood and body fluids Exposure to
certain

•
chemicals or toxins.
•
Family history of liver disease.
•
Metabolic syndrome including raised blood lipids.
 •
Certain prescription medications Viral hepatitis.

Signs and Symptoms

At first, symptoms of liver failure can look like other common

childhood illnesses, such as the flu. Early symptoms may include:

• Fatigue (feeling tired all the time)

• Nausea or vomiting
• Loss of appetite
• Abdominal (belly) pain

As liver failure gets worse, symptoms may include:

• Dark urine
• Jaundice (yellowish skin and eyes)
• Itching all over the body
• Bruising easily or bleeding for a long time
• Swollen abdomen from fluid building up (ascites)
• Brain problems, such as confusion, irritability, unusual sleepiness
during the day or sleeplessness at night (encephalopathy)

Complications of chronic liver failure

1) Liver encephalopathy : decrease of brain function due to build up
of toxins in blood stream.
2) Jaundice : a yellow discoloration of eyes and dark urines as a result
of high level of bilirubin in blood stream.
3) Coagulopathy : in ability of body to make clots.
4) Portal hypertension : high blood pressure in the Portal vein.
5) Acites : accumulation of fluids in abdominal cavity.
6) Hepatomegaly : enlargement of liver size that cause abdominal
pain.
7) Variceal bleeding : it occurs when normal blood flow to liver is
blocked so blood flows through small vessels that can't carry huge
quantity of blood so this vessels rupture and cause life threating
bleeding.
8) Hepatorenal syndrome : it's a life threating condition that is
common in patients with cirrhosis and acites.
9) Cirrhotic cardiomyopathy : complication to cirrhosis.

Diagnosis
 ➢ Chronic liver disease takes several years to develop and
the condition may not be recognized unless there is
clinical awareness of subtle signs and investigation of
abnormal liver function tests.
➢ Diagnostic approach starts with a detailed History
including family history.

1. Laboratory work up Biochemical tests indicating liver damage.

2. Investigations to find underlying etiology.
3. liver function status 4. liver function status.
5. evaluation Liver Biopsy

The liver biopsy is a simple procedure done with a fine thin needle
under local anesthesia. The tissue sample is sent to a laboratory
where it is examined underneath a microscope.
1. Liver Function Tests (LFTs)
2. Serum Bilirubin.
Modest elevation of alt& act indicate ongoing hepatocyte injury
followed by Progressive elevation of bilirubin.

•
Investigations for Liver Function Status.
•
Serum albumin levels.
•
Coagulation Profile.

•
Plasma glucose.

•
Radiology and Imaging Investigations.
•
Liver Ultrasound with Doppler Computed Tomography (CT
Scan).

•
Magnetic Resonance Imaging (MRI).
•
Ultrasonography is a safe and non-invasive imaging
investigation.
 Medical Managements (Pharmacological therapy)
• Treatment is designed to remove alleviate the
underlying cause of cirrhosis

• Paracentesis. Paracentesis may help alleviate ascites.

• Sengstaken-Blakemore or Minnesota tube. The Seng

taken-Blakemore or Minnesota tube may also help

control hemorrhage by applying pressure on the

Bleeding site

• Octreotide. If required, octreotide may be prescribed for

esophageal varices.

• Diuretics. Diuretics may be given for edema; however,

they require careful monitoring because fluid and

electrolyte imbalance may precipitate hepatic

encephalopathy.

• Lactulose. Encephalopathy is treated with lactulose.

 • Antibiotics. Antibiotics are used to decrease intestinal

bacteria and reduce ammonia production, one of the

causes of encephalopathy.

Surgical management

1. Trans jugular intrahepatic portosystemic shunt (TIPS) procedure: -

The TIPS procedure is used for the treatment of varices by upper

endoscopy with banding to relieve portal hypertension.

2. Liver transplant surgery: -

In advanced cases of cirrhosis, when the liver ceases to function, a liver

transplant may be the only treatment option. A liver transplant is a
procedure to replace your liver with a healthy liver from a deceased
donor or with part of a liver from a living donor
 Nursing diagnosis according disease

1. Imbalanced Nutrition: Less Than Body Requirements

➢ May be related to
Inadequate diet; inability to process/digest nutrients
Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
Abnormal bowel function
➢ Possibly evidenced by
Weight loss
Changes in bowel sounds and function
Poor muscle tone/wasting
Imbalances in nutritional studies

2. Excess Fluid Volume

➢ May be related to
Compromised regulatory mechanism (e.g., syndrome of
inappropriate antidiuretic hormone [SIADH], decreased
plasma proteins, malnutrition)
Excess sodium/fluid intake
➢ Possibly evidenced by
Edema, anasarca, weight gain
Intake greater than output, oliguria, changes in urine specific
gravity , Dyspnea, adventitious breath sounds, pleural effusion
BP changes, altered CVP JVD, positive hepato jugular reflex
Altered electrolyte levels , Change in mental status

3. Ineffective Breathing Pattern

➢ Risk factors may include
Intra-abdominal fluid collection (ascites)
Decreased lung expansion, accumulated secretions
Decreased energy, fatigue
 4. Risk for Injury
➢ Risk factors may include
Abnormal blood profile; altered clotting factors (decreased
production of prothrombin, fibrinogen, and factors VIII, IX,
and X; impaired vitamin K absorption; and release of
thromboplastin) , Portal hypertension, development of
esophageal varices

5. Risk for Acute Confusion

➢ Risk factors may include
Alcohol abuse
Inability of liver to detoxify certain enzymes/drugs
6. Disturbed Body Image
Situational Low Self-Esteem
➢ May be related to
Biophysical changes/altered physical appearance
Uncertainty of prognosis, changes in role function
Personal vulnerability
 Self-destructive behavior (alcohol-induced disease)

7. Deficient Knowledge
➢ May be related to
Lack of exposure/recall; information misinterpretation
Unfamiliarity with information resources
➢ Possibly evidenced by
Questions; request for information, statement of
misconception
Inaccurate follow-through of instructions/development of
preventable complications

8. Risk for Impaired Skin Integrity ➢

Risk factors may include
Altered circulation/metabolic state
Accumulation of bile salts in skin
Poor skin turgor, skeletal prominence, presence of edema,
ascites
 Nursing Management of children with chronic liver
failure:

➢ Improving nutritional status through:

• Restrict proteins intake.

• Fluid restriction (Fluid are restricted to 1 to 1.5 L/day.)

• Sodium restriction (Is usually restricted to 2g/day.)

• Calories without protein by administering total parenteral nutrition

with a high glucose content.

• Monitor serum glucose level.

• Add thiamine (usually from 50 to 100 mg) and B complex vitamins

(usually from 500 to 1000 mg) to intravenous solutions as
prescribed.

➢ Management of respiratory status through:

• Put child in the position bed for maximum respiratory.

• Provide oxygen therapy if needed.

• Provide ventilator support as necessary.

• Monitor hemodynamic status.

• Encourage child to increase activities gradually and plan rest with

activities and mild as necessary.

• Activities rest and moderate exercise is essential.

➢ Management of complications for ascites through:

• Fluid decreases according need gentle diuresis.

• Sodium restriction.

• Monitoring of electrolyte imbalance.

• Paracentesis as required.

➢ Management of Encephalopathy through:

• Managed by eliminating or treating precipitating factors.

• Give minimum protein only to support growth.

➢ Management of bleeding through:

• Administer vitamin K as ordered to reduce prolonged prothrombin

time and bleeding tendency.
 Prevention

1- Get a hepatitis vaccine or an immunoglobulin shot to prevent hepatitis

A and B.

2- Regular screening for hepatitis B and hepatitis C

3- Do not drink alcohol in excess, avoid various types of alcohol (wine,

liquor, mixed drinks, beer)

4- Maintain a healthy weight, obesity can cause nonalcoholic fatty liver

disease.

5- Use medications wisely, avoid over-the-counter painkillers

(aspirin ,acetaminophen) and other hepatotoxic drugs.

6- Practice proper hygiene. be sure to wash your hands

thoroughly after you use the bathroom. Also, wash your hands before you
touch any food.

7- Protect your skin from insecticides and other toxic chemicals wear
gloves.

8- don't share needles or your personal items with anyone.

 References
1. https://www.webmd.com/digestive-
disorders/digestivediseases-liver-failure
2. https://www.mayoclinic.org/diseases-
conditions/liverproblems/symptoms-causes/syc-20374502
3. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.100
2/hep.31117
4. https://pubmed.ncbi.nlm.nih.gov/21999650/
5. https://www.mayoclinic.org/diseasesconditions/cirrhosis/
diagnosis-treatment/drc-20351492