LIVER CIRRHOSIS

BY: BANDNA KUMARI

M.SC (N) 1ST YR
 OUTLINE OF THE TOPIC
• Anatomy of liver
• Liver functions
• Introduction and definition
• Epidemiology
• Etiology
• Types of liver cirrhosis
• Stages of liver damage
• Clinical manifestations
• Investigations
• Management
ANATOMY OF LIVER
 INTRODUCTION
• Term coined in 5th century by Hippocrates
• Greek word- kirrhos- yellowish
Osis – condition

• A chronic, progressive disease of the liver

• Destruction of parenchymal cells/ degeneration
 DEFINITION OF CIRRHOSIS

Cirrhosis of the liver is a chronic,

progressive disease characterized
by widespread fibrosis (scarring)
and nodule formation.

• Insidious, prolonged course

 EPIDEMIOLOGY
About 10 lakh people are diagnosed newly every year
10th most common cause of death in India as per WHO
14th leading cause of deaths in the world and may be 12th by
2020
HCC is the 2nd most common cause of death due to malignancy
in world
Men : women- 1:2

Times of India report – April11,2017

 ETIOLOGICAL FACTORS
 Alcohol consumption without proper nutrition

 Chronic hepatitis C. (20%)

 Chronic hepatitis B (10-20%) and D

 Non-alcoholic fatty liver disease (NAFLD).

 Autoimmune hepatitis

 Diseases that damage or destroy bile ducts

 E.g. primary sclerosing cholangitis)

 CAUSES OF LIVER CIRRHOSIS CONTD..

 Inherited diseases
 Cystic fibrosis,
 Alpha-1 antitrypsin deficiency,
 Hemochromatosis,
 Wilson disease,
 Galactosemia,
 Glycogen storage diseases
 Drugs, toxins, and infections (PCM, Methotrexate, Isoniazid)
ASSOCIATED FACTORS OF CIRRHOSIS
 TYPES OF LIVER CIRRHOSIS

Post-necrotic
cirrhosis • Alcoholic
cirrhosis

Billiary Cardiac
cirrhosis cirrhosis
 ALCOHOLIC (laennec’s) CIRRHOSIS

• Associated with alcohol abuse

• Preceded by a reversible
fatty infiltration of the liver cells
• Widespread scar formation
• Also called as micro-nodular liver cirrhosis
 POST NECROTIC CIRRHOSIS

• Complication of toxic or viral hepatitis

• Accounts for 20% of the cases of
cirrhosis
• Broad bands of scar tissue
form within the liver
• Macro-nodular liver cirrhosis
 BILLIARY CIRRHOSIS

• Associated with chronic biliary obstruction and infection

• Accounts for 15% of all cases of cirrhosis
 CARDIAC CIRRHOSIS

Results from longstanding severe

right-sided heart failure

Main causes are:

• Prolonged constrictive pericarditis
• Decompensated Cor Pulmonale
STAGES OF LIVER DAMAGE
REVERSIBILITY
CLINICAL
FEATURES
 OTHER CLINICAL MANIFESTATIONS Palmer
erythema
• Nail changes

Muehrcke's
nails
Terry’s nails
Caput medusae Spider angioma
 LATE MANIFESTATIONS

Two causative mechanisms

Hepatocellular Portal
failure hypertension
 INVESTIGATIONS

Most common measured laboratory test LFT include :

Serum Gamma Serum

Alkaline glutamyl Serum albumin
amino trans concentration
transferase
phosphatase bilirubin prothrombin
peptidase time
 LIVER BIOPSY

Radiographically-
guided fine-
needle approach
Laparoscopic

Transjugular
Percutaneous
 RADIOLOGICAL INVESTIGATIONS

• Can occasionally suggest the presence of cirrhosis,

• Not adequately sensitive/specific for use as a primary diagnostic modality
• To detect complications of cirrhosis
Eg.
oEndoscopy
oAbdominal CT and MRI
 COMPLICATIONS

• Portal hypertension
(Normal portal pressure: - 5-10mmhg Portal hypertension: - > 20 mmhg)
• Esophageal varices
• Peripheral edema
• Ascites
• Hepatic encephalopathy
• Fetor hepaticus
Hepatic
vein

Sinusoid

Portal vein Coronary veins

Splenic vein
Disturbed
sinusoidal
architecture
leads to
increased
resistance
Portal vein

Splenomegaly
 ASCITES

• Fluid accumulation in the abdominal cavity.

• Most common cause is portal hypertension.
 MECHANISM 1

INCREASED BP IN LIVER

Movement of Protein to Lymph space from blood vessel via capillaries

Excess protein &water leak through liver capsule into peritoneal cavity

Osmotic pressure increases in peritoneal cavity

Pull additional water

Ascites
 MECHANISM 2
Hyperaldosteronism due to impaired liver metabolism

Increased sodium re absorption by renal tubule

Sodium retention & increase in ADH

Water retention

Ascites
 CLINICAL FEATURES

Increase in Peripheral Hepatic Muscle Excessive

abdominal edema Dyspnea hydrothorax wasting weakness &
girth. fatigue
 DIAGNOSIS
• Physical examination
• Pt. May have bulging flanks, dullness on percussion)
• Ultrasound & CT- scan
• Diagnostic paracentesis.
• Patient with cirrhosis, the protein concentration of the ascitic
fluid is quite low, with the majority of patient having an
ascitic fluid concentration <1g/dl.
 MANAGEMENT OF ASCITES

• Patient with small amount of ascites

• managed with dietary sodium restriction alone.
• Patient instructed to ingest < 2g of sodium per day.
• Recommendation is to eat fresh foods, avoiding canned or
processed foods, which are usually preserved by sodium.
 MANAGEMENT OF ASCITES CONTD….

PATIENTS WITH MODERATE AMOUNT OF ASCITES

• Diuretic therapy are usually recommended.
• Spironolactone at 100-200mg/d as a single dose is
started
• Furosemide may be added at 40-80mg/d, particularly in
patients with peripheral edema.
• Repeated paracentesis or TIPS
MANAGEMENT OF ASCITES CONTD….

Tips(transjuglar intrahepatic porto systemic shunt)

MANAGEMENT OF LIVER CIRRHOSIS

Medical Dietary
management management

Surgical Nursing
management management
 MEDICAL MANAGEMENT OF LIVER CIRRHOSIS

• Antacids to decrease gastric distress.

• Vitamins and nutritional supplements.
• Diuretics
• Endoscopic variceal banding.
• Baloon temponade
 BALOON TAMPONADE

• Sangstaken blackmore tube

• To control acute UGI bleeding
• Emergency intervention
 VARICEAL BANDING OR LIGATION

• Large varices are ligated

• To prevent bleeding f/b tear
• Temporary management
 SCLEROTHERAPY

• Sclerosing agents are injected into

the varices
• Act by thrombosis and eventual
sclerosis
• Obliterates the vessels
 DIETARY MANAGEMENT

• Calorie requirement (2000-2200 /day)

• Carbohydrates should be the major source of diet.
• Moderate intake of fat(5 gm/day)
• Protein (80-100 gm/day) as tolerated without producing complications.
• Vitamin supplements especially B-complex.
• Low sodium diet (1gm/day) if ascitis , (4gm/day) if ascitis not present.
 GENERAL INSTRUCTIONS

• Healthy, balanced high energy, high protein diet.

• Use of milk and milk products, incase milk intolerance , yogurt can be
substituted.
• Pulses like soyabean, rajmah and gram should be given.
• Animal foods like fish and chicken in moderate amount.
• Eggs(preferably white) to maintain protein levels
 FOODS TO BE AVOIDED

• All bakery products :

biscuits, bread, buns, cookies, rusk, cakes and pastries.
• All processed foods:
cheese, sauces, tinned products, pickles,jams
• Alcohol
• Salt
 GENERAL INSTRUCTIONS CONTD….

• Fruit and fruit juices can be used if not diabetic.

• Low sodium diet should be maintained.
• Small frequent feedings (poor appetite)
• Skimmed milk powder can be used( to enhance energy and protein
content)
• Chocolates after a meal or mixed with milk preparations to enhance
nutrient density of meal
 SURGICAL MANAGEMENT

The only surgery that has been proven to improve the

chances of long-term survival is liver transplantation.
 LIVER TRANSPLANTATION
Minimal criteria for liver transplantation list include:
• An episode of spontaneous bacterial peritonitis
• A child-pugh score 7
• Less than 90 % chance of
surviving 1 year without a transplant
• GI hemorrhage r/t portal hypertension
 PREVENTIVE MEASURES

Vaccinations
• Hepatitis A and B
• Pneumococcal vaccine
• Influenza vaccination
 NURSING DIAGNOSES
• Imbalanced nutrition: less than body requirements r/t
nausea and vomiting, and anorexia secondary to diseased
condition

• Ineffective breathing pattern related to ascites, secondary

to complicated liver cirrhosis

• Impaired skin integrity related to compromised

immunologic status, edema, & poor nutrition
 NURSING DIAGNOSES CONTD..

• Hyperthermia related to inflammatory process of cirrhosis

• Risk for injury and bleeding related to altered clotting
mechanism
• Activity intolerance related to fatigue, general debility,
muscles wasting and discomfort
Ineffective breathing pattern related to accumulation of fluid in
the peritoneal cavity 2ndary to portal hypertension

• Elevate the head of the bed to at least 30 degree

• Change position everly 2 hrly
• Maintain intake and output chart
• Administer oxygen.
• Assist with paracentesis
 Hyperthermia related to inflammatory process of
cirrhosis

• Record temperature hourly

• Encourage fluid intake
• Apply cool sponges for elevated temperature
• Avoid exposure to infection
• Keep patient at rest while temperature is elevated
Risk for injury and bleeding related to altered clotting
mechanism

• Assess level of consciousness and cognitive level

• Provide safe environment.
• Replace sharp object with safer items
• Observe for hemorrhagic manifestations: ecchymosis, epitasis,
bleeding gums.
• Keep the patient quiet and limit activity
 Impaired skin integrity related to compromised
immunologic status, edema, & poor nutrition

• Assess degree of discomfort related to pruritus and edema.

• Note & record degree of jaundice and extent of edema
• Keep patient fingernails short and smooth
• Provide frequent skin care; avoid use of soaps and alcohol
based lotion.
 CONTD…
• Massage every 2hrs with emollients
• Turn every 2hrs.
• Initiate use of alternating pressure mattress or low air loss
bed
• Assess skin integrity every 4-8hrs.
• Perform rom every 4hrs; elevate edematous extremities
whenever possible
 Imbalanced nutrition less than body requirements,
related to decreased GI motility and anorexia
• Assess dietary intake and nutritional status through diet history.
• Provide diet high in carbohydrates with protein intake consistent
with liver function
• Assist patient with identifying low sodium foods
• Elevate the head of the bed during meals
• Provide oral hygiene before meal and pleasant environment for
meal at meal time
 CONTD..
• Offer smaller more frequent meal
• Provide attractive meal and an aesthetically pleasing setting
at the meal time
• Administer medication for nausea, vomiting, diarrhea or
constipation
• Encourage fluid intake and exercise if the patient reports
constipation
Activity intolerance related to fatigue, general debility,
muscles wasting and discomfort

• Assess the level of activity tolerance and degree of fatigue,

lethargy and malaise.
• Assist in the activities and hygiene when fatigued.
• Encourage the rest when fatigued.
• Provide high carbohydrates with protein intake consistent with
liver function
• Administer supplemental vitamins (vit A,B,C & K)
 REFERENCES
• Dianne. M.S., Management of client with hepatic disorders, in black hawks
medical surgical nursing (7 th ed., Pp. 1335-1355) vol. 1 elsevier
• Chung, R.T., & Podolsky, D.K. (2001) cirrhosis and its complications, in E.
Braunwalds, et al (eds) , harrison principals of internal medicine( 15th ed., Pp
1754-1767). New york: mcgraw hill
• Sommers, M. S.,& Johnson, S.A. (2002). Cirrhosis in M. S. Somers & S A johnson
(eds), disease and disorders: a nursing therapeutics manual (2nd ed., Pp. 253-
257). Philadelphia: F.A. Davis
• Sabiston, D.C. (2001). Liver and surgical complications of cirrhosis and portal
hypertension. In C. S. Townsend (ed.) Textbook of surgery: the biologic basis of
modern surgical practice (17 th ed. Pp.1974-1979). New york: mcgraw-hill
A 57 yr old male is admitted in MMW with the complaints of :
CASE-1
• Breathing difficulty since 1 week
• Memory impairment since 2 weeks
• Yellowish discoloration of skin and sclera since 1 month
• Enlargement of abdomen since 1 month H/O- alcohol consumption since 20 yrs
Diabetic since 5 years

On investigation
• Temp-38 c. Resp- 32/min. Pulse rate- 112/min. Bp- 100/68 mmhg
• Ascitic fluid- around 2000 ml
• Bilirubin-6mg/dl
• ALP- 300IU/ml