Cirrhosis of the Liver (relates to Chapter 42, “Nursing Management: Liver, Biliary Tract, and...
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Transcript of Cirrhosis of the Liver (relates to Chapter 42, “Nursing Management: Liver, Biliary Tract, and...
Cirrhosis of the LiverCirrhosis of the Liver
(relates to Chapter 42, “Nursing Management: Liver, Biliary Tract, and Pancreas Problems,” in
the textbook)
(relates to Chapter 42, “Nursing Management: Liver, Biliary Tract, and Pancreas Problems,” in
the textbook)
DescriptionDescription
• A chronic, progressive disease of the liver
– Extensive parenchymal cell degeneration
– Destruction of parenchymal cells
• A chronic, progressive disease of the liver
– Extensive parenchymal cell degeneration
– Destruction of parenchymal cells
DescriptionDescription
• Regenerative process is disorganized, resulting in abnormal blood vessel and bile duct relationships from fibrosis
• Regenerative process is disorganized, resulting in abnormal blood vessel and bile duct relationships from fibrosis
DescriptionDescription
• Normal lobular structure distorted by fibrotic connective tissue
• Lobules are irregular in size and shape with impaired vascular flow
• Insidious, prolonged course
• Normal lobular structure distorted by fibrotic connective tissue
• Lobules are irregular in size and shape with impaired vascular flow
• Insidious, prolonged course
StatisticsStatistics
• > 50% of liver disease in the US is directly related to alcohol consumption
• Of the estimated 15 million alcoholics in the USA 10-20% have or will develop cirrhosis
• > 50% of liver disease in the US is directly related to alcohol consumption
• Of the estimated 15 million alcoholics in the USA 10-20% have or will develop cirrhosis
StatisticsStatistics
• Growing number of cases related to chronic hepatitis C
• 4th leading cause of death in people between 35 and 54 years of age
• Growing number of cases related to chronic hepatitis C
• 4th leading cause of death in people between 35 and 54 years of age
StatisticsStatistics
• Direct correlation between alcohol consumption in any geographic area and the death rate from cirrhosis in that area
• Direct correlation between alcohol consumption in any geographic area and the death rate from cirrhosis in that area
Etiology and PathophysiologyEtiology and Pathophysiology
• Cell necrosis occurs
• Destroyed liver cells are replaced by scar tissue
• Normal architecture becomes nodular
• Cell necrosis occurs
• Destroyed liver cells are replaced by scar tissue
• Normal architecture becomes nodular
Etiology and PathophysiologyEtiology and Pathophysiology
• Four types of cirrhosis:
– Alcoholic (Laennec’s) cirrhosis
– Postnecrotic cirrhosis
– Biliary cirrhosis
– Cardiac cirrhosis
• Four types of cirrhosis:
– Alcoholic (Laennec’s) cirrhosis
– Postnecrotic cirrhosis
– Biliary cirrhosis
– Cardiac cirrhosis
Etiology and PathophysiologyEtiology and Pathophysiology
• Alcoholic (Laennec’s) Cirrhosis
– Associated with alcohol abuse
– Preceded by a theoretically reversible fatty infiltration of the liver cells
– Widespread scar formation
• Alcoholic (Laennec’s) Cirrhosis
– Associated with alcohol abuse
– Preceded by a theoretically reversible fatty infiltration of the liver cells
– Widespread scar formation
Etiology and PathophysiologyEtiology and Pathophysiology
• Postnecrotic Cirrhosis
– Complication of toxic or viral hepatitis
– Accounts for 20% of the cases of cirrhosis
– Broad bands of scar tissue form within the liver
• Postnecrotic Cirrhosis
– Complication of toxic or viral hepatitis
– Accounts for 20% of the cases of cirrhosis
– Broad bands of scar tissue form within the liver
Etiology and PathophysiologyEtiology and Pathophysiology
• Biliary Cirrhosis – Associated with chronic biliary
obstruction and infection
– Accounts for 15% of all cases of cirrhosis
• Biliary Cirrhosis – Associated with chronic biliary
obstruction and infection
– Accounts for 15% of all cases of cirrhosis
Etiology and PathophysiologyEtiology and Pathophysiology
• Cardiac Cirrhosis – Results from longstanding severe
right-sided heart failure
• Cardiac Cirrhosis – Results from longstanding severe
right-sided heart failure
Clinical ManifestationsEarly Manifestations
Clinical ManifestationsEarly Manifestations
• Onset usually insidious
• GI disturbances:
– Anorexia
– Dyspepsia
– Flatulence
– N-V, change in bowel habits
• Onset usually insidious
• GI disturbances:
– Anorexia
– Dyspepsia
– Flatulence
– N-V, change in bowel habits
Clinical ManifestationsEarly Manifestations
Clinical ManifestationsEarly Manifestations
• Abdominal pain
• Fever
• Lassitude
• Weight loss
• Enlarged liver or spleen
• Abdominal pain
• Fever
• Lassitude
• Weight loss
• Enlarged liver or spleen
Clinical ManifestationsLate Manifestations
Clinical ManifestationsLate Manifestations
• Two causative mechanisms
– Hepatocellular failure
– Portal hypertension
• Two causative mechanisms
– Hepatocellular failure
– Portal hypertension
Clinical ManifestationsJaundice
Clinical ManifestationsJaundice
• Occurs because of insufficient conjugation of bilirubin by the liver cells, and local obstruction of biliary ducts by scarring and regenerating tissue
• Occurs because of insufficient conjugation of bilirubin by the liver cells, and local obstruction of biliary ducts by scarring and regenerating tissue
Clinical ManifestationsJaundice
Clinical ManifestationsJaundice
• Intermittent jaundice is characteristic of biliary cirrhosis
• Late stages of cirrhosis the patient will usually be jaundiced
• Intermittent jaundice is characteristic of biliary cirrhosis
• Late stages of cirrhosis the patient will usually be jaundiced
Clinical ManifestationsSkin
Clinical ManifestationsSkin
• Spider angiomas (telangiectasia, spider nevi)
• Palmar erythema
• Spider angiomas (telangiectasia, spider nevi)
• Palmar erythema
Clinical Manifestations Endocrine DisturbancesClinical Manifestations Endocrine Disturbances
• Steroid hormones of the adrenal cortex (aldosterone), testes, and ovaries are metabolized and inactivated by the normal liver
• Steroid hormones of the adrenal cortex (aldosterone), testes, and ovaries are metabolized and inactivated by the normal liver
Clinical Manifestations Endocrine DisturbancesClinical Manifestations Endocrine Disturbances
• Alteration in hair distribution
– Decreased amount of pubic hair
– Axillary and pectoral alopecia
• Alteration in hair distribution
– Decreased amount of pubic hair
– Axillary and pectoral alopecia
Clinical Manifestations Hematologic Disorders
Clinical Manifestations Hematologic Disorders
• Bleeding tendencies as a result of decreased production of hepatic clotting factors (II, VII, IX, and X)
• Bleeding tendencies as a result of decreased production of hepatic clotting factors (II, VII, IX, and X)
Clinical Manifestations Hematologic Disorders
Clinical Manifestations Hematologic Disorders
• Anemia, leukopenia, and thrombocytopenia are believed to be result of hypersplenism
• Anemia, leukopenia, and thrombocytopenia are believed to be result of hypersplenism
Clinical Manifestations Peripheral Neuropathy
Clinical Manifestations Peripheral Neuropathy
• Dietary deficiencies of thiamine, folic acid, and vitamin B12
• Dietary deficiencies of thiamine, folic acid, and vitamin B12
ComplicationsComplications
• Portal hypertension and esophageal varices
• Peripheral edema and ascites
• Hepatic encephalopathy
• Fetor hepaticus
• Portal hypertension and esophageal varices
• Peripheral edema and ascites
• Hepatic encephalopathy
• Fetor hepaticus
Complications Portal Hypertension
Complications Portal Hypertension
• Characterized by:
– Increased venous pressure in portal circulation
– Splenomegaly
– Esophageal varices
– Systemic hypertension
• Characterized by:
– Increased venous pressure in portal circulation
– Splenomegaly
– Esophageal varices
– Systemic hypertension
Complications Portal Hypertension
Complications Portal Hypertension
• Primary mechanism is the increased resistance to blood flow through the liver
• Primary mechanism is the increased resistance to blood flow through the liver
Complications Portal Hypertension
Splenomegaly
Complications Portal Hypertension
Splenomegaly
• Back pressure caused by portal hypertension chronic passive congestion as a result of increased pressure in the splenic vein
• Back pressure caused by portal hypertension chronic passive congestion as a result of increased pressure in the splenic vein
Complications Portal Hypertension Esophageal Varices
Complications Portal Hypertension Esophageal Varices
• Increased blood flow through the portal system results in dilation and enlargement of the plexus veins of the esophagus and produces varices
• Increased blood flow through the portal system results in dilation and enlargement of the plexus veins of the esophagus and produces varices
Complications Portal Hypertension Esophageal Varices
Complications Portal Hypertension Esophageal Varices
• Varices have fragile vessel walls which bleed easily
• Varices have fragile vessel walls which bleed easily
Complications Portal Hypertension
Internal Hemorrhoids
Complications Portal Hypertension
Internal Hemorrhoids
• Occurs because of the dilation of the mesenteric veins and rectal veins
• Occurs because of the dilation of the mesenteric veins and rectal veins
Complications Portal Hypertension
Caput Medusae
Complications Portal Hypertension
Caput Medusae
• Collateral circulation involves the superficial veins of the abdominal wall leading to the development of dilated veins around the umbilicus
• Collateral circulation involves the superficial veins of the abdominal wall leading to the development of dilated veins around the umbilicus
Complications Peripheral Edema and Ascites
Complications Peripheral Edema and Ascites
• Ascites:- - Intraperitoneal accumulation of
watery fluid containing small amounts of protein
• Ascites:- - Intraperitoneal accumulation of
watery fluid containing small amounts of protein
Complications Peripheral Edema and Ascites
Complications Peripheral Edema and Ascites
• Factors involved in the pathogenesis of ascites:
- Hypoalbuminemia Levels of aldosterone Portal hypertension
• Factors involved in the pathogenesis of ascites:
- Hypoalbuminemia Levels of aldosterone Portal hypertension
Complications Hepatic Encephalopathy
Complications Hepatic Encephalopathy
• Liver damage causes blood to enter systemic circulation without liver detoxification
• Liver damage causes blood to enter systemic circulation without liver detoxification
Complications Hepatic Encephalopathy
Complications Hepatic Encephalopathy
• Main pathogenic toxin is NH3 although other etiological factors have been identified
• Frequently a terminal complication
• Main pathogenic toxin is NH3 although other etiological factors have been identified
• Frequently a terminal complication
Complications Fetor HepaticusComplications Fetor Hepaticus
• Musty, sweetish odor detected on the patient’s breath
• From accumulation of digested by-products
• Musty, sweetish odor detected on the patient’s breath
• From accumulation of digested by-products
Diagnostic StudiesDiagnostic Studies
• Liver function tests
• Liver biopsy
• Liver scan
• Liver ultrasound
• Liver function tests
• Liver biopsy
• Liver scan
• Liver ultrasound
Diagnostic StudiesDiagnostic Studies
• Esophagogastroduodenoscopy
• Prothrombin time
• Testing of stool for occult blood
• Esophagogastroduodenoscopy
• Prothrombin time
• Testing of stool for occult blood
Collaborative CareCollaborative Care
• Rest
• Avoidance of alcohol and anticoagulants
• Management of ascites
• Rest
• Avoidance of alcohol and anticoagulants
• Management of ascites
Collaborative CareCollaborative Care
• Prevention and management of esophageal variceal bleeding
• Management of encephalopathy
• Prevention and management of esophageal variceal bleeding
• Management of encephalopathy
Collaborative Care Ascites
Collaborative Care Ascites
• High carbohydrate, low protein, low Na+ diet
• Diuretics
• Paracentesis
• High carbohydrate, low protein, low Na+ diet
• Diuretics
• Paracentesis
Collaborative Care Ascites
Collaborative Care Ascites
• Peritoneovenous shunt
– Provides for continuous reinfusion of ascitic fluid from the abdomen to the vena cava
• Peritoneovenous shunt
– Provides for continuous reinfusion of ascitic fluid from the abdomen to the vena cava
Collaborative Care Esophageal Varices
Collaborative Care Esophageal Varices
• Avoid alcohol, aspirin, and irritating foods
• If bleeding occurs, stabilize patient and manage the airway, administer vasopressin (Pitressin)
• Avoid alcohol, aspirin, and irritating foods
• If bleeding occurs, stabilize patient and manage the airway, administer vasopressin (Pitressin)
Collaborative Care Esophageal Varices
Collaborative Care Esophageal Varices
• Endoscopic sclerotherapy or ligation
• Balloon tamponade
• Surgical shunting procedures (e.g., portacaval shunt, TIPS)
• Endoscopic sclerotherapy or ligation
• Balloon tamponade
• Surgical shunting procedures (e.g., portacaval shunt, TIPS)
Collaborative Care Hepatic EncephalopathyCollaborative Care
Hepatic Encephalopathy
• Goal: reduce NH3 formation– Protein restriction (0-40g/day)– Sterilization of GI tract with antibiotics
(e.g., neomycin)– lactulose (Cephulac) – traps NH3 in gut– levodopa
• Goal: reduce NH3 formation– Protein restriction (0-40g/day)– Sterilization of GI tract with antibiotics
(e.g., neomycin)– lactulose (Cephulac) – traps NH3 in gut– levodopa
Drug TherapyDrug Therapy
• There is no specific drug therapy for cirrhosis
• Drugs are used to treat symptoms and complications of advanced liver disease
• There is no specific drug therapy for cirrhosis
• Drugs are used to treat symptoms and complications of advanced liver disease
Nutritional TherapyNutritional Therapy
• Diet for patient without complications:
– High in calories CHO
– Moderate to low fat
– Amount of protein varies with degree of liver damage
• Diet for patient without complications:
– High in calories CHO
– Moderate to low fat
– Amount of protein varies with degree of liver damage
Nutritional TherapyNutritional Therapy
• Patient with hepatic encephalopathy
– Very low to no-protein diet
• Low sodium diet for patient with ascites and edema
• Patient with hepatic encephalopathy
– Very low to no-protein diet
• Low sodium diet for patient with ascites and edema
Nursing ManagementNursing Assessment
Nursing ManagementNursing Assessment
• Past health history
• Medications
• Chronic alcoholism
• Weight loss
• Past health history
• Medications
• Chronic alcoholism
• Weight loss
Nursing ManagementNursing Diagnoses
Nursing ManagementNursing Diagnoses
• Imbalanced nutrition: less than body requirements
• Impaired skin integrity• Ineffective breathing pattern• Risk for injury
• Imbalanced nutrition: less than body requirements
• Impaired skin integrity• Ineffective breathing pattern• Risk for injury
Nursing ManagementPlanning
Nursing ManagementPlanning
• Overall goals:
– Relief of discomfort
– Minimal to no complications
– Return to as normal a lifestyle as possible
• Overall goals:
– Relief of discomfort
– Minimal to no complications
– Return to as normal a lifestyle as possible
Nursing ManagementNursing ImplementationNursing ManagementNursing Implementation
• Health Promotion
– Treat alcoholism
– Identify hepatitis early and treat
– Identify biliary disease early and treat
• Health Promotion
– Treat alcoholism
– Identify hepatitis early and treat
– Identify biliary disease early and treat
Nursing ManagementNursing ImplementationNursing ManagementNursing Implementation
• Acute Intervention– Rest– Edema and ascites– Paracentesis– Skin care– Dyspnea– Nutrition
• Acute Intervention– Rest– Edema and ascites– Paracentesis– Skin care– Dyspnea– Nutrition
Nursing ManagementNursing ImplementationNursing ManagementNursing Implementation
• Acute Intervention
– Bleeding problems
– Balloon tamponade
– Altered body image
– Hepatic encephalopathy
• Acute Intervention
– Bleeding problems
– Balloon tamponade
– Altered body image
– Hepatic encephalopathy
Nursing ManagementNursing ImplementationNursing ManagementNursing Implementation
• Ambulatory and Home Care
– Symptoms of complications
– When to seek medical attention
– Remission maintenance
– Abstinence from alcohol
• Ambulatory and Home Care
– Symptoms of complications
– When to seek medical attention
– Remission maintenance
– Abstinence from alcohol
Nursing ManagementEvaluation
Nursing ManagementEvaluation
• Maintenance of normal body weight
• Maintenance of skin integrity
• Effective breathing pattern
• No injury
• No signs of infection
• Maintenance of normal body weight
• Maintenance of skin integrity
• Effective breathing pattern
• No injury
• No signs of infection