Cirrhosis of liver

Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism

1. By:-
MR.JAGDISH SAMBAD
M.Sc.Nursing-MSN

2. Introduction
•Theliverisalargeorganthatsitsintheright
upperabdomen,justundertherightlung.Itisone
ofthebody'smost"intelligent"organs,inthatit
performssomanydifferentfunctionsatthesame
time.Thelivermakesproteins,eliminateswaste
materialfromthebody,producescholesterol,
storesandreleasesglucoseenergyand
metabolizesmanydrugsusedinmedicine.Italso
producesbilethatflowsthroughbileductsintothe
intestinewhereithelpstodigestfood.
•Theliverreceivesbloodfromtwodifferent
sources,theheartandtheintestine.

4. Definition
•“Cirrhosisisachronicprogressivedisease
ofthelivercharacterizedbyextensive
degenerationanddestructionoftheliver
paranchymalcells”.
•Cirrhosisisachronicdegenerativedisease
inwhichnormallivercellsaredamagedand
arethenreplacedbyscartissue.

5. Incidence
•Thehighestincidenceoccursbetweenthe
agesof40and60,anditistwiceas
commoninmenasinwomen.

6. Causes

7. Causes
•Alcohol-relatedliverdisease.Mostpeoplewhoconsume
alcoholdonotsufferdamagetotheliver.Butheavy
alcoholuseoverseveralyearscancausechronicinjuryto
theliver.
•ChronicViralHepatitis--TypeBandTypeChepatitis,
andperhapsotherviruses,caninfectanddamagethe
liveroveraprolongedtimeandeventuallycause
cirrhosis.
•ChronicBileDuctBlockage--Thisconditioncanoccur
atbirth(biliaryatresia)ordeveloplaterinlife(primary
biliarycirrhosis).Thecauseofthelatterremains
unknown.Whenthebileductsoutsidetheliverbecome
narrowedandblocked,theconditioniscalledprimary
sclerosingcholangitis.Thisconditionisoftenassociated
withchroniculcerationofthecolon(colitis).

8. Causes
•AbnormalStorageofCopper(Wilson'sDisease)
orIron(Hemochromatosis)--Thesemetalsare
presentinallbodycells.Whenabnormalamounts
ofthemaccumulateintheliver,scarringand
cirrhosismaydevelop.
•DrugsandToxins--Prolongedexposureto
certainchemicalsordrugscanscartheliver.
•Autoimmune Hepatitis--Thischronic
inflammationoccurswhenthebody'sprotective
antibodiesfailtorecognizetheliverasitsown
tissue.Theantibodiesinjurethelivercellsas
thoughtheywereaforeignproteinorbacteria.

9. causes
•Nonalcoholicfattyliverdisease(NAFLD).In
NAFLD,fatbuildsupintheliverandeventually
causescirrhosis.Thisincreasinglycommonliver
diseaseisassociatedwithobesity,diabetes,
proteinmalnutrition,coronaryarterydisease,and
corticosteroidmedications.

10. Pathophysiology
•Alcohol, drug and Infection
•Synthesis of fatty acid & triglycerides increase
•Formation & release of lipoproteins decreases
•Fat appear in the liver
•Liver cells enlarge of accumulation of lipids
•Enlarge liver cells rupture

11. Pathophysiology
•Fatty contents from ruptured liver cells form fatty
cysts.
•Cell between adjoining veins in the liver are linked
by developing fibrosis.
•Continued scarring & necrosis lead to the liver
shrinking.
•Liver function decrease or ceases.

12. Pathophysiology
•Obstructed flow of blood leads to increased
pressure in the portal vein (Portal Hypertension)
•Blood backs up in the liver & spleen.
•Veins in the abdomen, rectum & esophagus dilate.
•The congestion of blood in the liver leads to
decrease production of albumin.
•Decrease serum albumin levels allow more water
to move in to other body compartments.

13. Pathophysiology
•Renin & aldosterone production level increase,
leading to water and sodium retention.
•Ascites

16. Symptoms
•Yellowing of the skin (jaundice) due to the
accumulation of bilirubinin the blood.
•Fatigue
•Weakness
•Loss of appetite
•Itching
•Easy bruising from decreased production of blood
clotting factors by the diseased liver.
•nausea
•vomiting
•weight loss
•abdominal pain and bloating when fluid
accumulates in the abdomen

18. Diagnostic findings
•HistoryTaking
•PhysicalExamination
•Bloodtests-Tocheckwhethertheliverisfunctioning
normally.
•Ultrasound,CTscan,orradioisotopescan-Tolookfor
signsofcirrhosiswithinoronthesurfaceoftheliver.
•Laparoscope-Averytinycamerainsertedthroughasmall
slitintheabdomentoviewtheliverdirectly.
•Liverbiopsy-Removingtissuefromtheliverandstudying
itunderamicroscopetoidentifyfibrosisandscarring.
Biopsyistheonlywaydiagnosiscanbe100%certain.

19. Treatment
•Aim of the treatment :-
1.preventing further damage to the liver,
2.treating the complications of cirrhosis, and
3.liver transplantation.

20. Preventing further damage to the liver
•Consumeabalanceddietandonemultivitamin
daily.
•Avoiddrugs(includingalcohol)thatcauseliver
damage.
•Avoidnonsteroidalantiinflammatorydrugs
(NSAIDs,e.g.,ibuprofen).Patientswithcirrhosis
canexperienceworseningofliverandkidney
functionwithNSAIDs.
•EradicatehepatitisBandhepatitisCvirusbyusing
anti-viralmedications.Notallpatientswithcirrhosis
duetochronicviralhepatitisarecandidatesfor
drugtreatment.

21. •Removebloodfrompatientswithhemochromatosis
toreducethelevelsofironandpreventfurther
damagetotheliver.
•Suppresstheimmunesystemwithdrugssuchas
prednisoneandazathioprine(Imuran)to
decreaseinflammationoftheliverinautoimmune
hepatitis.
•Immunizepatientswithcirrhosisagainstinfection
withhepatitisAandBtopreventaserious
deteriorationinliverfunction.

23. Treating the complications of cirrhosis
1)Edemaandascites:-
•Retentionofsaltandwatercanleadtoswellingof
theanklesandlegs(edema)orabdomen(ascites)
inpatientswithcirrhosis.
•Torestrictdietarysalt(sodium)andfluidto
decreaseedemaandascites.
•Diureticsaremedicationsthatworkinthekidneys
topromotetheeliminationofsaltandwaterintothe
urine.Acombinationofthediuretics
spironolactone(Aldactone)andfurosemidecan
reduceoreliminatetheedemaandascitesinmost
patients.

25. 2)Bleedingfromvarices:-
•Iflargevaricesdevelopintheesophagusorupper
stomach,patientswithcirrhosisareatriskfor
seriousbleedingduetoruptureofthesevarices.
Oncevariceshavebled,theytendtorebleedand
theprobabilitythatapatientwilldiefromeach
bleedingepisodeishigh(30%-35%).
•Propranolol(Inderal),abetablocker,iseffective
inloweringpressureintheportalveinandisused
topreventinitialbleedingandrebleedingfrom
varicesinpatientswithcirrhosis
•Octreotide(Sandostatin)alsodecreasesportal
veinpressureandhasbeenusedtotreatvariceal
bleeding.

27. •Transjugularintrahepaticportosystemicshunt
(TIPS)isanon-surgicalproceduretodecreasethe
pressureintheportalvein.TIPSisperformedbya
radiologistwhoinsertsastent(tube)througha
neckvein,downtheinferiorvenacavaandintothe
hepaticveinwithintheliver.Thestentthenis
placedsothatoneendisinthehighpressure
portalveinandtheotherendisinthelowpressure
hepaticvein.

28. 3)Hepaticencephalopathy:-
•Patientswithanabnormalsleepcycle,impairedthinking,
oddbehavior,orothersignsofhepaticencephalopathy
usuallyshouldbetreatedwithalowproteindietandoral
lactulose.
•Dietaryproteinisrestrictedbecauseitisasourceofthe
toxiccompoundsthatcausehepaticencephalopathy.
•Tobesurethatadequatelactuloseispresentinthecolonat
alltimes,thepatientshouldadjustthedosetoproduce2-3
semiformedbowelmovementsaday.(Lactuloseisa
laxative,andtheadequacyoftreatmentcanbejudgedby
looseningorincreasingfrequencyofstools.)
•Ifsymptomsofencephalopathypersist,oralantibioticssuch
asneomycinormetronidazole(Flagyl),canbeaddedto
thetreatmentregimen.

30. 4)Spontaneousbacterialperitonitis(SBP):-
•Patientssuspectedofhavingspontaneousbacterial
peritonitisusuallywillundergoparacentesis.Fluid
thatisremovedisexaminedforwhitebloodcells
andculturedforbacteria.
•Mostpatientswithspontaneousbacterialperitonitis
arehospitalizedandtreatedwithintravenous
antibioticssuchasampicillin,gentamycin,and
oneofthenewergenerationcephalosporin.

31. Liver transplantation
•Cirrhosisisirreversible.Manypatients'liverfunction
willgraduallyworsendespitetreatmentand
complicationsofcirrhosiswillincreaseandbecome
difficulttotreat.
•Therefore,whencirrhosisisfaradvanced,liver
transplantationoftenistheonlyoptionfor
treatment.

32. Nursing Management
•Assessment
•Subjective Data
•Objective Data

33. Nursing Diagnosis
1.Activityintolerancerelatedtofatigueandmalaise.
2.Imbalancenutritionlessthanbodyrequirementrelated
toincreasemetabolicdemand.
3.Impairedskinintegrityrelatedtopruritusfromjaundice
andedema.
4.Chronicpainanddiscomfortrelatedtoenlargetender
liverandAscites.
5.Fluidvolumeexcessrelatedtoascitesandedema
formation.
6.G.IBleedingandhemorrhagerelatedtoportal
hypertension.
7.Knowledgedeficitrelatedtodiseaseprocessand
treatmentplan.

34. Study of Alcoholic Liver Cirrhosis in Hospital Based Patients, Bijapur, Northern
Karnataka, India. A . M . Patil et.all
•Thisstudyrelatedtotheprevalenceofalcoholiclivercirrhosisinrelationtoage,sex,rural
andurbanareapatientsandalsoprevalenceofALCinliterateandilliteratePatients.
Prevalenceofmorphologicaltypesofcirrhosisofliverandcomplicationsofalcoholicliver
cirrhosis.MaterialandMethods:Thematerialforthisstudyisobtainedfromin-patientand
out-patientsattendingtheAl-AmeenMedicalCollegeandHospital,Bijapur,Karnataka.Atotal
of100casesofAlcoholiclivercirrhosispatientsstudiedoveraperiodofthreeyearofstudy
fromJanuary2010toJanuary2014.Results:Thestudyincludes100casesofAlcoholicliver
ccirrhosis(ALC).ThesexwisedistributionofprevalenceofALCcaseswashighestinmales
i.e.74cases(74%),ascomparetofemales,prevalencerateis26cases(26%).Accordingto
agewise,prevalenceofALCitishighestinagegroupof31-40yearsi.e.30cases(30%)
andnexthighestintheagegroup41-50yearsi.e.28cases(28%).Theprevalenceof
Morphologicaltypesofcirrhosisinoutof100cases.42cases(42.0%)aremicronodular
cirrhosisand30cases(30.0%)macronodularand28cases(28.0%)mixedcirrhosis.The
Prevalencerateishighintheilliteratepatientsascomparetoliteratepatients.Inruraland
urbanareawise,highestcasesseeninruralareapatientsi.e.,62cases(62%)ascompared
tourbanareapatientsi.e.38cases(38%)wereobservedinpresentstudy.