Int J Pharm Bio Sci 2016 July; 7(3): (B) 1116 - 1120

Case Report Allied science

International Journal of Pharma and Bio Sciences ISSN

0975-6299

CIRRHOSIS OF LIVER: CASE STUDY

Mrs.C.JEGATHA

Asso Prof. SreeBalaji College of Nursing, Bharathuniversity, Chrompet, Chennai.

ABSTRACT

Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. Cirrhosis
harms the structure of the liver and blocks the flow of blood. The loss of normal liver tissue slows the
processing of nutrients, hormones, drugs, and toxins by the liver. Also, the production of proteins and
other substances made by the liver is suppressed. People with cirrhosis often have few symptoms at first.
The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with
nausea and weight loss. As liver function declines, water may accumulate in the legs and the abdomen.
Cirrhosis greatly increases the risk for liver cancer.Gastrointestinal (GI) bleeding can occur from abnormal
blood clotting, which can be result of a combination of complications associated with cirrhosis.In severe
cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from
confusion to coma and death.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 colour urine and a
reduction in volume, yellowish skin, abdominal swelling, mental changes (delirium, confusion), jerking or
coarse muscle movement, nausea, and vomiting.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.About 30% of patients with chronic liver disease develop osteoporosis (loss of bone density),
which is twice the usual incidence.

KEY WORDS: Cirrhosis, Liver, Weakness, Fatigue, ascites.

Mrs.C.JEGATHA
Asso Prof. SreeBalaji College of Nursing, Bharath University, Chrompet, Chennai.

*Corresponding Author

This article can be downloaded from www.ijpbs.net

B - 1116
 Int J Pharm Bio Sci 2016 July; 7(3): (B) 1116 - 1120

INTRODUCTION usually develops after years of liver inflammation. When

chronic diseases cause the liver to become permanently
injured and scarred, the condition is called Cirrhosis.
Cirrhosis of liver is a chronic disease that causes cell
Cirrhosis harms the structure of the liver and blocks the
destruction and fibrosis (scarring) of hepatic tissue.
flow of blood. The loss of normal liver tissue slows the
Fibrosis alters normal liver structure and vasculature,
processing of nutrients, hormones, drugs, and toxins by
impairing blood and lymph flow and resulting in hepatic
the liver. Also, the production of proteins and other
insufficiency and hypertension in the portal vein.
substances made by the liver is suppressed. People
Complications include hypernatremia, water retention,
with cirrhosis often have few symptoms at first. The
bleeding oesophageal varies. Coagulopathy,
person may experience fatigue, weakness, and
spontaneous bacterial peritonitis, and hepatic
exhaustion. Loss of appetite is usual, often with nausea
encephalopathy. Cirrhosis is a potentially life-
and weight loss. As liver function declines, water may
threatening condition that occurs when scarring 1
accumulate in the legs and the abdomen.
damages the liver. This scarring replaces healthy tissue
and prevents the liver from working normally. Cirrhosis

CASE REPORT respiratory rate 32b/min, Bp 160/100 mm of Hg, weight

78Kg, Abdominal girth 72.
During the Anagaputhur posting I met Mr 64 Yrs. old
male known case of cirrhosis of liver with the complaints POST MEDICAL HISTROY
of Ascites, Palmar erythematic, Anaemia, Itching, He is a known hypertensive and diabetic for last 15
Stomatitis, Clay colour stool. On examination his heart years. He is under treatment. He is on
rate is 66b/mt, respiratory rate 32b/mt, Bp 160/100 mm tab.Dianorm, tab.atrovas, tab.losartan and
of Hg, weight 78Kg, Abdominal girth 72 cm was found. tab.supradyn for 15 years.
On the day of first home visit we collected history, vital
signs were checked and physical examination was PREDISPOSING FACTORS
done. Continuous follow-up were given for 5 days. 1. Chronic Alcoholism
During regular home visit health education regarding 2. Malnutrition – decrease Vitamin B, thiamine – main
diet, exercise, and medication were advised. cause
3. Virus
PRESENT MEDICAL HISTROY 4. Toxicity – e.g. carbon tetrachloride
Complaints of Swelling abdomen, Palmar erythematic, 5. Use of hepatotoxic agents.
1

numbness, tiredness, itching, mouth ulcer, Clay colour

stool. On examination his heart rate is 66b/min,

This article can be downloaded from www.ijpbs.net

B - 1117
 Int J Pharm Bio Sci 2016 July; 7(3): (B) 1116 - 1120

SIGNS AND SYMPTOMS

Book picture patient’s picture

Weakness, fatigue
Anorexia clay colour stool
Stomatitis stomatitis
Urine – tea colour pruritis
Stool – clay colour jaundice
Amenorrhea ascitis
Decrease sexual urge weakness, fatigue

Loss of pubic hair, axilla hair

Hepatomegaly
Jaundice
Pruritus or urticaria
Late Signs
Haematological changes – all blood cells decrease
Leucopoenia – decrease
Thrombocytopenia – decrease
Anaemia – decrease
Endocrine changes
Spider angiomas, Gynecomastia
Caput medusa, Palmer erythematic
GIT changes
Ascitis, bleeding oesophageal varices – due to portal Hypertension

PATHOPHYSIOLOGY 3. Variceal Bleeding

Cirrhosis is characterized by diffuse fibrotic bands
of connective tissue that distort the liver’s normal
architecture. Inflammation caused by either toxins or
disease results in extensive degeneration and
destruction of hepatocytes (liver cells). As cirrhosis
develops, the tissue becomes nodular. These nodules
can block Bile ducts and normal blood flow throughout
the liver. Flow alterations in the vascular system and
lymphatic bile duct channels result from compression
caused by the proliferation of fibrous tissue. In early
disease, the liver is usually enlarged, firm and hard. As
the pathologic process continues, the liver shrinks in
3 6
size.
COMPLICATIONS
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 build-up and bleeding.
4 anti-inflammatory drugs (NSAIDs), such as naproxen,
2. Ascites and Fluid Build-up
Ascites is fluid build-up 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 ascetic.
Some doctors even believe that ascites signals the need
for liver transplantation, particularly in alcoholic
cirrhosis.
5 Bacterial infections are very common in advanced
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 oesophagus. 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
7
event.
4. Kidney Failure
Portal hypertension can cause several secondary
complications, including kidney failure. Non-steroidal
8
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
9
advanced liver failure.
6. Infections
cirrhosis, and may even increase the risk for bleeding.
Most bacterial infections, including those in the urinary,

This article can be downloaded from www.ijpbs.net

B - 1118
 Int J Pharm Bio Sci 2016 July; 7(3): (B) 1116 - 1120
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
10
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:
Build-up 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
11
Dehydration.
8. 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
12
muscle movement, nausea, and vomiting.
9. 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
13
cancer over that period of time.
10. 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
14
of bone density.
This article can be downloaded from www.ijpbs.net
B - 1119
11. 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 oesophageal varices.
Paracentesis – to examine ascetic fluid for cell,
protein, and bacterial counts.
PTC – differentiates extra hepatic from intrahepatic
15
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 oedema 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 with gradually increasing
periods of exercise.
Protecting Skin Integrity
Note and record degree of jaundice of skin and sclera
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.
 Int J Pharm Bio Sci 2016 July; 7(3): (B) 1116 - 1120
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.
SUMMARY
The patient was very cooperative with health personnel;
although his symptoms were well. Responding to
treatment. He is recurring from disease condition and
there is not any complication during the visit.
REFERENCES
1. Brunner and Siddhartha’s ,”Text book of medical
th
and surgical nursing”, 12 edition , Lippincott
publication 2011,p 1146-1158.
2. Chopra S, Dodd III GD, Chanin MP, Chintapalli
KN. Radiofrequency ablation of hepatic tumors
adjacent to the gallbladder: feasibility and safety.
American Journal of Roentgenology. 2003
Mar;180(3):697-701.
3. Patti, J., Neeman, Z., Wood, B. Radiofrequency
Ablation for Cancer-Associated Pain. The Journal
of Pain, 2002; 3(6): 471-473.
nd
4. PK Panwar , “ medical and surgical nursing” 2
edition , Altbs publication 2013, p 90-91.
5. Queen mary “medical and surgical nursing”
rd
3 edition,Florence publication 2012,p 214-216.
6. Ignatavicius ,workman “medical and surgical
th
nursing” 8 edition ,Elsevier publication 2010. P
1192-1202.
7. BT Basavanthappa ,“medical and surgical
rd
nursing” 3 edition , Jaypee publications 2005,p
303-304.
8. Joy Chang, “ core clinical case for medical
nd
student” 2 edition ,viva books publication 2012,p
22-28.
This article can be downloaded from www.ijpbs.net
B - 1120
CONCLUSION
During my care period patient was co-operative. He
accepted my care and health education. He was feeling
better after his hospitalization.
ACKNOWLEDGEMENT
I extend sincere thanks to the respected principal Prof.
V.Hemavathy and reviewers’ Prof.KR.Vasantha kohila,
Prof.Sathyalatha sarathy for their guidance in the study.
CONFLICT OF INTEREST
I have no conflict of interest in the current study.
9. Wiley black well ,”critical care nursing ,monitoring
nd
and treatment for advanced nursing practice” , 2
edition, Florence publication 2012, p 126-127.
10. Jennifer “maintain health in primary care”
st
1 edition ,living stone publication 2001,p 72-73.
11. Pamela “ manual of medical and surgical nursing”
th
6 edition Elsevier publication 2003. P 585-1202.
12. Heller MT, Tublin ME. The Role of
Ultrasonography in the Evaluation of Diffuse Liver
Disease. Radiol. Clin. North Am. 2014; 52 (6):
1163-1175.
13. Deugnier Y, Turlin B. “Other causes of
nd
hepatocellular carcinoma”.2 edition, Churchill
Livingstone publication, New York, 1997, pp. 97-
110.
14. Ohayon, MM . Epidemiology of insomnia: what we
know and what we still need to learn. Sleep Med
Rev Apr 2002;6(2): 97–111.
15. Chopra S, Dodd III GD, Chanin MP, Chintapalli
KN. Radiofrequency ablation of hepatic tumors
adjacent to the gallbladder: feasibility and safety.
American Journal of Roentgenology. 2003
Mar;180(3):697-701.