CIRRHOSIS OF LIVER.pptx,etiology,signs and symtoms

full description of the disease cirrhosis of liver

1. Cirrhosis of liver

2. Cirrhosis of liver The end-stage of liver disease is called cirrhosis. Hepatic cirrhosis  is a chronic hepatic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

3. Causes Different types of cirrhosis have different causes. Excessive alcohol consumption.  Too much alcohol intake is the most common cause of cirrhosis as liver damage is associated with chronic alcohol consumption. Injury.  Injury or prolonged obstruction causes biliary cirrhosis. Hepatitis.  The different types of hepatitis can cause postnecrotic cirrhosis. Other diseases.  Diseases such as hemochromatosis causes pigment cirrhosis. Right-sided heart failure.  Cardiac cirrhosis, a rare kind of cirrhosis, is caused by right-sided heart failure.

4. Classification These clinical types of cirrhosis reflect its diverse etiology : 1.Laennec’s cirrhosis : The most common type, this occurs in 30% to 50% of cirrhotic patients, up to 90% of whom have a history of alcoholism. 2.Biliary cirrhosis : Biliary cirrhosis results in injury or prolonged obstruction. 3.Postnecrotic cirrhosis : Postnecrotic cirrhosis stems from various types of hepatitis.

5. Classification 4.Pigment cirrhosis : Pigment cirrhosis may result from disorders such as hemochromatosis. 5.Cardiac cirrhosis : Cardiac cirrhosis refers to cirrhosis caused by right-sided heart failure. 6.Idiopathic cirrhosis :  Idiopathic cirrhosis has no known cause.

6. Pathophysiology Necrosis :  Cirrhosis is characterized by episodes of necrosis involving the liver cells. Scar tissue : The destroyed liver cells are gradually replaced with a scar tissue. Fibrosis :  There is diffuse destruction and fibrotic regeneration of hepatic cells. Alteration :  As necrotic tissue yields to fibrosis, the disease alters the liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes  hepatic insufficiency.

7. Clinical Manifestations 1.GI system.   - anorexia, indigestion, nausea, vomiting constipation, or  diarrhea . 2.Respiratory system.  - pleural effusion and limited thoracic expansion due to abdominal ascites, interfering with efficient gas exchange leading to hypoxia.

8. Clinical Manifestations 3.Central nervous system :  Signs of hepatic encephalopathy also occur as a late sign, and these are  lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia, hallucinations and ultimately, coma.

9. Clinical Manifestations 4.Hematologic. The patient experiences bleeding tendencies and  anemia . 5.Endocrine  The male patient experiences testicular atrophies, - the female patient may have menstrual irregularities, - gynecomastia and loss of chest and axillary hair.

10. Clinical Manifestations 6.Skin : There is severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, palmar erythema, and possibly jaundice. 7.Hepatic : Cirrhosis causes jaundice, ascites, hepatomegaly,  edema  of the legs, hepatic encephalopathy, and hepatic renal syndrome.

11. Complications 1.Portal hypertension :   Portal hypertension is the elevation of pressure in the portal vein that occurs when blood flow meets increased resistance. 2.Esophageal varices :  Esophageal varices are dilated tortuous veins in submucosa of the lower  esophagus . 3.Hepatic encephalopathy :  Hepatic encephalopathy may manifest as deteriorating mental status and dementia or as physical signs such as abnormal involuntary and voluntary movements. 4.Fluid volume excess :  Fluid volume excess occurs due to an increased cardiac output and decreased peripheral vascular resistance.

12. Assessment and Diagnostic Findings Laboratory findings and imaging studies that are characteristic of cirrhosis include: 1.Liver scan : Liver scan shows abnormal thickening and a liver mass. 2.Liver biopsy : Liver biopsy is the definitive test for cirrhosis as it detects destruction and fibrosis of the hepatic tissue. 3.Liver imaging : Computed tomography scan, ultrasound, and magnetic resonance imaging may confirm the diagnosis of cirrhosis through visualization of masses, abnormal growths, metastases.

13. Assessment and Diagnostic Findings 4.Cholecystography and cholangiography :  These two visualize the gallbladder and the biliary duct system. 5.Splenoportal venography :   Splenoportal venography visualizes the portal venous system. 6.Percutaneous transhepatic cholangiography :   This test differentiates intrahepatic from extrahepatic obstructive jaundice and discloses hepatic pathology and the presence of gallstones.

14. Assessment and Diagnostic Findings 7.Complete blood count : There is decreased white blood cell count,  hemoglobin  level and hematocrit , albumin, or platelets.

15. Medical Management 1.Diet : The patient may benefit from a  high-calorie  and a  medium to high protein diet , as developing hepatic encephalopathy mandates restricted protein intake. 2.Sodium restriction : is usually restricted to  2g/day . 3.Fluid restriction :  Fluids are restricted to  1 to 1.5 liters /day .

16. Medical Management 4.Activity :  Rest and moderate exercise is essential. 5.Paracentesis :  Paracentesis may help alleviate ascites. 6.Sengstaken-Blakemore or Minnesota tube : The Sengstaken -Blakemore or Minnesota tube may also help control  hemorrhage  by applying pressure on the bleeding site.

17. Sengstaken -Blakemore or Minnesota tube :

18. A Sengstaken –Blakemore tube  is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage  due to esophageal varices (distended and fragile veins in the esophageal wall, usually a result of cirrhosis). 

19. Pharmacologic Therapy 1.Octreotide : If required, octreotide may be prescribed for esophageal varices. 2.Diuretics :  Diuretics may be given for  edema , however, they require careful monitoring because fluid and electrolyte imbalance may precipitate hepatic encephalopathy. 3.Lactulose :  Encephalopathy is treated with lactulose. 4.Antibiotics :  Antibiotics are used to decrease intestinal bacteria and reduce ammonia production, one of the causes of encephalopathy.

20. Surgical Management Surgical procedures for management of hepatic cirrhosis include: Transjugular intrahepatic portosystemic shunt (TIPS) procedure The TIPS procedure is used for the treatment of varices by upper endoscopy with banding to relieve portal hypertension. - procedure creates a connection between the portal vein and the hepatic vein in the liver, using a stent, to reduce portal hypertension.  - This allows blood to bypass the diseased liver and flow more easily towards the heart, addressing issues like variceal bleeding and ascites

21. Nursing Management Nursing management for the patient with cirrhosis of the liver should focus on - promoting rest, - improving nutritional status, - providing skin care, - reducing risk of injury, - monitoring and managing complications.

22. Nursing Assessment Assessment of the patient with cirrhosis should include assessing for: 1.Bleeding.  Check the patient’s skin, gums, stools, and vomitus for bleeding. 2.Fluid retention.  To assess for fluid retention, weigh the patient and measure abdominal girth at least once daily. 3.Mentation.  Assess the patient’s level of consciousness often and observe closely for changes in behavior or personality.

23. Nursing Diagnosis Based on the assessment data, the major nursing diagnosis for the patient are: 1.Activity intolerance  related to fatigue, lethargy and malaise. 2.Imbalanced nutrition: less than body requirements  related to abdominal distention and discomfort and anorexia. 3. Impaired skin integrity  related to pruritus from jaundice and  edema . 4. High risk for injury  related to altered clotting mechanisms and altered level of consciousness. 5. Disturbed body image  related to changes in appearance, sexual dysfunction, and role function.

24. Nursing Diagnosis 6.Chronic pain and discomfort  related to enlarged liver and ascites. 7.Fluid volume excess  related ascites and edema formation. 8.Disturbed thought processes and potential for mental deterioration  related to abnormal liver function and increased serum ammonia level. 9.Ineffective breathing pattern  related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity.

25. Nursing Interventions The patient with cirrhosis needs close observation, first-class supportive care, and sound nutrition  counseling . 1.Promoting Rest Position bed for maximal respiratory efficiency; provide oxygen if needed. Initiate efforts to prevent respiratory, circulatory, and vascular disturbances. Encourage patient to increase activity gradually and plan rest with activity and mild exercise.

26. 2.Improving Nutritional Status Provide a nutritious, high-protein diet supplemented by B-complex vitamins and others, including A, C, and K. Encourage patient to eat: Provide small, frequent meals, consider patient preferences, and provide protein supplements, if indicated. Provide nutrients by feeding tube or total PN if needed. Provide patients who have fatty stools (steatorrhea) with water-soluble forms of fat-soluble vitamins A, D, and E, and give folic acid and iron to prevent  anemia . Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma; restrict sodium if needed.

27. 3.Providing Skin Care - Change patient’s position frequently. - Avoid using irritating soaps and adhesive tape. - Provide lotion to soothe irritated skin; take measures to prevent patient from scratching the skin.

28. 4.Reducing Risk of Injury Use padded side rails if patient becomes agitated or restless. Orient to time, place, and procedures to minimize agitation. Instruct patient to ask for assistance to get out of bed. Carefully evaluate any injury because of the possibility of internal bleeding. Provide safety measures to prevent injury or cuts (electric razor, soft toothbrush). Apply pressure to venipuncture sites to minimize bleeding.

29. 5.Monitoring and Managing Complications Monitor for bleeding and  hemorrhage . Monitor the patient’s mental status closely and report changes so that treatment of encephalopathy can be initiated promptly. Carefully monitor serum electrolyte levels are and correct if abnormal. Administer oxygen if oxygen desaturation occurs; monitor for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection. Assess cardiovascular and respiratory status; administer diuretics, implement fluid restrictions, and enhance patient positioning, if needed. Monitor intake and output, daily weight changes, changes in abdominal girth, and edema formation. Monitor for nocturia and, later, for oliguria, because these states indicate increasing severity of liver dysfunction.