Cirrhosis of Liver.pptx

For 2nd year B.Sc Nursing students

1. CIRRHOSIS OF LIVER Presented By: Mr. Nandish. S Asso. Professor Mandya Institute of Nursing Sciences

2. Definition : It is a chronic progressive disease of the liver characterized by extensive degeneration & destruction of the Liver parenchymal cells. It is a chronic disease characterized by replacement of normal liver tissues with diffuse fibrosis that disrupts the structure & function of the liver. It is also called as End stage liver disease. It is a condition in which liver is scarred & permanently damaged. Scar tissue replaces healthy liver tissue.

3. Classification / Etiology There are Four types. Alcoholic (Laennec’s) Cirrhosis – it is associated with excessive alcohol abuse. The first change accompanied with excessive alcohol intake is accumulation of Fat in the Liver. Postnecrotic cirrhosis – it is a complication of viral, toxic or idiopathic or autoimmune hepatitis. Biliary cirrhosis – it is associated with chronic biliary obstruction and infection. Cardiac cirrhosis – it results from long standing, severe right sided heart failure in patients with constrictive pericarditis & tricuspid insufficiency.

4. Clinical Manifestations : Early features : A norexia Flatulence Dyspepsia Nausea & Vomiting Change in the bowel habits ( Diarrhea or constipation) Abdominal pain (dull, heavy feeling in the right upper quadrant)

5. Other Early S ymptoms : Fever Lassitude Weight Loss Enlargement of Liver & Spleen Palpable Liver

6. Later Manifestations : These symptoms are severe and results from Liver failure & Hypertension. Integumentary: Jaundice : it results due to decreased ability to conjugate & excrete bilirubin. Spider Angioma : they are small, dilated blood vessels with bright red centre point & spider like branches. They occur on nose, cheeks, upper trunk, neck & shoulders. Palmar Erythema : a red area that blanches with pressure. It is located on the palms of hands. Purpura & P etechiae

7. Hematologic : Anemia they are due to over activity of spleen Thrombocytopenia that results in increased removal of blood Leukopenia cells Coagulation disorders : due to liver’s inability to produce prothrombin & other factors essential for blood clotting. Splenomegaly

8. Endocrine / Reproductive disturbances : In men : Gynecomastia : Enlarged male breast tissue. Loss of axillary & pubic hair Testicular atrophy Impotence In women: Amenorrhea in young age Hyperaldosteronism (water & sodium retention)

9. Metabolic : Potassium deficiency Hyponatremia Hypoalbuminemia Cardio vascular : Fluid retention Peripheral edema Ascites (Complication) Neurologic : Hepatic encephalopathy Peripheral neuropathy Asterixis : motor disorder Deterioration of mental & cognitive function.

10. Gastro intestinal : Fetor hepaticus (a musty, sweet ador of patient’s breath seen in patients with encephalopathy) Esophageal & gastric varices Hematemesis Hemorrhoidal varices Congestive Gastritis

11. Diagnostic studies : History collection & physical examination Liver Function Test (Aspartate aminotransferase, Serum Glutamic Oxaloacetic Transaminase, Alanine aminotransferase, serum glutamate Pyruvate Transaminase, Gamma Glutamyl Transferase ) Liver Biopsy by using percutaneous needle Esophagogastro duodenoscopy Angiography ( transhepatic portography ) CT Scan of Liver Ultrasound of Liver Upper GI Barium swallow

12. Serum electrolytes Serum Albumin – decreased CBC Prothrombin Time Stool examination for Occult blood Serum Cholesterol level – decreased Serum Bilirubin Unconjugated : increased Conjugated : either increased or decreased Urine bilirubin - increased

13. Complications : Portal Hypertension Esophageal varices Peripheral Edema & Ascites Hepatic Encephalopathy / Coma Hepatorenal syndrome (it is characterized by functional renal failure with advancing azotemia , oliguria & intractable ascites)

14. Management : Although there is no specific treatment for cirrhosis, few measures can be taken to promote liver cell regeneration and prevent complications. Rest is very significant in reducing metabolic demands. Administration of vitamin B Complex tablets. Avoiding the consumption of alcohol and Tab. Aspirin. * Symptom based treatment is planned for the better outcome.

15. Ascites : management is focused on Sodium restriction (limit the consumption of sodium to 2gm/ day in the beginning & 250 to 500 mg / day in the severe cases). Diuretic therapy is an important part of treatment. Drugs commonly used are spironolactone (potassium sparing), Furosemide (Loop diuretic), Chlorothiazide (Thiazide diuretic) Abdominal paracentesis is performed to remove ascitic fluid. Peritoneovenous Shunt is a surgical procedure that provide continuous reinfusion of ascitic fluid into venous system. Tube runs from abdominal cavity through peritoneum, under the subcutaneous tissue into Jugular vein / inferior vena cava.

16. Esophageal varices : The main goal is to avoid bleeding & hemorrhage . It involves combination of drug & endoscopic therapy in the beginning. Drugs include octreotide , vasopressin, Nitroglycerin & β – adrenergic blockers (propranolol). Endoscopic therapies include sclerotherapy , Ligation of varices & shunt therapy. Sclerosing agent is introduced via endoscope, thromboses & obliterates the distended vein. Ligation is done by a small rubber band /O-rings slipping around the base of varix or by using clips. (continued)

17. Balloon tamponade controls the hemorrhage by mechanical compression of the varices . The minnesota or Sengstaken – B lakemore tube is used for the better outcome. Sengstaken – Blakemore tube has 3 lumen : one for gastric balloon, one for esophageal balloon & one for gastric aspiration. Supportive measures include : - administration of Fresh Frozen plasma & packed RBC. - Drugs include Vitamin K, H 2 receptor antagonist ( cimetadine ), Lactulose and Neomycin.

18. Shunting procedures : They are used after the major bleeding episode. Both surgical & Non surgical methods are available. Transjugular Intrahepatic portosystemic Shunt (TIPS) is a non surgical method where shunt between the systemic & portal venous systems is created to redirect portal blood flow. Portacaval shunt & distal splenorenal shunt are the surgical shunts which are most commonly used.

19. Drug therapy : Vasopressin Propranolol Lactulose Neomycin sulphate Cimetidine Spironolactone Chlorothiazide Furosemide Triamterene (inhibits reabsorption of sodium) Magnesium sulphate Vitamin K

20. Nutritional Therapy: Limit protein to 20gm / day. Diet must be high in calories. Fat is limited only to prevent early satiety. Foods allowed are Toast, Cereals, Rice, Tea, Fruit juices. Carbohydrates intake must be 1500 – 2000 calories to prevent hypoglycemia & catabolism.

21. Nursing diagnosis : Activity intolerance related to fatigue. Imbalanced Nutrition, less than body requirement related to abdominal distention & discmfort . Impaired skin integrity related to pruritus & jaundice. Disturbed body image related to changes in the appearance & role function. Fluid volume excess related to ascites. Confusion related to abnormal liver function & serum ammonia level. Ineffective breathing pattern related to restriction of thoracic excursion. Risk for injury related to impaired clotting mechanism.

22. Thank you