Hepatic cirrhosis and

Hepatitis
Dr. Lubna Dwerij
HEPATIC CIRRHOSIS
 Cirrhosis is a chronic disease characterized by
replacement of normal liver tissue with diffuse fibrosis
that disrupts the structure and function of the liver.
 There are three types of cirrhosis or scarring of the liver:
 Alcoholic cirrhosis, in which the scar tissue
characteristically surrounds the portal areas. This is most
frequently caused by chronic alcoholism and is the most
common type of cirrhosis.
 Postnecrotic cirrhosis, in which there are broad bands of
scar tissue. This is a late result of a previous bout of acute
viral hepatitis.
HEPATIC CIRRHOSIS
 Biliary cirrhosis, in which scarring occurs
in the liver around the bile ducts. This
type of cirrhosis usually results from
chronic biliary obstruction and infection
(cholangitis); it is much less common
than the other two types.
Pathophysiology
 Although several factors have been implicated in the
etiology of cirrhosis, alcohol consumption is considered
the major causative factor.
 Although nutritional deficiency with reduced protein
intake contributes to liver destruction in cirrhosis,
excessive alcohol intake is the major causative factor in
fatty liver and its consequences.
 However, cirrhosis has also occurred in people who do not
consume alcohol and in those who consume a normal diet
and have a high alcohol intake.
Pathophysiology
 Some people appear to be more susceptible than others to
this disease, whether or not they have alcoholism or are
malnourished.
 Other factors may play a role, including exposure to
certain chemicals carbon tetrachloride, chlorinated
naphthalene, arsenic, or phosphorus) or infectious
schistosomiasis.
 Women are at greater risk for development of alcohol-
induced liver disease.
Pathophysiology
 Alcoholic cirrhosis is characterized by episodes of necrosis
involving the liver cells, which sometimes occur
repeatedly throughout the course of the disease.
 The destroyed liver cells are gradually replaced by scar
tissue. Eventually, the amount of scar tissue exceeds that
of the functioning liver tissue.
 The disease usually has an insidious onset and a
protracted course, occasionally proceeding over a period
of 30 or more years.
Clinical Manifestations
 Signs and symptoms of cirrhosis increase in severity as the
disease progresses.
 Their severity is used to categorize the disorder as
compensated or decompensated cirrhosis.
 Compensated cirrhosis, with its less severe, often vague
symptoms, may be discovered secondarily at a routine
physical examination.
 The hallmarks of decompensated cirrhosis result from
failure of the liver to synthesize proteins, clotting factors,
and other substances and manifestations of portal
hypertension.
Clinical Manifestations
 Liver Enlargement
 Early in the course of cirrhosis, the liver tends to be large,
and the cells are loaded with fat. The liver is firm and has
a sharp edge that is noticeable on palpation.
 Abdominal pain may be present because of recent, rapid
enlargement of the liver, which produces tension on the
fibrous covering of the liver (Glisson’s capsule).
 Later in the disease, the liver decreases in size as scar
tissue contracts the liver tissue. The liver edge, if
palpable, is nodular.
Clinical Manifestations
 Portal Obstruction and Ascites
 Portal obstruction and ascites, late manifestations of
cirrhosis, are caused partly by chronic failure of liver
function and partly by obstruction of the portal
circulation.
 Because a cirrhotic liver does not allow free blood
passage, blood backs up into the spleen and the GI tract
 They are stagnant with blood and therefore cannot
function properly. Indigestion and altered bowel function
result.
 Fluid rich in protein may accumulate in the peritoneal
cavity, producing ascites
Clinical Manifestations
 Infection and Peritonitis
 Bacterial peritonitis may develop in patients with cirrhosis
and ascites in the absence of an intra-abdominal source of
infection or an abscess.
 This condition is referred to as spontaneous bacterial
peritonitis (SBP).
 Bacteremia due to translocation of intestinal flora is
believed to be the most likely route of infection.
 Clinical signs may be absent, necessitating paracentesis
for diagnosis.
Clinical Manifestations
 Antibiotic therapy is effective in the treatment and
prevention of recurrent episodes of SBP.
 The most severe complication of SBP is hepatorenal
syndrome, a form of renal failure unresponsive to
administration of fluid or diuretics.
Clinical Manifestations
 Gastrointestinal Varices
 The obstruction to blood flow through the liver
caused by fibrotic changes also results in the
formation of collateral blood vessels in the GI
system and shunting of blood from the portal
vessels into blood vessels with lower pressures.
 As a result, the patient with cirrhosis often has
prominent, distended abdominal blood vessels,
which are visible on abdominal inspection (caput
medusae) and distended blood vessels throughout
the GI tract.
Clinical Manifestations
 The esophagus, stomach, and lower rectum are common
sites of collateral blood vessels.
 These distended blood vessels form varices or
hemorrhoids, depending on their location.
 Because these vessels were not intended to carry the high
pressure and volume of blood imposed by cirrhosis, they
may rupture and bleed.
 Therefore, assessment must include observation for occult
and frank bleeding from the GI tract.
Clinical Manifestations
 Edema
 Another late symptom of cirrhosis is edema, which is
attributed to chronic liver failure.
 reduced plasma albumin concentration predisposes the
patient to the formation of edema.
 Although edema is generalized, it often affects the lower
extremities, the upper extremities, and the presacral
area.
 Facial edema is not typical
Clinical Manifestations
 Vitamin Deficiency and Anemia
 Because of inadequate formation, use, and storage of
certain vitamins (notably vitamins A, C, and K), signs of
deficiency are common, particularly hemorrhagic
phenomena associated with vitamin K deficiency.
 Chronic gastritis and impaired GI function, together with
inadequate dietary intake and impaired liver function,
account for the anemia that is often associated with
cirrhosis.
Clinical Manifestations
 Mental Deterioration
 Additional clinical manifestations include deterioration of
mental and cognitive function with impending hepatic
encephalopathy and hepatic coma.
Assessment and Diagnostic Findings
 The extent of liver disease and the type of treatment are
determined after review of the laboratory findings.
 The functions of the liver are complex, and many
diagnostic tests provide information about liver function.
 In severe parenchymal liver dysfunction, the serum
albumin level tends to decrease, and the serum globulin
level rises.
 Enzyme tests indicate liver cell damage: serum alkaline
phosphatase, AST, ALT, and GGT levels increase, and the
serum cholinesterase level may decrease.
Assessment and Diagnostic Findings
 Bilirubin tests are performed to measure bile excretion or
retention; increased levels of bilirubin can occur with
cirrhosis and other liver disorders. Prothrombin time is
prolonged.
 Ultrasound scanning is used to measure the difference in
density of parenchymal cells and scar tissue.
 CT, MRI, and radioisotope liver scans give information
about liver size and hepatic blood flow and obstruction.
 Diagnosis is confirmed by liver biopsy.
Medical Management
 The management of the patient with cirrhosis is usually
based on the presenting symptoms.
 For example, antacids or histamine-2 (H2) antagonists are
prescribed to decrease gastric distress and minimize the
possibility of GI bleeding.
 Vitamins and nutritional supplements promote healing of
damaged liver cells and improve the patient’s general
nutritional status.
 Potassium-sparing diuretics such as spironolactone or
triamterene (Dyrenium) may be indicated to decrease
ascites, if present;
Medical Management
 An adequate diet and avoidance of alcohol are essential.
 Although the fibrosis of the cirrhotic liver cannot be
reversed, its progression may be halted or slowed by such
measures.
 Some of these medications include angiotensin system
inhibitors, statins, diuretics, immunosuppressants, and
glitazones.
Medical Management

 Many patients who have end-stage liver disease (ESLD)

with cirrhosis use the herb milk thistle to treat jaundice
and other symptoms.
 Milk thistle has anti-inflammatory and antioxidant
properties that may have beneficial effects, especially in
hepatitis.
Nursing Management
 Promoting Rest
 The patient with cirrhosis requires rest and other
supportive measures to permit the liver to reestablish its
functional ability.
 If the patient is hospitalized, weight and fluid intake and
output are measured and recorded daily.
 The nurse adjusts the patient’s position in bed for
maximal respiratory efficiency, which is especially
important if ascites is marked, because it interferes with
adequate thoracic excursion.
 Rest reduces the demands on the liver and increases the
liver’s blood supply
Nursing Management

 Improving Nutritional Status

 The patient with cirrhosis without ascites, edema, or signs
of impending hepatic coma should receive a nutritious, high-
protein diet, if tolerated, supplemented by vitamins of the
B complex, as well as A, C, and K.
 The nurse encourages the patient to eat. If ascites is
present, small, frequent meals may be better tolerated than
three large meals because of the abdominal pressure
exerted by ascites.
Nursing Management
 Improving Nutritional Status
 Patients with prolonged or severe anorexia and those who
are vomiting or eating poorly for any reason may receive
nutrients by the enteral or parenteral route.
 Folic acid and iron are prescribed to prevent anemia.
 If the patient shows signs of impending or advancing
coma, the amount of protein in the diet is decreased
temporarily.
 Protein is restricted if encephalopathy develops.
 Sodium restriction is also indicated to prevent ascites.
Nursing Management
 Providing Skin Care
 Providing careful skin care is important because of
subcutaneous edema, the patient’s immobility, jaundice,
and increased susceptibility to skin breakdown and
infection.
 Frequent changes in position are necessary to prevent
pressure ulcers.
 Irritating soaps and the use of adhesive tape are avoided
to prevent trauma to the skin.
 Lotion may be soothing to irritated skin; the nurse takes
measures to minimize scratching by the patient.
Nursing Management
 Reducing Risk of Injury
 The nurse protects the patient with cirrhosis from falls and
other injuries.
 The side rails should be in place and padded with blankets or
other materials in case the patient becomes agitated or
restless.
 The nurse instructs the patient to ask for assistance to get out
of bed.
 The nurse carefully evaluates any injury because of the
possibility of internal bleeding.
 A soft-bristled toothbrush helps minimize bleeding gums, and
pressure applied to all venipuncture sites helps minimize
bleeding.
Monitoring and Managing Potential
Complications
 A major role of the nurse is monitoring of the patient with
cirrhosis for complications.
 Bleeding and Hemorrhage
 Hepatic Encephalopathy
 Fluid Volume Excess
Assignment
 PLAN OF NURSING CARE for The Patient With Impaired Liver Function
(page 1150- 1157)
 Assessment
 Diagnosis
 Nursing intervention
 Rational
 Outcomes
VIRAL HEPATITIS
 Viral hepatitis is a systemic, viral infection in which
necrosis and inflammation of liver cells produce a
characteristic cluster of clinical, biochemical, and cellular
changes.
 To date, five definitive types of viral hepatitis have been
identified:
 Hepatitis A, B, C, D, and E.
 Hepatitis A and E are similar in mode of transmission
(fecal–oral route), whereas hepatitis B, C, and D share
many other characteristics.
Hepatitis A Virus
 Hepatitis A virus (HAV) accounts for 20% to 25% of cases of
clinical hepatitis in the United States and other developed
countries.
 Hepatitis A, formerly called infectious hepatitis, is caused
by an RNA virus of the Enterovirus family.
 This form of hepatitis is transmitted primarily through the
fecal–oral route, by the ingestion of food or liquids
infected by the virus.
 It is more prevalent in countries with overcrowding and
poor sanitation.
Hepatitis A Virus
 Typically, a child or a young adult acquires the infection at
school through poor hygiene, hand-to-mouth contact, or
close contact during play.
 The virus is carried home, where haphazard sanitary
habits spread it through the family.
 An infected food handler can spread the disease, and
people can contract it by consuming water or shellfish
from sewage-contaminated waters.
 The incubation period is estimated to be between 2 to 6
weeks, with a mean of approximately 4 weeks.
 The illness may be prolonged, lasting 4 to 8 weeks.
Hepatitis A Virus
 It usually lasts longer and is more severe in those older
than 40 years of age.
 Most patients recover from hepatitis A; it rarely progresses
to acute liver necrosis or fulminant hepatitis resulting in
cirrhosis of the liver or death.
Clinical Manifestations
 Many patients are anicteric (without jaundice) and
symptomless.
 When symptoms appear, they resemble those of a mild,
flulike upper respiratory tract infection, with low grade
fever.
 Anorexia, an early symptom, is often severe.
 Later, jaundice and dark urine may become apparent.
Indigestion is present in varying degrees marked by vague
epigastric distress, nausea, heartburn, and flatulence.
 The patient may also develop a strong aversion to the
taste of cigarettes or the presence of cigarette smoke and
other strong odors.
Assessment and Diagnostic Findings
 The liver and spleen are often moderately enlarged for a
few days after onset; other than jaundice, there are few
other physical signs.
 Hepatitis A antigen may be found in the stool 7 to 10 days
before illness and for 2 to 3 weeks after symptoms appear.
 HAV antibodies are detectable in the serum, but usually
not until symptoms appear.
Prevention
 A number of strategies exist to prevent transmission of
HAV.
 Patients and their families are encouraged to follow
general precautions that can prevent transmission of the
virus.
 Patients and their families are encouraged to follow
general precautions that can prevent transmission of the
virus.
 Scrupulous handwashing, safe water supplies, and proper
control of sewage disposal are just a few of these
prevention strategies
Prevention
 Effective (95% to 100% after two to three doses) and safe
HAV vaccines include Havrix and Vaqta.
 It is recommended that the two-dose vaccine be given to
adults 18 years of age or older, with the second dose given
6 to 12 months after the first.
 Protection against hepatitis A develops within several
weeks after the first dose of the vaccine.
 Children and adolescents 2 to 18 years of age receive
three doses.
 Hepatitis A vaccine is recommended for people traveling
to locations where sanitation and hygiene are
unsatisfactory.
Prevention
 Vaccination is also recommended for those from high-risk
groups, such as IV or injection drug users, staff of day care
centers, and health care personnel.
 The vaccine has also been used to interrupt community-
wide outbreaks.
 For people who have not been previously vaccinated,
hepatitis A can be prevented by intramuscular
administration of globulin during the incubation period, if
given within 2 weeks of exposure.
Prevention
 Immune globulin is also recommended for household
members of people with hepatitis A.
 Susceptible people in the same household as the patient
are usually also infected by the time the diagnosis is made
and should receive immune globulin.
 Institutional contacts of patients with hepatitis A should
also receive postexposure prophylaxis with immune
globulin.
 Prophylaxis is not necessary for casual contacts of an
infected person, such as classmates, coworkers, or
hospital employees.
 Epinephrine should be available in case of systemic,
anaphylactic reaction for immune globulin .
Medical Management
 Bed rest during the acute stage and a diet that is both
acceptable to the patient and nutritious are part of the
treatment and nursing care.
 During the period of anorexia, the patient should receive
frequent small feedings, supplemented if necessary by IV
fluids with glucose.
 Because the patient often has an aversion to food, gentle
persistence and creativity may be required to stimulate
appetite.
 Optimal food and fluid levels are necessary to counteract
weight loss and to speed recovery
Medical Management
 The patient’s sense of well-being and laboratory test
results are generally appropriate guides to bed rest and
restriction of physical activity.
 The patient’s sense of well-being and laboratory test
results are generally appropriate guides to bed rest and
restriction of physical activity.
 Gradual but progressive ambulation seems to hasten
recovery, provided the patient rests after activity and
does not participate in activities to the point of fatigue.
Nursing Management
 Management usually occurs in the home unless symptoms
are severe.
 Therefore, the nurse assists the patient and family in
coping with the temporary disability and fatigue that are
common in hepatitis and instructs them to seek additional
health care if the symptoms persist or worsen.
 The patient and family also need specific guidelines about
diet, rest, follow-up blood work, and the importance of
avoiding alcohol, as well as sanitation and hygiene
measures (particularly handwashing) to prevent spread of
the disease to other family members.
Nursing Management
 Specific teaching to patients and families about reducing
the risk of contracting hepatitis A includes good
personalmhygiene, stressing careful handwashing (after
bowel movements and before eating) and environmental
sanitation (safe food and water supply, effective sewage
disposal).
Hepatitis B Virus
 Unlike HAV, the hepatitis B virus (HBV) is transmitted
primarily through blood (percutaneous and permucosal
routes).
 HBV can be found in blood, saliva, semen, and vaginal
secretions and can be transmitted through mucous
membranes and breaks in the skin. HBV is also transferred
from carrier mothers to their infants, especially in areas
with a high incidence (eg, Southeast Asia).
 HBV has a long incubation period. It replicates in the liver
and remains in the serum for relatively long periods,
allowing transmission of the virus.
 Screening of blood donors has greatly reduced the
occurrence of hepatitis B after blood transfusion
Hepatitis B Virus
 Most people (more than 90%) who contract HBV infection
develop antibodies and recover spontaneously in 6
months.
 HBV remains a major worldwide cause of cirrhosis and
hepatocellular carcinoma.
Clinical Manifestations
 Clinically, the disease closely resembles hepatitis A, but
the incubation period is much longer (1 to 6 months).
 Signs and symptoms of hepatitis B may be insidious and
variable.
 Fever and respiratory symptoms are rare; some patients
have arthralgias and rashes.
 The patient may have loss of appetite, dyspepsia,
abdominal pain, generalized aching, malaise, and
weakness.
 Jaundice may or may not be evident. If jaundice occurs,
light-colored stools and dark urine accompany it.
Clinical Manifestations
 The liver may be tender and enlarged to 12 to 14 cm
vertically. The spleen is enlarged and palpable in a few
patients.
 Subclinical episodes also occur frequently
Assessment and Diagnostic Findings
 HBV is a DNA virus
 HBV DNA, detected by polymerase chain reaction testing.
Prevention
 Preventing Transmission
 Continued screening of blood donors for the presence of
hepatitis B antigens further decreases the risk of
transmission by blood transfusion.
 The use of disposable syringes, needles, and lancets and
the introduction of needleless IV administration systems
have reduced the risk of spreading this infection from one
patient to another or to health care personnel.
 Good personal hygiene is fundamental to infection
control.
Prevention
 Gloves are worn when handling all blood and body fluids,
as well as HBAg positive specimens, or when there is
potential exposure to blood (eg, blood drawing) or to
patients’ secretions.
 Eating and smoking are prohibited in the laboratory and in
other areas exposed to secretions, blood, or blood
products.
Prevention
 Active Immunization: Hepatitis B Vaccine
 Active immunization is recommended for:
 People who are at high risk for hepatitis B (eg, health care
personnel, hemodialysis patients).
 People with hepatitis C and other chronic liver diseases
should receive the vaccine.
 A yeast-recombinant hepatitis B vaccine (Recombivax HB)
is used to provide active immunity and has shown rates of
protection greater than 90% in healthy people.
 Although antibody levels may become low or undetectable,
immunologic memory may remain intact for at least 5 to
10 years.
Prevention
 A hepatitis B vaccine prepared from plasma of humans
chronically infected with HBV is used only rarely in patients
who are immune deficient or allergic to recombinant yeast-
derived vaccines.
 Both forms of the hepatitis B vaccine are administered
intramuscularly in three doses; the second and third doses
are given 1 and 6 months, respectively, after the first dose.
 The third dose is very important in producing prolonged
immunity.
 Hepatitis B vaccination should be administered to adults in
the deltoid muscle.
 People who do not respond may benefit from one to three
additional doses
Prevention
 People who are at high risk, including nurses and other
health care personnel exposed to blood or blood products,
should receive active immunization.
 hepatitis B vaccine does not provide protection to those
already exposed to HBV, and it provides no protection
against other types of viral hepatitis.
 Side effects of immunization are infrequent; soreness and
redness at the injection site are the most common
complaints.
Prevention
 Passive Immunity: Hepatitis B Immune Globulin
 Hepatitis B immune globulin (HBIG) provides passive
immunity to hepatitis B and is indicated for people
exposed to HBV who have never had hepatitis B and have
never received hepatitis B vaccine.
 Specific indications for post exposure vaccine with HBIG
include:
 (1) Inadvertent exposure to HBAg-positive blood through
percutaneous (needlestick) or transmucosal (splashes in
contact with mucous membrane) routes.
Prevention
 Perinatal exposure (infants born to HBV-infected mothers
should receive HBIG within 12 hours after delivery).
 HBIG is prepared from plasma selected for high titers of
anti-HBs.
 Prompt immunization with HBIG (within hours to a few
days after exposure to hepatitis B) increases the likelihood
of protection.
Medical Management
 The goals of treatment are to minimize infectivity and
liver inflammation and decrease symptoms.
 Of all the agents that have been used to treat chronic
type B viral hepatitis, alpha-interferon as the single
modality of therapy that offers the most promise.
 A regimen of 5 million units daily or 10 million units three
times weekly for 16 to 24 weeks results in remission of
disease in approximately one third of patients.
 Interferon must be administered by injection and has
significant side effects, including fever, chills, anorexia,
nausea, myalgias, and fatigue.
Medical Management
 Delayed side effects are more serious and may necessitate
dosage reduction or discontinuation.
 These include bone marrow suppression, thyroid
dysfunction, alopecia, and bacterial infections.
 Two antiviral agents, lamivudine (Epivir) and adefovir
(Hepsera), oral nucleoside analogs, have been approved
for use in chronic hepatitis B
 Bed rest may be recommended, regardless of other
treatment, until the symptoms of hepatitis have subsided.
Medical Management
 Activities are restricted until the hepatic enlargement and
levels of serum bilirubin and liver enzymes have
decreased.
 Gradually increased activity is then allowed.
 Adequate nutrition should be maintained. Proteins are
restricted if symptoms indicate that the liver’s ability to
metabolize protein byproducts is impaired.
 Measures to control the dyspeptic symptoms and general
malaise include the use of antacids and antiemetics.
Nursing Management
 Convalescence may be prolonged, with complete
symptomatic recovery sometimes requiring 3 to 4 months
or longer.
 During this stage, gradual resumption of physical activity
is encouraged after the jaundice has resolved.
 The nurse identifies psychosocial issues and concerns,
particularly the effects of separation from family and
friends if the patient is hospitalized during the acute and
infective stages.
Nursing Management
 Teaching Patients Self-Care
 Because of the prolonged period of convalescence, the
patient and family must be prepared for home care.
 Provision for adequate rest and nutrition must be ensured.
 The nurse informs family members and friends who have
had intimate contact with the patient about the risks of
contracting hepatitis B and makes arrangements for them
to receive hepatitis B vaccine or hepatitis B immune
globulin as prescribed.
Hepatitis C Virus
 A significant proportion of cases of viral hepatitis are
neither hepatitis A, hepatitis B, nor hepatitis D, and are
classified as hepatitis C.
 Whereas blood transfusions and sexual contact once
accounted for most cases of hepatitis C in the United
States,
 Other parenteral means, such as sharing of contaminated
needles by IV or injection drug users and unintentional
needlesticks and other injuries in health care workers now
account for a significant number of cases.
 chronic carrier state occurs frequently, and there is an
increased risk of chronic liver disease
Hepatitis C Virus
 People who are at particular risk for hepatitis C include IV
or injection drug users, patients receiving frequent
transfusions, those who require large volumes of blood,
and health care personnel.
 The incubation period is variable and may range from 15
to 160 days.
 The clinical course of acute hepatitis C is similar to that of
hepatitis B; symptoms are usually mild.
 However, a chronic carrier state occurs frequently, and
there is an increased risk of chronic liver disease including
cirrhosis or liver cancer, after hepatitis C.
Hepatitis C Virus
 Alcohol and medications that may affect the liver should be
avoided.
 Studies have demonstrated that a combination of two
antiviral agents, interferon (Intron-A) and ribavirin
(Rebetol), is effective in producing improvement in patients
with hepatitis C and in treating relapses.
 Some patients experience complete remission with
combination therapy.
 Hemolytic anemia, the most frequent side effect, may be
severe enough to require discontinuation of treatment.
 Screening of blood has reduced the incidence of hepatitis C
associated with blood transfusion.
Reference
 Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of
medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott
Williams & Wilkins.