A CASE

PRESENTATION
ON: LIVER
CIRRHOSIS

MEDICAL WARD
Illustration DUTY ROTATION
by Smart-Servier Medical Art
 INTRODUCTION
On October 18, 2023, a 67-year-old man residing in Purok Central II, Barangay
Hinapu Daku, Maasin City, Southern Leyte, arrived at the Salvacion Oppus Yniguez
Memorial Provincial Hospital with a concerning medical issue. He had presented with
blood-tinged vomitus, a symptom that required immediate attention. After a thorough
assessment and examination, it became evident that this patient was a chronic alcoholic.
His diagnosis was Upper Gastric Intestinal Bleeding secondary to Portal Gastropathy,
attributed to the underlying conditions of Liver Cirrhosis and Alcoholic Liver Disease.
Consequently, hospitalization was recommended to address his medical situation.

Liver cirrhosis, often a consequence of chronic alcohol abuse, is a progressive and

irreversible condition characterized by the replacement of healthy liver tissue with fibrous
scar tissue. This liver damage can lead to portal hypertension, a condition in which
increased pressure within the portal vein system results in various complications,
including portal gastropathy. Portal gastropathy is characterized by changes in the
stomach lining's blood vessels, which can make them prone to bleeding. When this
bleeding occurs in the upper gastrointestinal tract, it can be life-threatening and requires
prompt diagnosis and intervention.
INTRODUCTION

MEDICAL WARD
Illustration DUTY ROTATION
by Smart-Servier Medical Art
 INTRODUCTION

Patients with liver cirrhosis often present with a range of symptoms, from mild to severe,
and may experience complications like ascites, hepatic encephalopathy, and variceal bleeding.
In this case, upper gastrointestinal bleeding related to portal gastropathy will be focused. The
clinical presentation can include symptoms such as hematemesis (vomiting blood), melena
(black, tarry stools), or hematochezia (bright red blood in stools), often accompanied by signs of
anemia, such as fatigue and weakness.

Diagnosing and managing upper gastrointestinal bleeding in the context of liver cirrhosis
and portal gastropathy can be a complex and challenging task. Effective management requires
a multidisciplinary approach.

This case presentation also seeks to emphasize the complexities surrounding portal
gastropathy and its severe effects in patients with alcoholic liver disease, highlighting the need
for a multidisciplinary approach and comprehensive patient care. By addressing this
multidisciplinary issue, this case presentation aims to improve patient outcomes and enhance
the quality of care for individuals battling this challenging medical condition.
 EPIDEMIOLOGY

The most recent data on the global prevalence of cirrhosis, obtained from the Global
Burden of Diseases, Injuries, and Risk Factors Study (GBD) in 2017, shows a significant
increase in cirrhosis cases worldwide. In 2017, there were an estimated 112 million cases of
compensated cirrhosis and 10.6 million cases of decompensated cirrhosis worldwide, up from
1990 figures of 65.9 million and 5.20 million, respectively. The age-standardized prevalence of
compensated cirrhosis ( The early stage of cirrhosis in which the liver can still perform most of its
essential functions despite the presence of scarring) increased from 1354.5 per 100,000 in 1990
to 1395.0 per 100,000 in 2017, while decompensated cirrhosis ( The advanced stage of cirrhosis
in which the liver's ability to function is severely impaired) increased from 110.6 per 100,000 in
1990 to 132.5 per 100,000 in 2017. Men were found to suffer from cirrhosis at higher rates, with
58.8% of compensated cirrhosis cases and 60.3% of decompensated cirrhosis cases occurring
in males. Regionally, the high-income Asia-Pacific region had the highest age-standardized
prevalence of cirrhosis, while Australia reported the lowest. Etiology-specific statistics revealed
that hepatitis B and C infections, as well as alcohol consumption and non-alcoholic
steatohepatitis, were major contributors to cirrhosis.
 EPIDEMIOLOGY

According to WHO, in the Philippines, cirrhosis is a notable concern, as it accounted

for 7,076 or 1.05% of total deaths in the country in 2019, with an adjusted death rate of
8.65 per 100,000 population, making it the 19th leading cause of death. The Philippines
also reported 328.4 cases of compensated cirrhosis and 41.8 cases of decompensated
cirrhosis per 100,000 population. Moreover, there were a total of 229,100 reported cases
of cirrhosis-related morbidities in the country. These statistics emphasize the impact of
cirrhosis on public health in the Philippines, and the data is sourced from a
comprehensive study on global liver disease epidemiology.

These findings indicate a substantial global burden of cirrhosis, with a notable

increase over the years, highlighting the importance of public health efforts to address the
underlying causes and risk factors contributing to cirrhosis. Additionally, the data
underscore the need for region-specific strategies to combat cirrhosis and its associated
health complications effectively.
 OBJECTIVES
GENERAL OBJECTIVES:

After 3-4 hours of case presentations, the audience and the other students will be able to learn, acquire the
necessary skills, display a positive outlook, put the knowledge they have learned to use, and provide the best
nursing care for a patient with liver cirrhosis.

SPECIFIC OBJECTIVES:

Over a 2-3 hour in-depth exploration of the case presentation, nursing students will attain the following specific
objectives:

Comprehend Liver Cirrhosis: Gain a comprehensive understanding of Liver Cirrhosis, including its etiology
and pathophysiology.
Patient Health History: Skillfully identify and discuss the patient's past and current health history, recognizing
its relevance to managing Liver Cirrhosis.
Precise Physical Assessment: Execute a precise and accurate physical assessment of the patient to
establish a baseline of data, facilitating effective care.
 OBJECTIVES

Pathophysiological Insights: Present a diagrammatic representation of the pathophysiological mechanisms

in Liver Cirrhosis.
Medical Management Awareness: Enumerate the various medical management approaches and their
significance in patient care, while comprehending nursing responsibilities in the management of Liver
Cirrhosis.
Medication Knowledge: Identify and discuss the medications prescribed for the patient, including their mode
of action, potential side effects/adverse effects, indications, contraindications, and nursing responsibilities in
their administration.
Surgical Interventions: Determine the different surgical interventions indicated for Liver Cirrhosis,
considering the potential benefits and risks.
 OBJECTIVES

Nursing Care Planning: Formulate comprehensive nursing care plans rooted in the data collected through
patient assessments, tailoring care to individual needs.
Patient-Centered Care: Identify the unique needs and challenges facing patients with Liver Cirrhosis and
provide essential health education and support.
Nursing Practice, Education, and Research: Evaluate the broader implications of Liver Cirrhosis
management on nursing practice, education, and research, fostering a holistic approach to patient care and
continually improving healthcare standards.
 COMPLETE HEALTH HISTORY
I. COMPLETE HEALTH HISTORY

A. BIOGRAPHIC DATA
Name: A.G.L
Age: 67
Sex: Male
Address: P. Central II Hinapu Daku, M.C
Status: Married
Birthday: 7-30-1956
Place of Birth: Matalom Leyte
Religion: Roman Catholic
Nationality: Filipino
Doctor-in-charge: Dr. Alenna Bianca F. Redulla/ Dr. Dela Cruz
Admission date: 10-18-23
 COMPLETE HEALTH HISTORY
B. CHIEF COMPLAINT/REASON:
Hematemesis
C. HISTORY OF PRESENT ILLNESS
According to the significant other (SO) of the patient, the day before seeking medical
attention, the patient had consumed an alcoholic beverage and had been engaged in carpentry
work, which the patient continued until midnight. Upon waking up the following morning, the patient
expressed complaints of abdominal pain in the upper abdomen and epigastric region. Additionally,
the patient vomited blood-tinged vomitus, prompting them to promptly seek medical attention at the
SOYMPH facility, where they were subsequently admitted.

Upon admission, the patient's examination revealed the following: pain in the upper abdomen
and epigastric region, hematemesis was noted, occurring approximately 8 times with a half-cough
per episode. The patient also had a history of peptic ulcer, chronic alcohol consumption, and
smoking, which they had ceased two years ago and now consumed alcohol occasionally.
 COMPLETE HEALTH HISTORY

D. PAST HEALTH HISTORY

The patient has a past health history of Diabetes Mellitus and Hypertension.
Upon examination and interview, the patient has also undergone nephrectomy or
the surgical removal of one of his kidneys.
FAMILY HEALTH HISTORY
 PHYSICAL EXAMINATION
SYSTEM NORMAL FINDINGS ACTUAL FINDINGS
Temperature: 36.5 C Temperature: 36.8 C
Pulse Rate: 60-100 bpm Pulse Rate: 78 bpm
Respiratory Rate: 16-20 cpm Respiratory Rate: 17 cpm
VITAL SIGNS
BP: 120-90 Systolic, 80-60 diastolic BP: 130/70 mmHg
SPO2: 95-100% SPO2: 97%

Well-developed, well -nourished, appearing Patient is well-developed and appears on his

stated age. Alert, oriented to time, place, stated age, he is also conscious and coherent
person and situation recent and remote to time, place and situation. He has good insight
memory intact. Good insight and cognitive and hearing, even skin tone, has hematemesis,
function. No aphasia, dysarthria or hair is black and white , grey positive has
GENERAL SURVEY
hoarseness. Gait and station normal, greasy texture. The nails are dirty and bolbous
Rhomberg (-) skin warm, dry, good skin in shape
turgor, No abnormal pigmentation, bleeding,
rash or other lesions. Hair normal texture and
distribution. No nail changes
 PHYSICAL EXAMINATION
HEAD- head is normocephalic and atraumatic, without
tenderness, visible or palpable masses, depressions, or
scaring. Hair is evenly distribution and normal in texture
EYES- visual acuity is intact, Conjunctivae are clear
without exudates or hemorrhage. Sclera is non-icteric,
EOM are intact, PERRLA fundi appears normal including
optic discs and vessels. No signs of nystagmus
EARS- pinna, tragus, and ear canal are non-tender
without swelling. The ear canal is clear without
discharge. The tympanic membrane is normal
appearance with a good cone of light. Hearing is intact
HEENT with good acuity to whispered voice
NOSE- nasal mucosa is pink and moist. The nasal
septum is midline. Nares are patent bilaterally
TROATH/MOUTH- oral mucosa is pink and moist with
good dentition. Tongue normal in appearances without
lesions and good symmetrical movement. No buccal
nodules or lesions are noted. The pharynx is normal in
appearance without tonsil or swelling or exudates. No
adenopathy is noted.
HEAD- is round, symmetric, proportional and at midline to
patients body. No lesions, face is symmetric with an oral
appearance. Hair is evenly distributed black, white, grey
hair color without lice of dandruffs
EYES- eyes are not sunken, depressed or protruding it is
symmetrical, white sclera, pupils dilate and constricts. Iris is
round has eye lashes, without lesions , cataract, sore eyes,
clear vision responds to light, can close and open
EARS- are equal in size bilaterally. The auricle aligns with
corner of each eye. Skin is even with facial color. Small
amount of brow flaky cerumen present.
NOSE- even skin with the rest of the face, smooth and
symmetric, client is able to breath with using accessory
muscle, no anosmia of has hair inside
THROAT/MOUTH – is able to verbalize and talk clearly with
pain and difficulty, no lesions, oral mucosa is appeared dark
red, moist and with not really good dentition. Tounge is at
midline without lesions ulcers, and symmetrical in
movements. No tonsillar swelling, no pharyngitis and
adenopathy
 PHYSICAL EXAMINATION
Scaphoid without scars. No abnormal Patient has even color, scaphoid without
tympany. Normal bowel sounds, no scars slow bowel sounds, no lesions , no
bruits, superficial and deep palpation rashes , umbilicus is midline
ABDOMEN
without organomegaly or masses: no
direct/ rebound tenderness,
rigidity/guarding
Skin is warm to touch on extremities, Skin is dark brown in color and is evenly
especially on patient’s palm. distributed has dry and scale skin without

SKIN Skin is brown in color and fairly lesions, edema, abrasion, ecchymosis and
other discoloration. The skin turgor is normal
distributed.
and also is capillary refill time
Clubbing of the finger nails noted
No lymph nodes are distended. No Neck is symmetric with head centered and
masses and tenderness noted. without bulging masses, thyroid cartilages
move symmetrically as patient swallow.
NECK
No thyroid enlargement. Neck movement
is smooth and controlled without
restriction
 PHYSICAL EXAMINATION
Chest is symmetrical, sternum The chest and lungs appear
located at midline. Chest wall is symmetrical with normal
intact without tenderness and expansion. No cough and
CHEST AND LUNGS masses. Equal expansion on abnormal breathing. No lesions or
both lungs. Breath sounds are discoloration. When breathing, the
clear client does not use any accessory
muscles.
Equal size on both sides of the Client’s extremities are intact. No
body; No contractures or presence of swelling, redness,
tremors; Normally firm and lesions, or injuries. Function
smooth; With coordinated well/ambulatory
BACK AND EXTREMITIES movement noted; No observable
bone deformities, tenderness;
There are no swelling,
tenderness, and joints smoothly;
capillary refill is 2 seconds
 PHYSICAL EXAMINATION

No blowing or swishing or other Slow rhythm and heartbeat,

sounds regular rhythm, poor/decrease
are heard. No murmurs are heard. cycle per minute. No murmurs,
No
thrills upon auscultation.
extra heart sounds. Rate should be
60-
100 beats.min, with regular rhythm.
CARDIOVASCULAR A
regularly irregular rhythm, such as
sinus
arrhythmia when the HR increases
with
inspiration and decreases with
expiration, may be normal in young
adults.
 GORDON’S FUNCTIONAL HEALTH PATTERN
FUNCTIONAL HEALTH PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Prior to her diagnosis, the Now that he is in the hospital, he has become
patient had not been health-conscious. The patient diligently
HEALTH PERCEPTION/ HEALTH
particularly attentive to her health complies with the treatments and necessary
MANAGEMENT
because, in her opinion, he was in tests. He actively engages with his healthcare
good health. providers and adheres to the advice provided.
The patient mentioned that she Following his doctor's guidance, the patient
typically consumes whatever is restricts his consumption of both food and
provided at the table and doesn't liquids. He is currently on a soft diet, limiting or
make a habit eliminating foods that are hard to chew and
of avoiding fatty or salty foods. swallow. Additionally, he has refrained from
NUTRITION METABOLIC PATTERN
Patient stated also that he has a consuming alcohol and coffee.
high consumption of alcohol he
uses to drink everyday and he
uses to drink coffee everyday also
GORDON’S FUNCTIONAL HEALTH PATTERN

The patient experienced no The patient continues to urinate without

difficulties with urination but he any discomfort. He has stated that he is
has a problem in bowel able to defecate daily without difficulties, at
movement he takes 4 times a least once a day
ELIMINATION PATTERN day in the toilet. Her urine
appears yellowish, and she
typically urinates 2-3 times
daily, he’s stool is dark in color
and had a blood.
According to the patient, his Due to his hospitalization, the patient's
exercise was through chopping physical activity has become limited, as he
ACTIVITY AND TOLERANCE wood. He also does walking primarily focuses on bed rest.
PATTERN daily. The SO stated that the
patient doesn’t like being idle
or not doing anything everyday
GORDON’S FUNCTIONAL HEALTH PATTERN

The patient stated that he The patient's sleep has notably

has a difficulty in improved compared to the period
SLEEP REST PATTERN sleeping, He can’t sleep before hospitalization. He can now
properly even with eyes enjoy 7-8 hours of uninterrupted
closed, he still awake. sleep.
The patient has no The patient cooperates effectively
sensory deficits and is with the nurses and is well-aware of
COGNITIVE PERCEPTION very oriented to people, his surroundings, providing
PATTERN time, and place. coherent answers to questions.
GORDON’S FUNCTIONAL HEALTH PATTERN
The patient wife stated that During his hospitalization, the patient's
before hospitalization she behavior has undergone a positive
experience physical abuse change. He no longer engages in
with he’s husband which is actions that would cause fear to his
ROLE- RELATIONSHIP
the patient. He’s wife is wife, and communication with his
PATTERN
afraid of him so much family has strengthened since he
because of that. Their family entered the hospital.
still communicates regularly
through gadgets.
The patient's religion is The patient has mentioned that he is
Roman Catholic. He unable to attend mass, especially due
sometimes attends mass to his hospitalization, but he
VALUE-BELIEF PATTERN and prays daily consistently prays.
 GORDON’S FUNCTIONAL HEALTH PATTERN

The patient stated that The patient has verbalized his

when stressed, he would difficulty in accepting his current
do work like chopping situation. He is confused as to why,
COPING STRESS
woods or walking but among all the people, it had to be
TOLERANCE COPING
mostly drinking alcohol him to face these circumstances.
and smoking are he’s
coping mechanisms
 PATIENT’S
DEVELOPMENTAL
TASK

MEDICAL WARD
Illustration DUTY ROTATION
by Smart-Servier Medical Art
 PATIENT’S DEVELOPMENTAL TASK
A. SIGMUND FREUDS STAGES OF PSYCHOSEXUAL DEVELOPMENT

STAGE BASIC ACTUAL

The sexual desire returns to The patient enjoys a great

being active with the advent of connection with her wife, children,
puberty. The person develops a and other family members.
strong sexual desire in the
opposite sex during the last
stage of psychosexual
development. Although it starts
during puberty, this stage lasts
the rest of a person's life.
The interest in the wellbeing of
others increases during this
stage, whereas in earlier phases
The Genital Stage (Puberty
the focus was entirely on own
to Death )
needs. This stage's objective is
to achieve balance in all aspects
of life. This stage differs from the
others in that, in Freud's opinion,
the ego and superego have
reached their complete maturity
by this point. Teenagers are able
to check their urges by the time
they reach puberty, as opposed
to when they were younger and
mostly dominated by the id.
 PATIENT’S DEVELOPMENTAL TASK
B. ERIK ERIKSON’s STAGES OF PSYCHOSOCIAL
DEVELOPMENT

STAGES BASIC ACTUAL

Erik Erikson's psychosocial The patient, who is 67 years
development theory old, derives great joy from
suggests that individuals in engaging in his daily activities.
their later years, from 65 to As a carpenter, farmer, and
death, experience a stage laborer, he finds fulfillment in
of integrity vs. despair. pursuing these occupations
Integrity involves a sense of that bring him happiness.
Despite not leading a life of
Integrity vs. Despair in accomplishment and
material wealth, he embraces
Psychosocial wisdom from leading a
the simplicity of his
Development purposeful life. Successful circumstances and takes
individuals accept both pleasure in the modest
(Older adulthood from 65 positive and negative aspects of life. Whether it's
to death) aspects of their lives, find crafting intricate wooden
meaning in past structures as a carpenter. His
experiences, and pass belief in the value of "poor
down wisdom to future things" is at the core of his
generations. Conversely, contentment. He finds beauty
those struggling may and satisfaction in the humble
experience despair, regret, and unassuming aspects of
and bitterness. life that others may overlook
 PATIENT’S DEVELOPMENTAL TASK
C. JEAN PIAGET’S 4 STAGES OF COGNITIVE DEVELOPMENT

STAGES BASIC ACTUAL

The Formal Operational Stage
(Adolescence to adulthood)
As adolescents enter this stage, The patient thoughtful
they gain the ability to think in an decision-making abilities, logical
abstract manner, the ability to reasoning skills, and ability to
combine and classify items in a effectively respond to inquiries
more sophisticated way, and the about his health, coupled with
capacity for higher-order his commitment to following
reasoning. medical professionals'
Adolescents can think instructions and
systematically and reason about recommendations, exemplify his
what might be as well as what is proactive approach to his own
(not everyone achieves this well-being. His active
stage). This allows them to engagement in his healthcare
understand politics, ethics, and journey showcases his
science fiction, as well as to dedication to maintaining a
engage in scientific reasoning. healthy and fulfilling life.
During this time, people develop
the ability to think about abstract
concepts, and logically test
hypotheses.
This stage sees the emergence
of scientific thinking, formulating
abstract theories and
hypotheses when faced with a
problem.
 PATIENT’S DEVELOPMENTAL TASK

D. FOWLER’S STAGE OF FAITH

STAGES BASIC ACTUAL

“Conjunctive” Faith Stage 5
(Mid-life Crisis)
At this point, a person is The patient is receptive and
aware of the conflicts and accepts others' advise with a
problems concerning willing heart, which
transcendent values. As a strengthens her confidence in
result, the person overcomes God.
any conventional beliefs or
ideas that he could have
absorbed from earlier
developmental phases. When
the person is able to maintain
a multiple point of view that
respects "truth" as something
that cannot be stated by any
specific statement of fact, the
conflicts are resolved at
this level
 PATIENT’S DEVELOPMENTAL TASK
E. KOHLBERG’S MORAL
DEVELOPMENT THEORY
STAGES BASIC
Level 3: The child or person learns
Postconventional that although rules and
Morality laws may exist for
advantage of everyone,
Stage 5. Social Contract there are occasions when
and Individual Rights they will act against the
interests of certain people.
ACTUAL
The patient contemplates
his morality and expresses
concern about his
interactions with others.
Upon reflection, he arrives
at the conclusion that he
maintains positive
relationships with those
around his
COMPLETE
DIAGNOSIS

MEDICAL WARD
Illustration DUTY ROTATION
by Smart-Servier Medical Art
 III. COMPLETE DIAGNOSIS OF LIVER CIRRHOSIS

DEFINITION

Upper Gastrointestinal Bleeding - bleeding in the upper gastrointestinal tract refers to bleeding that originates from the esophagus, stomach,
or duodenum (small intestine). It is a common medical emergency with symptoms including anemia, blood or coffee-ground-like material
vomiting, black tarry stools, and abdominal pain. Hypovolemic shock may occur in extreme circumstances, resulting in organ failure and death.

Source: Bleeding in upper gastrointestinal tract: FMA. Family medicine austin. (n.d.).
https://familymedicineaustin.com/upper-gastrointestinal-bleeding-pathophysiology/

Portal Hypertensive Gastropathy (PHG) - is characterized as lesions caused in the inner surface of the mucous layer of the stomach. It is
usually associated with gastric varices, portal hypertension, and liver cirrhosis.

Source: Portal hypertensive gastropathy. News. (2022, December 29). Portal hypertension most commonly develops in the setting of chronic
liver injury with cirrhosis and typically is the result of a combination of an increase in resistance to portal blood flow and an increase in portal
blood flow.https://www.news-medical.net/health/Portal-Hypertensive-Gastropathy.aspx

Liver Cirrhosis - Cirrhosis is scarring (fibrosis) of the liver caused by long-term liver damage. The scar tissue prevents the liver working
properly. It is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from
functioning properly.

Source: NHS. (n.d.). NHS choices. https://www.nhs.uk/conditions/cirrhosis/

DEFINITION

MEDICAL WARD
Illustration DUTY ROTATION
by Smart-Servier Medical Art
 III. COMPLETE DIAGNOSIS OF LIVER CIRRHOSIS

Upper Gastrointestinal Bleeding - bleeding in the upper gastrointestinal tract refers to bleeding that originates from the esophagus, stomach,
or duodenum (small intestine). It is a common medical emergency with symptoms including anemia, blood or coffee-ground-like material
vomiting, black tarry stools, and abdominal pain. Hypovolemic shock may occur in extreme circumstances, resulting in organ failure and death.

Source: Bleeding in upper gastrointestinal tract: FMA. Family medicine austin. (n.d.).
https://familymedicineaustin.com/upper-gastrointestinal-bleeding-pathophysiology/

Portal Hypertensive Gastropathy (PHG) - is characterized as lesions caused in the inner surface of the mucous layer of the stomach. It is
usually associated with gastric varices, portal hypertension, and liver cirrhosis.

Source: Portal hypertensive gastropathy. News. (2022, December 29). Portal hypertension most commonly develops in the setting of chronic
liver injury with cirrhosis and typically is the result of a combination of an increase in resistance to portal blood flow and an increase in portal
blood flow.https://www.news-medical.net/health/Portal-Hypertensive-Gastropathy.aspx

Liver Cirrhosis - Cirrhosis is scarring (fibrosis) of the liver caused by long-term liver damage. The scar tissue prevents the liver working
properly. It is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from
functioning properly.

Source: NHS. (n.d.). NHS choices. https://www.nhs.uk/conditions/cirrhosis/

 III. COMPLETE DIAGNOSIS OF LIVER CIRRHOSIS

Alcoholic Liver Disease - is caused by heavy use of alcohol. The liver’s job is to break down alcohol. If you drink more than it can
process, it can become badly damaged. Fatty liver can happen in anyone who drinks a lot. Alcoholic hepatitis and alcoholic cirrhosis
are linked to the long-term alcohol abuse seen in alcoholics.
Source: Alcoholic liver disease. Johns Hopkins Medicine. (2022, April 12).
https://www.hopkinsmedicine.org/health/conditions-and-diseases/alcoholinduced-liver-disease

Peptic Ulcer - result from infection with Helicobacter pylori bacteria or from use of medications, such as aspirin or other
nonsteroidal anti-inflammatory drugs (NSAIDs), that weaken the lining of the stomach or duodenum.
Source: Vakil, N. (2023, October 13). Peptic ulcer disease - digestive disorders. MSD Manual Consumer Version.
https://www.msdmanuals.com/home/digestive-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease
ETIOLOGY

MEDICAL WARD
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 ETIOLOGY

PREDISPOSING FACTORS RATIONALE ACTUAL JUSTIFICATION

Certain genetic diseases can

increase someone’s chances of
developing cirrhosis. Wilson
disease, hemochromatosis,
Genetics/ Family History glycogen storage diseases,
alpha-1 antitrypsin deficiency,
and autoimmune hepatitis are all
genetic diseases that can cause
cirrhosis.

An autoimmune liver disease

means that the body’s immune
system is attacking the liver.
These diseases can lead to
cirrhosis and eventually liver
failure. Autoimmune liver
Autoimmune Liver Disease diseases occur when the body’s
immune system attacks the liver,
causing inflammation. If left
untreated, the liver inflammation
may eventually cause cirrhosis of
the liver, which may lead to liver
cancer and liver failure.
 ETIOLOGY

PRECIPITATING
RATIONALE ACTUAL JUSTIFICATION
FACTORS
Alcohol is toxic to the liver, The patient was a chronic
and drinking too much can alcohol drinker, it was
lead to inflammation of the stopped 2 years ago but still
Excessive Drinking of
liver and changes in the liver drinks occasionally.
Alcohol
cells themselves. This
causes swelling and,
eventually, cirrhosis.

Non-alcoholic fatty liver

disease is a
hepato-metabolic syndrome
risk factor for various
metabolic diseases such as
type 2 diabetes,
Fatty Liver Disease
dyslipidaemia, and
(Non-Alcoholic
hypertension. The
Steatohepatitis)
progression of NAFLD
includes simple steatosis to
non-alcoholic steatohepatitis
(NASH), leading to cirrhosis
of the liver or hepatocellular
cancer.
ANATOMY AND
PHYSIOLOGY

MEDICAL WARD
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by Smart-Servier Medical Art
 ANATOMY AND PHYSIOLOGY

The liver is a critical organ in the human body that is responsible for an array of functions that help
support metabolism, immunity, digestion, detoxification, vitamin storage among other functions. It comprises
around 2% of an adult's body weight. The liver is a unique organ due to its dual blood supply from the portal
vein (approximately 75%) and the hepatic artery (approximately 25%).
 ANATOMY AND PHYSIOLOGY

When cells are injured or damaged and die off, usually that dead tissue that was previously full of living
cells becomes fibrotic, meaning it becomes thickened with heaps of protein and forms scar tissue. So when the
liver is constantly forced to process alcohol like in Alcoholic Liver Disease, or subject to a viral attack for a long
time or anything else that causes a long-term or chronic state of the liver cell or hepatocyte destruction and
inflammation, the liver can become seriously scarred and damaged to the point where it is no longer reversible, at
which point it becomes fibrotic.
In healthy tissue, the main function of these are are to store Vitamin A and are considered 'quiescent'. When the
hepatocytes are injured they secrete paracrine factors that "activate" and change stellate cells. When activated,
the stellate cells lose Vitamin A, proliferate, and start to produce collagen which is the main ingredient in
extracellular matrix, fibrosis, and scar tissue.
 ANATOMY AND PHYSIOLOGY

The fibrotic tissue, pressure build up, and diversion of blood from the hepatic circulation essentially reduces the
number of functional sinusoidal veins, and the number of functional portal triads in general. As the liver loses it's
basic liver functional units, the liver becomes less able to do its job of detoxification.

The activated stellate cells do a few things including further stimulating the macrophages to release
cytokines and secrete chemokines such as CCL 2 which attract more innate immune cells to the area via the CCL
2 receptor. The activation of stellate cells release many more cytokines mainly
● TNF - a
● Interleukin 6
● Interleukin 1B
● TGF
Transforming Growth Factor (TGF) is released primarily by stellate cells, it
further stimulates other stellate cells to become cells known as
myofibroblasts proliferation, and it further releases TGF which stimulate
stellate cells to proliferate and become more myofibroblast, which is the one
that produces matrix, the collagen which leads to fibrosis.
 ANATOMY AND PHYSIOLOGY

When circulation through the portal vein is blocked, blood may back up into other blood vessels —
mainly those in your stomach and esophagus. The blood vessels are thin walled, and because they're filled
with more blood than they're meant to carry, they're likely to bleed. Massive bleeding in the esophagus or
stomach from these blood vessels is a life-threatening emergency that requires immediate medical care. Portal
hypertensive gastropathy is a finding in portal hypertension, whereby chronic portal venous congestion leads
to dilatation and ectasia of the submucosal vessels of the stomach (portal hypertensive gastropathy), small
bowel (portal hypertensive enteropathy) and/or large bowel (portal hypertensive colopathy). This may result in
upper or lower gastrointestinal (GI) bleeding, even in the absence of varices. The bleeding may be acute or
chronic but is most commonly chronic low-grade GI blood loss associated with iron-deficiency anemia.
SYMPTOMATOLOGY

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 SYMPTOMATOLOGY
SYMPTOMS RATIONALE ACTUAL JUSTIFICATION

Portal gastropathy, a Prior to admission the patient had vomited

complication of blood-tinged vomitus which urged him and his
cirrhosis, can lead to SO to seek medical attention.
the development of
dilated blood vessels
(varices) in the upper
Hematemesis
gastrointestinal tract,
(Vomiting Blood)
which are prone to
bleeding. Vomiting
blood is a direct result
of this bleeding.

When blood from the The patient claimed prior to admission, he had
upper gastrointestinal been defecating dark or tarry stools for the past
tract, such as the weeks.
stomach, mixes with
digestive enzymes and
passes through the
Melena (Black, Tarry
intestines, it causes
Stools)
the stool to turn black
and tarry. This is a
classic sign of upper
GI bleeding.
 In some cases, the
bleeding might occur
lower in the
Hematochezia
gastrointestinal tract,
(Bright Red or
but it appears red or
Maroon-Colored
maroon due to its
Blood in Stool)
freshness. This can
still be related to the
underlying condition.

Chronic blood loss, The patient claimed

even if it's not feeling of tiredness and
immediately obvious, was observed to be
can lead to anemia, lying on bed most of
resulting in fatigue the time.
Fatigue and
and weakness. In
Weakness
cirrhotic patients,
anemia can
exacerbate their
already
compromised health.
 Anemia from
ongoing bleeding
can reduce the
oxygen-carrying
Dizziness and capacity of the
Lightheadedness blood, leading to
dizziness and
lightheadedness,
especially when
changing positions.

Bleeding and The patient claimed to

irritation in the be experiencing
stomach can lead to gnawing and burning
abdominal pain or sensation pain in the
Abdominal Pain or
discomfort. This is epigastric region
Discomfort
often described as a
gnawing or burning
sensation in the
upper abdomen.
 As blood volume
decreases due to
ongoing bleeding,
the heart rate
Increased Heart
increases in an
Rate (Tachycardia)
attempt to maintain
and Low Blood
blood flow. Low
Pressure
blood pressure can
result from a
reduced blood
volume.

In severe cases,
when there is
significant blood loss
and decreased
oxygen delivery to
the brain, patients
Confusion or Altered
may experience
Mental Status
confusion or altered
mental status. This
is a sign of
decompensation and
can be a medical
emergency.
 Alcoholic liver
disease can lead to
liver cirrhosis, and
as liver function
deteriorates, it can
Jaundice (Yellowing
result in jaundice. In
of Skin and Eyes)
the context of upper
GI bleeding,
jaundice may
worsen due to liver
impairment.

Cirrhosis can lead to

ascites, and in the
presence of upper
Ascites (Abdominal GI bleeding, this
Fluid Accumulation) condition may
worsen due to
further hepatic
decompensation.
 DIAGRAMMED
PATHOPHYSIOLOGY

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MANAGEMENT

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 IV. MANAGEMENT:
MEDICAL MANAGEMENT

COMPLETE BLOOD COUNT – is a blood test used to evaluate your overall health and detect a
wide range of disorders. Measures include red blood cells, white blood cells, Hemoglobin,
Hematocrit, Platelets
INDICATIONS:
● To monitor your general health and to screen for a variety of disorders.
● If experiencing weakness, fatigue, fever, inflammation, bruising or bleeding.
● It helps diagnose the cause of the signs and symptoms
● If diagnosed with a blood disorder that affects the blood cell counts.
● To monitor health if taking medications that may affect blood cell counts.
 SURGICAL MANAGEMENT
BASIC

SURGICAL MANAGEMENT INDICATION NURSING CONSIDERATION

Severe variceal Pre-operative Nursing Considerations:

bleeding that is 1. Assess coagulation status to ensure
unresponsive to safety during the procedure.
medical therapy. 2. Verify the patient's consent and provide
Patients with education regarding the procedure.
high-risk stigmata
Transjugular Intrahepatic Portosystemic of recent Intra-operative Nursing Considerations:
Shunt (TIPS): hemorrhage (SRH) 1. Monitor vital signs and oxygen
on endoscopy. saturation throughout the procedure.
TIPS is a radiologically-guided procedure that Portal 2. Assist the interventional radiologist as
creates a shunt between the portal vein and the hypertension with needed.
hepatic vein, reducing portal hypertension. refractory ascites
or hydrothorax. Post-operative Nursing Considerations:
Contraindications 1. Monitor for bleeding complications.
to surgery or liver 2. Assess hepatic encephalopathy and
transplantation. manage symptoms if they occur.
3. Provide wound care and pain
management as needed.
 SURGICAL MANAGEMENT
BASIC
SURGICAL MANAGEMENT INDICATION NURSING CONSIDERATION

Active bleeding
from esophageal or Pre-operative Nursing
gastric varices. Considerations:
High-risk varices 1. NPO status before the
with stigmata of procedure.
recent hemorrhage. 2. Administer prophylactic
Secondary antibiotics if indicated.
prophylaxis to
Endoscopic Variceal Ligation (EVL) or
prevent variceal Intra-operative Nursing
Sclerotherapy:
rebleeding. Considerations:
1. Monitor patient sedation and
EVL and sclerotherapy are endoscopic
vital signs.
procedures to treat bleeding varices by either
2. Assist the gastroenterologist
ligating or injecting a sclerosing agent into the
during the procedure.
varices to induce thrombosis.
Post-operative Nursing
Considerations:
1. Monitor for complications
like re-bleeding or infection.
2. Provide education on
post-procedure dietary and
lifestyle modifications.
 SURGICAL MANAGEMENT
BASIC

SURGICAL MANAGEMENT BASIC/ACTUAL NURSING CONSIDERATION

Massive or recurrent Pre-operative Nursing Considerations:

upper 1. Assess patient's nutritional status
gastrointestinal and comorbidities.
bleeding from 2. Ensure adequate preoperative
gastric varices. hydration.
Bleeding that is
refractory to other Intra-operative Nursing Considerations:
Gastric Bypass or Gastrectomy: treatment 1. Monitor intraoperative blood loss
modalities. and vital signs.
Surgical removal of a portion of the stomach or Patients with severe 2. Assist the surgeon during the
creation of a bypass to reduce the pressure on portal hypertensive procedure.
gastric blood vessels. gastropathy and
gastric varices who Post-operative Nursing Considerations:
are not candidates 1. Monitor for signs of infection,
for TIPS or liver bleeding, or anastomotic leakage.
transplantation. 2. Manage pain and provide
nutritional support.
3. Educate on dietary restrictions
and lifestyle changes.
 SURGICAL MANAGEMENT
BASIC

SURGICAL MANAGEMENT BASIC/ACTUAL NURSING CONSIDERATION

Severe liver Pre-operative Nursing Considerations:

cirrhosis and 1. Comprehensive patient assessment
decompensation and transplant evaluation.
(Child-Pugh Class 2. Coordination with the transplant
C) due to alcoholic team.
liver disease.
Recurrent or Intra-operative Nursing Considerations:
Liver Transplantation: uncontrolled 1. Provide support to the surgical
variceal bleeding team.
Replacing the diseased liver with a healthy liver with liver failure. 2. Monitor for hemodynamic instability
from a donor. Refractory ascites, and coagulation issues.
encephalopathy, or
hepatorenal Post-operative Nursing Considerations:
syndrome. 1. Intensive care and
A life-saving option immunosuppression management.
for patients with 2. Vigilant monitoring for graft function,
end-stage liver rejection, and infections.
disease.
NURSING CARE
PLAN

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NURSING CARE PLAN (1)
NURSING CARE PLAN (2)
NURSING CARE PLAN (3)
NURSING CARE PLAN (4)
NURSING CARE PLAN (5)
JOURNAL READING

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 JOURNAL READING

ABSTRACT:
Cirrhosis is an advanced stage of liver fibrosis caused by chronic alcoholism, exposure to
environmental chemicals, and viral diseases. Oxidative stress is primarily mediated by alcohol
metabolism, which produces reactive oxygen species (ROS), mitochondrial damage, and steatosis.
Hepatitis C, a viral disease, is another significant cause of liver cirrhosis due to its impairment of
antioxidant function in the liver. This leads to increased oxidative stress, contributing to the development
and progression of liver cirrhosis. Understanding the relationship between oxidative stress and cirrhosis is
crucial for identifying potential therapeutic targets and developing strategies to prevent or attenuate the
progression of this debilitating liver condition (Zeliger, 2023).
 JOURNAL READING

INTRODUCTION
Liver cirrhosis is a progressive and irreversible liver disease characterized by the replacement of healthy liver tissue
with scar tissue. It is typically the result of long-term, chronic inflammation of the liver known as hepatitis (Cleveland Clinic,
n.d.). Hepatitis can be caused by various factors, including viral infections (such as hepatitis B and C), excessive alcohol
consumption, autoimmune diseases, and certain genetic conditions. When the liver is chronically inflamed, it attempts to
repair itself by forming scar tissue. However, prolonged and excessive scarring disrupts the normal structure and function of
the liver (Reddivari & Mehta, 2022). As cirrhosis progresses, the scar tissue accumulates and replaces healthy liver cells,
impairing the liver's ability to carry out its essential functions.The liver plays a crucial role in detoxification, metabolism of
nutrients, production of proteins, and regulation of hormones. When cirrhosis develops, these functions become
compromised, leading to a decline in liver function. This can result in various complications, including jaundice (yellowing of
the skin and eyes), fluid retention, increased pressure in the blood vessels of the liver (portal hypertension), and impaired
blood clotting.In advanced stages of cirrhosis, known as chronic liver failure, the liver's functional capacity is significantly
impaired, leading to severe health consequences. In some cases, a liver transplant may be the only viable treatment option
for individuals with advanced cirrhosis and liver failure. Understanding the causes, progression, and complications of liver
cirrhosis is crucial for effective management and prevention of this debilitating condition. Early detection, lifestyle
modifications, and appropriate medical interventions can help slow down the progression of cirrhosis and improve the quality
of life for affected individuals.
 JOURNAL READING

CLINICAL MANISFESTATION AND DIAGNOSIS

Liver cirrhosis is a chronic liver disease with various symptoms, including fatigue, weakness, jaundice,
portal hypertension, gastrointestinal symptoms, hepatic encephalopathy, and coagulation abnormalities.
Diagnosis involves a comprehensive medical history, physical examination, blood tests, imaging studies, and
non-invasive tests. Early diagnosis is crucial for effective management, allowing for timely intervention, treatment,
and lifestyle modifications. Regular monitoring and follow-up are essential to assess disease progression,
manage complications, and adjust treatment plans. By identifying and addressing liver cirrhosis, healthcare
providers can optimize patient care and improve long-term prognosis.
 JOURNAL READING

MANAGEMENT STRATEGIES

The management strategies for liver cirrhosis focus on slowing disease progression, addressing
complications, and improving the patient's quality of life. Treatment begins with managing the underlying cause,
such as antiviral medications for viral hepatitis or cessation of alcohol consumption for alcohol-related cirrhosis.
Lifestyle modifications, including a healthy diet, regular exercise, and the avoidance of substances harmful to the
liver, are recommended. Medications may be prescribed to manage or control specific complications. The
management strategies for liver cirrhosis focus on slowing disease progression, addressing complications, and
improving the patient's quality of life. Treatment begins with managing the underlying cause, such as antiviral
medications for viral hepatitis or cessation of alcohol consumption for alcohol-related cirrhosis. Lifestyle
modifications, including a healthy diet, regular exercise, and the avoidance of substances harmful to the liver, are
recommended. Medications may be prescribed to control hepatitis. Medicines may limit further damage to liver cells
caused by hepatitis B or C through specific treatment of these viruses. Nutritional support and monitoring of liver
function are crucial aspects of management. In cases of advanced cirrhosis, liver transplantation may be
considered. Regular monitoring, screening for complications, and emotional support are also important components
of comprehensive management for individuals with liver cirrhosis. Collaborating closely with a healthcare team
specializing in liver diseases ensures personalized care and optimal outcomes. Nutritional support and monitoring of
liver function are crucial aspects of management. In cases of advanced cirrhosis, liver transplantation may be
considered. Regular monitoring, screening for complications, and collaborating closely with a healthcare team
specializing in liver diseases ensures personalized care and optimal outcomes
 JOURNAL READING

RECENT ADVANCES AND EMERGING THERAPIES

Emerging therapies for liver cirrhosis have the potential to address the limitations of current treatments, which are
primarily focused on managing complications rather than providing a cure. These new therapies offer improved efficacy,
reduced toxicity, and disease modification, aiming to meet the unmet medical needs of patients and enhance their
treatment experience. One example is the development of combination therapies, such as the combination of
Semaglutide (SEMA) with Cilofexor (CILO) and Firsocostat (FIR), which target multiple mechanisms involved in liver
cirrhosis. This approach offers a more comprehensive treatment strategy that addresses various aspects of the disease.
By targeting multiple pathways, these therapies hold promise in improving patient outcomes. Moreover, emerging
therapies aim to minimize the toxicity and side effects associated with current treatments, thereby enhancing patient
compliance and overall treatment satisfaction. Nonetheless, it is important to emphasize that further research and clinical
trials are necessary to establish the safety and efficacy of these emerging therapies. The ongoing advancements in the
field of liver cirrhosis treatment provide hope for the development of more effective and patient-friendly therapeutic
options.
 JOURNAL READING

CONCLUSION

In conclusion, liver cirrhosis is a complex condition that requires comprehensive clinical evaluation for accurate diagnosis.
The clinical manifestations of liver cirrhosis can vary, and early recognition of symptoms is crucial for timely intervention.
Diagnostic approaches include medical history, physical examination, laboratory tests, imaging studies, and occasionally liver
biopsy. Regular monitoring and follow-up are important to track disease progression, manage complications, and adjust
treatment plans. With early diagnosis and effective management, healthcare providers can improve patient outcomes and quality
of life for individuals with liver cirrhosis. Ongoing research and advancements in diagnostics and treatments offer hope for
further advancements in the field.
 JOURNAL READING

References:
(Cleveland Clinic, n.d.). Cirrhosis of the liver.
https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver
(Mayo Clinic, n.d.). Cirhosis
https://www.mayoclinic.org/diseases-conditions/cirrhosis/diagnosis-treatment/drc-20351492

(Mehta, Reddivari, 2022). Hepatitis.

https://www.ncbi.nlm.nih.gov/books/NBK554549/
(Deveignsight, 2023). A Beacon of Hope: A Look at the Latest Advances in Emerging Therapies for Liver Cirrhosis
Treatment
https://www.delveinsight.com/blog/liver-cirrhosis-treatment#:~:text=Some%20emerging%20therapies%20for%20liver
,multiple%20mechanisms%20underlying%20the%20disease.
 REFERENCES

VI. REFERENCES

Cirrhosis and Portal Hypertension - familydoctor.org. (2022, July 20). familydoctor.org.

https://familydoctor.org/condition/cirrhosis-and-portal-hypertension/

Thalheimer, U., Triantos, C., Samonakis, D., Patch, D., & Burroughs, A. K. (2005, April 1). Infection, coagulation, and variceal
bleeding in cirrhosis. Gut; BMJ. https://doi.org/10.1136/gut.2004.048181

Eating, Diet, & Nutrition for GI Bleeding. (2022, July 22). National Institute of Diabetes and Digestive and Kidney
Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/gastrointestinal-bleeding/eating-diet-nutrition

Professional, C. C. M. (n.d.). Cirrhosis of the Liver. Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver

Cirrhosis - Diagnosis and treatment - Mayo Clinic. (2023, February 11).

https://www.mayoclinic.org/diseases-conditions/cirrhosis/diagnosis-treatment/drc-20351492
 REFERENCES

Mehta, P. (2022, October 24). Hepatitis. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK554549/

Joshi, S. (2023, July 7). Promising Therapies for Liver Cirrhosis Treatment in the Pipeline. DelveInsight Business Research.
https://www.delveinsight.com/blog/liver-cirrhosis-treatment#:~:text=Some%20emerging%20therapies%20for%20liver,multiple%
20mechanisms%20underlying%20the%20disease

Liu, Y.-B., & Chen, M.-K. (2022, November 7). Epidemiology of liver cirrhosis and associated complications: Current
knowledge and Future Directions. World journal of gastroenterology.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9669831/#:~:text=Recent%20epidemiological%20studies%20reported%20an,of
%208.1%25%20compared%20to%202017.

Ornos, E. D., Murillo, K. J., Ong, J. P., & AbstractLiver diseases are a major cause of morbidity and mortality globally. In
the Philippines. (2023, March 6). Liver diseases: Perspective from the Philippines. Annals of Hepatology.
https://www.sciencedirect.com/science/article/pii/S1665268123001898?via%3Dihub#bib0090
EVALUATION AND
IMPLICATION

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EVALUATION & IMPLICATION:

A. Nursing Practice:

This will allow nurses to develop crucial clinical skills in assessing and managing patients with this
complex and life-threatening condition. By understanding the pathophysiology, signs, and symptoms of liver
cirrhosis, nurses can provide comprehensive care, monitor patients effectively, and administer appropriate
treatments to improve patient outcomes. Moreover, it enhances their ability to educate patients and their families
about the condition, its causes, and prevention, promoting a holistic approach to patient care and empowerment.

B. Nursing Education:

The presentation will offer a practical opportunity for students to apply theoretical knowledge in a
real-world context, fostering critical thinking, problem-solving, and clinical judgment skills. Students can learn to
navigate the complexities of cirrhosis management and understand the importance of multidisciplinary
collaboration. Additionally, this case study will provide a platform for educators to assess students' clinical
competence and readiness for professional practice, ensuring that they graduate with the skills necessary to
care for patients with liver cirrhosis competently.
C. Nursing Research:

Research on liver cirrhosis case presentations is pivotal in advancing the nursing field. It allows
researchers to investigate new interventions, therapies, and care models that can improve patient outcomes and
quality of life. By exploring the unique challenges and complexities of cirrhosis care, nursing researchers can
contribute to evidence-based practice, guide healthcare policies, and develop innovative solutions that enhance
patient care and support.
THANK YOU!