Liver Cirrhosis: Causes and Clinical Features

• Liver Cirrhosis is an end-stage liver disease resulting from repeated injury to liver cells which leads to scarring and hardening of the tissue, it is manifested by fibrotic scar tissue (nodules).

Two Types of Cirrhosis

• Alcoholic cirrhosis is direct injury caused by alcohol to the liver.
• Nonalcoholic fatty liver disease is caused by viral Hepatitis B or C, autoimmune disorders, hepatotoxic drugs, and fat collections in the liver.

Other Causes of Cirrhosis

• Chronic viral Hep B
• Hepatitis C left untreated can lead to cirrhosis
• Alcohol consumption damages the liver cells.

Clinical Features of Cirrhosis

• Decreased bilirubin metabolism results in jaundice, intense itching, darkened urine, and pale stools.
• Decreased functionality of coagulation causes a high risk of bleeding.
• Coagulation factors such as prothrombin are created within the liver, including albumin, immunoglobulins, and estrogen.
• Signs and symptoms of coagulation deficiency is manifested by ecchymosis, edema on the abdomen and lower extremities, loss of sexual hair and testicular atrophy, vasodilation manifested by Palmer Erythema (red palm).
• A build-up of estrogen leads to gynecomastia in males.
• Altered blood flow can lead to portal vein hypotension. The portal veins allows receiving of blood from the veins of the esophagus and the stomach as well as the spleen and the intestines.
• Portal vein hypotension causes blood to pool back towards organs such as stomach varices, esophageal varices, splenomegaly, and can lead to the rupture of stomach varices and esophageal varices.
• Watch for signs of GI bleeding (hematemesis, black tarry stool, coffee ground vomitus).
• Hepatic Encephalopathy is triggered by the liver's inability to synthesize ammonia, leading to ammonia build up within the body and the brain.
• Cerebral HTN and cerebral hypertension may occur.
• Always monitor liver cirrhosis patients for altered mental status.
• Encephalopathy leads to asterixis (flapping tremor)
• Ascites is the enlargement of the abdomen which puts pressure on the diaphragm in the lungs leading to atelectasis and pneumonia.
• Bacterial peritonitis happens because the liver is unable to synthesize immunoglobulins and fluid within the body is present, promoting bacterial infection, so keep an eye out for abdominal rigidity and guarding and signs of infection.
• Higher risk of liver cancer.

Laboratory Result Abnormality

• High Serum Bilirubin
• Prolonged clotting times due to poor coagulation
• Elevated ALT levels, also known as high liver enzymes, indicating potential liver damage or inflammation.
• High Ammonia is a toxic waste product produced by the breakdown of proteins in the body, if the liver is sick this leads to poor detoxification of ammonia.
• Low WBC is caused by the spleen trapping white blood cells due to portal vein hypertension leading to a high risk of infection.
• Decreased Serum Albumin leads to swelling, itchiness, vomiting, nausea, and muscle cramps because the liver is responsible for producing albumin that maintains fluid balance. Poor albumin leads to fluid accumulation causing ascites and edema.

Nursing Intervention

• HOB Elevated decreases difficulty breathing caused by an distended abdomen due to ascites building intraabdominal pressure to the diaphragm.
• Administer Diuretics to get rid of excessive fluid.
• Monitor Potassium levels (potassium sparing diuretics)
• Manage ascites with paracentesis.
• Daily Weighing, girth measurements
• Sodium and fluid restrictions is required.
• Monitor mental status due to ammonia build up.
• Altered mental status means high ammonia level
• Avoid sedatives to help reduce any kind of confusion that may have due to ammonia build up and to increase gut motility. (opiods, benzodiazepines)
• Avoid hepatotoxic drugs
• Encourage Hep A and B vaccines
• A skin care regimen with calamine lotion helps relieves some itching (pruritus) caused by bilirubin build up.
• Paracentesis - HCP help to relieve abdominal pressure by inserting a needle into the abdomen to drain the fluid and send off to the lab for culture.
• Treat hypotension after paracentesis with a Colloid solution (25% albumin IV) because of the large fluid being withdrawn.
• Always check BP during and after the procedure and administer albumin solution IV to maintain oncotic pressure and maintain the balance of water in the circulatory system.

Medications

• Lactulose lowers the serum ammonia in the blood through the stool.
• "LactuLOOSE – LOOSENS the stools"
• This medication lessens amount of ammonia, reducing risk of hepatic encephalopathy
• Acid reducers
• Diuretics get rid of excessive fluid in the body
• Vitamins
• Avoid hepatotoxic drugs like NSAIDS and raw foods which may cause parasite infections
• Avoid alcohol, raw or undercooked meat and seafood, highly processed foods, foods high in sodium, unhealthy fats, sugary drinks, caffeinated beverages, and certain medications like nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.