Cirrhosis of the Liver
(relates to Chapter 42, “Nursing Management:
Liver, Biliary Tract, and Pancreas Problems,” in
the textbook)
Description
• A chronic, progressive disease of the liver
– Extensive parenchymal cell
degeneration
– Destruction of parenchymal cells
Description
• Regenerative process is disorganized,
resulting in abnormal blood vessel and
bile duct relationships from fibrosis
Description
• Normal lobular structure distorted by
fibrotic connective tissue
• Lobules are irregular in size and shape
with impaired vascular flow
• Insidious, prolonged course
Statistics
• > 50% of liver disease in the US is directly
related to alcohol consumption
• Of the estimated 15 million alcoholics in the
USA 10-20% have or will develop cirrhosis
Statistics
• Growing number of cases related to chronic
hepatitis C
• 4th leading cause of death in people between
35 and 54 years of age
Statistics
• Direct correlation between alcohol
consumption in any geographic area and the
death rate from cirrhosis in that area
Etiology and Pathophysiology
• Cell necrosis occurs
• Destroyed liver cells are replaced by
scar tissue
• Normal architecture becomes nodular
Etiology and Pathophysiology
• Four types of cirrhosis:
– Alcoholic (Laennec’s) cirrhosis
– Postnecrotic cirrhosis
– Biliary cirrhosis
– Cardiac cirrhosis
Etiology and Pathophysiology
• Alcoholic (Laennec’s) Cirrhosis
– Associated with alcohol abuse
– Preceded by a theoretically reversible
fatty infiltration of the liver cells
– Widespread scar formation
Etiology and Pathophysiology
• Postnecrotic Cirrhosis
– Complication of toxic or viral hepatitis
– Accounts for 20% of the cases of
cirrhosis
– Broad bands of scar tissue form within
the liver
Etiology and Pathophysiology
• Biliary Cirrhosis
– Associated with chronic biliary
obstruction and infection
– Accounts for 15% of all cases of
cirrhosis
Etiology and Pathophysiology
• Cardiac Cirrhosis
– Results from longstanding severe rightsided heart failure
Manifestations of Liver Cirrhosis
Fig. 42-5
Clinical Manifestations
Early Manifestations
• Onset usually insidious
• GI disturbances:
– Anorexia
– Dyspepsia
– Flatulence
– N-V, change in bowel habits
Clinical Manifestations
Early Manifestations
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Abdominal pain
Fever
Lassitude
Weight loss
Enlarged liver or spleen
Clinical Manifestations
Late Manifestations
• Two causative mechanisms
– Hepatocellular failure
– Portal hypertension
Clinical Manifestations
Jaundice
• Occurs because of insufficient
conjugation of bilirubin by the liver cells,
and local obstruction of biliary ducts by
scarring and regenerating tissue
Clinical Manifestations
Jaundice
• Intermittent jaundice is characteristic of
biliary cirrhosis
• Late stages of cirrhosis the patient will
usually be jaundiced
Clinical Manifestations
Skin
• Spider angiomas (telangiectasia, spider
nevi)
• Palmar erythema
Clinical Manifestations
Endocrine Disturbances
• Steroid hormones of the adrenal cortex
(aldosterone), testes, and ovaries are
metabolized and inactivated by the
normal liver
Clinical Manifestations
Endocrine Disturbances
• Alteration in hair distribution
– Decreased amount of pubic hair
– Axillary and pectoral alopecia
Clinical Manifestations
Hematologic Disorders
• Bleeding tendencies as a result of
decreased production of hepatic clotting
factors (II, VII, IX, and X)
Clinical Manifestations
Hematologic Disorders
• Anemia, leukopenia, and
thrombocytopenia are believed to be
result of hypersplenism
Clinical Manifestations
Peripheral Neuropathy
• Dietary deficiencies of thiamine, folic
acid, and vitamin B12
Complications
• Portal hypertension and esophageal
varices
• Peripheral edema and ascites
• Hepatic encephalopathy
• Fetor hepaticus
Complications
Portal Hypertension
• Characterized by:
– Increased venous pressure in portal
circulation
– Splenomegaly
– Esophageal varices
– Systemic hypertension
Complications
Portal Hypertension
• Primary mechanism is the increased
resistance to blood flow through the liver
Complications
Portal Hypertension
Splenomegaly
• Back pressure caused by portal
hypertension  chronic passive congestion
as a result of increased pressure in the
splenic vein
Complications
Portal Hypertension
Esophageal Varices
• Increased blood flow through the
portal system results in dilation
and enlargement of the plexus
veins of the esophagus and
produces varices
Complications
Portal Hypertension
Esophageal Varices
• Varices have fragile vessel walls
which bleed easily
Complications
Portal Hypertension
Internal Hemorrhoids
• Occurs because of the dilation of
the mesenteric veins and rectal
veins
Complications
Portal Hypertension
Caput Medusae
• Collateral circulation involves the
superficial veins of the abdominal wall
leading to the development of dilated
veins around the umbilicus
Complications
Peripheral Edema and Ascites
• Ascites:
- Intraperitoneal accumulation of
watery fluid containing small
amounts of protein
Complications
Peripheral Edema and Ascites
• Factors involved in the pathogenesis of
ascites:
- Hypoalbuminemia
-  Levels of aldosterone
-  Portal hypertension
Complications
Hepatic Encephalopathy
• Liver damage causes blood to enter
systemic circulation without liver
detoxification
Complications
Hepatic Encephalopathy
• Main pathogenic toxin is NH3 although
other etiological factors have been
identified
• Frequently a terminal complication
Complications
Fetor Hepaticus
• Musty, sweetish odor detected on the
patient’s breath
• From accumulation of digested byproducts
Development of Ascites
Fig. 42-6
Diagnostic Studies
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Liver function tests
Liver biopsy
Liver scan
Liver ultrasound
Diagnostic Studies
• Esophagogastroduodenoscopy
• Prothrombin time
• Testing of stool for occult blood
Collaborative Care
• Rest
• Avoidance of alcohol and anticoagulants
• Management of ascites
Collaborative Care
• Prevention and management of
esophageal variceal bleeding
• Management of encephalopathy
Collaborative Care
Ascites
• High carbohydrate, low protein, low Na+
diet
• Diuretics
• Paracentesis
Collaborative Care
Ascites
• Peritoneovenous shunt
– Provides for continuous reinfusion of
ascitic fluid from the abdomen to the
vena cava
Peritoneovenous Shunt
Fig. 42-8
Collaborative Care
Esophageal Varices
• Avoid alcohol, aspirin, and irritating
foods
• If bleeding occurs, stabilize patient and
manage the airway, administer
vasopressin (Pitressin)
Collaborative Care
Esophageal Varices
• Endoscopic sclerotherapy or ligation
• Balloon tamponade
• Surgical shunting procedures (e.g.,
portacaval shunt, TIPS)
Sengstaken-Blakemore Tube
Fig. 42-9
Portosystemic Shunts
Fig. 42-11
Collaborative Care
Hepatic Encephalopathy
• Goal: reduce NH3 formation
– Protein restriction (0-40g/day)
– Sterilization of GI tract with antibiotics
(e.g., neomycin)
– lactulose (Cephulac) – traps NH3 in gut
– levodopa
Drug Therapy
• There is no specific drug therapy for
cirrhosis
• Drugs are used to treat symptoms and
complications of advanced liver disease
Nutritional Therapy
• Diet for patient without complications:
– High in calories
–  CHO
– Moderate to low fat
– Amount of protein varies with degree
of liver damage
Nutritional Therapy
• Patient with hepatic encephalopathy
– Very low to no-protein diet
• Low sodium diet for patient with ascites
and edema
Nursing Management
Nursing Assessment
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Past health history
Medications
Chronic alcoholism
Weight loss
Nursing Management
Nursing Diagnoses
• Imbalanced nutrition: less than body
requirements
• Impaired skin integrity
• Ineffective breathing pattern
• Risk for injury
Nursing Management
Planning
• Overall goals:
– Relief of discomfort
– Minimal to no complications
– Return to as normal a lifestyle as
possible
Nursing Management
Nursing Implementation
• Health Promotion
– Treat alcoholism
– Identify hepatitis early and treat
– Identify biliary disease early and treat
Nursing Management
Nursing Implementation
• Acute Intervention
– Rest
– Edema and ascites
– Paracentesis
– Skin care
– Dyspnea
– Nutrition
Nursing Management
Nursing Implementation
• Acute Intervention
– Bleeding problems
– Balloon tamponade
– Altered body image
– Hepatic encephalopathy
Nursing Management
Nursing Implementation
• Ambulatory and Home Care
– Symptoms of complications
– When to seek medical attention
– Remission maintenance
– Abstinence from alcohol
Nursing Management
Evaluation
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Maintenance of normal body weight
Maintenance of skin integrity
Effective breathing pattern
No injury
No signs of infection