Cirrhosis Flashcards
Cirrhosis
Normal Lobular structure of the liver is distorted by fibrotic connective tissue. Scarred tissue presses hepatic cells between them.
Lobules are irregular in size and shape with impaired vascular flow
Insidious, prolonged course
Cirrhosis Patho
Some offending agent such as alcohol intake over many years causes cell necrosis
Destroyed liver cells are replaced by scar tissue
Normal architecture becomes nodular
Alcoholic Cirrhosis
Associated with alcohol abuse
Preceded by a potentially reversible fatty infiltration of liver cells
Widespread scar formation
Post-necrotic cirrhosis
Complication of toxic or viral hepatitis
~20% of cases
Broad bands of scar tissue form within liver
Biliary Cirrhosis
Associated with chronic obstruction and infection of bile ducts, bile can’t move well out of liver so it stagnates and causes inflammation
~15% all cases
Cardiac Cirrhosis
Secondary to longstanding severe right sided heart failure
Caused by the transmission of elevated right atrial pressure to the liver via inferior vena cava and hepatic veins
Treatment is often aimed at underlying heart failure
Lab studies
Protein-decreased albumin level
Increased alkaline phosphate, AST/SGOT, ALT/SGPT
Prolonged PT, PTT
Increased total bili
Increased ammonia level (byproduct of protein metabolism which liver processes by turning to urea)
Physical Manifestations of Cirrhosis
Onset usually insidious GI disturbances Anorexia Dyspepsia Flatulence N&V, change in bowel habits Abdominal pain Fever Weight loss Enlarged liver or spleen
Hematologic Manifestations of Cirrhosis
Jaundice: occurs because insiffucient conjugation of bili by the liver cells and local obstruction of biliary ducts by scarring and regenerating tissue
Hematologic disorders (blood cells don’t form quite right)
Bleeding tendencies as result of decreased production of clotting factors
Anemia, leukopenia, thrombocytopenia resulting from enlarged spleen
Dietary deficiencies of thiamine, folic acid, B12
Portal HTN
Peripheral edema and Ascites: intraperitoneal accumulation of watery fluid containing small amounts of protein
Due to hypoalbumenia, elevated aldosterone and ADH, and portal HTN
Portal Hypertension
Primary mechanism is the increased resistance to blood flow through the liver
Characterized by: splenomegaly, esophageal varices, increased venous pressure in the portal circulation, systemic HTN, Caput Medusae: collateral circulation involves the superficial veins of the abdominal wall leading to the development of dilated veins around the umbilicus
Splenomegaly
back pressure caused by portal HTN 🡪 chronic passive congestion as a result of increased pressure in the splenic vein
Esophageal varices
blood flow backs up through portal system resulting in dilation and enlargement of plexus veins of esophagus and produces varices; can impair swallowing and are susceptible to bleeding
Management of Esophageal Varices
Avoid alcohol, aspirin, and irritating food
Control coughing
Non-selective beta blockers to reduce risk of bleeding
If bleeding occurs, stabilize patient and manage the airway, administer vasopressin (Pitressin)
Prepare Pt with Esophageal Varices For:
Endoscopic sclerotherapy or ligation
Balloon tamponade – used when patient is bleeding
Shunting procedures (portacaval shunt, TIPS)
Tips – Transjugular Intrahepatic Portosystemic Shunt: tunnel through the liver connect portal vein to one of the hepatic veins to decrease pressure and in 90% of cases reduces variceal bleeding
Sengstaken-Blakemore tube
Hepatic Encephalopathy
Liver damage cause blood to enter the systemic circulation without liver detox
Main pathogenic toxin is Ammonia (NH3) although other etiologic factors have been identified
Frequently results in coma and death
Management of Encephalopathy
Goal: reduce ammonia (NH3) formation
Protein restriction: 0-40g/day
Sterilization of GI tract with Abx (neomycin)
Lactulose (Cephulac): traps ammonia in gut to be expelled
Stages of Hepatic Encephalopathy
- Awake, apathetic, mental clouding
- Decreased LOC, lethargy, drowsiness, confusion, disoriented to time/place asterixis – flapping tremor
- Stupor, Seizures
- Coma
Ascites
Can interfere with eating, sleeping, breathing
Management of Ascites
High carb, low protein, low sodium diet
Diuretics
Peritoneovenous shunt provides for continuous reinfusion of ascitic fluid from abdomen to vena cava
Paracentesis: procedure to remove accumulated fluid in the peritoneal cavity
After procedure:
Monitor VS and dressing for excessive fluid leak
Place in high fowler’s
Encourage coughing and deep breathing
Monitor resp status
Hepatorenal Syndrome
Characterized by renal failure with advancing azotemia (buildup of nitrogenous waste products in the blood) and oliguria
The kidneys are normal but can’t process toxic load that liver is failing to clear
Renal failure results from the damaged liver
Best managed by CRRT due to patient hemodynamic instability
Collaborative Care
Rest, plan rest periods Avoidance of alcohol and anticoagulants Management of ascites Prevention and management of esophageal variceal bleeding Management of encephalopathy
Fetor Hepaticus
Musty sweetish odor detected on patient’s breath
From accumulation of by-products
Medications
No specific drug therapy for cirrhosis
Drugs used to treat symptoms and complications
Vasopressors for variceal bleeding
Diuretics given to patients who have significant ascites
Patients often are given lactulose, a sugary alcohol that doesn’t get absorbed, stays in GI and helps to keep ammonia in GI tract to be excreted
Does cause stools to form 🡪 diarrhea
Neomycin: aminoglycoside antibiotic, not absorbed, stays in GI and kills off bacteria that live in GI tract that produce ammonia, given to decrease ammonia levels
Nursing Role for Cirrhosis
Patients with cirrhosis may be faced with a prolonged illness and the possibility of serious, life-threatening problems and complications
Teach lifestyle modifications to reduce complications
The patient and caregiver(s) need to understand the importance of continuous healthcare and medical supervision
Transportation considerations
Cirrhosis is a chronic disease that affects the patient physically, socially, psychologically, emo
Teaching your patient and the caregiver about the management of liver disease also includes a collaborative approach to care with other health team professionals
Consulting social services, case management, and understanding what needs the patient and/or caregiver may need is important to assess the RN
Referrals to community groups and organizations is part of the nursing role
