LIVER CIRRHOSIS

Definition  and Causes of Liver Cirrhosis

Definition of liver cirrhosis

·         Cirrhosis is scarring of the liver that involves the formation of fibrous (scar) tissue associated with the destruction of the normal architecture of the organ; it is the result of long-standing injury.

Causes of liver cirrhosis

·         Alcohol excess: the rate of cirrhosis in a country is directly related to the average alcohol consumption in that country. Half of all cases of cirrhosis are due to alcohol excess.

·         Chronic viral hepatitis: the two important viruses are hepatitis B and hepatitis C.

·         Primary biliary cirrhosis: this is an uncommon disease mainly affecting women.

·         Autoimmune chronic active hepatitis: another uncommon condition that results in the body's immune system attacking and destroying liver cells.

·         Drugs and chemicals: a number of drugs and chemicals can cause liver damage but few cause cirrhosis. Certain specialized drugs need monitoring for their effect on the liver.

Pathophysiology

·         The liver plays a vital role in synthesis of proteins (e.g., albumin, clotting factors and complement), detoxification and storage (e.g., vitamin A). In addition, it participates in the metabolism of lipids and carbohydrates.

·         Cirrhosis is often preceded by hepatitis and fatty liver (steatosis), independent of the cause. If the cause is removed at this stage, the changes are still fully reversible.

·         The pathological hallmark of cirrhosis is the development of scar tissue that replaces normal parenchyma, blocking the portal flow of blood through the organ and disturbing normal function. R

·         Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissues.

·         Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein.

Signs and Symptoms of Patient with Liver Cirrhosis

·         The symptoms will depend on how much damage has occurred to the liver.

·         In the early stages there may be no symptoms at all and the disease may be discovered as a result of an investigation for another illness.

·         As the disease progresses, tiredness, weakness, lack of energy, loss of appetite, nausea and weight loss may develop.

·         In the later stages the liver is struggling to perform all its functions and any or all of the following symptoms may be present.

• Jaundice: this is the yellowing of the skin (jaundice) and the eyes due to the failure of the liver to remove a substance called bilirubin from the blood.
• Nail changes: the shape and appearance of the nails may change. They may be more curved (clubbing) and they may be white rather than pink.
• Skin changes: about a quarter of patients will have darkening of the skin.
• Fluid retention: this is common at some stage in cirrhosis. An important function of the liver is to rid the body of excess fluid through the kidneys and when it fails, fluid gathers in the legs (oedema) or in the abdomen (ascites).
• Abnormal blood vessels: the commonest abnormality is a spider naevus, which is a spot surrounded by fine blood vessels. A red face is also common.
• Easy bruising: nosebleeds and easy bruising occur as a result of abnormal blood vessels and delayed clotting because the liver does not make enough clotting proteins.
• Enlargement of breasts in men: the liver destroys the female sex hormones and in cirrhosis these accumulate and cause enlargement of the breasts and shrinking of the testes in men.

·         In the very late stages of the disease, serious complications may occur. These include vomiting of blood, either from ulcers in the stomach or from leaking varicose veins in the lower end of the oesophagus (gullet). This is serious and requires hospital treatment.

·         The liver is responsible for removing poisonous substances from the blood. In cirrhosis, the blood may bypass the liver and these poisonous substances pass to the brain where they may result in alteration in brain function, causing confusion, drowsiness and finally coma. This is called hepatic encephalopathy. This is also serious and requires hospital treatment.

Diagnosis of with liver cirrhosis

·         Clinical examination supported by the analysis of blood samples.

·         Confirmed by an ultrasound examination,

·           Liver biopsy - obtain tissue samples from the liver

Treatment and nursing care of patient with liver cirrhosis

Treatment for cirrhosis cannot reverse liver damage, but it can stop or slow progression of the disease and reduce complications. Treatment depends on what is causing the cirrhosis and which particular complications, if any, have appeared

Nursing care of patient with liver cirrhosis

Nursing Key outcomes

The patient will:

·         Perform activities of daily living without excessive fatigue or exhaustion. 

·         Remain oriented to his environment. 

·         Show no signs of circulatory overload. 

·         Participate in decisions about care. 

·         Maintain adequate caloric intake. 

·         Patient's fluid volume will remain within normal parameters. 

·         Patient's skin integrity will remain intact. 

·         Avoid or minimize complications.

Nursing interventions

·         Monitor vital signs, intake and output, and electrolyte levels to determine fluid volume status. 

·         Assess fluid retention 

·         Weigh the patient daily and document his weight. 

·         Administer diuretics, potassium, and protein or vitamin supplements

·         Restrict sodium and fluid intake. 

·         Assist and provide oral hygiene before and after meals. 

·         Determine food preferences and provide them within the patient's prescribed diet limitations. 

·         Provide frequent, small meals. 

·         Observe and document the degree of sclera and skin jaundice. 

·         Give the patient frequent skin care. 

·         Observe for bleeding gums, ecchymosed, epitasis, and petechiae. 

·         Inspect stools for amount, color, and consistency. 

·         Increase the patient's exercise tolerance by decreasing fluid volumes and providing rest periods before exercise. 

·         Use appropriate safety measures to protect the patient from injury. 

·         Watch for signs of anxiety , epigastric fullness, restlessness, and weakness. 

·         Observe closely for signs of behavioral or personality changes. 

·         Observe Report increasing stupor, lethargy, hallucinations, or neuromuscular dysfunction. Arouse the patient periodically to determine level of consciousness. Watch for asterixis, a sign of developing encephalopathy. 

·         Allow the patient to express his feelings about having cirrhosis. 

·         Provide psychological support and encouragement, when appropriate.

Patient teaching

·         Warn the patient against taking nonsteroidal anti-inflammatory drugs, straining to defecate, and blowing his nose or sneezing too vigorously. To minimize the risk of bleeding. 

·         Suggest using a soft toothbrush.

·         Advise the patient that rest and good nutrition conserve energy and decrease metabolic demands on the liver. 

·         Suggest the patient to eat frequent, small meals. Teach him to alternate periods of rest and activity to reduce oxygen demand and prevent fatigue. 

·         Tell the patient how he can conserve energy while performing activities of daily living. For example, suggest that he sit on a bench while bathing or dressing. 

·         Stress the need to avoid infections and abstain from alcohol. Refer the patient to alcohol abuse treatment , if appropriate 

·         Alcohol abuse treatment. Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in. Assist the patient in obtaining counseling or support for her or his alcoholism. 

·         Encourage the patient to seek frequent medical follow-up and  Refer the patient to an alcohol support group or liver transplant support group.

Prognosis of patient with liver cirrhosis

·         Scarring of the liver caused by cirrhosis of the liver cannot be reversed or cured. However, patient compliance with a good treatment plan may be able to slow or stop progression of the disease and minimize complications

 Complications Of Liver Cirrhosis

·         Ascites,

·         Hepatic encephalopathy,

·         Variceal hemorrhage