Cirrhosis of the Liver

A chronic, progressive disease of the liver

Regenerative process is disorganized, resulting in abnormal blood vessel and bile
duct relationships from fibrosis
Statistics
> 50 of liver disease in the !S is directl" related to alcohol consumption
#f the estimated $5 million alcoholics in the !SA $0%&0 have or 'ill develop
cirrhosis
(ro'ing number of cases related to chronic hepatitis C
)th leading cause of death in people bet'een *5 and 5) "ears of age
+tiolog" and ,athoph"siolog"
Cell necrosis occurs
-estro"ed liver cells are replaced b" scar tissue
.ormal architecture becomes nodular
Alcoholic /Laennec0s1 Cirrhosis
2 Associated 'ith alcohol abuse
2 ,receded b" a theoreticall" reversible fatt" infiltration of the liver cells
2 3idespread scar formation
,ostnecrotic Cirrhosis
2 Complication of to4ic or viral hepatitis
2 Accounts for &0 of the cases of cirrhosis
2 5road bands of scar tissue form 'ithin the liver
5iliar" Cirrhosis
2 Associated 'ith chronic biliar" obstruction and infection
2 Accounts for $5 of all cases of cirrhosis
Cardiac Cirrhosis
2 Results from longstanding severe right%sided heart failure
Clinical 6anifestations
+arl" 6anifestations
#nset usuall" insidious
(7 disturbances8
2 Anore4ia
2 -"spepsia
2 9latulence
2 .%:, change in bo'el habits
Abdominal pain
9ever
Lassitude
3eight loss
+nlarged liver or spleen
Late 6anifestations
;'o causative mechanisms
2 <epatocellular failure
2 ,ortal h"pertension
=aundice
#ccurs because of insufficient con>ugation of bilirubin b" the liver cells, and local
obstruction of biliar" ducts b" scarring and regenerating tissue
7ntermittent >aundice is characteristic of biliar" cirrhosis
Late stages of cirrhosis the patient 'ill usuall" be >aundiced
S?in
Spider angiomas /telangiectasia, spider nevi1
,almar er"thema
+ndocrine -isturbances
Steroid hormones of the adrenal corte4 /aldosterone1, testes, and ovaries are
metabolized and inactivated b" the normal liver
Alteration in hair distribution
2 -ecreased amount of pubic hair
2 A4illar" and pectoral alopecia
<ematologic -isorders
5leeding tendencies as a result of decreased production of hepatic clotting factors
/77, :77, 7@, and @1
Anemia, leu?openia, and thromboc"topenia are believed to be result of
h"persplenism
,eripheral .europath"
-ietar" deficiencies of thiamine, folic acid, and vitamin 5$&
Complications
,ortal h"pertension and esophageal varices
,eripheral edema and ascites
<epatic encephalopath"
9etor hepaticus
,ortal <"pertension
Characterized b"8
2 7ncreased venous pressure in portal circulation
2 Splenomegal"
2 +sophageal varices
2 S"stemic h"pertension
,rimar" mechanism is the increased resistance to blood flo' through the liver
Splenomegaly
5ac? pressure caused b" portal h"pertension chronic passive congestion as a
result of increased pressure in the splenic vein
Esophageal Varices
7ncreased blood flo' through the portal s"stem results in dilation and enlargement
of the ple4us veins of the esophagus and produces varices
Esophageal Varices
:arices have fragile vessel 'alls 'hich bleed easil"
Internal Hemorrhoids
#ccurs because of the dilation of the mesenteric veins and rectal veins
Caput Medusae
Collateral circulation involves the superficial veins of the abdominal 'all leading
to the development of dilated veins around the umbilicus
,eripheral +dema and Ascites
Ascites8
% % 7ntraperitoneal accumulation of 'ater" fluid containing small amounts of protein
9actors involved in the pathogenesis of ascites8
% % <"poalbuminemia
% % Levels of aldosterone
% % ,ortal h"pertension
<epatic +ncephalopath"
Liver damage causes blood to enter s"stemic circulation 'ithout liver
deto4ification
6ain pathogenic to4in is .<* although other etiological factors have been
identified
9reAuentl" a terminal complication
9etor <epaticus
6ust", s'eetish odor detected on the patient0s breath
9rom accumulation of digested b"%products
-iagnostic Studies
Liver function tests
Liver biops"
Liver scan
Liver ultrasound
+sophagogastroduodenoscop"
,rothrombin time
;esting of stool for occult blood
Collaborative Care
Rest
Avoidance of alcohol and anticoagulants
6anagement of ascites
,revention and management of esophageal variceal bleeding
6anagement of encephalopath"
Ascites
<igh carboh"drate, lo' protein, lo' .aB diet
-iuretics
,aracentesis
,eritoneovenous shunt
2 ,rovides for continuous reinfusion of ascitic fluid from the abdomen to the vena
cava
Esophageal Varices
Avoid alcohol, aspirin, and irritating foods
7f bleeding occurs, stabilize patient and manage the air'a", administer
vasopressin /,itressin1
+ndoscopic sclerotherap" or ligation
5alloon tamponade
Surgical shunting procedures /eCgC, portacaval shunt, ;7,S1
Hepatic Encephalopathy
(oal8 reduce .<* formation
2 ,rotein restriction /0%)0gDda"1
2 Sterilization of (7 tract 'ith antibiotics /eCgC, neom"cin1
2 lactulose /Cephulac1 2 traps .<* in gut
2 levodopa
-rug ;herap"
;here is no specific drug therap" for cirrhosis
-rugs are used to treat s"mptoms and complications of advanced liver disease
.utritional ;herap"
-iet for patient 'ithout complications8
2 <igh in calories
2 C<#
2 6oderate to lo' fat
2 Amount of protein varies 'ith degree of liver damage
,atient 'ith hepatic encephalopath"
2 :er" lo' to no%protein diet
Lo' sodium diet for patient 'ith ascites and edema
.ursing 7mplementation
Acute 7ntervention
2 Rest
2 +dema and ascites
2 ,aracentesis
2 S?in care
2 -"spnea
2 .utrition
Acute 7ntervention
2 5leeding problems
2 5alloon tamponade
2 Altered bod" image
2 <epatic encephalopath"
Ambulator" and <ome Care
2 S"mptoms of complications
2 3hen to see? medical attention
2 Remission maintenance
2 Abstinence from alcohol