Transcript Cirrhosis by

Cirrhosis
by: Ashley Anderton, RN, BSN
From the notes of:
John Nation, RN, MSN
Charlene Morris, RN, MSN
Kelle Howard, MSN. RN, CNE
Cirrhosis Facts:
 Progressive, leads to liver failure
 Insidious, prolonged course
 9th leading cause of death in U.S.
 Twice as common in men
 Highest incidence between ages
40 and 60.
What is Cirrhosis?
 Extensive destruction of liver cells
 Cells attempt to regenerate
 Regenerative process is disorganized
 Functional liver tissue is destroyed and
scarring of liver occurs
 Overgrowth of fibrous connective tissue,
distorting liver structure; obstructing blood
flow
Four Types of Cirrhosis:
 Alcoholic
 formerly called ________
 Post-necrotic
 Biliary/obstructive
 Cardiac
Alcoholic cirrhosis:
 Usually associated with alcohol abuse
 Most common cause of cirrhosis
 Causes metabolic changes in liver

fat accumulates in liver (fatty liver)
 Fatty liver potentially reversible
 If alcohol abuse continues, widespread liver scar
formation occurs
Post Necrotic cirrhosis:
 Complication of:



viral infections
toxicity
autoimmune hepatitis
 20% of patient’s with chronic hepatitis C will
develop cirrhosis
 Broad bands of scar tissue form within the liver
Biliary cirrhosis:
 Associated with chronic biliary obstruction and/or
infection
Primary sclerosing cholangitis?
 Diffuse fibrosis of liver
 Jaundice is main feature
www.humanillnesses.com
Cardiac cirrhosis:
 Develops from long-standing right sided heart
failure
 Results in patients with cor-pulmonale, constrictive
pericarditis, and tricuspid insufficiency
Diagnostic Studies:
• Enzyme levels (AST, ALT)
•
initially elevated due to release from damaged liver cells
• In end-stage liver disease
•
AST & ALT may be normal
• Decrease:
•
•
total protein
albumin
• Increase:
•
•
serum bilirubin
globulin levels
• Prothrombin time prolonged
Early Signs of cirrhosis:
 Nausea and vomiting
 Anorexia
 Diarrhea or constipation
 Pain
 Fever
 Weight loss
Later Manifestations:
 Jaundice
 Skin Lesions/Spider angiomas
 Palmer erythema
 Thrombocytopenia, Leukopenia, Anemia
 Coagulation disorders
 Endocrine disturbance
 Peripheral neuropathy & peripheral edema
Jaundice
• Results from functional derangement of liver
cells, compression of bile ducts
• Liver’s decreased ability to excrete _________
• + Biliary obstruction, obstructive jaundice may
occur accompanied by pruritus (accumulation
of bile salts)
Skin Lesions
• WHY?
• Dilated blood vessels (spider angiomas)
• Palmar erythema
Hematologic Problems




Thrombocytopenia
Leukopenia
Anemia
Vitamin K deficiency
www.elements4health.com
Endocrine Problems:




Inactivation of adrenocortical hormones
Men
Women
Hyperaldosteronism
Peripheral Neuropathy
&
Peripheral Edema
 Neuropathies due to:
 Results in mixed nervous
symptoms
 Sensory symptoms are
most common
 Edema due to:
http://www.jhu.edu
Complications:
 Portal Hypertension
 Esophageal & Gastric Varices
 Peripheral Edema & Ascites
 Hepatic Encephalopathy
Complications:
Portal Hypertension
• Compression and destruction of portal &
hepatic veins
• Increased venous pressure in portal
circulation
• Characterized by:
• Collateral circulation develops
Complications:
Esophageal & Gastric Varices:
• Esophageal:
•
•
Complex of twisting veins at lower end of esophagus
enlarged & swollen
• Gastric•
•
upper portion of stomach
may occur alone or in combination with esophageal
• Tolerate high pressure poorly, bleeding
easily with distention
• Rupture in response to irritation
• Most life threatening complication!!
Treatment for Varices:
•
•
•
•
•
•
Stop bleeding, manage airway, prevent aspiration of blood!!
Drug Therapy:
• Propranolol, Sandostatin, Vasopressin, NTG
Band ligation of varices
Endoscopic sclerotherapy
• thromboses and obliterates distended veins
Balloon tamponade-mechanical compresson of varices
• Sengstaken-Blakesmore
Avoid:
• alcohol & irritating foods
• What common drugs should be avoided?
Sengstaken-Blakesmore
www. medical-dictionary.com
Sengstaken-Blakemore Tube
Three Lumens:
 Esophageal balloon
inflation
 Gastric balloon
inflation
 Gastric aspiration
Acute Bleed
Supportive Measures:
•
FFP, PRBC’s, Vitamin K
•
Antibiotics
•
Protonix, Zantac
•
Propanolol
•
Prevent factors that may increase intra-abdominal pressure
•
Higher incidence of recurrent bleeds, so continued therapy is
necessary!!
Shunting Procedures:
 Used more after 2nd major bleeding
episode
 TIPS
 shunt is placed between systemic and
portal venous systems
 redirect’s portal blood flow
 reduces portal venous pressure
 decompresses varices
 contraindicated in patient’s with
hepatic encephalopathy
TIPS
Transjugular intrahepatic
portosystemic shunt
Complications:
Ascites & Peripheral Edema
• Results from impaired liver synthesis of
albumin = hypoalbuminemia
• Occurs as ankle and presacral edema
• Ascites
• accumulation of serous fluid in
periotoneal or abdominal cavity
• Hyperaldosteronism
Four Factors Lead to Ascites
Hypoproteinemia
Increased Na+
&
Increased
capillary
permeability
H2O retention
Portal Hypertension
www.patient.co.uk
Nursing Management of ASCITES:
 Assess for respiratory
distress

Fowler’s position helps ease
work of breathing
 Daily weights
 Measure abdominal girth
 Accurate I&O
Medical Management of Ascites:
•
•
•
•
Na+ and Fluid restriction
Albumin
Diuretic therapy:
• Aldactone, HCTZ, Lasix
Paracentesis
• needle puncture of abdominal cavity to remove ascitic
fluid- temporary
• have patient void before procedure
Management of Ascites:
• Peritoneovenous Shunt
• surgical procedure
• provides continuous reinfusion of
ascitic fluid into venous system
• Not 1st line therapy due to high
number of complications
• Does not improve survival rates
Hepatic Encephalopathy:
• Terminal complication of liver disease
• Disorder of protein metabolism and excretion
• Ammonia
• enters the systemic circulation without liver
detoxification
• crosses blood-brain barrier, causing
neurologic toxic manifestations
• Four stages of manifestations
http://chemistry.about.com
Where does ammonia come from?
 A by-product of protein metabolism
 Protein and amino acids are broken down by
bacteria in GI tract, producing ammonia.
 Liver converts this to urea which is eliminated
in the urine
Hepatic Encephalopathy
Stages
0-1st
 Insomnia
 Personality changes
 Disturbances of
awareness
 Forgetfulness,
irritability, &
confusion
 Trouble writing
http://lukeromyn.com/blog
Hepatic Encephalopathy
Stages
2nd & 3rd
 Lethargy, drowsiness
 Inappropriate speech

Slurred speech
 Disorientation
 Asterixis

flapping tremors
 Hiccups
 Hyperactive reflexes
 Violent behavior
 Slow, deep respirations
 Fetor hepaticus

musty sweet smell to breath
Hepatic Encephalopathy
Stages
th
4
 + Babinski
 Possible
seizures
 Swelling of
brain tissue
Treatment
Hepatic Encephalopathy
•
•
•
•
•
•
Reduce ammonia formation
• Lactulose
Control GI bleeding
Decreasing protein in intestine
Neomycin
Electrolyte replacement
Possible liver transplant
• (depends on a number of factors)
Hepatorenal Syndrome:
 Serious complication
 Functional renal failure with advancing
azotemia, oliguria, and ascites
 Portal hypertension + liver
decompensation = decreased arterial
blood volume & renal vasoconstriction
 May be reversed by liver transplantation
Nutritional Therapy:
• High calorie/High Carb diet
• Low protein diet
•
if Hepatic Encephalopathy present
• Parenteral nutrition of tube
feedings may be required
• Low-sodium diet
•
if ascites and edema
• Dietary education on reading labels
at home
www.reneerogers.com/nutrition
Overall Goals:
 Relief of discomfort
 Minimal to no complications
 (ascites, varices, hepatic encephalopathy)
 Return to normal as possible lifestyle
http://www.fontana.org/index
Liver Dialysis
 Bridge to transplant
 Dialyze 6 hours at a time
Donors:
 Live donor liver transplants are an excellent option.
 Liver regenerates to appropriate size for their
individual bodies.
 Survival rates increase / shorter wait time
 The donor - a blood relative, spouse, or friend, will
have extensive medical and psychological
evaluations to ensure the lowest possible risk.
Liver Transplantation
 Blood type and body size are critical factors in determining
who is an appropriate donor.
 Potential donors evaluated for:
 liver disease, alcohol or drug abuse, cancer, or infection.
 hepatitis, AIDS, and other infections.
 matched according to blood type and body size.
 Age, race, and sex are not considered.
 Cadaver donor have to wait
Liver Transplant Video
Liver Transplant
complications
 Rejection. About 70% of all liver-transplant patients have




some degree of organ rejection prior to discharge.
Anti-rejection medications are given to ward off the
immune attack.
Infection
Most infections can be treated successfully as they occur.
Cancer
Review Questions:
1. A priority of care for a client having a
paracentesis is to?
A. Force fluids, instruct patient to keep
bladder full prior to procedure
B. Instruct patient on how to cough
during procedure
C. Assist patient into supine position with
feet elevated
D. Monitor patient’s BP during and after
procedure
2. After receiving shift report, which of
the following patients would you see
first?
A. 56 year old with Hepatitis B and D
B. 58 year old male, recently diagnosed
with hepatic cancer
C. Patient with esophageal varices treated
with sclerotherapy this AM.
D. Patient with splenomegaly, anemia,
and PLT count of 60,000
3. During the treatment of a patient with
active bleeding esophageal varices, the
priority nursing goal is to:
A. Perform guiac testing on all stool
B. Prevent aspiration of blood
C. Prepare the client for portal vein
shunting
D. Monitor effect of IV Vasopressin
http://www.murketing.com/journal