LIVER CIRRHOSIS
LIVER CIRRHOSIS
- is a chronic disease of the liver characterized by alteration in structure, degenerative changes and widespread destruction of hepatic cells, impairing cellular function and impeding blood flow through the liver. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.
- Is extensive scarring of the liver, usually caused by a chronic irreversible reaction to hepatic inflammation and necrosis. The disease typically develops insidiously and has a prolonged, destructive course.
- The most common causes of cirrhosis in the United States are alcoholic liver disease and hepatitis C... Worldwide, hepatitis B is the leading cause.
- Three types of cirrhosis:
· Alcohol cirrhosis, in which the scar tissue characteristically surrounds the portal areas. This is most frequently due to chronic alcoholism and is the most common type cirrhosis.
· Postnecrotic cirrhosis, in which there are broad bands of scar tissue as a late result of a previous bout of acute viral hepatitis.
· Biliary cirrhosis, in which scarring occurs in the liver around the bile ducts. This type usually is the result of chronic Biliary obstruction and infection (cholangitis); it is much less common than the other two types.
OBJECTIVES:
· To be able to describe the pathophysiology and complications associated with cirrhosis of the liver.
· To be able to interpret laboratory test findings commonly seen in clients with cirrhosis.
· To be able to analyze assessment data from clients with cirrhosis to determine priority nursing diagnosis and collaborative problems.
· To be able to formulate a collaborative plan of care for the client with severe late-stage cirrhosis.
· To be able to identify emergency intervention for the client with bleeding esophageal varices.
· To be able to evaluate care for client with liver cirrhosis.
· To be able to develop a community based teaching plan for the client with cirrhosis of the liver.
PREDISPOSING FACTORS/ETIOLOGY:
Cirrhosis can occur as a result of many factors and diseases such alcoholic liver disease, viral hepatitis, autoimmune hepatitis, steatohepatitis, drugs and toxins, biliary disease, metabolic/genetic causes, and cardiovascular disease.
ALCOHOL
Alcohol has a direct toxic effect on the hepatocytes and causes liver inflammation. The liver becomes enlarge with cellular degeneration and infiltration by fat, leukocytes and lymphocytes. Overtime the inflammatory process decreases and the destructive phase increases. Early scar formation is caused by fibroblast infiltration and collagen formation. Damage to liver tissue progresses as a result of malnutrition and repeated exposure to alcohol. If alcohol is withheld, the fatty infiltration and inflammation is reversible. If alcohol abuse continues, wide spread scar tissue formation and fibrosis infiltrate the liver as a result of cellular necrosis.
The amount of alcohol necessary to cause cirrhosis varies widely from person to person and there are gender differences. In women it may take as few as two to three drinks per day over a minimum of 10 years. In men, perhaps six drinks per day over the same time period may be needed to cause disease. However, there are other individuals, both male and female, who consume far more alcohol per day over a period of several years without ever developing cirrhosis.
VIRAL HEPATITIS
Hepatitis C is an infectious bloodborne illness that usually causes chronic diseases. Inflammation caused by infection over time leads to progressive scarring of the liver. It usually take decades for cirrhosis to develop, although alcohol use in combination with hepatitis C may accelerate the process.
Hepatitis B is the most common cause of cirrhosis worldwide. Hepatitis B also causes inflammation and low-grade damage over decades that can ultimately lead to cirrhosis. The role that concomitant use of alcohol plays in Hepatitis B cirrhosis is not a clear as that of hepatitis C cirrhosis.
Hepatitis D is another virus that reflects the liver, but only in people who already have hepatitis B.
AUTOIMMUNE HEPATITIS
Unlike viral hepatitis, this is not an infectious disease. For reasons not clearly understood, the host’s immune system produces high level of circulating autoantibodies, causing inflammation of liver. This chronic inflammation can lead to fibrosis and eventual cirrhosis.
STEATOHEPATITIS
Frequently referred to us “Fatty liver”, steatohepatitis occurs when fat and cholesterol deposits in the liver cause chronic inflammation. Overtime this inflammation may cause liver damage, or fibrosis and eventual cirrhosis. Obesity and elevated lipid profile are risk factors for steatohepatitis.
DRUGS AND TOXINS
Medication, herbal supplements, and environmental exposure to toxins may damage the liver so significantly that cirrhosis occurs. Sometimes the development of cirrhosis occurs decades after the initial exposure.
BILIARY DISEASE
Biliary cirrhosis develops as a result of chronic Biliary obstruction, bile stasis, inflammation, or diffuse hepatic fibrosis. The most common causes of Biliary cirrhosis are primary Biliary cirrhosis and primary sclerosing cholangitis. Both of these forms of Biliary cirrhosis may also present as secondary to either stone or strictures affecting the common bile duct.
Primary Biliary cirrhosis (PBC) is a disease, probably with an immunologic basis, that involves the slow progressive destruction of small intrahepatic duct, resulting in cholestasis. The disease usually affects middle-aged women. One of the most common presenting features is an asymptomatic elevation of the alkaline phosphatase.
Primary sclerosing cholangitis (PSC) is an illness that is characterize by diffuse inflammation and fibrosis that involves the Biliary system. It has the potential to cause chirrhosis because this process leads to a narrowing and eventual obliteration of the intrahepatic bile ducts. There is a strong association between PSC and inflammatory disease. This disease predominantly affects men.
METABOLIC/GENETIC CAUSES
There are many metabolic and genetic disorders that can cause cirrhosis of the liver:
A. Hemachromatosis, which is characterize by excessive iron storage.
B. Wilson’s disease, a disorder of copper metabolism.
C. Alpha 1, antitrypsin deficiency which may cause an abnormal accumulation of antitrypsin and produce inflammatory activity.
D. Cystic Fibrosis, which can cause cirrhosis from intrahepatic bile duct plugging.
CARDIOVASCULAR DISEASE
Vascular (cardiac) cirrhosis is associated with severe right sided heart failure. The liver becomes enlarge, is congested with venous blood, and appears edematous and dark in color. The liver serves as a reservoir for large amounts of venous blood that the failing part cannot pump back into the systemic circulation. The increase in hepatic volume and pressure causes severe venous congestion. The decrease in nourishing blood flow to the liver results in hepatic cell necrosis and fibrosis.
ANATOMY AND PHYSIOLOGY
The liver is located in the right upper quadrant of the abdomen in the peritoneal space just below the right side of the diaphragm and under the rib cage. It weighs approximately 1400 g in the adult and is covered by a fibrous capsule. It receives nearly 25% of the cardiac output, approximately 1500 mL of blood flow per minute, via two sources: venous flow from the portal vein, which is crucial to performance of the liver's roles in bodily functions, and arterial flow from the hepatic artery, which is important for liver oxygenation and which supplies the biliary system. These vessels converge within the liver, and the combined blood flow exits via the so-called central veins (also called terminal veins) that drain into the hepatic vein and ultimately the inferior vena cava.
The portal vein carries venous blood from the small intestine, rich in freshly absorbed nutrients—as well as drugs and poisons—directly to the liver. Also flowing into the portal vein before its entry into the liver is the pancreatic venous drainage, rich in pancreatic hormones (insulin, glucagon, somatostatin, and pancreatic polypeptide). The portal vein forms a specialized capillary bed that allows individual hepatocytes to be bathed directly in portal blood. In part because of this system of blood supply, the liver is a prime site for metastatic spread of cancer, especially from the GI tract, breast, and lung.
There is considerable overlap between them, systematic consideration of each category is a useful way of approaching the patient with liver disease.
FUNCTIONS OF NORMAL LIVER
Energy metabolism and substrate interconversion
Glucose production through gluconeogenesis and glycogenolysis
Glucose consumption by pathways of glycogen synthesis, fatty acid synthesis, glycolysis, and the tricarboxylic acid cycle
Cholesterol synthesis from acetate, triglyceride synthesis from fatty acids, and secretion of both in VLDL particles
Cholesterol and triglyceride uptake by endocytosis of HDL and LDL particles with excretion of cholesterol in bile, beta-oxidation of fatty acids, and conversion of excess acetyl-CoA to ketones
Deamination of amino acids and conversion of ammonia to urea via the urea cycle
Transamination and de novo synthesis of nonessential amino acids
Protein synthetic functions
