Liver CirrhosisLiver Cirrhosis

OutlineOutline

• What is cirrhosis?What is cirrhosis?• What causes cirrhosis?What causes cirrhosis?• What are the symptoms of cirrhosis?What are the symptoms of cirrhosis?• What are the complications of cirrhosis?What are the complications of cirrhosis?• How is cirrhosis diagnosed?How is cirrhosis diagnosed?• How is the severity of cirrhosis measured?How is the severity of cirrhosis measured?• How is cirrhosis treated?How is cirrhosis treated?• Nursing ManagementNursing Management• When is a liver transplant indicated for cirrhosis?When is a liver transplant indicated for cirrhosis?

What is cirrhosisWhat is cirrhosis??

Is a condition in which the liver slowly Is a condition in which the liver slowly deteriorates and malfunctions due to deteriorates and malfunctions due to chronic injury. Scar tissue replaces chronic injury. Scar tissue replaces healthy liver tissue, partially blocking healthy liver tissue, partially blocking the flow of blood through the liverthe flow of blood through the liver . .

-Scarring also impairs the liver’s ability to-Scarring also impairs the liver’s ability to::

• control infectionscontrol infections

• remove bacteria and toxins from the bloodremove bacteria and toxins from the blood

• process nutrients, hormones, and drugsprocess nutrients, hormones, and drugs

• make proteins that regulate blood clottingmake proteins that regulate blood clotting

• produce bile to help absorb fats—including produce bile to help absorb fats—including cholesterol—and fat-soluble vitaminscholesterol—and fat-soluble vitamins

A healthy liver is able to regenerate A healthy liver is able to regenerate most of its own cells when they most of its own cells when they become damaged. With end-stage become damaged. With end-stage cirrhosis, the liver can no longer cirrhosis, the liver can no longer effectively replace damaged cellseffectively replace damaged cells . .

• Cirrhosis is the twelfth leading cause Cirrhosis is the twelfth leading cause of death by disease, accounting for of death by disease, accounting for 27,000 deaths each year.(1) The 27,000 deaths each year.(1) The condition affects men slightly more condition affects men slightly more often than women.often than women.

(1) Miniño AM, Heron MP, Murphy SL, Kochanek KD. Deaths: Final data for (1) Miniño AM, Heron MP, Murphy SL, Kochanek KD. Deaths: Final data for

2004. Centers for Disease Control and Prevention Web site.2004. Centers for Disease Control and Prevention Web site.

There are three types of There are three types of cirrhosis livercirrhosis liver::

•Alcoholic cirrhosis

The scar tissue characteristically surrounds the portal areas. This is most frequently due to chronic alcoholism and is the most common type of cirrhosis.

•Postnecrotic cirrhosis

There are broad bands of bscar tissue as a late result of a previous bout of acute viral hepatitis.

•Biliary cirrhosis

Scarring occurs in the liver around the bile ducts. This type usually is the result of chronic biliary obstruction and infection (cholangitis); it is much less common than the other two types.

What causes cirrhosisWhat causes cirrhosis??

• Alcohol-related liver diseaseAlcohol-related liver disease

• Chronic hepatitis B CChronic hepatitis B C DD

• Nonalcoholic fatty liver disease Nonalcoholic fatty liver disease (NAFLD)(NAFLD)

• Autoimmune hepatitisAutoimmune hepatitis

• Diseases that damage or destroy bile Diseases that damage or destroy bile ductsducts

• Inherited diseasesInherited diseases

• Drugs, toxins, and infectionsDrugs, toxins, and infections

What are the symptoms of What are the symptoms of cirrhosiscirrhosis??

• CompensatedCompensated

• DecompensatedDecompensated

CompensatedCompensated

• Intermittent mild feverIntermittent mild fever• Vascular spidersVascular spiders• Palmar erythema (reddened palms)Palmar erythema (reddened palms)• Unexplained epistaxisUnexplained epistaxis• Ankle edemaAnkle edema• Vague morning indigestionVague morning indigestion• Flatulent dyspepsiaFlatulent dyspepsia• Abdominal painAbdominal pain• Firm, enlarged liverFirm, enlarged liver• SplenomegalySplenomegaly

DecompensatedDecompensated

• AscitesAscites• JaundiceJaundice• WeaknessWeakness• Muscle wastingMuscle wasting• Weight lossWeight loss• Continuous mild feverContinuous mild fever• Clubbing of fingersClubbing of fingers• Purpura (due to decreased platelet count)Purpura (due to decreased platelet count)• Spontaneous bruisingSpontaneous bruising• EpistaxisEpistaxis• HypotensionHypotension• Sparse body hairSparse body hair• White nailsWhite nails• Gonadal atrophyGonadal atrophy

What are the complications What are the complications of cirrhosisof cirrhosis??

• Liver enlargementLiver enlargement

• Edema and ascites Edema and ascites

• Portal hypertension Portal hypertension

• Esophageal varices and Esophageal varices and gastropathy gastropathy

• Jaundice Jaundice

• GallstonesGallstones

• Sensitivity to medications Sensitivity to medications

• Hepatic encephalopathy Hepatic encephalopathy

• Insulin resistance and type 2 Insulin resistance and type 2 diabetes diabetes

• Liver cancer Liver cancer

• Other problemsOther problems Cirrhosis can cause immune Cirrhosis can cause immune system dysfunction, leading to the risk of infection. system dysfunction, leading to the risk of infection. Cirrhosis can also cause kidney and lung failure, known Cirrhosis can also cause kidney and lung failure, known

as hepatorenal and hepatopulmonary syndromes.as hepatorenal and hepatopulmonary syndromes.

How is cirrhosis How is cirrhosis diagnoseddiagnosed??

• History History • Physical examination Physical examination • Blood testsBlood tests• UltrasoundUltrasound• CT scanCT scan• MRI MRI • liver biopsy liver biopsy

- -Physical examinationPhysical examination: :

Obesity, the liver may feel hard or Obesity, the liver may feel hard or enlargedenlarged

And ascitesAnd ascites..

- Blood testsBlood tests serum albumin level (Decreased) serum globulin level (Increased) serum alkaline phosphatase (Increased) AST,ALT, and GGT levels (Increased) serum cholinesterase level (Decreased) Bilirubin (Increased)

-Ultrasound

Used to measure the difference in density of parenchymal cells and scar tissue.

--MRI and CT scanMRI and CT scan

Give information about liver size and hepatic blood flow and obstruction.

--Liver biopsy

can confirm the diagnosis of cirrhosis but is not always necessary.

How is the severity of How is the severity of cirrhosis measuredcirrhosis measured??

• MELD : The Model for End-stage Liver Disease .MELD : The Model for End-stage Liver Disease .

--The MELD score was developed to predict the The MELD score was developed to predict the 90-day survival of people with advanced 90-day survival of people with advanced cirrhosis.cirrhosis.

--MELD scores usually range between 6 and 40, MELD scores usually range between 6 and 40, with a score of 6 indicating the best likelihood with a score of 6 indicating the best likelihood of 90-day survival.of 90-day survival.

The MELD score is based on The MELD score is based on three blood teststhree blood tests::

• international normalized ratio (INR)—international normalized ratio (INR)—tests the clotting tendency of bloodtests the clotting tendency of blood

• bilirubin—tests the amount of bile bilirubin—tests the amount of bile pigment in the bloodpigment in the blood

• creatinine—tests kidney functioncreatinine—tests kidney function

How is cirrhosis treatedHow is cirrhosis treated??

• Eating a nutritious diet Eating a nutritious diet

• Avoiding alcohol and other substances Avoiding alcohol and other substances

• MedicationsMedications::--DiureticsDiuretics --Oral and IV antibioticsOral and IV antibiotics --Beta-blocker or nitrateBeta-blocker or nitrate --LactuloseLactulose--Corticosteroids Corticosteroids --antiviralantiviral

**hemodialysis treatment hemodialysis treatment

Nursing ManagmentNursing Managment

--Diagnosis

--Planning and Goals

--Nursing Interventions

-Evaluation

--DiagnosisDiagnosis

1-1- Activity intolerance related to fatigue, general Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort.debility, muscle wasting, and discomfort.

2-2- Imbalanced nutrition, less than body Imbalanced nutrition, less than body requirements, related to chronic gastritis, requirements, related to chronic gastritis, decreased GI motility, and anorexia.decreased GI motility, and anorexia.

3-3- Impaired skin integrity related to compromised Impaired skin integrity related to compromised immunologic status, edema, and poor nutrition.immunologic status, edema, and poor nutrition.

4-4- Risk for injury and bleeding related to altered Risk for injury and bleeding related to altered clottingclotting

mechanisms mechanisms and altered level of consciousness.

-Planning and Goals

The goals for the patient may include increased participation in activities, improvement of nutritional status, improvement of skin integrity, decreased potential for injury, improvement ofmental status, and absence of complications.

Patient reports decrease in fatigue and reports increased ability to participate in activities

Positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements

Decrease potential for pressure ulcer development; breaks in skin integrity

Reduced risk of injury

Nursing InterventionsNursing Interventions Promoting restPromoting rest

The patient with active liver disease requires rest and other supportive measures to permit the liver to reestablish its functionalability.

If the patient is hospitalized, weight and fluid intake and output are measured and recorded daily.

Improving nutritional statusImproving nutritional status

--high-protein diet if tolerated

-supplemented by vitamins of the B complex and others as indicated (including vitamins A, C, K and folic acid).

-Patients with fatty stools (steatorrhea) should receive watersoluble forms of fat-soluble vitamins—A, D, and E (Aquasol A, D, and E).

Providing skin careProviding skin care

--Providing careful skin care is important because of subcutaneous edema, the patient’s immobility, jaundice, and increased susceptibility to skin breakdown and infection.

-Frequent position changes are necessary to prevent pressure ulcers.

Reducing risk for injuryReducing risk for injury

--The nurse protects the patient with cirrhosis from falls and other injuries. The side rails should be in place and padded with blankets in case the patient becomes agitated or restless.

-To minimize agitation, the nurse orients the patient to time and place and explains all procedures.

--The nurse instructs the patient to ask for assistance to get out of bed.

-The nurse carefully evaluates any injurybecause of the possibility of internal bleeding.

-Evaluation-Expected patient outcomes may include:

1. Participates in activities

2. Increases nutritional intake

3. Exhibits improved skin integrity

4. Avoids injury

5. Is free of complications

When is a liver transplant When is a liver transplant indicated for cirrhosisindicated for cirrhosis??

• Is used to treat life-threatening, end-stage

liver disease for which no other form of treatment is available.

•The transplantation procedure involves total removal of the diseased liver and its replacement with a healthy liver.

Liver donor requirementsLiver donor requirements

• Being in good healthBeing in good health • Having aHaving a blood type that matches or is blood type that matches or is

compatible with the recipient'scompatible with the recipient's • Having a charitable desire of donation without Having a charitable desire of donation without

financial motivationfinancial motivation • Being between 18 and 60 years oldBeing between 18 and 60 years old • Being of similar or bigger size than the recipientBeing of similar or bigger size than the recipient • Before one becomes a living donor, the donor Before one becomes a living donor, the donor

must undergo testing to ensure that the must undergo testing to ensure that the individual is physically fitindividual is physically fit. .

-SURGICAL PROCEDURE

--The donor liver is freed from other structures :

The bile is flushed from the gallbladder to prevent damage to the walls of the biliarytract.

Before the donor liver is placed in the recipient, it is flushed with cold lactated Ringer’s solution to remove potassiumand air bubbles.

Anastomoses (connections) of the blood vessels and bile duct are performed between the donor liver and the recipient liver.

Biliary reconstruction is performed with an end-to-end anastomosis of the donor and recipient common bile ducts; a stented T-tube is inserted for external drainage of bile.

If an end-to-end anastomosis is not possible because of diseased or absent bile ducts, an end-toside anastomosis is made between the common bile duct of the graft and a loop (Roux-en-Y portion) of jejunum .

In this case, bile drainage will be internal and a T-tube will not be inserted.

-COMPLICATIONS

The postoperative complication rate is high, primarily because of technical complications or infection.

Immediate postoperative complications may include:

1)Bleeding

2) Infection

3)Rejection

1) Bleeding

-Bleeding is common in the postoperative period and may result from coagulopathy, portal hypertension, and fibrinolysis caused by ischemic injury to the donor liver.

-Hypotension may occur in this phase secondary to blood loss.

Administration of platelets, fresh-frozen plasma, and other blood products may be necessary.

2) Infection

-precautions must be taken to prevent nosocomial infections:

strict asepsis when manipulating arterial lines and urine, bile, and other drainage, and changing dressings.

3) Rejection

Rejection is a key concernRejection is a key concern..

A transplanted liver is perceived by the immune system as a foreign antigen.

This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver.

Immunosuppressive agents are used long term to prevent this response and rejection of the transplanted liver.

These agents inhibit the activation ofimmunocompetent T lymphocytes to prevent the production of effector T cells.

Corticosteroids, azathioprine, mycophenolate mofetil, rapamycin, antithymocyte globulin, and OKT3 are also elements of the various regimens of immunosuppression and may be used as the initial therapy to prevent rejection, or later to treat rejection.

Liver biopsy and ultrasound may be required to evaluate suspected episodes of rejection.

Complications for the donorComplications for the donor

Other risks of donating a liver include Other risks of donating a liver include bleeding, infection, painful incision, bleeding, infection, painful incision, possibility of blood clots and a possibility of blood clots and a prolonged recoveryprolonged recovery..

Nursing Care

PREOPERATIVE CAREPREOPERATIVE CARE

• •Obtain a complete nursing history and Obtain a complete nursing history and physical examination. A complete physical examination. A complete preoperative nursing assessment provides preoperative nursing assessment provides baseline data for comparison after baseline data for comparison after surgerysurgery..

• •Discuss preoperative and postoperative Discuss preoperative and postoperative expectations with the client and family. expectations with the client and family. Introduce to the intensive care unit, and Introduce to the intensive care unit, and discuss anticipated drainage tubes and discuss anticipated drainage tubes and supportive measures in the immediate supportive measures in the immediate postoperative periodpostoperative period..

Preoperative teaching helps relieve anxiety in the client and family members.

Clients return from surgery to an intensivecare or specialized care unit. Restrictions on the number of visitors and the time they may spend with the client are common.

Once a donor liver is located, check for Once a donor liver is located, check for evidence of infection;if no infection is evidence of infection;if no infection is present, begin preoperative antibiotics as present, begin preoperative antibiotics as orderedordered . .

An acute or chronic infection may contraindicate liver transplantation as drugs given postoperatively to suppress rejection of the transplanted organ also impair the ability to fight infection.

POSTOPERATIVE CAREPOSTOPERATIVE CARE

• •Maintain airway and ventilatory support until awake and Maintain airway and ventilatory support until awake and alertalert..Until the new liver clears the anesthesia, the client requires Until the new liver clears the anesthesia, the client requires measuresmeasuresto support respirations and ventilationto support respirations and ventilation..

• •Monitor temperature and implement rewarming measuresMonitor temperature and implement rewarming measures((such as warming blankets,heating lamps, and head coverssuch as warming blankets,heating lamps, and head covers ) )asas

indicatedindicated . .The client often is hypothermic after liver transplant, The client often is hypothermic after liver transplant, necessitating careful rewarming while maintaining necessitating careful rewarming while maintaining hemodynamichemodynamicstabilitystability..

• •Frequently monitor hemodynamic Frequently monitor hemodynamic pressures, including arterial blood pressures, including arterial blood pressure, central venous pressure, and pressure, central venous pressure, and pulmonary artery pressurespulmonary artery pressures . .

Postoperative fluid volume status may be Postoperative fluid volume status may be difficult to determine without careful difficult to determine without careful pressure measurementspressure measurements..

The rate and type of fluids administered are The rate and type of fluids administered are determined by hemodynamicdetermined by hemodynamic

statusstatus..

• •Monitor urine output hourly;maintain Monitor urine output hourly;maintain careful intake and output careful intake and output records.Weigh dailyrecords.Weigh daily..

Urine output and weight provide Urine output and weight provide additional information about fluid additional information about fluid volume status. In addition, renal volume status. In addition, renal function may be altered after liver function may be altered after liver transplant; acute renal failure is a transplant; acute renal failure is a significant risksignificant risk..

• •Monitor for signs of active bleeding, Monitor for signs of active bleeding, including excess drainage, increasing including excess drainage, increasing abdominal girth, bloody nasogastric abdominal girth, bloody nasogastric drainage, black tarry stools, tachypnea, drainage, black tarry stools, tachypnea, tachycardia, diminished peripheraltachycardia, diminished peripheral

pulses, or pallor. Report immediatelypulses, or pallor. Report immediately..

Altered coagulation in the early Altered coagulation in the early postoperative period increases the risk for postoperative period increases the risk for bleeding. Bloodbleeding. Blood

products to replace volume and clotting products to replace volume and clotting factors may be necessaryfactors may be necessary..

• •Monitor serum electrolytes and laboratory Monitor serum electrolytes and laboratory values related to blood coagulation, liver values related to blood coagulation, liver function, and renal function. Report function, and renal function. Report abnormal results or significant changes abnormal results or significant changes immediatelyimmediately..

Electrolyte imbalances are common Electrolyte imbalances are common postoperativelypostoperatively..

Altered liver or renal function tests may Altered liver or renal function tests may indicate rejection of the transplanted liver indicate rejection of the transplanted liver or acute renal failureor acute renal failure..

Other early signs of transplant rejection Other early signs of transplant rejection include fever, a drop in bile output, or a include fever, a drop in bile output, or a change in bile color and Viscositychange in bile color and Viscosity..

• •Monitor neurologic status. With good Monitor neurologic status. With good function of the transplanted organ, function of the transplanted organ, mental status should clear within mental status should clear within days of thedays of the

transplanttransplant..

• •Provide discharge teachingProvide discharge teaching::

a. Teach how to reduce risk of infection, a. Teach how to reduce risk of infection, and signs of infection to reportand signs of infection to report..

b. Instruct to recognize and report signs b. Instruct to recognize and report signs of organ rejectionof organ rejection..

c. Discuss all medications, including c. Discuss all medications, including their purpose, schedule, adverse their purpose, schedule, adverse effects, and potential long-term effects, and potential long-term effectseffects..

Stress the importance of complying Stress the importance of complying with all prescribed medications and with all prescribed medications and postoperative precautions for the postoperative precautions for the remainder of the client’s liferemainder of the client’s life..

d. Discuss possible changes in body d. Discuss possible changes in body image and psychologic responses to image and psychologic responses to receiving a transplanted organ. Refer receiving a transplanted organ. Refer to a counselor or support group as to a counselor or support group as indicatedindicated..

e. Refer for home health services for e. Refer for home health services for continued assessment and teachingcontinued assessment and teaching..

f. Stress importance of continued follow-f. Stress importance of continued follow-up with transplantup with transplant