Liver cirrhosis is a chronic, end-stage liver disease. It is a term given to a condition where normal liver parenchyma is replaced by fibrotic tissues. This condition arises once hepatocytes become unable to overcome the hepatic insults via undergoing the process of mitosis. Alcohol, hepatitis B, hepatitis C, Wilson disease, hemochromatosis, aldolase B deficiency, alpha 1 antitrypsin deficiency, and autosomal recessive polycystic kidney diseases are few risk factors for liver cirrhosis. Ascites, asterixis, hepatic encephalopathy, scleral icterus, portal hypertension, and gynecomastia are a few symptoms of this condition. Liver transplant is the only definitive treatment for this condition, so symptoms management become the main means of addressing the need of the majority of patients

Lamichhane Wagle, Sabina

English

Otterbein University

Otterbein University Digital Commons @ Otterbein Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work 2019 Cirrhosis of the Liver Sabina Lamichhane Wagle lamichhanewagle1@otterbein.edu Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn  Part of the Nursing Commons Recommended Citation Lamichhane Wagle, Sabina, "Cirrhosis of the Liver" (2019). Nursing Student Class Projects (Formerly MSN). 361. https://digitalcommons.otterbein.edu/stu_msn/361 This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact digitalcommons07@otterbein.edu. Cirrhosis	of	the	Liver	Sabina	Lamichhane	Wagle		BSN,	RN,	CCRNIntroduction	• Liver	cirrhosis	is	 a	chronic	condition	where	a	liver	becomes	f ibrotic	and	loses	its	normal	function	and	architecture	(Hiorth et	al.,	2018).	• Liver	cirrhosis	can	be	classif ied	 as	either	compensated	liver	cirrhosis,	 if 	signs	and	symptoms	are	not	yet	experienced	by	the	patients	or	uncompensated	liver	cirrhosis,	if 	signs	 and	symptoms	experienced	by	the	patients	(Bixler et	al.,	2019).		Several	 factors,	such	as	alcoholism,	Hepatitis	 B,	Hepatitis	 C,	hemochromatosis,	Wilson	disease,	 and	fructose	intolerance	can	predispose	a	person	to	this	condition	(Vatansever &	Pakoz,	2019).	• It	is	a	commonly	encountered	condition	throughout	the	world.	 Annually ,	about	30,000	people	in	the	United	States	die	due	to	a	complication	of 	liver	cirrhosis,	making	it	the	12th leading	 cause	of 	the	death	in	this	country	(Yoon	&	Chen,	2017).	• Liver	cirrhosis	has	been	selected	 as	 a	topic	due	to	its	high	prevalence	and	poor	prognosis.	Information	on	this	should	be	helpful	to	future	nurses	to	appreciate	the	role	of 	liver	in	metabolizing	and	detoxifying	various	medicines.	Thus,	understanding	the	disease	process	 in	detail	is	 necessary	to	prevent	any	adverse	reactions	related	 to	drug-overdose	or	drug-drug	interactions	(Kockerlinget	al.,	2019.	Future,	advance	nurse	practitioner	needs	in-depth	information	about	the	current	knowledge	of 	this	condition	and	ways	of	addressing	its	complications.Otterbein	University,	Westerville,	OhioImplication	 for	Nursing	careFigure	2:	(Hussain,	2017) 	Signs	 and	symptoms	of 	of 		liver	cirrhosis	arises	due	to	the	presence	of 	fewer						functional	hepatocytes:• Lower	clearance	 of 	bilirubin	results	in	an	increase	 in	the	quantity	of 	total,	direct,	and	indirect	bilirubin,	resulting	 in	pruritus,	scleral	 icterus,	kernicterus,	pale	 stool,	and	dark	urine.• Lower	clearance	 of 	ammonia	presents	as	hepatic	encephalopathy	and	asterixis.• Fibrosis	of 	liver	leads	to	portal	hypertension,	which	presents	as	splenomegaly,	 caput	medusa,	esophageal	 varices,	and	anorectal	 varices.• Lower	production	of	albumin	and	transthyretin	presents	as	edema,	ascites,	peritonitis,	and	hepatic	hydrothorax,	secondary	to	low	oncotic	pressure.• Lower	production	of	sex-hormone	binding	globulin	leads	to	estrogen	amplif ication,	which	presents	as	gynecomastia	 and	telangiectasia• Lower	production	of	coagulation	factors	and	thrombopoietin presents	as	prolonged	bleeding	time,	 prothrombin	time,	and	partial	thromboplastin	time.• Liver	cirrhosis	can	eventually 	lead	 to	hepatocellular	carcinoma.(Pinderup &	Bager,	 2019)		Hepatocytes	are	stable	 cells,	 which	remains	in	G0 phase	of 	cell	 cycle,	but	go	into	G1phase	and	mitosis	after	an	insult	to	regenerate	 more	hepatocytes.	In	minor	circumstances,	 hepatocyte	will	fully 	resolve	the	insult	without	the	formation	of 	scar	tissue	(Gonzalez,	 Gilger,	 Huh,	&	Washington,	2017).	However,	following	a	prolonged	damage,	 hepatocytes	cannot	effectively	regenerate	to	resolve	the	situation.	It	has	to	undergo	the	process	of 	repair.	There	is	a	gap	 between	fenestrated	hepatic	sinusoids	and	hepatocyte,	which	is	called	the	space	of 	disse(Pinderup	&	Bager,	 2019).	Hepatic	stellate	 cells	 are	 found	in	the	space.	When	it	is	inactive,	hepatic	stellate	cells	 store	vitamin	A.	However,	in	its	active	form,	this	cells	synthesizes	collagen	 to	repair	damages.	 Activation	of 	many	Ito	cells	leads	to	f ibrotic	scar	formation	in	the	liver.	This	will	 hamper	the	normal	function	of 	liver	parenchyma,	leading	to	the	condition	of 	liver	cirrhosis.	Nodules	made	by	hepatocyte	with	bridging	f ibrosis	is	a	pathognomonic	histological	f inding	in	liver	cirrhosis	(Gonzalez,	Gilger,	 Huh,	&	Washington,	2017).	Figure	 1:		(American	 Liver	foundation,	2017)• Ascites• Jaundice• Peripheral	 edema	• Bruising• Flapping	tremor	• Enlarged	 spleen	• Esophageal	 varices	Signs	and	Symptoms:• Cirrhosis	is	an	 irreversible	 condition,	so	liver	transplant	is	the	most	definitive	treatment	(Vatansever &	Pakoz,	2019).	However,	symptom	management	 can	be	a	 strategy	to	address	the	need	of 	a	patient	with	liver	cirrhosis.	Thus,	educating	the	patient	about	the	disease	process	and	healthy	habits	to	delay	symptom	progression	is	important.• Education	can	be	implemented	as	an	interventional	strategy	in	nursing	care.	 Education	on	alcohol	abstinence	can	 be	the	single-most	important	topic	to	address	the	issue	 of 	liver	cirrhosis.	However,	education	should	also	be	focused	on	motivating	patients	with	risk	factors	to	undergo	screening	tests	so	that	the	condition	can	be	detected	early .	For	example,	 newborn	should	be	screened	for	hepatitis;	children	should	be	screened	for	metabolic	conditions,	like	glycogen	storage	disorders	or	lysosomal	storage	disorders;	adults	should	be	screened	 for	alpha-1	antitrypsin	deficiency,	Wilson	disease,	 and	hemochromatosis.• Advance	nursing	care	 should	be	based	on	the	knowledge	that	liver	cirrhosis	affects	cytochrome	P450	and	other	drug-metabolizing	enzymes	in	liver.	This	will	 signif icantly	affect	the	f irst-pass	metabolism.	Therefore,	doses	of 	the	drugs	that	depend	on	those	enzymes	for	activation	or	eventual	excretion	should	be	adjusted	to	avoid	patients	suffering	symptoms	of 	drug	overdose	or	under-dose	(Bixler et	al..,	 2019).	• Nurse	 anesthetics	should	use	Lorazepam,	Oxazepam,	 and	Temazepam and	avoid	all	other	benzodiazepines,	 if 	one	is	indicated	for	the	patient	with	liver	cirrhosis.	It	is	because	 those	three	benzodiazepines	 have	liver-independent	processing	(Kockerlinget	al.,	 2019)Underlying	pathophysiologyFigure	3:	(Rehaim&	Mohamed,	2017)	Significance	of	Pathophysiology• Understanding	the	pathophysiology	of 	liver	cirrhosis	helps	to	adequately	diagnose	the	condition	at	an	earlier	stage	 of 	the	condition.	For	example,	being	able	to	detect	nodules	in	a	CT	scan	helps	to	detect	the	disease	at	an	earlier	 stage.• Understanding	the	pathophysiology	also	helps	to	decide	on	treatment.	For	example,	a	 person	showing	the	signs	of 	ascites	and	painless	 vomiting	needs	furosemide	or	octreotide;	a	person	showing	the	signs	of 	coagulopathy	needs	plasma	transfusion	or	thrombopoietin injection;	a	person	showing	the	signs	of 	hepatic	encephalopathy	needs	lactulose	(Kodali,	Kaif ,	Tariq,	&	Singal,	 2018).• Due	to	its	chronic	nature,	patients	will	benefit	if 	healthcare	providers	can	detect	this	condition	at	an	earlier	stage.	There	 is	no	definitive	test	to	detect	liver	cirrhosis,	so	providers	should	investigate	 the	presence	of 	signs	and	symptoms	of 	liver	damage	in	patients	with	positive	risk	factors	as	potential	cases	of 	liver	cirrhosis.	• Scleral	 icterus	is	 one	of 	the	earliest	signs	of 	liver	cirrhosis;	 however,	this	is	a	 non-specif ic	f inding.	Esophageal	varices	is	 one	of 	the	later	f indings,	which	leads	to	painless	 emesis,	 the	most	common	cause	of 	death	in	people	with	liver	cirrhosis.	Deposition	of 	collagen	by	Ito	(hepatic	stellate)	 cells	 is	 the	pathophysiological	reason	behind	this	condition	(Vatansever,	&	Pakoz,	2019).• Stopping	Ito	cells	activation	is	a	noble	approach	in	delaying	hepatic	f ibrosis,	hence,	slowing	down	the	progression	to	liver	cirrhosis.	This	approach	is	derived	based	upon	the	understanding	of 	pathophysiology	(Rehaim&	Mohamed,	2017).Case	StudyA	50	years	old	women	came	to	the	Emergency	room	with	a	complain	of 	recent	onset	non-painful	hematemesis.	She	reports	that	her	abdomen	is	increasing	distended	for	the	last	15	days,	shocks	are	getting	tighter	to	wear,	and	is	breathing	faster	than	usual.	On	examination,	 she	appears	malnourished	and	confused;	she	has	scleral	 icterus,	shifting	dullness	in	 abdomen,	and	bilateral	pitting	edema.	 Patient	reports	drinking	at	least	2-3	glass	 of 	wine	every	evening	for	the	past	10	years.	The	blood	test	revealed	elevated	ammonia,	alanine	 aminotransferase	 (ALT)	,	aspartate	aminotransferase	(AST),	total	bilirubin,	but	low	albumin	and	thrombocyte	count.	Total	two	units	of	PRBC	was	transfused	and	a	liter	of 	0.9%	NS	was	provided.	Emergency	endoscopy	revealed	esophageal	 varices.	 Pt	was	diagnosed	with	liver	cirrhosis	and	transferred	to	the	intensive	care	 unit	for	further	management.Liver	Cirrhosis	Cascade	Conclusion• In	conclusion,	liver	cirrhosis	is	a	common	condition	in	the	world,	claiming	 lives	of 	several	thousands	of 	individuals	every	year.	Even	though	the	most	common	etiologies	of 	this	condition	are	hepatitis	viruses	and	alcohol,	several	 metabolic	syndromes	are	 responsible	for	causing	this	condition	in	younger	people.	• Understanding	this	condition	by	nurses	help	to	educate	patients	about	the	risk	factors	and	healthy	habits	to	delay	the	progression,	and	motivate	patients	to	undergo	screening	 tests	for	viruses	or	metabolic	syndromes.	Nurses	should	be	mindful	about	the	need	of 	medication	adjustment	to	patients	with	liver	cirrhosis	to	avoid	adverse	events	due	to	impaired	 liver	metabolism.ReferencesFigure	4:	(American	Liver	Foundation,	2017)• Dull	 abdominal		pain	• Spider	 angioma• Asterixis• Electrolyte	abnormalities	• Gynecomastia		• (Yoon	&	Chen	2017)	

Cirrhosis of the Liver

https://digitalcommons.otterbein.edu/cgi/viewcontent.cgi?article=1353&context=stu_msn

Cirrhosis of the Liver

Abstract

Similar works

Full text

Available Versions

Otterbein University