• 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 is the formation of an
abnormally large amount of scar
tissue in the liver. It occurs when the
liver attempts to repair and replace
damaged cells.
ALCOHOLIC CIRRHOSIS
The scar tissue characteristically
surrounds the portal areas. This is most
frequently
caused
by
chronic
alcoholism and is the most common
type of cirrhosis.
POST NECROTIC CIRRHOSIS
There are broad bands of scar
tissue. This is a late result of a
previous bout of acute viral
hepatitis.
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).
ALCOHOL
HEPATITIS B AND C
NON-ALCOHOLIC FATTY
LIVER DISEASE (NAFLD)
• AUTOIMMUNE BILIARY DISEASE
• GENETIC DISORDERS
⚬ Haemochromatosis
⚬ Wilson disease
⚬ Galactosaemia
• EXPOSURE TO POISON
⚬ Cystic fibrosis
Their severity is used to categorize the disorder a s compensated or
decompensated cirrhosis.
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Intermittent mild fever
Vascular spiders
Palmar erythema (reddened palms)
Unexplained epistaxis
Ankle edema
Vague morning indigestion
Flatulent dyspepsia
Abdominal pain
Firm, enlarged liver
Splenomegaly
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Ascites
Jaundice
Weakness
Muscle wasting
Weight loss
Continuous mild fever
Clubbing of fingers
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Liver enlargement
Portal obstruction and ascites
Infection and peritonitis
Gastrointestinal varices
Purpura
Spontaneous bruising
Epistaxis
Hypotension
Sparse body hair
White nails
Gonadal atrophy
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Edema
Vitamin Deficiency
Anemia
Mental deterioration
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History and physical examination
Liver function studies
Liver biopsy (percutaneous needle)
Upper endoscopy
(esophagogastroduodenoscopy)
CT scan, multiphase
Liver ultrasound (e.g., FibroScan for
stiffness)
Serum electrolytes
Prothrombin time
Serum albumin
Complete blood count
✓ DRUG THERAPY
❑ 22 Patients with severe ascites may need to restrict their
sodium intake to 250 to 500 mg/day.
❑ Diuretic therapy
❑ Tolvaptan (Samsca), a vasopressin-receptor antagonist,
❑ somatostatin analog octreotide (Sandostatin) or vasopressin
(VP).
❑ Lactulose (Cephulac) and rifaximin (Xifaxan)
❑ Patients with varices at risk of bleeding are started on a
nonselective β-blocker (nadolol [Corgard] or propranolol
[Inderal]) Paracentesis
❑ All patients with cirrhosis should have an upper endoscopy
(esophagogastroduodenoscopy [EGD]).
✓ All patients with cirrhosis should have an upper endoscopy
(esophagogastroduodenoscopy [EGD]). Endoscopic variceal
ligation (EVL, or “banding”) is performed by placing a small
rubber band (elastic O-ring) around the base of the varix
(enlarged vein).
✓ Sclerotherapy involves injection of a sclerosant solution
into the varices through an injection needle that is placed
through the endoscope
✓ Balloon tamponade may be used in patients with acute
esophageal or gastric variceal hemorrhage that cannot be
controlled on initial endoscopy.
✓ Paracentesis: Draining ascitic fluid to relieve symptoms
and prevent complications such as spontaneous bacterial
peritonitis.
✓ Transjugular Intrahepatic Portosystemic Shunt (TIPS): A
procedure to relieve portal hypertension by creating a
shunt within the liver to redirect blood flow.
✓ The diet for the patient who has cirrhosis without
complications is high in calories (3000 cal/day) with high
carbohydrate content and moderate to low levels of fat.
LIVER TRANSPLANTATION
➢ In cases of advanced cirrhosis with liver
failure, liver transplantation may be necessary.
PORTCAVAL SHUNT
➢ also known as portsystemic shunt, a surgical
procedure used to decompress the portal
venous system in patients with portal
hypertension.
DISTAL SPLENORENAL SHUNT
➢ also known as the Warrant shunt, a surgical
procedure used to treat complications of portal
hypertension, particularly in patients with
cirrhosis
SPLENECTOMY
➢ In some cases, removal of the spleen may be
performed to reduce portal hypertension.
The prognosis for cirrhosis depends on various factors such as the
underlying cause, the severity of liver damage, and the presence of
complications. Generally, cirrhosis is a progressive condition that can lead
to liver failure and other serious complications. However, with proper
management, including lifestyle changes and medical treatment, some
people can live for many years with cirrhosis.
• Also known as “Fulminant Hepatic
Failure” or “Acute Hepatic Failure”
• ALF is the clinical syndrome of sudden
and severely impaired liver function in
a person who was previously healthy.
• It is characterized by a rapid onset of
severe liver dysfunction and often
accompanied
by
hepatic
encephalopathy.
HYPERACUTE LIVER FAILURE
Very rapid injury, typically occurring within
hours from the onset of symptoms to the
development of encephalopathy.
WITHIN 7 DAYS (>7 DAYS)
ACUTE LIVER FAILURE
Faster yet still rapid progression, with
symptoms developing within days to weeks.
The duration of jaundice before the onset of
encephalopathy in acute liver failure is 8 to
28 days.
SUBACURE LIVER FAILURE
This form presents a slower, immunebased injury compared to hyperacute and
acute liver failure, with symptoms
manifesting over weeks.
28 to 72 days.
DRUGS
(acetaminophen)
HEPATITIS A, B, and E
Conditions
• Isoniazid
• Sulfa-containing drugs
• Anticonvulsants
Exposure to toxic
chemicals
Jaundice
Coagulation problems
Encephalopathy
Changes in cognitive function (often the first clinical
sign)
✓ Susceptibility to a wide variety of complications,
including:
❑ Cerebral edema
❑ Renal failure
❑ Hypoglycemia
❑ Metabolic acidosis
❑ Sepsis
❑ Multiorgan failure
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Serum bilirubin
Prothrombin
Liver enzyme levels (AST, ALT)
Blood chemistries
Complete blood counts (CBCs)
Acetaminophen level
Screening for other drugs and toxins
Viral hepatitis serologies (especially HAV and HBV)
Serum ceruloplasmin (enzyme synthesized in liver) levels
α1-antitrypsin levels
Iron levels, and autoantibodies (antinuclear and anti–
smooth muscle antibodies).
• Plasma ammonia levels.
• CT or magnetic resonance imaging (MRI)
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✓ Identification and Treatment of Underlying Cause: Prompt identification and
treatment of the underlying cause of ALF, such as drug overdose, viral hepatitis,
or autoimmune hepatitis.
✓ Liver Supportive Therapies:
❑N-Acetylcysteine (NAC): Administration of NAC in cases of acetaminophen
overdose to replenish glutathione stores and prevent liver injury.
❑Intravenous Glucose: Continuous glucose infusion to prevent hypoglycemia
and provide energy for hepatocytes.
❑Correction of Coagulopathy: Administration of fresh frozen plasma or
vitamin K to correct coagulopathy.
✓ 3. Management of Complications:
❑Hepatic Encephalopathy: Lactulose or lactitol to promote ammonia excretion
and reduce ammonia levels.
❑Cerebral Edema: Osmotic agents such as mannitol or hypertonic saline to
reduce intracranial pressure.
❑ Hemodynamic Support: Vasopressors or inotropes to maintain adequate
perfusion in patients with hemodynamic instability.
✓ Conduct frequent neurologic evaluations for signs of elevated intracranial
pressure. Position the patient with the head elevated at 30 degrees.
✓ Maintaining adequate fluid balance, avoiding nephrotoxic agents (e.g.,
aminoglycosides, NSAIDs), and promptly identifying and treating infection.
LIVER TRANSPLANTATION
➢ Definitive treatment for ALF in patients with irreversible liver damage or those who are
not responding to medical therapy. Transplantation may be performed as a life-saving
measure in selected cases.
Acute liver failure, on the other hand, is a
medical emergency with a high mortality
rate if not promptly treated. The prognosis
for acute liver failure depends on the
cause, the patient's overall health, and how
quickly medical intervention is initiated.
Prompt medical care, including liver
transplant if necessary, can improve the
chances of survival. However, even with
treatment, acute liver failure can be lifethreatening, and some cases may result in
death or require lifelong management.
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2021). Brunner & suddarth’s
textbook of medical-surgical nursing (15th ed.). Wolters Kluwer Health.
Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020).
Lewis's medical-surgical nursing: Assessment and management of clinical
problems (11th ed.). Elsevier
Yu, Y. (2022, December 21). Acute Liver Failure: Pathogenesis and clinical
findings. The Calgary Guide to Understanding Disease; Calgary Guide.
https://calgaryguide.ucalgary.ca/acute-liver-failure-pathogenesis-andclinical-findings/