Cirrhosis of the Liver Cirrhosis of the Liver andand

Liver FailureLiver Failure

Developed by Developed by

Cheryl McConnell RN MSNCheryl McConnell RN MSN

PathophysiologyPathophysiology

Slow, insidious, progressive, chronicSlow, insidious, progressive, chronic Fibrous bands replace normal liver Fibrous bands replace normal liver

structurestructure Cell degeneration occursCell degeneration occurs Liver attempts to regenerate cells but Liver attempts to regenerate cells but

cells are abnormal and disorganizedcells are abnormal and disorganized Causes abnormal blood and lymph flowCauses abnormal blood and lymph flow Results in more fibrous tissue formationResults in more fibrous tissue formation

Normal LiverNormal Liver

Incidence of CirrhosisIncidence of Cirrhosis

Tenth leading cause of death in USTenth leading cause of death in US At least 25,000 deaths annuallyAt least 25,000 deaths annually Higher death rates for men than Higher death rates for men than

womenwomen mortality in African Americans mortality in African Americans

and Hispanicsand Hispanics

Types of CirrhosisTypes of Cirrhosis

Laennec’s Laennec’s (alcoholic)(alcoholic)

PostnecroticPostnecrotic

BiliaryBiliary

CardiacCardiac

Laennec’s CirrhosisLaennec’s Cirrhosis

Most common type of cirrhosisMost common type of cirrhosis Also called alcoholic or portalAlso called alcoholic or portal Alcohol causes inflammation to liver cellsAlcohol causes inflammation to liver cells Leads to fatty deposits and hepatomegalyLeads to fatty deposits and hepatomegaly Scarring formed and liver cells destroyedScarring formed and liver cells destroyed Malnutrition and more alcohol accelerate Malnutrition and more alcohol accelerate

the damagethe damage

Postnecrotic CirrhosisPostnecrotic Cirrhosis

Caused by viral hepatitis Caused by viral hepatitis or hepatotoxinsor hepatotoxins

Scar tissue destroys liver Scar tissue destroys liver lobeslobes

Liver initially enlarges but Liver initially enlarges but then shrinks in sizethen shrinks in size

10 – 30% of all cirrhoses10 – 30% of all cirrhoses

Biliary CirrhosisBiliary Cirrhosis

Caused by chronic biliary Caused by chronic biliary obstruction or stasis of bile, obstruction or stasis of bile, biliary inflammation, or hepatic biliary inflammation, or hepatic fibrosisfibrosis

Excessive bile leads to liver cell Excessive bile leads to liver cell destruction and formation of destruction and formation of nodules in the lobesnodules in the lobes

5 – 10% of all cirrhoses5 – 10% of all cirrhoses

Cardiac CirrhosisCardiac Cirrhosis

Seen with right sided heart failureSeen with right sided heart failure Liver is engorged with venous bloodLiver is engorged with venous blood Becomes enlarged, edematous, and Becomes enlarged, edematous, and

darkdark Venous congestion results in anoxiaVenous congestion results in anoxia Cell necrosis resultsCell necrosis results

Diagnostic DataDiagnostic Data

AST, ALT, LDH, Alk phosAST, ALT, LDH, Alk phos bilirubin, ammonia,bilirubin, ammonia, coagulation studiescoagulation studies Serum protein levels depend on diseaseSerum protein levels depend on disease

with acute liver diseasewith acute liver disease with chronic liver diseasewith chronic liver disease

More DiagnosticsMore Diagnostics

Abdominal x-rayAbdominal x-ray Upper GI seriesUpper GI series AngiographyAngiography Abdominal CTAbdominal CT EGDEGD Liver biopsyLiver biopsy Nuclear scanNuclear scan

Signs and SymptomsSigns and Symptoms NeurologicalNeurological

AsterixisAsterixis ParaesthesiasParaesthesias LOCLOC Sensory disturbancesSensory disturbances Behavorial changesBehavorial changes Cognitive changesCognitive changes

SkinSkinSpider angiomasSpider angiomas Palmar erythmaPalmar erythmaJaundiceJaundice PruitisPruitis hair productionhair production caput medusacaput medusa pigmentationpigmentation BruisingBruising

White NailsWhite Nails

Caput MedusaeCaput Medusae

Spider AngiomasSpider Angiomas

Palmar ErythemaPalmar Erythema

More Signs and SymptomsMore Signs and Symptoms

GIGI

Abdominal painAbdominal pain AnorexiaAnorexia

AscitesAscites DiarrheaDiarrhea

Clay colored stoolsClay colored stools Fetor hepaticusFetor hepaticus

GastritisGastritis GI bleedingGI bleeding

N/VN/V VaricesVarices

MalnutritionMalnutrition

““White Nails”White Nails”

More Signs and SymptomsMore Signs and Symptoms

CardiovascularCardiovascular

DysrhythmiasDysrhythmias Portal hypertensionPortal hypertension

Collateral circulationCollateral circulation FatigueFatigue

Peripheral edemaPeripheral edema EndocrineEndocrine

Gynecomastia Gynecomastia AmenorrheaAmenorrhea

aldosterone, ADH, estrogens, aldosterone, ADH, estrogens, glucocorticoidsglucocorticoids

More Signs and SymptomsMore Signs and Symptoms RespiratoryRespiratory

DyspneaDyspnea HypoxiaHypoxia

BloodBloodAnemiaAnemia DICDICThrombocytopeniaThrombocytopenia WBCs WBCsHypokalemiaHypokalemia HypocalcemiaHypocalcemiaHypo/HypernatremiaHypo/HypernatremiaHypomagnesiaHypomagnesia

More Signs and SymptomsMore Signs and Symptoms

ImmuneImmune

Susceptibility to Susceptibility to infectionsinfections Leukopenia Leukopenia

RenalRenal

Urinary output Urinary output

Complications Complications Portal hypertensionPortal hypertension

AscitesAscites VaricesVarices

Coagulation defectsCoagulation defects JaundiceJaundice

PSE (portal systemic PSE (portal systemic encephalopathy)encephalopathy)

Hepatorenal syndromeHepatorenal syndrome

Portal HypertensionPortal Hypertension

Increased pressure within the portal Increased pressure within the portal veinvein

Results in obstruction of blood flow Results in obstruction of blood flow through the portal veinthrough the portal vein Blood tries to find new ways around Blood tries to find new ways around

obstructed area = collateral circulationobstructed area = collateral circulation Causes venous distention in entire GI Causes venous distention in entire GI

tracttract

AscitesAscites

Accumulation of plasma in the peritoneal Accumulation of plasma in the peritoneal cavitycavity Caused by increased pressure forcing fluid out Caused by increased pressure forcing fluid out

of intravascular space into cavityof intravascular space into cavity Plasma contains albumin so circulating Plasma contains albumin so circulating

proteins decreasedproteins decreased serum osmotic pressureserum osmotic pressure Intravascular fluid depletion stimulates kidney Intravascular fluid depletion stimulates kidney

to conserve sodium and water = to conserve sodium and water = hydrostatic hydrostatic pressure and creates more ascitespressure and creates more ascites

AscitesAscites

VaricesVarices Occur anywhere in the GI tract Occur anywhere in the GI tract

especiallyespecially EsophagealEsophageal

HemorrhoidsHemorrhoids Bleeding esphageal varices Bleeding esphageal varices

Caused by thin walled veins Caused by thin walled veins that are irritated, distended that are irritated, distended and eventually ruptureand eventually ruptureChemical irritantsChemical irritants

Mechanical traumaMechanical trauma Esophagus pressureEsophagus pressure

Prone to hemorrhage – medical Prone to hemorrhage – medical emergencyemergency

Esophageal VaricesEsophageal Varices

Coagulation DefectsCoagulation Defects

Susceptible to bleedingSusceptible to bleeding Bruises easilyBruises easily Does not clot Does not clot

Esophageal varices Esophageal varices bleedingbleeding

JaundiceJaundice

Due to hepatocellular destruction or Due to hepatocellular destruction or hepatic obstructionhepatic obstruction Hepatocellular – cannot metabolize Hepatocellular – cannot metabolize

bilirubin so it builds upbilirubin so it builds up Obstruction – clogs bile ducts so Obstruction – clogs bile ducts so

excretion is not possibleexcretion is not possible

JaundiceJaundice

PSEPSE Also known as Also known as

hepatic comahepatic coma Seen in end stage Seen in end stage

hepatic failurehepatic failure Can be insidious or Can be insidious or

rapid onset rapid onset depending on the depending on the severity of liver severity of liver diseasedisease

Caused by impaired Caused by impaired ammonia metabolismammonia metabolism

PSE ContinuedPSE Continued Usually protein breaks down into Usually protein breaks down into

ammonia in GI tract, then ammonia ammonia in GI tract, then ammonia into urea --- excreted by the kidneysinto urea --- excreted by the kidneys

Liver cannot convert ammonia into Liver cannot convert ammonia into ureaurea Results in Results in serum ammonia levels serum ammonia levels Toxic to the central nervous systemToxic to the central nervous system

PSE ContinuedPSE Continued

Other factors that Other factors that add to PSE:add to PSE:

High protein dietHigh protein dietInfectionInfection

HypovolemiaHypovolemia

ConstipationConstipation

GI bleedingGI bleedingMedicationsMedications

Stages of PSEStages of PSE #1 - Prodomal – very #1 - Prodomal – very

subtle changessubtle changes Personality/behavior Personality/behavior

changeschanges Impaired Impaired

thinking/concentrationthinking/concentration Emotional highs and Emotional highs and

lowslows Fatigue, drowsinessFatigue, drowsiness Slurred or slow speechSlurred or slow speech Sleep pattern Sleep pattern

disturbancedisturbance

Stages of PSEStages of PSE

#2 – Impending #2 – Impending Continued mental Continued mental

deteriorationdeterioration ConfusionConfusion

Disoriented Disoriented AsterixisAsterixis

Stages of PSEStages of PSE #3 – Stuporuous#3 – Stuporuous

Marked mental Marked mental confusionconfusion

Drowsy but Drowsy but arousablearousable

Abnormal EEGAbnormal EEG Muscle twitchingMuscle twitching HyperreflexiaHyperreflexia Continued asterixisContinued asterixis

Stages of PSEStages of PSE ##4 – Comatose (85% 4 – Comatose (85%

mortality rate)mortality rate) UnresponsiveUnresponsive Responds to painful Responds to painful

stimuli onlystimuli only No asterixisNo asterixis Positive Babinski’s Positive Babinski’s

signsign Muscle rigidityMuscle rigidity Fetor hepaticusFetor hepaticus SeizuresSeizures

Hepatorenal SyndromeHepatorenal Syndrome A primary cause of death with A primary cause of death with

hepatic failure/cirrhosishepatic failure/cirrhosis Kidneys cannot excrete ammonia Kidneys cannot excrete ammonia

and bilirubin and bilirubin Results in acute tubular necrosisResults in acute tubular necrosis

Signs/symptomsSigns/symptomsSudden Sudden urinary output urinary output

BUN, Cr, urine osmolarityBUN, Cr, urine osmolarity Urine Na Urine Na

TreatmentTreatment

DietDiet Sodium (< 2 grams)Sodium (< 2 grams) Carbohydrate, moderate fatsCarbohydrate, moderate fats ProteinProtein

Unless PSE present then Unless PSE present then protein protein Fluid restriction (total of ≤ 1500cc/day)Fluid restriction (total of ≤ 1500cc/day) Vitamin supplementsVitamin supplements

Treatment ContinuedTreatment Continued MedicationsMedications

DiureticsDiuretics Electrolyte replacementElectrolyte replacement AntacidsAntacids

Must be low sodium – RiopanMust be low sodium – Riopan LactuloseLactulose

Facilitates evaculation of Facilitates evaculation of ammoniaammonia

NeomycinNeomycin Eliminates intestinal flora = Eliminates intestinal flora =

protein breakdownprotein breakdown LevadopaLevadopa

For PSE – repairs damaged For PSE – repairs damaged neurotransmittersneurotransmitters

More TreatmentsMore Treatments Ascites controlAscites control

ParacentesisParacentesis ShuntsShunts

Le Veen Shunt - drains ascites fluid Le Veen Shunt - drains ascites fluid into superior vena cavainto superior vena cava

Denver Shunt – subcutaneous pump Denver Shunt – subcutaneous pump that is manually compressedthat is manually compressed

Post op care: same as with any Post op care: same as with any abdominal surgery, watch for fluid abdominal surgery, watch for fluid volume overload and bleeding volume overload and bleeding disorders, measure abdominal disorders, measure abdominal girth every shiftgirth every shift

Le Veen ShuntLe Veen Shunt

More TreatmentsMore Treatments

Hemorrhage from varicesHemorrhage from varices Esophagogastric balloon tamponadeEsophagogastric balloon tamponade

Sengstaken-Blakemore tube – balloon inflates in esophagus Sengstaken-Blakemore tube – balloon inflates in esophagus and puts pressure on varicesand puts pressure on varices

Blood transfusionsBlood transfusions MedicationsMedications

Beta blockers to decrease HR and BPBeta blockers to decrease HR and BP Pitressin (vasopressin) IV or into superior mesenteric artery Pitressin (vasopressin) IV or into superior mesenteric artery

(via endoscopy)(via endoscopy) SclerotherapySclerotherapy

Sclerosing agents injected into varices during EGDSclerosing agents injected into varices during EGD Transjugular intrahepatic portal systemic shunt (TIPS)Transjugular intrahepatic portal systemic shunt (TIPS)

Shunt between portal and hepatic vein to Shunt between portal and hepatic vein to pressure = pressure = bleedingbleeding

Other portal system shunts – poor prognosisOther portal system shunts – poor prognosis

Sclerosing ProcedureSclerosing Procedure

Blakemore TubeBlakemore Tube

Another Blakemore TubeAnother Blakemore Tube

More TreatmentsMore Treatments

PSEPSE Low protein dietLow protein diet

May need TPNMay need TPN Control GI bleedingControl GI bleeding MedicationsMedications Neuro checksNeuro checks Look for signs and symptoms of the Look for signs and symptoms of the

stages of PSEstages of PSE

Home CareHome Care DietDiet

calories, vitamins, protein calories, vitamins, protein (unless PSE)(unless PSE)

sodiumsodium MedicationsMedications

DiurecticsDiurectics Antacids, H2-receptor Antacids, H2-receptor

antagonistsantagonists No OTC medicationsNo OTC medications

No alcohol consumptionNo alcohol consumption activity – rest periodsactivity – rest periods Home care equipmentHome care equipment

Evaluation OutcomesEvaluation Outcomes Patient willPatient will

in ascitesin ascites Electrolytes WNLElectrolytes WNL B/P WNLB/P WNL No bleeding or No bleeding or

complications from complications from bleedingbleeding

PSE managed PSE managed immediatleyimmediatley

Optimal quality of lifeOptimal quality of life

EVOLUŢIEEVOLUŢIECiroză compensată Ciroză compensată ciroză ciroză decompensată vascular şi decompensată vascular şi parenchimatosparenchimatos

Rezerva funcţională – Clasificarea Rezerva funcţională – Clasificarea Child PughChild PughParametruParametru

Albumina sericăAlbumina sericăAscitaAscita

EncefalopatiaEncefalopatiaBilirubinaBilirubina

Indicele QuickIndicele Quick

1 pct.1 pct.>>3,53,5AbsAbsAbsAbs<< 2 2

>> 70% 70%

2 pct.2 pct.2,8-3,52,8-3,5

ModeratăModeratăGrd. I, IIGrd. I, II

2-32-340-70%40-70%

3 pct.3 pct.<< 2,8 2,8MareMare

Grd. III, IVGrd. III, IV>> 3 3

<< 40% 40%

A: 5-6 pct., B: 7-9 pct., C: 10-15 pct.A: 5-6 pct., B: 7-9 pct., C: 10-15 pct.