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Hepatic Cirrhosis

Mr. Cruz has always been fond of drinking alcohol since he was in his high school. Up until his mid-50s, his habit of drinking has never worn off. One day, he felt pain at his abdomen. He also noticed that his once big belly is now larger than usual. Alarmed, he had himself examined by a physician, and it was found out that Mr. Cruz has hepatic cirrhosis, specifically Laennec’scirrhosis.

Description


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.
  • The prognosis is better in noncirrhotic forms of hepatic fibrosis, which cause minimal hepatic dysfunction and don’t destroy liver cells.

Classification


These clinical types of cirrhosis reflect its diverse etiology:
  • 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.
  • Biliary cirrhosis. Biliary cirrhosis results in injury or prolonged obstruction.
  • Postnecrotic cirrhosis. Postnecrotic cirrhosis stems from various types of hepatitis.
  • Pigment cirrhosis. Pigment cirrhosis may result from disorders such as hemochromatosis.
  • Cardiac cirrhosis. Cardiac cirrhosis refers to cirrhosis caused by right-sided heart failure.
  • Idiopathic cirrhosis. Idiopathic cirrhosis has no known cause.

Pathophysiology


Although several factors have been implicated in the etiology of cirrhosis, alcohol consumption is considered the major causative factor.
  • 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.

Statistics and Incidences


Various types of cirrhosis may occur in different types of individuals.
  • The most common, Laennec’s cirrhosis, occurs in 30% to 50% of cirrhotic patients.
  • Biliary cirrhosis occurs in 15% to 20% of patients.
  • Postnecrotic cirrhosis occurs in 10% to 30% of patients.
  • Pigment cirrhosis occura in 5% to 10% of patients.
  • Idiopathic cirrhosis occurs in about 10% of patients.

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.

Clinical Manifestations


Clinical manifestations of the different types of cirrhosis are similar, regardless of the cause.
  • GI system. Early indicators usually involve gastrointestinal signs and symptoms such as anorexia, indigestion, nausea, vomiting constipation, or diarrhea.
  • Respiratory system. Respiratory symptoms occur late as a result of hepatic insufficiency and portal hypertension, such as pleural effusion and limited thoracic expansion due to abdominal ascites, interfering with efficient gas exchange leading to hypoxia.
  • 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, extreme obtundation, and ultimately, coma.
  • Hematologic.The patient experiences bleeding tendencies and anemia.
  • Endocrine. The male patient experiences testicular atrophies, while the female patient may have menstrual irregularities, and gynecomastia and loss of chest and axillary hair.
  • Skin. There is severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema, and possibly jaundice.
  • Hepatic. Cirrhosis causes jaundice, ascites, hepatomegaly, edema of the legs, hepatic encephalopathy, and hepatic renal syndrome.

Complications


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

Assessment and Diagnostic Findings


Laboratory findings and imaging studies that are characteristic of cirrhosis include:
  • Liver scan. Liver scan shows abnormal thickening and a liver mass.
  • Liver biopsy. Liver biopsy is the definitive test for cirrhosis as it detects destruction and fibrosis of the hepatic tissue.
  • Liver imaging. Computed tomography scan, ultrasound, and magnetic resonance imaging may confirm the diagnosis of cirrhosis through visualization of masses, abnormal growths, metastases, ans venous malformations.
  • Cholecystography and cholangiography. These two visualize the gallbladder and the biliary duct system.
  • Splenoportal venography. Splenoportal venography visualizes the portal venous system.
  • Percutaneous transhepatic cholangiography. This test differentiates intrahepatic from extrahepatic obstructive jaundice and discloses hepatic pathology and the presence of gallstones.
  • Complete blood count. There is decreased white blood cell count, hemoglobin level and hematocrit, albumin, or platelets.

Medical Management


Treatment is designed  to remove or alleviate the underlying cause of cirrhosis.
  • Diet. The patient may benefit from a high-calorie and a medium to high protein diet, as developing hepatic encephalopathy mandates restricted protein intake.
  • Sodium restriction.is usually restricted to 2g/day.
  • Fluid restriction. Fluids are restricted to 1 to 1.5 liters/day.
  • Activity. Rest and moderate exercise is essential.
  • Paracentesis. Paracentesis may help alleviate ascites.
  • Sengstaken-Blakemore or Minnesota tube. The Sengstaken-Blakemore or Minnesota tube may also help control hemorrhage by applying pressure on the bleeding site.

Pharmacologic Therapy

Drug therapy requires special caution because the cirrhotic liver cannot detoxify harmful agents effectively.
  • Octreotide. If required, octreotide may be prescribed for esophageal varices.
  • Diuretics. Diuretics may be given for edema, however, they require careful monitoring because fluid and electrolyte imbalance may precipitate hepatic encephalopathy.
  • Lactulose. Encephalopathy is treated with lactulose.
  • Antibiotics. Antibiotics are used to decrease intestinal bacteria and reduce ammonia production, one of the causes of encephalopathy.

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.

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, and monitoring and managing complications.

Nursing Assessment

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

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis for the patient are:

Nursing Care Planning & Goals

Main Article: 8 Liver Cirrhosis Nursing Care Plans

The major goals for a patient with cirrhosis are:
  • Report decrease in fatigue and increased ability to participate in activities.
  • Maintain a positive nitrogen balance, no further loss of muscle mass, and meet nutritional requirements.
  • Decrease potential for pressure ulcer development and breaks in skin integrity.
  • Reduce the risk of injury.
  • Verbalize feelings consistent with improvement of body image and self-esteem.
  • Increase level of comfort.
  • Restore normal fluid volume.
  • Improve mental status, maintain safety, and ability to cope with cognitive and behavioral changes.
  • Improve respiratory status.

Nursing Interventions

The patient with cirrhosis needs close observation, first-class supportive care, and sound nutrition counseling. 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.
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.
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.
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.
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.
Home Management
  • Prepare for discharge by providing dietary instruction, including exclusion of alcohol.
  • Refer to Alcoholics Anonymous, psychiatric care, counseling, or spiritual advisor if indicated.
  • Continue sodium restriction; stress avoidance of raw shellfish.
  • Provide written instructions, teaching, support, and reinforcement to patient and family.
  • Encourage rest and probably a change in lifestyle (adequate,well-balanced diet and elimination of alcohol).
  • Instruct family about symptoms of impending encephalopathy and possibility of bleeding tendencies and infection.
  • Offer support and encouragement to the patient and provide positive feedback when the patient experiences successes.
  • Refer patient to home care nurse, and assist in transition from hospital to home.

Evaluation

Expected patient outcomes include:
  • Reported decrease in fatigue and increased ability to participate in activities.
  • Maintained a positive nitrogen balance, no further loss of muscle mass, and meet nutritional requirements.
  • Decreased potential for pressure ulcer development and breaks in skin integrity.
  • Reduced the risk of injury.
  • Verbalized feelings consistent with improvement of body image and self-esteem.
  • Increased level of comfort.
  • Restored normal fluid volume.
  • Improved mental status, maintain safety, and ability to cope with cognitive and behavioral changes.
  • Improved respiratory status.

Discharge and Home Care Guidelines

The focus of discharge education is dietary instructions.
  • Alcohol restriction. Of greatest importance is the exclusion of alcohol from the diet, so the patient may need referral to Alcoholics Anonymous, psychiatric care, or counseling.
  • Sodium restriction. Sodium restriction will continue for considerable time, if not permanently.
  • Complication education. The nurse also instructs the patient and family about symptoms of impending encephalopathy, possible bleeding tendencies, and susceptibility to infection.

Documentation Guidelines

The focus of documentation may include:
  • Level of activity.
  • Causative or precipitating factors.
  • Vital signs before, during, and following activity.
  • Plan of care.
  • Response to interventions, teaching, and actions performed.
  • Teaching plan.
  • Changes to plan of care.
  • Attainment or progress toward desired outcome.
  • Caloric intake.
  • Individual cultural or religious restrictions, personal preferences.
  • Availability and use of resources.
  • Duration of the problem.
  • Perceptio of pain, effects on lifestyle, and expectations of therapeutic regimen.
  • Results of laboratory tests, diagnostic studies, and mental status and cognitive evaluation.

Practice Quiz: Hepatic Cirrhosis


Here are some practice questions for this study guide:

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Hepatic Cirrhosis|Practice Mode

Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
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Text Mode

Text Mode: All questions and answers are given on a single page for reading and answering at your own pace. Be sure to grab a pen and paper to write down your answers. 1. Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily. B. Evidence of watery diarrhea. C. Daily deterioration in the client’s handwriting. D. Appearance of frothy, foul-smelling stools. 1. Answer: A. Passage of two or three soft stools daily.
  • A: Two or three soft stools daily indicate effectiveness of the drug.
  • B: Watery diarrhea indicates overdose.
  • C:  Daily deterioration in the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy.
  • D: Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
2. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility. B. Applying pressure to injection sites. C. Administering antibiotics as prescribed. D. Increasing nutritional intake. 2.  Answer: B. Applying pressure to injection sites.
  • B: Prolonged application of pressure to injection or bleeding sites is important.
  • A: Complete independence may increase the client’s potential for injury, because an unsupervised client may injure himself and bleed excessively.
  • C&D: Antibiotics and good nutrition are important to promote liver regeneration.
3. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise. B. Stomatitis. C. Hand tremors. D. Weight loss. 3. Answer: C. Hand tremors.
  • C:  Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common.
  • A&B: Malaise and stomatitis are not related to neurological involvement.
  • D:  These clients typically have ascites and edema so experience weight gain.
4.  A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? A. Range of motion every 4 hours. B. Turn and reposition every 2 hours. C. Abdominal and foot massages every 2 hours. D. Sit in chair for 30 minutes each shift. 4. Answer: B. Turn and reposition every 2 hours.
  • B: Careful repositioning can prevent skin breakdown.
  • A: Range of motion exercises preserve joint function but do not prevent skin breakdown.
  • C:  Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity.
  • D: The feet should be kept at the level of heart or higher so Fowler’s position should be employed.
5. The nurse must be alert for complications with Sengstaken-Blakemore intubation including: A. Pulmonary obstruction. B. Pericardiectomy syndrome. C. Pulmonary embolization. D. Cor pulmonale. 5. Answer: A. Pulmonary obstruction.
  • A: Rupture or deflation of the balloon could result in upper airway obstruction.
  • B, C, D: The other choices are not related to the tube.

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