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Chapter 61
Cirrhosis
Cirrhosis is extensive scarring of the liver, usually
caused by a chronic reaction to hepatic
inflammation and necrosis.
Complications depend on the amount of damage
sustained by the liver.
In compensated cirrhosis, the liver has significant
scarring but performs essential functions without
causing significant symptoms.
Complications
Portal hypertension
Ascites
Bleeding esophageal varices
Coagulation defects
Jaundice
Portal-systemic encephalopathy with hepatic
coma
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Esophageal
Varices
Etiology
Known causes of liver disease include:
Alcohol
Viral hepatitis
Autoimmune hepatitis
Steatohepatitis
Drugs and toxins
Biliary disease
Metabolic/genetic causes
Cardiovascular disease
Clinical Manifestations
In early stages, signs of liver disease include:
Fatigue
Significant change in weight
GI symptoms
Abdominal pain and liver tenderness
Pruritus
Abdominal Assessment
Massive ascites
Umbilicus protrusion
Caput medusae (dilated abdominal veins)
Hepatomegaly (liver enlargement)
Liver
Dysfunction
Laboratory Assessment
Aminotransferase serum levels and lactate
dehydrogenase may be elevated.
Alkaline phosphatase levels may increase.
Total serum bilirubin and urobilinogen levels may
rise.
Total serum protein and albumin levels decrease.
Comfort Measures
For dyspnea, elevate the head of the bed at least
30 degrees, or as high as the patient wishes to
help minimize shortness of breath.
Patient is encouraged to sit in a chair.
Weigh patient in standing position, because
supine position can aggravate dyspnea.
Surgical Interventions
Peritoneovenous shunt & Portocaval shunt are rarely
done today because of serious complications. They are
shunts that divert fluid away from the diseased liver into
the venous system.
Esophageal
Gastric
Tamponade
Management of Hemorrhage
Blood transfusions
Esophagogastric balloon tamponade
Vasoactive therapy
Endoscopic procedures
Transjugular intrahepatic portal-systemic shunt
Surgical management
Hepatitis
Widespread viral inflammation of liver cells
can lead to Hepatic Encephalopathy (brain
dysfunction due to high ammonia levels or
orther liver problems. Can lead to a coma.
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Hepatitis A
Similar to that of a typical viral syndrome; often goes
unrecognized
Spread via the fecal-oral route by oral ingestion of fecal
contaminants
Contaminated water, shellfish from contaminated water,
food contaminated by handlers infected with hepatitis A
Also spread by oral-anal sexual activity
Incubation period for hepatitis A is 15 to 50 days.
Disease is usually not life threatening.
Disease may be more severe in individuals older than
40 years.
Many people who have hepatitis A do not know it;
symptoms are similar to a GI illness.
Hepatitis B
Spread is via unprotected sexual intercourse with
an infected partner, sharing needles, accidental
needle sticks, blood transfusions, hemodialysis,
maternal-fetal route.
Symptoms occur in 25 to 180 days after
exposure; symptoms include anorexia, nausea
and vomiting, fever, fatigue, right upper quadrant
pain, dark urine, light stool, joint pain, and
jaundice.
Hepatitis carriers can infect others, even if they
are without symptoms.
Hepatitis C
Spread is by sharing needles, blood, blood
products, or organ transplants (before 1992),
needle stick injury, tattoos, intranasal cocaine
use.
Incubation period is 21 to 140 days.
Most individuals are asymptomatic; damage
occurs over decades.
Hepatitis C is the leading indication for liver
transplantation in the United States.
Hepatitis D
Transmitted primarily by parenteral routes
Incubation period 14 to 56 days
Hepatitis E
Present in endemic areas where waterborne
epidemics occur and in travelers to those areas
Transmitted via fecal-oral route
Resembles hepatitis A
Incubation period 15 to 64 days
Clinical Manifestations
Abdominal pain
Changes in skin or eye color (Jaundice)
Arthralgia (joint pain)
Myalgia (muscle pain)
Diarrhea/constipation
Fever
Lethargy
Malaise
Nausea/vomiting
Pruritus (itching)
Nonsurgical Management
Physical rest
Psychological rest
Diet therapy
Drug therapy includes:
Antiemetics
Antiviral medications
Immunomodulators
AVOID DRUGS METABOLISED BY THE
LIVER SUCH AS TYLENOL
Hepatic Abscess
Liver invaded by bacteria or protozoa causing
abscess
Pyrogenic liver abscess; amebic hepatic abscess
Treatment usually involves:
Drainage with ultrasound guidance
Antibiotic therapy
Liver Trauma
The liver is one of the most common organs to be
injured in patients with abdominal trauma.
Clinical manifestations include abdominal
tenderness, distention, guarding, rigidity.
Treatment involves surgery, multiple blood
products.
Liver Transplantation
Used in the treatment of end-stage liver disease,
primary malignant neoplasm of the liver
Donor livers obtained primarily from trauma
victims who have not had liver damage
Donor liver transported to the surgery center in a
cooled saline solution that preserves the organ for
up to 8 hours
Complications
NCLEX TIME
Question 1
These laboratory results are expected with
which type
of jaundice?
Indirect serum bilirubin: Increased
Direct serum bilirubin: Normal
Stool urobilinogen: Increased
Urine urobilinogen: Increased
A.
B.
C.
D.
Intrahepatic
Hemolytic
Obstructive
Hepatocellular
Question 2
A possible outcome for the patient receiving a liver
transplant because of hepatitis Cinduced cirrhosis
is that the newly transplanted liver may
A. Be a likely site for cancer growth in the future
B. Make the patient more likely to develop
obstructive jaundice in the future
C. Become re-infected with the hepatitis C virus
D. Make the patient more susceptible to develop
other forms of hepatitis
Question 3
Which assessment parameter requires
immediate
intervention in a patient with severe ascites?
A.
B.
C.
D.
Question 4
A priority intervention in the management of a patient
with decompensated cirrhosis would be:
A.
B.
C.
D.
Question 5
Which racial group is at the highest risk for
developing
liver cancer?
A.
B.
C.
D.
Caucasian
African American
Asian
Hispanic/Latino