Hepatic Cirrhosis
Hepatic Cirrhosis
Hepatic Cirrhosis
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− Metabolic and Genetic Disorders INVOLVE FROM 2 FACTORS: MAJOR FUNCTIONAL
LOSSES IN PERSONS WITH CIRRHOSIS
VASCULAR DISORDER TYPES − Decreased removal and conjugation of bilirubin.
− Decreased production of bile.
− Impaired digestion and absorption of nutrients,
ALCOHOLIC CIRRHOSIS:
particularly fats and fats soluble vitamins.
− Scar tissue characteristically surrounds the − Decreased production of blood clotting factors
portal areas. (prothrombin, fibrinogen) and plasma proteins
− Most frequent due to cirrhosis or chronic (albumin).
alcoholism and the most common type of − Impaired glucose/glycogen metabolism.
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cirrhosis. inadequate storage of iron and vitamin B.
POSTNECROTIC CIRRHOSIS: − Decreased inactivation of hormones such as
aldosterone and estrogen.
− Broad bands of scar tissues as late result of a
− Decreased removal of toxic substances such as
previous bout of actual viral nep. ammonia and drugs.
BILIARY CIRRHOSIS: − Altered blood chemistry including abnormal
− Scarring occurs in the liver around the bile levels of electrolytes or amino acids and
ducts. excessive ammonia or other toxic chemicals
− A result of chronic biliary obstruction and affect the CNS, leading to hepatic
encephalopathy.
infection (cholangitis). It is much less
common than the other types.
THE 2ND GROUP OF EFFECTS IS RELATED TO
OBSTRUCTION OF BILE DUCTS AND BLOOD PLOW
PORTIONS OF THE LIVER INVOLVED IN CIRRHOSIS BY FIBROUS TISSUE AS FOLLOWS
− Reduction of the amounts of bile entering the
PORTAL AND PERIPHERAL SPACES: intestine, impairing digestion and absorption.
− Where the bile canaliculi of each lobule − Back up of bile in the liver, leading to obstruction
jaundice with elevated conjugated and
communicate to form the liver bile ducts.
unconjugated bilirubin levels in the blood.
− These areas become the site of
− Blockage of blood flow through the liver, leading
inflammation, and the bile ducts become to high pressure in the portal veins or portal
occluded with thickened bile and pus. hypertension.
− Congestion in the spleen (splenomegaly) − As a result, patient with cirrhosis often has
increasing hemolysis. prominent distended abdominal blood vessels
− Congestion in the intestinal walls and stomach which are visible on abdominal inspection.
impairing digestion and absorption. − Esophagus, stomach and lower rectum are
− Development of ascites, an accumulation of common sites of collateral blood vessels.
fluid in the peritoneal cavity that causes − This form varices or hemorrhoids.
abdominal distention and pressure. EDEMA:
− Another late symptom.
MAJOR CLINICAL MANIFESTATIONS − Reduced plasma albumin concentration
predisposes the patient to formation of edema.
LIVER ENLARGEMENT: − Generalized but often affects the lower, upper
− Early in the course or cirrhosis, the liver tends to extremities and presacral areas.
be large, and its cell loaded with fat. − Overproduction of aldosterone occur, causing
− Liver is firm and has a sharp edge noticeable by sodium and water retention and potassium
palpation. excretion.
− Abdominal pain may be present because of VITAMIN DEFICIENCY AND ANEMIA:
recent rapid enlargement, producing tension on − Inadequate formation, use and storage of
the fibrous covering of the liver. certain vitamins (Vit. A, C and K).
− Later, the liver decreases in sizes as scar tissue − Chronic gastritis and impaired 6l function
contracts the liver. together with inadequate dietary intake and
− Liver edge, if palpable is nodular. impaired liver function accounts for the anemia
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PORTAL OBSTRUCTION AND ASCITES: associated with cirrhosis.
− Cirrhotic liver does not allow the blood free − Anemia and poor nutritional status results in
passage. severe fatigue.
− It backs up into the spleen and the GI tract and MENTAL DETERIORATION:
these organs becomes the seat of chronic − Deterioration of mental function with impending
passive congestion. hepatic encephalopathy and hepatic coma are
− They become stagnant with blood and thus additional clinical manifestations.
cannot function properly. − Neurologic assessment is indicated and
− Indigestion and altered bowel function may includes the patient’s general behavior,
result. cognitive abilities, orientation to time, place and
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− Fluid rich in proteins may accumulate in the speech patterns.
peritoneal cavity producing ascites.
− This can be demonstrated by percussion for OTHER SIGNS AND SYMPTOMS
shifting dullness or a fluid wave.
− A late manifestation due to chronic failure of the CIRCULATORY CHANGES:
liver function. − Spider telangiectasia
INFECTION AND PERITONITIS: − Palmar erythema
− Bacterial peritonitis may develop in cirrhotic − Cyanosis
patients with ascites in the absence of an intra- ENDOCRINE CHANGES:
abdominal source of infection or an abscess. − Loss of libido
− This is referred to as spontaneous Bacterial − Hair loss
Peritonitis. HEMORRHAGIC TENDENCY:
− BACTEREMIA: believed to be the most likely − Bruises
route of infection. − Purpura
GASTROINTESTINAL VARICES: − Epistaxis
− Obstruction to blood flow through the liver − Menorrhagia
resulting from the fibrotic changes also results PORTAL HPN:
in the formation of collateral blood vessels in − Variceal bleeding
the GI system and hunting of blood from the FETOR HEPATICUS:
portal vessels into blood vessels with lower − Fruity
pressures. − Musty
− Breath odor
ASSESSMENT AND DIAGNOSTIC FINDINGS o ADEQUATE DIET AND AVOIDANCE OF
− ENZYMES TESTS indicate liver cell damage. ALCOHOL ARE ESSENTIAL.
− SERUM ALKALINE PHOSPHATASE, AST, ALT, o Colchicine
AND GGT LEVELS increase, and serum o ANTI- INFLAMMATORY AGENT used to treat
cholinesterase level may decrease. gout may increase the length of survival in
− BILIRUBIN TEST: are performed to measure patients with mild to moderate cirrhosis.
bile excretion or bile retention, elevated levels o ADMINISTER LACTULOSE: helps excrete
can occur with cirrhosis. ammonia.
− PROTHROMBIN TIME is prolonged. o Believe to reverse the fibrotic process in
− ULTRASOUND SCANNING is used to cirrhosis and this has improved survival.
measure the difference in density of
parenchymal cells and scar tissue. NURSING MANAGEMENT FOCUSES ON
− CT, MRI AND RADIOISOTOPE LIVER SCANS − The onset of symptoms and history of
give information about liver size and hepatic precipitating factors, particularly long-term
blood flow and obstruction. alcohol abuse.
− DIAGNOSIS is confirmed by LIVER BIOPSY. − Dietary intake.
− ARTERIAL BLOOD GAS ANALYSIS may reveal − Changes in the patients physical and mental
a ventilation-perfusion imbalance and hypoxia. status.
− Patients past and current patterns of alcohol
LABORATORY TESTS FOR EVALUATION OF LIVER use.
DISEASE − Documents any exposure to toxic agents
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encountered in the workplace or during
LABORATORY NORMAL VALUES IN recreational activities.
TEST VALUES LIVER DISEASE − Document and report exposure to potentially
Alanine MALE: 10-40 ELEVATED hepatotoxic substances (medications, IV
Aminotransferase U/L injection drug, inhalants) or general anesthesia
(ALT) FEMALE: 7-35 agents.
U/L − Patients’ mental status through interview.
Albumin 3.4-4.8 g/dL DECREASED − Patients’ ability to carry out ADL.
Alkaline 25-100 U/L NORMAL OR − Patients’ relationship with family, friends and
Phosphatase ELEVATED co-workers.
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Ammonia 15-45 ug N/dL ELEVEATED − Abdominal distension and bloating, GI bleeding,
Aspartate 10-30 U/L ELEVATED bruising and weight changes are noted.
Aminotransferase − Nutritional status is also assessed, which is of
(AST) major importance in cirrhosis by daily weight
Bilirubin (total) 0.3-1.2 mg/dL ELEVEATED and monitoring of plasma proteins and
Blood Urea 6-20 mg/dL NORMAL OR creatinine levels.
Nitrogen (BUN) DECREASED
Prothrombin Time 10-13 seconds PROLONGED
MEDICAL MANAGEMENT
ANTACIDS:
− To decrease gastric distress and minimize the
possibility of GI Bleeding.
VITAMINS AND NUTRITIONAL SUPPLEMENTS:
− Promote healing of damaged liver cells and
improve the general nutritional status.
POTASSIUM:
− Sparing diuretics (Spironolactone, Aldaxtone,
Triamterene and Dyrenium) may be indicated
to decrease ascites.
− This diuretic agent minimizes the fluid and
electrolytes changes common in other agents.