I. INTRODUCTION

The liver, the largest organ in the body, is essential in keeping the body functioning properly. It removes or neutralizes poisons from the blood, produces immune agents to control infection, and removes germs and bacteria from the blood. It makes proteins that regulate blood clotting and produces bile to help absorb fats and fat-soluble vitamins. You cannot live without a functioning liver.

Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein.

Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. This scarring replaces healthy tissue and prevents the liver from working normally. Cirrhosis usually develops after years of liver inflammation. When chronic diseases

cause the liver to become permanently injured and scarred, the condition is called

Cirrhosis. Cirrhosis harms the structure of the liver and blocks the flow of blood. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also, the production of proteins and other substances made by the liver is suppressed.

People with cirrhosis often have few symptoms at first. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. As liver function declines, water may accumulate in the legs and the abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise,

bleeding or infection. In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is passed by the liver into the intestines. The

liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. Drugs taken usually are filtered out by the liver, and this cleansing process also

is slowed down by cirrhosis. People with cirrhosis often are very

sensitive to medications and their side effects. The doctor often can diagnose cirrhosis from the patient’s symptoms and from laboratory tests. During a physical exam, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects

Cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan, and ultrasound. The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue

from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver.

Three major forms:

1. Laennec’s (alcohol induced) Cirrhosis

Fibrosis occurs mainly around central veins and portal areas. This is the most common form of cirrhosis and results from chronic alcoholism and

malnutrition.

2. Postnecrotic (micronodular) Cirrhosis

Consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis.

3. Biliary Cirrhosis

Consist of Scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis), and is much rarer than the preceding forms.

II. PATIENT’S PROFILE

Patient’s Name: Manuel Tambago

Address: 181, Salaca, Bugallon, Pangasinan

Sex: Male

Age:: 63

Nationality: Filipino

Religion: Roman Catholic

Admitted Date: February 14, 2009 @ 7:35 am

Chief Complaints: Epigastric Pain

Admitting Physician: Dr. Cabuang

Diagnosis: Liver Parenchymal Disease

III. ETIOLOGY / CAUSES

Alcoholic liver disease . For many people, cirrhosis of the liver is synonymous with chronic alcoholism, but in fact, alcoholism is only one of the causes. Alcoholic cirrhosis usually develops after more than a decade of heave drinking. The amount of alcohol that can injure the liver varies greatly from person to person. In women, as few as two to three drinks per day have been linked with cirrhosis and in men, as few as three to four drinks per day. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates.

Chronic hepatitis C . The hepatitis C virus ranks with alcohol as a major cause of chronic liver disease and cirrhosis in the US. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis.

Chronic hepatitis B and D . The hepatitis B virus is probably the most common cause of cirrhosis worldwide, but less common in the US and other western countries. Hepatitis B, like hepatitis C, causes liver inflammation and injury that over several decades can lead to cirrhosis. Hepatitis D is another virus that infects the liver, but only in people who already have hepatitis B.

Autoimmune hepatitis . This disease appears to be caused by the immune system attacking the liver and causing inflammation, damage, and eventually scarring and cirrhosis.

Inherited Disease . Alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, galactosemia, and glycogen storage diseases are among the inherited diseases that

interfere with the way the liver produces, processes, and stores enzymes, proteins, metals, and other substances the body needs to function properly.

Nonalcoholic steatohepatitis (NASH) . In NASH, fat builds up in the liver and eventually causes scar tissue. this type of hepatitis appears to be associated with diabetes, protein malnutrition, obesity, coronary artery disease, and treatment with corticosteroid medications.

Blocked bile ducts . When the ducts that carry bile out of the liver are blocked, bile backs up and damages liver tissue. In babies, blocked bile ducts are most commonly caused by biliary atresia, a diseases in which the bile ducts are absent or injured. In adults, the most common cause is primary biliary cirrhosis, a disease in which the ducts become inflamed, blocked, and scarred. Secondary biliary cirrhosis can happen after gall bladder surgery if the ducts are inadvertently tied off or injured.

Drugs, toxins, and infections . Severe reactions to prescription drugs, prolonged exposure to environmental toxins, the parasitic infection schistosomiasis, and repeated bouts of heart failure with liver congestion can all lead to cirrhosis.

IV. CLINICAL MANIFESTATIONS

SIGNS AND SYMPTOMS

Early Signs

Weakness, fatigue Anorexia Stomatitis Urine - tea color Stool - clay color Amenorrhea Decrease sexual urge Loss of pubic hair, axilla hair Hepatomegaly Jaundice Pruritus or urticaria

Late Signs

Hematological changes - all blood cells decrease o Leukopenia - decreaseo Thrombocytopenia - decreaseo Anemia - decrease

Endocrine changes o Spider angiomas, Gynecomastiao Caput medusa, Palmar errythema

GIT changes o Ascitis, bleeding esophageal varices - due to portal Hypertension

Neurological Changes

COMPLICATIONS OF CIRRHOSIS

Loss of liver function affects the body in many ways. Following are the common problems, or complications, caused by cirrhosis:

Edema and ascites . When the liver loses its ability to make the protein albumin, water accumulates in the legs (edema) and abdomen (ascites).

Bruising and bleeding . When the liver slows or stops production of the proteins needed for blood clotting, a person will bruise or bleed easily. The palms of the hands may be reddish and blotchy with palmar erythema.

Jaundice . Jaundice is yellowing of the skin and eyes that occurs when the diseased liver does not absorb enough bilirubin.

Itching . Bile products deposited in the skin may cause intense itching. Gallstones . If cirrhosis prevents bile from reaching the gallbladder, gallstones may

develop. Toxins in the blood or brain . A damaged liver cannot remove toxins from the blood,

causing them to accumulate in the blood and eventually the brain. There, toxins can dull mental functioning and cause personality changes, coma, and even death. Signs of the buildup of toxins in the brain include neglect of personal appearance, unresponsiveness, forgetfulness, trouble concentrating, or changes in sleep habits.

Sensitivity to medication . Cirrhosis slows the liver’s ability to filter medications from the blood. Because the liver does not remove drugs from the blood at the usual rate, they act longer than expected and build up in the body. This causes a person to be more sensitive to medications and their side effects.

Portal hypertension . Normally, blood from the intestines and spleen is carried to the liver through the portal vein. But cirrhosis slows the normal flow of blood through the portal vein, which increases the pressure inside it. This condition is called portal hypertension.

Varices . When blood flow through the portal vein slows, blood from the intestines and spleen backs up into blood vessels in the stomach and esophagus. These blood vessels may become enlarged because they are not meant to carry this much blood. The enlarged blood vessels, called varices, have thin walls and carry high pressure, and thus are more

likely to burst. if they do burst, the result is a serious bleeding problem in the upper stomach or esophagus that requires immediate medical attention.

Insulin resistance and type 2 diabetes . Cirrhosis causes resistance to insulin. This hormone, produced by the pancreas, enables blood glucose to be used as energy by the cells of the body. If you have insulin resistance, your muscle, fat, and liver cells do not use insulin properly. The pancreas tries to keep up with the demand for insulin by producing more. Eventually, the pancreas cannot keep up with the body’s need for insulin, and type 2 diabetes develops as excess glucose builds up in the bloodstream.

Liver cancer . Hepatocellular carcinoma, a type of liver cancer commonly caused by cirrhosis, starts in the liver tissue itself. It has a high mortality rate.

Problems in other organs . Cirrhosis can cause immune system dysfunction, leading to infection. Fluid in the abdomen (ascites) may become infected with bacteria normally present in the intestines. Cirrhosis can also lead to impotence, kidney dysfunction and failure, and osteoporosis.

PATHOPHYSIOLOGY:

V. DIAGNOSTIC EVALUATION:

Liver biopsy - detects destruction and fibrosis of hepatic tissue. Liver scan - shows abdominal thickening and a liver mass.

Modifiable Factors

Non-modifiableFactors

Liver inflammation Pain

Liver necrosis

Metastasis of the liver /

Ascites

Total liver failure / Liver

cirrhosisDeath

CT scan - determines the size of the liver and its irregular nodular surface. Esophagoscopy - to determine esophageal varices. Paracentesis - to examine ascetic fluid for cell, protein, and bacterial counts. PTC - differentiates extrahepatic from intrahepatic obstructive jaundice. Laparoscopy and liver biopsy - permit direct visualization of the liver. Serum liver function test - results are elevated

VI. MANAGEMENT / INTERVENTION

A. MEDICAL MANAGEMENT

Pharmacologic Interventions:

1. Provide asymptomatic relief measures such as pain medications and antiemetics.2. Diuretic therapy, frequently with spironolactone, a potassium-sparing diuretic that

inhibits the action of aldosteroe on the kidneys.3. I.V albumin to maintain osmotic pressure and reduce ascites.4. Administration of lactulose or neomycin through a nasogastric tube or retention enema to

reduce ammonia levels during periods of hepatic encephalopathy.

Surgical Intervention:

1. Transjugular intrahepatic portosystemic shunt may be performed in patients whose ascites prove resistant. This percutaneous procedure creates a shunt from the portal to systemic circulation to reduce portal pressure and relieve ascites.

2. Orthotopic liver transplantation may be necessary.

B. NURSING INTERVENTIONS:

Promoting Activity Tolerance

Encourage alternating periods of rest and ambulation. Maintain some periods of bed rest with legs elevated to mobilize edema and ascites. Encourage and assist with gradually increasing periods of exercise.

Improving Nutritional Status

Encourage patient to eat high calorie, moderate protein meal and to have supplementary feedings.

Suggest small, frequent feedings and attractive meals in an aesthetically pleasing setting at meal time.

Encourage and assist with gradually increasing periods of exercise.

Protecting Skin Integrity

Note and record degree of jaundice of skin and sclera and scratches on the body. Encourage frequent skin care, bathing without soap, and massage with emollient lotions. Advise patient to keep fingernails short.

Patient Education and Health Maintenance

Stress the necessity of giving up alcohol completely. Urge acceptance of assistance from a substance abuse program. Provide written dietary instructions. Encourage daily weighing for self-monitoring of fluid retention depletion. Discuss adverse effects of diuretic therapy. Emphasize the importance of rest, a sensible lifestyle, and an adequate, well-balanced

diet. Involve the person closest to the patient because recovery usually is not easy and relapses

are common. Stress the importance of continued follow –up for laboratory test and evaluation by a

health care provider

EVALUATION

Achievement of outcomes is successful if the patient with cirrhosis:

1. Has clear breath sounds throughout lung fields and normal percussion results from thoracic cavity.

2. Increases involvement in daily self-care activities and ambulation in hospital hallways.3. Loses 1 to 2 lb/day until dry weight is reached; has decreasing edema, decreasing

abdominal girth, and urine output of 500 to 1000 ml greater than intake until dry weight is reached.

4. Has normal body temperature and no indications of infections.5. Shows normal prothrombin time and hematocrit; hemoglobin levels that are increasing;

no orthostatic vital sign changes; and no falls, cuts, or other injuries.6. Maintains adequate food intake to regain or keep weight as appropriate with

incorporation of foods from all food groups and restriction of sodium and protein as necessary.

7. Shows no evidence of scratching and states that itching is decreased and controlled.8. Makes positive statements about self and realistic statements about future goals.9. Maintains intact skin and appropriate healing of any lesions.

RECOMMENDATION:

Avoid further hepatic damage: abstain from alcohol; abstain from any drugs not prescribe by physician, including over-the-counter drugs, such as analgesics or cold remedies; avoid exposure to hepatotoxins in the work and home environments.

Dietary regimen (may include sodium and/or protein restrictions) should be well balanced and include sources high in protein such as milk, eggs, fish, and poultry.

Fluid restriction if required; how to incorporate restrictions throughout the day. Signs and symptoms requiring immediate follow-up: weight gain; increased abdominal

girth; recurrence of edema, fever, or bleeding (blood in urine, stool, or vomitus; epistaxis; cuts that continue to bleed); change in metal function or behavior.

Measures that lessen chance of bleeding. Activity plan than promotes adequate rest. Care measures that help to control prurirus.