HOSPITAL FINAL EXAMINATION FOR JULY 2000
MARKING KEY: CIRRHOSIS OF THE LIVER
A (i)
Definition: is a chronic progressive disease of the liver characterised by diffuse
destruction and regeneration of hepatic parenchymal cells. The process of regeneration
leads to increased fibrotic connective tissue that distorts the tubular and vascular
Structure in the liver hence resulting in loss of function and obstruction of hepatic flow.
(5%)
ii.)
Four (4) Major Pathologic Classifications of Cirrhosis: (20%)
1) Portal Cirrhosis (or alcoholic Cirrhosis or Laennec's Cirrhosis): Chronic
alcoholism is its major cause with the month and duration of ethanol ingestion
important determinants of liver injury. It begins in individuals in the 4th, 5th and
6th decades. The incidence of Portal Cirrhosis in females appears to be
increasing.
(5%)
2) Post-necrotic Cirrhosis - Common type of Cirrhosis on a worldwide basis. There
is massive necrosis from hepatotoxins. Hence, chronic hepatitis, drugs and
industrial chemicals are the major risk factors for developing this type of
Cirrhosis. Commonly found in groups at high risk for hepatitis B which include
promiscuous homosexual males, intravenous drug abusers, and recipients of
blood transfusions.
(5%)
3) Biliary Cirrhosis - Results from prolonged stasis of bile over a period of years.
Types:
(i)
(ii)
4)
10 Biliary Cirrhosis is due to intrahepatic obstruction throught to be
caused by a disordered immune response that damages the bile
ducts. Women between ages of 35 and 60 are mostly affected by
this type of Cirrhosis.
20 Biliary Cirrhosis is due to extrahepatic biliary obstruction. It is
uncommon type of Cirrhosis. Obstruction may be caused by
gallstones, postoperative bile duct strictures, pancreatitis or tumors
of the common bile duct. Seen in patients with partial or complete
obstruction of the common bile duct or its major branches.
(5%)
Cardiac Cirrhosis Occurs as a result of prolonged severe rightsided congestive
heart failure Return of venous blood to the heart is slowed producing
hepatomegaly.
(5%)
TOTAL
(20%)
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B. Five (5) Signs and Symptoms: 15%)
1. Dyspepsia - Disturbed carbohydrate and fat metabolism.
2. Flatulance - Due to disturbed metabolism.
3. Vomiting and nausea - Due to reduced carbohydrate blood contents, muscle wasting
and general debilitation.
4. Anorexia - Due to reduced carbohydrate blood contents, muscle wasting and general
debilitation.
5. Diarrhoea or constipation - Disturbed metabolism of food.
6. Pain and heavy feeling in the right upper quadrant or epigastrium which is as a
result of swelling and stretching of the liver capsule, spasms of the biliary ducts and
vascular spasms.
7. Skin lesions are due to
(i)
Spider Angiomas - these are small dilated blood vessels with a bright red
centre and spiderlike branches commonly seen on the nose, cheeks,
upper trunk, neck and shoulder.
(ii)
Palmar Erythema - red areas on the palms of the hands.
These are due to elevation in circulating oestrogen because the liver
cannot metabolise hormone.
8. Ascites due to portal hypertension and change in osmotic pressure in the liver blood
vessels. The changes in the formation and absorption of hepatic lymph also leads to
ascites. Alterations in the metabolism of salt and water by the kidneys equally cause
ascites.
9. Jaundice due to changes in the liver functions and compression of bile ducts by
connective tissue overgrowth. Also it is due to decreased ability of the liver to
conjugate and excrete bilirubin.
10. Pruritus as a result of elevated bilirubin. Hence, itching may lead to thickening and
darkening of the skin.
11. Anaemia as a result of gastrointestinal bleeding, haemolysis secondary to
hypersplenism or nutritional deficiencies of folic acid and Vit. B12.
12. Pallor which is due to inadequate red blood cell production and survival, although
poor diet and bleeding are also responsible.
13. Testicular atrophy/Impotence/Loss of libido - due to inability of liver to metabolise
oestrogen.
(Give 3% each to any 5 points Max 15%)
C.
Five (5) investigations to confirm the Diagnosis: (10%)
1. Liver Biopsy: is the procure of choice for diagnosing Cirrhosis. It detects destruction
and fibrosis of hepatic tissue.
2. Liver scan: (Computed Tomography - CT) - this demonstrate liver size, shape and to
some extent function as the isotopes used are selectively extracted by the liver.
3. Ultrasonographic Imaging: determines if biliary obstruction is present.
4. Serum Liver Function Tests:
(i) Serum Prothrombin Time (PT): the time is prolonged due to reduced synthesis
of proteins that aid in clotting.
(ii) Serum Albumin Level: is usually decreased in the end stage of Cirrhosis due to
reduction in synthesis.
(iii) Serum Globulins: are increased due to shunting of antigens past the liver and
impaired clearance by the hepatic kupffer cells.
(iv) Serum Alkaline Phosphatase: is elevated due to disruption in the bile flow.
2
5. Blood Haemoglobin Level/PCV: Anaemia is common finding in Cirrhosis due to
Gastro-intestinal (GI) bleeding. Haemolysis due to hypertension or nutritional
deficiencies of folic acid and Vit B12.
6. Blood White Blood Cells: Leukopenia and Thrombocytopenia due to
hypersplenism.
7. Antimitochondrial Antibody (AMA) Test: This antibody is primarily directed
against a lipo-proein within the mitochondrial membrane. A positive test is consistent
with autoimmune pathophysiology, e.g. may indicate a viral cause for the Cirrhosis.
(Give 2% each to any 5 points. Max 10%)
D.
MANAGEMENT OF MR WALELA (50%)
1.
Medical Treatment: (10%)
There is no specific treatment except for symptomatic:
1. Bed rest
2. Diuretics to relieve ascites. E.g. Frusemide 80 - 160 mg
3. Restrict all nephrotoxic drugs such as methyldopa
4. High calorie diet is prescribed
5. Low fat diet and low sodium diet is ordered
6. Alcohol is forbidden
7. Vitamin supplements of B.C.D.K, folic acid, multivitamin
8. Blood transfusion if there is bleeding from the varices
9. Paracentesis Abdominis to relieve ascites
10. Neomycin 2- 4 gms orally O.D to reduce intestinal normal flora
11. Antiemetics.
(Give 1% each to any 10 points. Max 10%)
2.
Nursing Care: (40%)
Objectives: (3%)
1. To prevent further damage to the liver
2. To maintain adequate nutritional level
3. To prevent patient from developing complications
4. To prevent and control bleeding
5. To control clinical manifestations.
(Give 1% each to any 3 points. Max 3%)
Admission / Environment: (3%)

Admit the patient in a quiet, well ventilated, warm environment for good air
flow and for adequate rest.

The patient preferably be reverse isolated in a separate room or corner of the
ward to protect him from catching infections

The patient is on oxygen therapy if dyspnoeic with cyanosis.
(Give 1% each to any 3 points. Max 3%)
3
Position and Rest: (2%)



Control traffic to promote rest.
Encourage strict bed rest to conserve energy
Encourage comfortable position, possibly upright position to promote effective
breathing.
(Give 1% each to any 2 points. Max 2%)
Psycological care: (4%)

Provide basic emotional needs by promoting patient - relatives relationship

Explain the disease process to the patient

Allow the patient to express his fears/worries

Provide spiritual care

Invite Psychotherapist if the patient is alcoholic

Divertional therapy
(Give 1% each to any 4 points. Max 4%)
Observations: (6%)

Vital signs observations 4 - 6 hourly

Observe breathing patterns

Watch for signs of infestations.

Observe for any bleeding and report accordingly

Observe stool and urine for colour and amount

Enquire about itching, and hyperpigmetation

Watch for vomiting and if it occurs, assess the colour and amount

Observe and monitor sleeping and eating patterns

Maintain intake and output record

Observe behavioural pattern - for restlessness, confusion, delirium, hallucination
as this is a bad sign

Assess consciousness levels.

Maintain blood transfusion observations.
(Give 1% each to any 6 points. Max 6%)
Nutrition: (6%)

Give 3,000 calories per day for energy

Give high carbohydrates, and vitamins for the liver cannot anabolise glucose.

In ascitic stage, give low protein when there is high urea and nitrogen levels in
the blood to prevent hepatic encephalopathy.

Patients with alcoholic cirrhosis has protein - energy malnutrition. So give Mr.
Walela high protein diet in this case.

If there is oedema and ascites, then a low sodium diet is ordered and given.

Prepare food in an attractive way and serve small frequent meals.
(Give 1% each to any 6 points. Max 6%)
Elimination:(2%)

Ensure patient opens bowels

Watch for diarrhoea or constipation

Record any intake and output on the fluid balance chart

Enteric isolation if there is hepatitis.
(Give 1% each to any 2 points. Max 2%)
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Drug administration: (1%)

Administer all drugs according to doctor's orders. While observing for any side
effect and expected action.
Exercises: (2%)
 Moderate active and passive leg and chest exercises when the patient is on
complete bed rest until oedema, ascites and jaundice subside.
 As condition improves, patient can sit out of bed in the chair, and as strength
returns, the patient can move around.
 Encourage the patient to alternate periods of rest and ambulation.
 Maintain periods of bed rest with legs, elevated to mobilise oedema and ascites.
(Give 1% each to any 2 points. Max 2%)
Hygiene: (5%)
 Encourage frequent skin care such as bathing gently with application of
emollient lotions control itching.
 Mouth care be done gently four hourly to prevent bleeding from the gums
 Treat pressure areas to prevent decubitus formation
 Change position 2 - 4 hourly
 Prevent self injury and crisis infection by nail care (keep them short)
(Give 1% each to any 5 points. Max 5%)
Health Education: (6%)
 Teach on disease process and possible complications and ways to prevent them.
 Dietary regulations, low salt protein and having balanced diet
 Alcohol withdrawal
 Importance of rest
 Personal and environmental hygiene:
- Safe enviroment
- Gentle blowing of nose to prevent bleeding
- Use of soft tooth - brush to prevent gum bleeding
 Avoid hepatotoxic drugs
(Give 1% each to any 6 points. Max 6%)
5