1. Adult Medical- Surgical Nursing Gastro-intestinal Module: Liver Cirrhosis

2. Liver Cirrhosis: Classification  Liver cirrhosis is a progressive, chronic degeneration of the liver cells (hepatocytes)  There is inadequate blood flow to the hepatocytes, therefore poor cellular nutrition and hypoxia → necrosis

3. Liver Cirrhosis: Aetiology  Hepatotoxicity from:  Alcohol abuse (the most common risk factor)  Drug abuse/ chemicals  Acute or chronic inflammation from:  Hepatitis, especially B and C  Chronic biliary stenosis  → Necrosis of hepatocytes)

4. Liver Cirrhosis: Pathophysiology  Fatty tissue is deposited in the liver instead of glycogen storage (fatty infiltration)  Disorganised attempts at regeneration of liver cells leads to:-  Abnormal blood vessel and bile duct formation and relationships →  Poor vascular flow and cholestasis (bile) and  Progressive chronic destruction of liver cells: chronic inflammation with fibrosis and liver atrophy (a shrunken, fibrotic liver)

5. Liver Cirrhosis: Effects on Liver Function  Abnormal CHO metabolism:  ↓ glycogen storage, ↑ fatty deposits, ↓ gluconeogenesis  Serum ammonia elevated (indicating liver failure)  Nutritional deficiencies: ↓ protein synthesis (albumen, prothrombin, fibrinogen)  Reduced synthesis of vitamins (B complex)  Cholestasis obstructs bile flow to intestine to emulsify fats → poor digestion/ absorption of fats/ fat-soluble vitamins (ADEK)

6. Liver Cirrhosis: Effects on Liver Function (cont)  ↑ reabsorption of bilirubin into the circulation (unconjugated)  Poor detoxification of drugs including alcohol  Back-pressure on the portal circulation (↑ hydrostatic pressure). Leads to:-  Oedema (ascites) (↑ also by lower osmotic pressure from ↓ albumen) → hypovolaemia  Oesophageal varices/ haemorrhoids

7. Liver Cirrhosis: Clinical Manifestations  Clinical manifestations are related to:  Poor hepatic function (→ hepatic failure)  Cholestasis

8. Liver Cirrhosis: Clinical Manifestations  Fatigue, ↓ energy, nausea, malaise  ↓ mental function, drowsiness, hiccoughs → hepatic coma  Liver enlarged, tender or later shrunken  Ascites (oedema): abdominal distension  Protein malnutrition  Peripheral neuropathy (vitamin B complex)  Bleeding tendency (vit K, prothrombin)

9. Liver Cirrhosis: Clinical Manifestations (cont)  Osteomalacia & osteoporosis (vitamin D)  Pale, bulky, fatty stools and dark urine  Jaundice (skin and sclera)  Itching  Enhanced effects of drugs and alcohol  Dehydration and hypotension

10. Liver Cirrhosis: Diagnosis  History and clinical examination  Liver function tests (LFT):  ↑ unconjugated and total bilirubin  ↑ Alkaline phosphatase (liver cell injury  ↑ AST, ALT, GGT and cholestasis)  ↓ Serum albumen, globulin (plasma proteins)  ↑ Serum ammonium

11. Liver Cirrhosis: Diagnosis (cont)  Blood coagulation studies:  ↑ PT, PTT, INR (low prothrombin)  Urea and electrolytes  CBC (↑ haematocrit: hypovolaemia)  Viral studies (Hepatitis)  Liver scan  Liver biopsy

12. Liver Cirrhosis: Medical Treatment  *This is a progressive chronic disease  Rest  High glucose, low protein, low fat diet  Vitamin supplements (B complex, K)  IV Albumen if necessary  Fluid intake/ fluid and electrolyte balance  Diuretics/ paracentesis for ascites  Lactulose to reduce serum ammonia

13. Liver Cirrhosis: Surgery or Adjuvant Treatment  Endoscopy:  Measures to treat or prevent haemorrhage from oesophageal varices:  Injection with sclerosing agent  Cautery/ laser  Bands to tie off  Surgery:  Porto-caval shunt  Liver Transplant

14. Liver Cirrhosis: Nursing Care  Patient education on lifestyle, diet, fluids, vitamins  Weight and girth measurements and BP  Foot care  Care pre- and post-liver biopsy*  Care pre- and post-surgery*