What is a Liver Cirrhosis?
1. Portal Hypertension
In cirrhosis, liver cell damage slows down blood flow. This causes a backup of blood through the portal vein, a condition called portal hypertension . The effects of portal hypertension can be widespread and serious, including fluid buildup and bleeding.
2. Ascites and Fluid Buildup. Ascites is fluid buildup in the abdomen. It is uncomfortable and can reduce breathing function and urination. Ascites is usually caused by portal hypertension, but it can result from other conditions. Swelling can also occur in the arms and legs and in the spleen. Although ascites itself is not fatal, it is a marker for severe progression. Once ascites occurs, only half of patients survive after 2 years. In fact, some experts refer to the phases of cirrhosis as preascitic and ascitic . Some doctors even believe that ascites signals the need for liver transplantation, particularly in alcoholic cirrhosis.
3. Variceal Bleeding. One of the most serious repercussions of portal hypertension is the development of varices , which are blood vessels that enlarge to provide an alternative pathway for blood diverted from the liver. In about two-thirds of patients they form in esophagus. Varices pose a high risk for rupture and bleeding because of the following characteristics:
They are thin-walled.
They are often twisted.
They are subject to high pressure.
Internal bleeding from these varices (variceal bleeding) occurs in 20 – 30% of patients with cirrhosis. The risk of death from a single episode can reach 70%.
Bleeding commonly recurs within 2 weeks of the first episode, but after 6 weeks, the risk for recurrence is the same as for patients who have not had a bleeding event.
Factors that predict variceal bleeding include:
Ascites.
Encephalopathy.
Large veins.
Factors that can increase the danger for a bleeding episode in high-risk individuals include the following:
Moderate to intense exercise.
Bacterial infection.
Certain times of the day. Eating increases portal pressure, and there is a greater risk for bleeding in the evening. A lesser but still significant risk occurs in the early morning.
It is important for patients to be screened for esophageal varices and treated with preventive beta blockers if they show signs of risk. Between 30 – 40% of patients with cirrhosis experience bleeding. this complication has a mortality rate of 20 – 35%. Some experts recommend that all newly diagnosed patients be screened using endoscopy. Screening should also be considered for all previously diagnosed patients who have not been screened but would benefit from preventive treatments.
4. Kidney Failure
Portal hypertension can cause several secondary complications, including kidney failure. Non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen, may increase the risk for kidney failure.
5. Gastrointestinal Bleeding
Gastrointestinal (GI) bleeding can occur from abnormal blood clotting, which can be result of a combination of complications associated with cirrhosis. They include vitamin K deficiencies and thrombocytopenia — a drop in platelets (the blood cells that normally initiate the clotting process). Some research now suggests that thrombocytopenia itself may be associated with more advanced liver failure.
6. Infections
Bacterial infections are very common in advanced cirrhosis, and may even increase the risk for bleeding. Most bacterial infections, including those in the urinary, respiratory, or gastrointestinal tracts, develop when patients are in the hospital. Abdominal infections are a particular problem in cirrhosis and occur in up to 25% of patients with cirrhosis within a year of diagnosis.
7. Mental Impairment and Encephalopathy
Mental impairment is a common event in advanced cirrhosis. In severe cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from confusion to coma and death. A combination of conditions associated with cirrhosis causes this serious complication:
Buildup in the blood of harmful intestinal toxins, particularly ammonia.
An imbalance of amino acids that affect the central nervous system.
Encephalopathy is often triggered by certain conditions, including:
Gastrointestinal bleeding
Constipation
Excessive dietary protein
Infection
Surgery
Dehydration
Alcoholics with cirrhosis are believed to be at higher risk for this complication than are nonalcoholic cirrhosis, but one study suggested that alcoholics simply tend to have more severe cirrhosis. Even minimal hepatic encephalopathy (MHE) can have detrimental effects on functional ability. One study suggested that MHE impairs the ability to safely drive a car, and that all patients with cirrhosis be tested for MHE.
8. Symptoms of Encephalopathy. Early symptoms of hepatic encephalopathy include forgetfulness, unresponsiveness, and trouble concentrating. Sudden changes in the patient’s mental state, including agitation or confusion, may indicate an emergency condition. Other symptoms include bad fruity-smelling breath and tremor. Late stage symptoms of encephalopathy are stupor and eventually coma.
9. Hepatorenal Syndrome
Hepatorenal syndrome occurs if the kidneys drastically reduce their own blood flow in response to the altered blood flow in the liver. It is a life-threatening complication of late-stage liver disease that occurs in patients with ascites. Symptoms include dark colored urine and a reduction in volume, yellowish skin, abdominal swelling, mental changes (delirium, confusion), jerking or coarse muscle movement, nausea, and vomiting.
10. Liver Cancer
Cirrhosis greatly increases the risk for liver cancer, regardless of the cause of cirrhosis. Although few studies have been conducted on the risk for liver cancer in patients with primary biliary cirrhosis, one study reported an incidence of 2.3%. About 4% of patients with cirrhosis caused by hepatitis C develop liver cancer. In Asia about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. (One Italian study that followed a group of hepatitis B patients for 11 years found no liver cancer over that period of time.)
11. Osteoporosis
About 30% of patients with chronic liver disease develop osteoporosis (loss of bone density), which is twice the usual incidence. Patients with primary biliary cirrhosis have a particularly high risk for osteoporosis. Treating osteoporosis in patients with cirrhosis can be complicated. One study found that calcitriol (a form of vitamin D) is especially helpful in preventing bone loss in patients with cirrhosis.
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular exercise and vitamin and mineral supplements may reduce and even reverse loss of bone density.
12. Insulin Resistance
Nearly all patients with cirrhosis are insulin resistant. Insulin resistance is a primary feature in type 2 diabetes and occurs when the body is unable to use insulin. This hormone is important for delivering blood sugar and amino acids into cells and helps determine whether these nutrients will be burned for energy or stored for future use.
DIAGNOSTIC EVALUATION:
Liver biopsy – detects destruction and fibrosis of hepatic tissue.
Liver scan – shows abdominal thickening and a liver mass.
CT scan – determines the size of the liver and its irregular nodular surface.
Esophagoscopy – to determine esophageal varices.
Paracentesis – to examine ascetic fluid for cell, protein, and bacterial counts.
PTC – differentiates extrahepatic from intrahepatic obstructive jaundice.
Laparoscopy and liver biopsy – permit direct visualization of the liver.
Serum liver function test – results are elevated
NURSING INTERVENTIONS:
Promoting Activity Tolerance
Encourage alternating periods of rest and ambulation.
Maintain some periods of bed rest with legs elevated to mobilize edema and ascites.
Encourage and assist with gradually increasing periods of exercise.
Improving Nutritional Status
Encourage patient to eat high calorie, moderate protein meal and to have supplementary feedings.
Suggest small, frequent feedings and attractive meals in an aesthetically pleasing setting at meal time.
Encourage and assist withgradually increasing periods of exercise.
Protecting Skin Integrity
Note and record degree of jaundice of skin and sclerae and scratches on the body.
Encourage frequent skin care, bathing without soap, and massage with emollient lotions.
Advise patient to keep fingernails short.
Patient Education and Health Maintenance
Stress the necessity of giving up alcohol completely.
Urge acceptance of assistance from a substance abuse program.
Provide written dietary instructions.
Encourage daily weighing for self-monitoring of fluid retention depletion.
Discuss adverse effects of diuretic therapy.
Emphasize the importance of rest, a sensible lifestyle, and an adequate, well-balanced diet.
Involve the person closest to the patient because recovery usually is not easy and relapses are common.
Stress the importance of continued follow –up for laboratory test and evaluation by a health care provider
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