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Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. The fibrosis alters liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. After years of liver inflammation, it will gradually lose its ability to function well, which can lead to a serious problem in other parts of the body.

The three classifications of Cirrhosis

  1. Alcoholic cirrhosis -scar tissue chacteristically surrounds the portal areas.This is the most prevalent type that caused by long history of chronic alcoholism
  2. Postnecrotic cirrhosis-consist broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis.
  3. Biliary cirrhosis-consist of scarring of liver around the bile ducts. This type of cirrhosis usually results from chronic biliary obstruction and infection(cholangitis) it is much less common than the other two classifications of cirrhosis.

Causes

The various causes of cirrhosis are a combination of alcohol, hepatis C or both. People with cirrhosis typically not caused by trauma to the liver or other acute or short term cause of damage. It usually years of prolonged injury required to cause the disease.

  1. Choronic alcoholism-The amount of alcohol intake is broken down act as a toxin, leading to inflammation .With prolonged use, scar tissue develops and the liver is unable to function properly.
  2. Viral or Autoimmune hepatitis-This disease appears to be caused by the immune system and inflammatory responses by attacking the liver and causing damage, and eventually scarring of the liver tissues
  3. Inherited or Genetic disorder-Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, galactosemia, and glycogen storage diseases are inherited diseases that interfere with how the liver produces, processes, and stores enzymes, proteins, metals, and other substances the body needs to function properly. Cirrhosis can result from these conditions
  4. Bile ducts obstruction-The duct thats carry the bile out of the liver blocked,bile backs up and damages liver tissue.
  5. Drugs and toxin-Prolonged exposure to drugs and enviromental toxins can lead to hepatic cell damage.

Clinical Manifestations

Signs and symptoms of cirrhosis increase in severity as disease progresses.Clinical manifestation are categories as compensated and decompensated.

Compensated cirrhosis means that the liver is heavily scarred but can still perform many important bodily functions. Many people with compensated cirrhosis experience few or no symptoms and can live for many years without serious complications.

      Compensated
     Decompensated
  • Intermitent mild fever
  • Vague morning indigestion
  • Vascular spiders
  • Flatulent dyspepsia
  • Palmar erythema(reddened palms)
  • Abdominal pain
  • Unexplained epitaxis
  • Firma,enlarged liver
  • Ankle edema
  • Splenomegaly
  • Ascites
  • Jaundice
  • Weakness
  • Muscle wasting
  • Weight loss
  • Continuous mild fever
  • clubbing of fingers
  • Purpura (due to decreased platelet count
  • Spontaneous bruising
  • Epitaxis
  • Hypotension
  • Sparse body hair
  • White nails
  • Gonadal atrophy

Decompensated cirrhosis means that the liver is extensively scarred and unable to function properly.People with decompensated cirrhosis eventually develop many symptoms and complications that can be life threatening.

Diagnostic Test

  • CT scan or Ultrasound– show shrinkage or abnormal appearance of the liver.
  • Laboratory studies – bilirubin, albumin, alanine transaminase (ALT), aspartate transaminase (AST),prothrombin time, and serum ammonia- to check for elevated values, which indicate hepatic cell destruction.
  • Laparoscopy and liver biopsy-direct visualization of the liver
  • Paracentesis-to examine ascetic fluid for cell,protein and bacterial counts.
  • Esophagoscopy– to determine the presence of esophageal varices.

Medical Management

Pharmacological

  • Potassium sparing diuretic spironolactone (Aldactone)-use to decreased ascited and pleural enffusion.
  • Lactulose(Cholac)-used to eliminate the ammonia from the blood into the bowel.Tap water enemas may also be ordered to help the body eliminate the ammonia.
  • Propranolol hydrochloride(Inderal)- an anti hypertensive medication  may be ordered to lower portal hypertension.

Surgical

  • Paracentesis– may perform to remove the fluid from the abdomen and relive pressure on the diaphragm and lungs.A paracentesis is done by making a small incision and inserting a trochar into the abdomen to drain the fluid. Albumin may be infused at the same time to pull excess fluid back into vascular system.
  • Esophagogastric intubation (balloon placed into the esophagus and inflated to put pressure on bleeding sites) or endoscopic sclerotherapy (placing a flexible tube into the esophagus and using anagent that causes sclerosing of the bleeding area) for bleeding esophageal varices. If sclerotherapy is unsuccessful, endoscopic banding may be performed. This technique involves banding of the varices causing strangulation and eventually fibrosis of the area.

Cirrhosis Nursing Management

  • Monitor vital signs, intake and output and electrolyte levels to determine fluid volume status.
  • Maintain some periods of rest wtih legs elevated to mobilize edema and ascites.Alternate rest periods with ambulation.
  • To assess fluid retention, measure and record abdominal girth every shift. Weight the patient daily and document his weight.
  • Administer diuretics,potasium and protein or vitamin supplements as ordered. Restrict sodium and fluid intake as ordered.
  • Observe and document for bleeding gums,ecchymoses,epistaxis,petechiae and degree of sclerae, skin jaundice. Remain with the patient during the hemorrhagic episodes.
  • Inspect stools for ammount,color and consistency. Test stools and vomitus for occult blood as ordered.
  • Watch for signs of anxiety,epigastric fullness, restlessness and weakness.
  • Observe closely for signs of behavioral or personality changes. Report increasing stupor,lethargy,hallucinations or neuromuscular dysfunction. Arouse the patient periodically to determine level of consciouness. Watch for asterixis, a sign of developing encephalopathy.
  • Allow the patient to express his feelings about having cirrhosis.Offer psychological support and encouragement,when appropriate.

Patient teaching

  • To minimize the risk for bleeding,warn the patient against taking nonsteroidal anti-inflammatory drugs,straining to defecate and blowing his nose or sneezing to vigorously.Suggest using an electric razor and a soft toothbrush.
  • Advise the patient that rest and good nutrition conserve energy and decrease metabolic demands on the liver.Urge him to eat frequent,small meals.Teach him to alternate periods of rest and activity to reduce oxygen demand and prevent fatigue.
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