CIRRHOSIS OF LIVER

DEFINITION

Cirrhosis is defined as the histological development of regenerative nodules surrounded by fibrous bands in response to chronic liver injury, which leads to portal hypertension and end-stage liver disease.

or Cirrhosis is a diffuse process characterized by tissue

fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.

(Pinzani et al., 2014).

INCIDENCE

• Cirrhosis is the seventh leading cause of disease-related death in the United States. It is the third most common cause of death in adults between the ages of 45 and 65. It is twice as common in men as in women. The disease occurs in more than half of all malnourished chronic alcoholics, and kills about 25,000 people a year. In Asia and Africa, however, most deaths from cirrhosis are due to chronic hepatitis B.

(Haqqert et al., 2011)

CAUSES• Alcohol• Hepatitis B • Hepatitis C • Non alcoholic fatty liver disease

RISK FACTORS• Autoimmune diseases that attack the bile ducts or liver cells• Severe reactions to prescription drugs• Prolonged exposure to environmental toxins• Infections from bacteria and parasites usually found in the tropics or

Asia• Repeated episodes of heart failure with liver congestion.• Certain inherited diseases, including:• Hemochromatosis, in which too much iron builds up in the liver and

other organs• Wilson's disease, which produces abnormal concentrations of copper• Alpha-1-antitrypsin deficiency, which is the absence of a particular

enzyme in the liver (Pinzani et al., 2011)

SIGN AND SYMPTOMS

• Fatigue• Loss of appetite• Nausea• Weakness• Weight loss• Fluid accumulation in the legs (edema) and abdomen

(ascites)• Increased bleeding and bruising• Jaundice, a yellowing of the skin and eyes• Itching• Confusion

CONT....• Increased sensitivity to drugs• Personality and behavioral changes, including confusion,

neglect of appearance, forgetfulness, trouble concentrating and changes in sleep habits

• Loss of consciousness• Coma

(Belvoir., 2007)

Diagnostic test for Identifying cirrhosis

• Physical exam. a cirrhotic liver is enlarged and irregular instead of smooth.

• Blood tests:CBC LFT

The following findings are typical in cirrhosis: Thrombocytopenia – Low platelet counts Aminotransferases - AST (aspartate aminotransferase) and

ALT(Alanine transaminase) are moderately elevated, with AST > ALT. Alkaline phosphatase - slightly elevated

CONT…. Gamma- glutamyl transferase – correlates with AP levels. Typically

much higher in chronic liver disease from alcohol. Bilirubin - Levels normal when compensated but may elevate as

cirrhosis progresses. Albumin - levels fall as the synthetic function of the liver declines

with worsening cirrhosis since albumin is exclusively synthesized in the liver

Prothrombin time - increases since the liver synthesizes clotting factors.

Globulins - increased due to shunting of bacterial antigens away from the liver to lymphoid tissue.

Serum sodium - hyponatremia due to inability to excrete free water resulting from high levels of ADH and aldosterone.

CONT...

• Other tests. CT scan Ultrasound

• Biopsy. A liver biopsy is the definitive test to diagnose

cirrhosis

(Mahl &Grady., 2006)

Special diet for cirrhosis

• A balanced diet.• Salt restriction if fluid retention is present.• Diet low in sodium, high carbohydrates and vitaminsPatient Education:• Avoid drugs (including alcohol) that cause liver

damage.• Avoid non-steroidal anti-inflammatory drugs

(NSAIDs, for example, ibuprofen). (L Dan,F Antony,L carol., 2013)

Expected duration

• Cirrhosis is usually a progressive disease. Although it usually cannot be reversed, the liver damage can be halted or slowed down with treatment or changes in behaviour in many cases.

Treatment

Life style stages Stop drinking alcohol. You need to quit completely. • Talk to your doctor about all of the medicines you take,

including non-prescription drugs such as acetaminophen (for example, Tylenol), aspirin, ibuprofen (for example, Advil or Motrin), and naproxen (Aleve). These could increase the risk of liver damage and bleeding.

• Get immunized (if you have not already) against hepatitis A and hepatitis B, influenza, and pneumococcus.

• Begin following a low-sodium diet if you have fluid build up (ascites). Reducing your sodium intake can help prevent fluid build up in your belly and chest.

Drugs

• Iron supplements, diuretics, and antibiotics may be used for anemia, fluid retention, and ammonia accumulation associated with cirrhosis.

• Vasoconstrictors are sometimes needed to stop internal bleeding and antiemetic may be prescribed to control nausea.

• Laxatives help the body absorb toxins and accelerate their removal from the digestive tract.

• Beta blockers may be prescribed to control cirrhosis induced portal hypertension. Because the diseased liver can no longer efficiently neutralize harmful substances, medications must be given with caution. Interferon medicines may be used by patients with chronic hepatitis B and hepatitis C to prevent post hepatic cirrhosis.

Surgical management

• Liver transplantation In this operation ,the diseased liver is removed and replace with a healthy liver from an organ donor.

Follow up

• Regular follow ups are required and in severe cases hospitalization is needed.

Prognosis: Recovery depends on the cause of your

cirrhosis and whether you are able to remove or stop the cause. complete recovery is not possible.

(L Dan,F Antony,L carol., 2013)

Prognosis

• Cirrhosis-related liver damage cannot be reversed, but further damage can be prevented by patients who:

• eat properly• get enough rest• do not consume alcohol• remain free of infection• If the underlying cause of cirrhosis cannot be corrected or

removed, scarring will continue. The liver will fail, and the patient will probably die within five years. Patients who stop drinking after being diagnosed with cirrhosis can increase their likelihood of living more than a few years from 40% up to 70%.

(L Dan,F Antony,L carol., 2013)

NURSING DIAGNOSIS

1.Imbalanced nutrition related to indigestion or nausea and vomiting.

• Measure dietary intake by calorie count.• Compare changes in fluid status and weight history.• Give small and frequent meals.• Encourage frequent mouth care.• Recommend cessation of smoking.• Monitor laboratory studies like serum glucose and

total proteins.

CONT....

2.Ineffective breathing pattern related to ascites or accumulated secretions.

• Monitor respiratory rate and depth.• Keep head of bed elevated because it facilitates the

breathing with reducing pressure on diaphragm.• Encourage frequent repositioning, deep breathing exercises

and coughing exercises that aids in lung expansion and removes secretions.

• Monitor temperature and check for chills, coughing and colour of secretions that are very helpful to check the infection especially pneumonia.

Conti...

3.Excessive fluid volume related to compromised regulatory mechanism or excess sodium fluid intake.

• Monitor daily weight and blood pressure.• Assess respiratory status may be indicative of

pulmonary congestion.• Monitor for cardiac dysrythmia and auscultation of

heart sounds may be caused by electrolyte imbalance and heart failure.

• Restrict sodium and fluids as indicated.• Provide frequent mouth care and encourage bed rest.

TOTAL PARENTERAL NUTRITION

Total Parenteral Nutrition will help mother and child to get nutrition through vein. Physicians select the correct amount of calories and TPN solution. They can also eat and drink in between the TPN therapy.

(Wimore & Groff., 1999)

GENERAL NURSING CARE

• Check vital signs and determine body weight.• Monitor laboratory results and abnormal findings

especially electrolytes, proteins and glucose.• Measure intake and output.• Monitor temperature changes for possible infection .Use

aseptic techniques while dealing with the client.• Check blood glucose level periodically.• Monitor the flow rate of TPN. Start with 60 to 80ml per

hour and increases the rate slowly.• Refrigerate TPN solution while not in use.

CLIENT TEACHING

Provide emotional support to client and family before and during TPN therapy

Instruct the client to notify health care provider immediately if he is facing any discomfort.

Keep client informed about the effectiveness of TPN.

INDICATIONS

• It is very useful in premature infants with respiratory distress syndrome.

• Children with diarrhoea.• Patients with short bowel syndrome and renal

failure.• Useful in acutely and chronically ill patients. (Wimore & Groff., 1999)

RISKS• Infection is a common and major risk in IV infusion.

approximately 15% cases occurs with infections and death usually results from septic shock.

• Hunger is very common because the patients are being fed intravenously so the brain usually take impulses from mouth, stomach and blood regarding the conscious feeling of hunger.

• Fatty liver and liver failure occurs after a long enough use. This pathogenesis happens due to more calories.

(Wimore & Groff., 1999)

References

• Haggert, Maureen, Rebecca J. Frey, and Laura Jean Cataldo. "Cirrhosis." The Gale Encyclopedia of Medicine. Ed. Laurie J. Fundukian. 4th ed. Vol. 2. Detroit: Gale, 2011. 1031-1035. Gale Virtual Reference Library. Web. 23 Mar. 2015.

• Longo Dan L ,Fauci Antony S, Langford Carol A. Harrisson’s gastroenterology and hepatology(2013) 2nd edition

• Thomas Mahl .John O’grady. Fast Facts:Liver disorders(2006) pages 71 to 79 ,29,39,98 to 100.

• Pinzani, Massimo., Rosselli., Matteo., Zuckermann., Mi chelle. (2011). Liver cirrhosis. Best Practice & Research, 25.2, 281-90.

CONT....

• http://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/-plans

• http://europepmc.org/abstract/med/6773167• Wimore,D.W & Groff, D.B.(1999). Total

parenteral nutrition in infants with catastrophic gastrointestinal anomalies, Paediatrics Surgical, 181-9.