Cirrhosis Overview and Laennec's Stages

Cirrhosis

• Chronic liver disease characterized by replacement of liver cells with scar tissue, leading to impaired liver function.
• Classified into four types:
  • Laennec's/Alcoholic/Portal Cirrhosis: Most common type, often associated with long-term heavy alcohol consumption.
  • Biliary Cirrhosis: Caused by bile duct obstruction, leading to bile accumulation and liver damage.
  • Post-Hepatic Cirrhosis: Advanced form of chronic hepatitis B or C, or unknown causes, characterized by shrunken & nodular liver.
  • Cardiac Cirrhosis: Results from chronic heart failure, leading to liver congestion and cell death.

Laennec's Cirrhosis Stages

• Progresses through three stages:
  • Stage 1: Fatty liver characterized by fat accumulation in liver cells. Reversible with alcohol abstinence.
  • Stage 2: Alcoholic hepatitis, involving inflammation, necrosis, and fibrosis.
  • Stage 3: End stage, fibrosis replaces normal tissue, leading to severe liver dysfunction.

Pathophysiology of Cirrhosis

• Liver tissue replaced by fibrotic scar tissue.
• Abnormal nodules form, restricting blood, lymph, and bile flow.

Clinical Manifestations of Cirrhosis

• Often develop gradually over years.
• Early: Enlarged liver, vague symptoms like pain in upper right abdomen, fever, nausea, diarrhea, loss of appetite, and fatigue.
• Later:
  • Edema & ascites: Caused by low albumin, fluid retention, and increased portal pressure.
  • Bleeding & bruising: Due to decreased clotting factors, increased platelet destruction, and impaired vitamin K absorption.
  • Esophageal varices & hemorrhoids: Caused by increased portal pressure, leading to dilated veins.
  • Gastritis, anorexia, diarrhea: Caused by congested veins in gastrointestinal tract and impaired bile production.
  • Abdominal wall vein distention (caput medusae): Result of portal hypertension.
  • Jaundice: Due to impaired bilirubin metabolism.
  • Malnutrition, muscle wasting: Caused by impaired nutrient & fat absorption, and hormone metabolism.
  • Anemia, leukopenia, increased risk of infection: Due to bleeding and blood cell destruction.
  • Asterixis, encephalopathy: Caused by accumulated toxins and impaired ammonia metabolism.
  • Gynecomastia, infertility, impotence: Result of altered sex hormone metabolism.

Major Complications of Cirrhosis

• Portal hypertension: Increased pressure in portal vein due to impaired blood flow. Leading to:
  • Bleeding esophageal varices - life-threatening due to rupture of veins.
  • Hemorrhoids & caput medusae.
  • Peripheral edema and ascites.

Management of Cirrhosis

• Nursing Diagnosis:
  • Activity intolerance.
  • Altered nutrition: less than body requirement.
  • Risk for injury (bleeding).
  • Disturbed thought processes.
  • Risk for impaired skin integrity.
  • Risk for fluid volume excess.
• Nursing Interventions:
  • Promote activity tolerance by encouraging rest and gradual exercise.
  • Improve nutritional status with high-calorie, moderate protein diet, small frequent meals, and antiemetics.
  • Prevent bleeding by monitoring stools, observing for symptoms of gastrointestinal bleeding, administering vitamin K, and teaching client to avoid trauma.
  • Promote improved thought processes by restricting high-protein diet, monitoring ammonia levels, and protecting from infection.
  • Manage fluid volume excess by measuring weight and abdominal girth, restricting fluids, and providing a low sodium diet.
  • Promote gas exchange by positioning the client in semi-Fowler's with feet elevated, administering oxygen, and monitoring oxygen saturation.
  • Promote skin integrity by using warm water, preventing dry skin, applying mittens, and turning frequently.
  • Manage bleeding esophageal varices by assessing vital signs, monitoring for hypovolemia, observing for straining, gagging or vomiting, monitoring gastrointestinal secretions, administering blood products and vitamin K.

Additional Notes

• Diet: Low-protein diet for patients with liver problems.
• Alcohol: Beer is less harmful than whiskey.
• Assessment: Observe sclera, tongue, skin, and abdominal distention.
• Bleeding: Any GI bleeding is an emergency.
• Hepatic encephalopathy: Can increase ICP and lead to impaired consciousness.
• Room assignments:
  • Avoid placing liver patients with patients who have pneumonia, TB, or active infections.
• Fall risk: Patients with hepatic encephalopathy are at high risk for falls.
• Medication: Avoid acetaminophen in liver patients.