Cirrhosis: Pathophysiology and Clinical Manifestations

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Questions and Answers

What occurs due to the impaired plasma protein synthesis associated with cirrhosis?

Jaundice

Ascites (correct)

Increased bile production

Anorexia

Which clinical manifestation is specifically associated with increased pressure in the portal venous system?

Dull, aching pain in the RUQ

Abdominal wall vein distension (caput medusae) (correct)

Fever

Hypertension

What is a major complication of cirrhosis that can result from impaired blood flow?

Nausea

Portal hypertension (correct)

Increased nutrient absorption

Edema

Which of the following best describes the early stage clinical manifestation of cirrhosis?

Enlarged tender liver with vague symptoms Signup and view all the answers

What is the underlying reason for the increased bleeding risk in cirrhosis patients?

Decreased clotting factor synthesis Signup and view all the answers

Which symptom is likely caused by impaired ammonia metabolism in cirrhosis patients?

Asterixis Signup and view all the answers

What is the primary consequence of accumulation of metabolic toxins in cirrhosis?

Encephalopathy Signup and view all the answers

Which of the following complications is characterized by tearing of veins during food passage in cirrhosis patients?

Massive hemorrhage Signup and view all the answers

Which local factor is primarily associated with ascites related to fluid retention?

Portal hypertension Signup and view all the answers

What clinical sign is characteristic of Stage II hepatic encephalopathy?

Asterixis Signup and view all the answers

What is typically observed in coagulation studies for a patient with cirrhosis?

Prolonged prothrombin time Signup and view all the answers

What lab result is commonly associated with hyponatremia in patients with cirrhosis?

Low RBC count Signup and view all the answers

Which stage of hepatic encephalopathy is characterized by slurred speech and impaired decision making?

Stage I Signup and view all the answers

During an abdominal ultrasound for diagnosing cirrhosis, which aspect is typically evaluated?

Liver size and ascites Signup and view all the answers

What is the leading cause of death in individuals with portal systemic encephalopathy and liver failure?

Cerebral hypoxia Signup and view all the answers

What condition may lead to elevated serum ammonia levels in individuals with liver issues?

Inability to convert ammonia to urea Signup and view all the answers

What is the recommended daily caloric intake for a patient with cirrhosis?

2000-3000 kcal/day Signup and view all the answers

Which vitamin is NOT typically supplemented for patients with cirrhosis?

Vitamin D Signup and view all the answers

What is the drug of choice for the infusion of vasoconstrictors in cases of variceal hemorrhage?

Sandostatin (Ocreotide) Signup and view all the answers

Which treatment method uses a Sengstaken-Blakemore tube?

Esophageal balloon tamponade Signup and view all the answers

What is the primary purpose of administering Spironolactone (Aldactone) to patients with ascites?

Reduce fluid retention Signup and view all the answers

What dietary modification is recommended for managing symptoms of cirrhosis?

High-calorie, moderate protein meals Signup and view all the answers

Which of the following complications is associated with esophageal balloon tamponade?

Esophageal necrosis Signup and view all the answers

What is the main function of endoscopic sclerotherapy in the treatment of variceal hemorrhage?

To promote inflammation and scar tissue development Signup and view all the answers

What is the primary goal of therapeutic paracentesis?

To relieve respiratory distress caused by excess fluid Signup and view all the answers

Which nursing responsibility is essential before conducting a paracentesis?

Obtain signed consent Signup and view all the answers

What complication can occur from a transjugular intrahepatic portosystemic shunt (TIPS)?

Hepatic encephalopathy Signup and view all the answers

What dietary modification is recommended for the management of hepatic encephalopathy?

Low protein diet Signup and view all the answers

How does Lactulose help in managing hepatic encephalopathy?

It decreases systemic absorption of ammonia Signup and view all the answers

Why is neomycin used in the management of hepatic encephalopathy?

To reduce intestinal bacteria Signup and view all the answers

What is the maximum amount of fluid that should be withdrawn during a large-volume paracentesis at one time?

4 to 6 liters Signup and view all the answers

Which of the following medications is known as a cornerstone treatment for increasing ammonia levels?

Neomycin/Lactulose Signup and view all the answers

What should be avoided to ensure patient safety in this scenario?

Rectal manipulation Signup and view all the answers

In managing a patient with elevated serum ammonia, which dietary restriction should be implemented?

High-protein load Signup and view all the answers

Which position is recommended for a patient experiencing impaired gas exchange due to ascites?

Semi-Fowler's with feet elevated Signup and view all the answers

What should be monitored to prevent dehydration and hypokalemia in this patient?

Fluid intake and output Signup and view all the answers

Which intervention is crucial for maintaining skin integrity in patients?

Turn the patient every 2 hours Signup and view all the answers

What is an appropriate action to take for patients with bleeding esophageal varices?

Assess vital signs and monitor for hypovolemia Signup and view all the answers

Which action should be performed to promote improved thought processes in the patient?

Provide frequent reorientation Signup and view all the answers

What should be assessed to ensure adequate tissue perfusion in patients with bleeding?

Vital signs including blood pressure Signup and view all the answers

Study Notes

Cirrhosis

Cirrhosis is a chronic liver disease that occurs when healthy liver tissue is replaced by scar tissue.
Scar tissue forms bands that constrict the liver and interfere with blood, lymph, and bile flow.
Cirrhosis can lead to loss of liver function and a variety of complications.

Pathophysiologic Effect of Cirrhosis

Loss of liver function
Interference with blood, lymph, and bile flow in the liver.

Clinical Manifestations of Cirrhosis

Onset is insidious and may take years to develop.
Early Stage:
- Enlarged and tender liver.
- Vague symptoms such as dull, aching pain in the right upper quadrant (RUQ), fever, nausea, vomiting, diarrhea, anorexia, and malaise.
Later Complaints:
- Edema and ascites:
  - Impaired plasma protein synthesis (hypoalbuminemia).
  - Disrupted hormone balance and fluid retention.
  - Increased pressure in the portal venous system.
- Bleeding and bruising:
  - Decreased clotting factor synthesis.
  - Increased platelet destruction by an enlarged spleen.
  - Impaired vitamin K absorption and storage.
- Esophageal varices and hemorrhoids:
  - Increased pressure in the portal venous system leading to collateral vessel development.
- Gastritis, anorexia, and diarrhea:
  - Engorged veins in the gastrointestinal system.
  - Alcohol ingestion.
  - Impaired bile synthesis and fat absorption.
- Abdominal wall vein distension (caput medusae): Portal hypertension.
- Jaundice: Impaired bilirubin metabolism and excretion.
- Malnutrition and muscle wasting:
  - Impaired nutrient metabolism.
  - Impaired fat absorption.
  - Impaired hormone metabolism.
- Anemia, leukopenia, and an increased risk of infection: Bleeding and increased blood cell destruction by the spleen.
- Asterixis and encephalopathy:
  - Accumulation of metabolic toxins.
  - Impaired ammonia metabolism and excretion.
- Gynecomastia, infertility, and impotence: Altered sex hormone metabolism.

Major Complications of Cirrhosis

Portal Hypertension:
- Impaired blood flow caused by tissue damage and fibrosis.
- Increased pressure within the portal circulation.
- Impaired blood flow to the liver.
- Slowed, congested circulation from the portal vein.
- Veins are easily torn by the passage of food, leading to massive hemorrhage (often the first sign of this complication).
- Characterized by:
  - Bleeding esophageal varices.
  - Hemorrhoids.
  - Collateral veins on the abdominal wall (caput medusae).
  - Peripheral edema (feet ankles, pre-sacral area).
  - Ascites.
Fluid Retention: In the form of ascites and edema.
- Ascites can result from disturbances in both local and systemic mechanisms that govern the movement of fluid and electrolytes.
- Local factors:
  - Portal hypertension.
  - Increased hepatic lymph flow.
- Systemic factors:
  - Decreased colloid oncotic pressure.
  - Hyperaldosteronism.
  - Impaired water excretion.
Hepatic Encephalopathy:
- A metabolic disorder of the nervous system that may occur as cirrhosis progresses.
- Results from the inability of the liver to convert ammonia to urea, leading to an accumulation of neurotoxins in the blood and cerebral edema.
- Cerebral edema leads to increased intracranial pressure and cerebral hypoxia, which is often the leading cause of death in people with portal systemic encephalopathy and liver failure.

Clinical Signs of Hepatic Encephalopathy

Stages of Hepatic Encephalopathy:
- Stage I: Tremors, slurred speech, impaired decision-making.
- Stage II: Drowsiness, loss of sphincter control, asterixis (liver flap; an early sign of portal systemic encephalopathy).
- Stage III: Dramatic confusion, somnolence.
- Stage IV: Coma, unresponsiveness.

Diagnostic Tests for Cirrhosis

Liver function studies: May be elevated in cirrhosis.
FBC with platelets:
- Low red blood cell (RBC) count, hemoglobin, and hematocrit.
- Low platelets.
- Leukopenia.
Coagulation studies: Show a prolonged prothrombin time.
Serum electrolytes:
- Hyponatremia is common.
- Hypokalemia, hypophosphatemia, and hypomagnesemia.
Bilirubin levels: Elevated in severe cirrhosis.
Serum albumin levels: Hypoalbuminemia.
Serum ammonia levels: Elevated.
Serum glucose and cholesterol levels: Frequently abnormal in people with cirrhosis.
Abdominal ultrasound: Evaluates liver size, detects ascites, and identifies liver nodules.
Liver biopsy under ultrasound: Useful to aid diagnosis.
Endoscopy: Determines the presence of esophageal varices.

Medical Management of Cirrhosis

Nutritional measures:
- Diet modification: Encourage the client to eat high-calorie moderate protein meals and to have supplementary feedings.
- Abstinence from alcohol.
- Recommended diet: 2000-3000 kcal/day, low protein (at least 10-20g/day), low sodium (<2g/day).
- Vitamin supplementation: Vitamin A, B-complex, C, and K.
 - Needed for healing damaged liver cells and to improve nutritional status.
 - Parenteral nutrition may be needed for anorexic patients.
Management of variceal hemorrhage:
- Diet: Soft, non-irritating foods (or parenteral nutrition).
- Emergency treatment:
  - Restoration of circulating blood volume: Blood and IV fluids for massive hematemesis and melena.
  - Infusion with vasoconstrictors:
    - Sandostatin (Ocreotide) IV: Drug of choice.
    - Pitressin (Vasopressin) IV: Urgent condition.
    - Beta-blocker (Nadolol (Corgard)) with isosorbide mononitrate (Imdur, Monodur): To prevent re-bleeding of esophageal varices; this drug combination lowers hepatic venous pressure.
  - Gastric lavage.
  - Esophageal balloon tamponade: Using a Sengstaken-Blakemore tube to apply direct pressure on bleeding varices; used only when conservative therapy fails.
    - Complications: Esophageal necrosis, perforation, aspiration, asphyxiation, stricture.
- Endoscopic sclerotherapy: Injection of a sclerosing agent (often with epinephrine) to promote inflammation and cause the development of scar tissue.
  - Complications: Esophageal ulceration, stricture, and perforation.
- Endoscopic esophageal ligation (variceal banding).
- Emergency surgical shunting:
  - Porto-systemic shunt or portacaval shunt.
Management of ascites/fluid retention:
- Bedrest.
- Strict fluid and sodium restriction:
  - 2 gm sodium/day.
  - High in kilojoules, moderate protein, moderate fat intake.
  - Limit fluid intake to 1 to 1.5L/day.
- Weigh daily.
- Diuretics: Reduce fluid retention and ascites.
  - Spironolactone (Aldactone): First diuretic of choice; potassium-sparing diuretic that reduces ascites by increasing renal excretion of fluid and decreasing aldosterone levels.
  - Furosemide (Lasix): Loop diuretic.
- Albumin infusion: Maintains osmotic pressure.
- Therapeutic paracentesis: Aspiration of fluid from the peritoneal cavity to relieve severe ascites that does not respond to diuretic therapy; the goal is to relieve respiratory distress caused by excess fluid in the abdomen.
  - Moderate amount withdrawn: 500mL to 1L daily.
  - Large-volume paracentesis: Withdrawal of 4 to 6L of fluid at one time.
  - Nursing responsibilities:
    - Weigh before and after the procedure.
    - Obtain baseline vital signs; monitor during and after every 15 minutes until stable.
    - Have the client void before the procedure.
    - Obtain signed consent.
    - Position the client appropriately.
    - Drain fluid slowly; limit to 1 to 2L.
    - Apply a dressing when the needle is removed; record the amount and characteristics of the fluid.
Peritoneovenous shunt: Surgical implantation of a plastic shunt between the peritoneal cavity and the superior vena cava (also referred to as a Le Veen or Denver shunt).
TIPS (Transjugular intrahepatic portosystemic shunt): Used to relieve portal hypertension and its complications of esophageal varices and ascites.
- Complications: Stenosis and occlusion of the shunt, which increases the risk of developing hepatic encephalopathy.
Management of hepatic encephalopathy:
- Neomycin/Lactulose PO: Cornerstone of treatment for an increased ammonia level.
- No/Low protein in the diet temporarily: Until ammonia levels decrease.
- Neomycin: Non-systemic aminoglycoside antibiotic; reduces intestinal bacteria and decreases ammonia production in the bowel lumen.
- Lactulose: Can be given PO or by enema; helps in the elimination of ammonia from the GI tract.
  - Reduces the number of ammonia-forming organisms in the bowel and increases the acidity of the colon contents.
  - Converts ammonia into ammonium ions, which are not absorbed and are excreted in the stool, thereby decreasing the ammonia level.
Other drugs for relief measures:
- Pain medication: Opioids, barbiturates, and sedatives are used with caution.
- Antiemetics: Metoclopramide IV PRN for nausea and vomiting.
- Antacids.
- Vitamins.

Nursing Management of Cirrhosis

Avoid: Rectal manipulation.
Assess:
- Oral cavity for bleeding gums.
- Coagulation studies including platelet count, prothrombin time, and partial thromboplastin time.
- Skin for bruising, hematoma, purpura, or petechiae.
Promote: Improved thought processes.
Restrict: High-protein load in the diet if serum ammonia is elevated; monitor ammonia levels.
Protect: From sepsis through good hand washing and prompt recognition and management of infection.
Monitor:
- Fluid intake and output.
- Serum electrolytes to prevent dehydration and hypokalemia, which may precipitate hepatic coma.
Keep: environment warm and limit visitors.
Pad: Side rails and provide careful nursing surveillance to ensure safety.
Assess: LOC/NVS and reorient the client frequently.
Administer: Lactulose/Neomycin as ordered.
For fluid volume excess:
- Measure weight and abdominal girth daily.
- Monitor I&O strictly.
- Restrict fluid intake.
- Provide a low sodium diet.
For impaired gas exchange related to ascites and fatigue: Promote gas exchange.
- Place in semi-Fowler's with feet elevated.
- Administer oxygen.
- Monitor oxygen saturation and arterial blood gas (ABG) levels.
Promote: Skin integrity.
- Use warm water (hot water stimulates pruritus).
- Prevent dry skin; avoid soap or preparations with alcohol and do not rub the skin.
- Apply mittens to protect the skin from injury.
- Turn the client every 2 hours.
- Assess for skin breakdown.
For clients with bleeding esophageal varices:
- Maintain adequate tissue perfusion:
  - Assess vital signs; monitor for hypovolemia.
  - Monitor clients with vasopressin infusion for complications such as hypertension, bradycardia, abdominal cramps, chest pain, or water intoxication.
  - Observe for straining, gagging, or vomiting (these increase portal pressure and increase the risk of further bleeding)
  - Check GI secretions and feces for occult and frank bleeding.
  - Monitor infusion of blood products.
  - Administer vitamin K as ordered.

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This quiz covers the chronic liver disease cirrhosis, including its pathophysiologic effects and clinical manifestations. Participants will explore the progression of symptoms and complications associated with this condition. Enhance your understanding of how cirrhosis affects liver function and overall health.