Cirrhosis and Hepatitis: In-Depth Notes

• Characterized by widespread fibrotic (scarred) bands of connective tissue that disrupt normal liver architecture.

• Tissue becomes nodular, obstructing both blood and lymph flow through the liver, leading to increased intrahepatic vascular resistance.

• Results in shrinking and hardening of the liver, contributing to various portal complications.

Types of Liver Diseases

• Cirrhosis Types:

  • Postnecrotic: Often follows severe liver damage or necrosis.

  • Laennec's (alcoholic): Resulting from chronic alcohol abuse.

  • Biliary: Due to bile duct obstruction and injury.

• Other Conditions:

  • Hepatitis A, B, C, D, E: Viral infections causing inflammation of the liver.

  • Liver tumors/cancers: Both primary (like hepatocellular carcinoma) and metastatic cancers.

Complications of Cirrhosis

• Portal hypertension: Increased pressure in the portal venous system leading to varices.

• Ascites and esophageal varices: Fluid accumulation in the abdominal cavity and swollen veins in the esophagus that can bleed.

• Biliary obstruction: Leading to jaundice and potential liver failure.

• Hepatic encephalopathy: Impaired brain function due to liver failure, characterized by confusion and altered consciousness.

• Potential for liver failure and other severe complications affecting overall health.

Nursing Management Priorities

• Key Interventions for Decompensated Cirrhosis:

  • Limiting protein intake to lower ammonia production.

  • Managing nausea and vomiting to ensure nutritional intake.

  • Monitoring fluid intake and output to prevent fluid overload.

  • Elevating the head of the bed > 30 degrees to help with breathing and reduce ascites discomfort.

Etiology and Genetic Risk Factors

• Leading Causes of Cirrhosis:

  • Hepatitis C (most common in U.S.): One of the major causes due to chronicinfection.

  • Hepatitis B and D (common causes worldwide): Hepatitis B can lead to cirrhosis if untreated.

  • Non-alcoholic fatty liver disease (NAFLD): Associated with obesity and metabolic syndrome, another growing concern.

  • Excessive and prolonged alcohol use: A primary risk factor in many patients.

Assessment: Recognizing Cues

• History:

  • Age, gender, and employment history (exposure risk to toxins, viruses).

  • Social and family history, including instances of liver disease and substance use.

  • Needlestick injuries, especially in healthcare workers.

• Physical Assessment:

  • Signs including fatigue, unintentional weight change, gastrointestinal symptoms like dyspepsia.

  • Abdominal assessment for presence of ascites and tenderness indicating potential liver enlargement or inflammation.

• Psychosocial Assessment:

  • Assess for alcohol withdrawal symptoms in patients with a history of chronic alcohol use.

Key Features of Cirrhosis

• Signs include:

  • Jaundice, spider nevi, pallor, and caput medusae (dilated abdominal veins).

  • Anemia, leukopenia, thrombocytopenia commonly observed in late-stage disease.

  • Ascites presenting as abdominal distension, splenomegaly, and testicular atrophy are common physical findings.

  • Hemorrhagic tendencies due to coagulopathy, altered hair distribution in some cases of hepatic dysfunction.

Laboratory Assessment

• Key laboratory tests:

  • ALP, ALT, AST, GGT, serum bilirubin, serum albumin, PT/INR, CBC, ammonia level critical for diagnosis and monitoring.

• Normal Liver Functions:

  • AST: 8-48 U/L

  • ALT: 7-55 U/L

  • LDH: 122-222 U/L

  • ALP: 40-129 U/L

  • GGT: 8-61 U/L

  • Bilirubin: 0.1-1.2 mg/dL

  • Albumin: 3.5-5.0 g/dL

  • Total protein: 6.3-7.9 g/dL

  • PT: 11-12.5 seconds

  • INR: 0.8-1.1

Diagnostic/Treatment

• Imaging Assessments:

  • Abdominal X-rays, CT, MRI to visualize structural changes.

• Diagnostic Procedures:

  • Liver ultrasound for size and blood flow evaluation, transient elastography for stiffness assessment, paracentesis for ascitic fluid analysis, ERCP for biliary tree evaluation.

Nursing Interventions

• Fluid Management:

  • Address fluid overload and manage ascites via paracentesis, where large amounts of fluid are drained.

• Management of Hemorrhage:

  • Use of Sengstaken-Blakemore tube for varices management to control and prevent bleeding.

• Preventing Confusion:

  • Monitor and manage increased serum ammonia levels, initiating therapy as needed.

Home Care Management

• Self-management education regarding medications such as lactulose and diuretics for symptom control and ascites management.

• Avoidance of alcohol, monitoring for signs and symptoms of encephalopathy to prevent worsening conditions.

• Beta-Blockers:

  • To reduce portal inflow and manage bleeding risks effectively.

Evaluation of Outcomes

• Expected outcomes include:

  • Decreased or no ascites with fluid therapy.

  • Normal electrolyte levels and balanced nutritional intake.

  • No occurrences of hemorrhage with effective management and intervention.

  • Successful abstinence from alcohol, as determined by patient self-reports and clinical evaluation.

Hepatitis Overview

• Types of Viral Hepatitis:

  • HAV, HBV, HCV, HDV, HEV noted for their public health impact.

• Etiology of Hepatitis:

  • HAV: Shellfish contamination, poor food handling practices, especially in endemic areas.

  • HBV: Transmitted through unprotected sex, needle sharing, blood transfusions (pre-1992), and more.

  • HCV: Primarily through illicit IV drug use and occupational exposure risks.

  • HDV: Requires HBV to replicate and is primarily seen in high-risk IV drug users.

  • HEV: Waterborne infection prevalent in certain geographic regions during poor sanitation conditions.

Health Promotion

• Vaccination for HAV and HBV to prevent infections.

• Infection control education, especially for healthcare workers, to mitigate transmission risks.

Conclusion

• Successful management and understanding of the complications and treatment options for liver diseases are crucial for patient outcomes, emphasizing the importance of early detection and intervention.