Cirrhosis

General

DRG Category: 432

Mean LOS: 6.3 days

Description MEDICAL Cirrhosis and Alcoholic Hepatitis With Major Complication or Comorbidity

DRG Category: 5

Mean LOS: 19.5 days

Description SURGICAL Liver Transplant With Major Complication or Comorbidity or Intestinal Transplant

Introduction

The Centers for Disease Control and Prevention (CDC) report that 4.5 million people in the United States have liver disease. Cirrhosis along with other chronic liver diseases result in approximately 45,000 deaths annually. In cirrhosis, the damaged liver cells regenerate as fibrotic areas instead of functional cells, causing lymph damage and alterations in liver structure, function, and blood circulation. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells.

The classification of cirrhosis is controversial at present. However, most types may be classified by a mixture of causes and cellular changes, defined as follows: alcoholic; cryptogenic and postviral or postnecrotic; biliary; cardiac; metabolic, inherited, and drug related; and miscellaneous. The first three types are the most commonly seen, accounting for 55% to 90% of cases of cirrhosis. Although each of these types has a different etiology, the clinical findings, including portal vein hypertension and eventual liver failure, are much the same. (Box 1 explains the effects of alcohol on the liver.)

BOX 1 Pathophysiology of Cirrhosis: Progression of Effects

Effects of Occasional Drinking

Several days after drinking, synthesis of fatty acids and triglycerides increases.
Fatty acid oxidation decreases.
Formation and release of lipoproteins decrease.
Fat appears in the liver.

Effects of Continual Drinking

Liver cells enlarge because of accumulation of lipids.
Enlarged liver cells rupture.
Fatty contents from ruptured liver cells form fatty cysts.
Cells between adjoining veins in the liver are linked by developing fibrosis.
Continued scarring and necrosis lead to the liver shrinking.
Liver function decreases or ceases.
Obstructed flow of blood leads to increased pressure in the portal vein (portal hypertension).
Blood backs up in the liver and spleen.
Veins in the abdomen, rectum, and esophagus dilate.
The congestion of blood in the liver leads to the leakage of plasma into the peritoneal cavity.
The liver’s production of albumin decreases.
Decreased serum albumin levels allow more water to move into other body compartments.
Renin and aldosterone production levels increase, leading to water and sodium retention.
Ascites, the accumulation of fluid in the peritoneal cavity, results.

Causes

Liver cirrhosis is most commonly associated with hepatitis C (26% of cases), alcohol abuse (21%), hepatitis C plus alcohol abuse (15%), cryptogenic causes (etiology not determined; 18%), hepatitis B (15%), and other miscellaneous causes (5%) such as malnutrition, protein deficiency, biliary disease, and chemical toxins. Alcoholic liver disease is also known as Laënnec cirrhosis, portal cirrhosis, nutritional cirrhosis, and fatty cirrhosis. A serious complication is hepatocellular carcinoma. Primary biliary cirrhosis is a chronic and progressive liver disease thought to be of autoimmune derivation. In this condition, a continuous destruction of small and medium bile ducts occurs due to immune effects of complement, a protein that is part of the immune response.

Genetic Considerations

Cirrhosis is a complex disease including both genetic and environmental factors. The keratin 8 and keratin 18 genes, as well as genes involved in immune signaling, have been implicated in both susceptibility to disease and severity of course. Proinflammatory cytokines have been associated with increased risk of hepatitis and cirrhosis. In addition, several genes have been identified that increase susceptibility to alcoholic liver disease, including higher levels of alcohol dehydrogenase (ADH) and cytochrome P450 2E1 activity, and lower levels of acetaldehyde dehydrogenase (ALDH) activity. Shared environment also contributes to what may at first appear to be genetic transmission.

Sex Life Span Considerations

Cirrhosis is most commonly seen in the middle-aged population; it is the fifth leading cause of death in the population that is 35 to 55 years of age. It is more common in males than in females. Although the cause is obscure, liver disease appears to be more prevalent in preterm infants who have minimum enteral feedings and who were begun on total parenteral nutrition at an early age.

Health Disparities Sexual/Gender Minority Health

Health disparities exist in the management and outcomes of people treated for cirrhosis. Black persons in the United States have the highest rates of both hospital admission and readmission. Black and Hispanic patients are less likely to receive portosystemic shunts and liver transplantations as compared to White patients (Spiewak et al., 2020). Indigenous peoples, such as Native Americans and Australian Indigenous people, have higher rates of hospital readmissions and poorer survival outcomes after being diagnosed with cirrhosis than other groups. Veterans have higher rates of drinking than their civilian counterparts, likely because of the effect of posttraumatic stress disorder. Not only are there high rates of cirrhosis among Veterans, but also one-third of those diagnosed continue to drink after the diagnosis. Alcohol use disorders, which place people at risk for cirrhosis, are more prevalent in White and Native American persons and younger as compared to older adults. While little is known about the epidemiology of cirrhosis in gender and sexual minority persons, gender and sexual minority youths and young adults have higher rates of alcohol use than their counterparts. Estimates are that 25% of gender and sexual minority adults have moderate alcohol dependency.

Global Health Considerations

Cirrhosis is among the leading causes of death globally. Half of all cirrhosis-related deaths globally are thought to be related to alcohol consumption. The average global per capita alcohol consumption per year is approximately 6.4 liters The lowest per capita consumption is in the Middle East and Northern Africa, whereas the highest occurs in Russia and Eastern Europe. Primary biliary cirrhosis is more common in Northern Europeans and is less common in people with African ancestry. The World Health Organization reports that the highest death rates occur in Mexico and South America, Central Africa, and Eastern Europe. North American and European countries have lower mortality rates, and rates in Asia vary sharply by country. Hepatocellular carcinoma has the highest prevalence in Asia, South Africa, and some areas of the Middle East. Susceptibility to the disease is believed to be based not on ancestry or nationality but on environmental factors.

Assessment

History

Determine if the patient has experienced personality changes such as agitation, forgetfulness, and disorientation. Inquire about fatigue, drowsiness, mild tremors, or flu-like symptoms. Ask about any past or present symptoms that may indicate cirrhosis, such as changes in bowel habits or menstrual irregularities. Elicit a history of easy bruising, nosebleeds, or bleeding gums. Determine the patient’s drinking patterns and how long they have existed. Determine if the patient has had early morning nausea and vomiting, anorexia, indigestion, weight loss, weakness, lethargy, epigastric discomfort, or altered bowel habits. Ask about any recent sexual dysfunction.

Physical Examination

Common signs and symptoms include bleeding from esophageal varices, increased bleeding tendencies from coagulopathies, ascites, and abdominal pain. Inspect for signs of muscle atrophy. Note whether the patient’s abdomen is protruding. Assess the patient’s skin, sclera, and mucous membranes, observing for poor skin turgor, signs of jaundice, bruising, spider angiomas, and palmar erythema (reddened palms). Observe the patient’s trunk and note the presence of gynecomastia (enlarged breasts). Observe the abdomen for distention, an everted umbilicus, and caput medusae (a plexus of dilated veins about the umbilicus); measure the abdominal girth.

When assessing the patient’s upper extremities, test for asterixis (liver flap or flapping tremor). Have the patient stretch out the arm and hyperextend the wrist with the fingers separated, relaxed, and extended. The patient in stages II (impending) and III (stuporous) of hepatic encephalopathy may have a rapid, irregular flexion and extension (flapping) of the wrist. Note any tenderness or discomfort in the patient’s abdomen. Palpate for hepatomegaly by gently rolling the fingers under the right costal margin. The liver is normally soft and usually can be felt under the costal margin. Percuss the patient’s abdomen. Note a shifting dullness in the abdomen if ascites is present. Auscultate the abdomen and assess for hypoactive, hyperactive, or normal bowel sounds.

Psychosocial

Cirrhosis is a chronic disease that dictates lifestyle changes for the patient and significant others. Determine the patient’s response to the diagnosis and the patient’s ability to cope with change. Identify the patient’s past ability to cope with stressors and determine if these mechanisms were successful.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Percutaneous or laparoscopic liver needle biopsy	Normal hepatocytes	Cellular degeneration	Distinguishes advanced liver disease from cirrhosis; excludes other forms of liver injury such as viral hepatitis
Liver enzymes: Aspartate aminotransferase (AST); alanine aminotransferase (ALT); lactate dehydrogenase (LDH), bilirubin	AST: 10-35 units/L; ALT: 10-40 units/L; LDH: 45-90 units/L; bilirubin < 1.2 mg/dL	Elevated	Liver cellular dysfunction leads to accumulation of enzymes; cirrhosis decreases portal blood flow and hepatic clearance of bilirubin

Other Tests: Ultrasound; computed tomography; magnetic resonance imaging; other supporting tests including antimitochondrial antibodies; serum alkaline phosphate; total serum, serum bilirubin, indirect bilirubin, and urine bilirubin; serum ammonia; and serum albumin, serum total protein, and prothrombin

Primary Nursing Diagnosis

Diagnosis: Excess fluid volume related to retention as evidenced by ascites and/or abdominal pain

Outcomes: Fluid balance; Hydration; Nutritional status; Knowledge: Disease process; Knowledge: Treatment regime

Interventions: Fluid/electrolyte management; Fluid monitoring; Medication administration; Nutrition management

Planning and Implementation

Collaborative

MEDICAL Patients will likely undergo a complete nutritional assessment. Protein levels and calorie intake will be determined by the severity of illness, whether or not malnutrition is present, and the patient’s level of activity. Frequently, vitamin K injections are ordered to improve blood-clotting factors. If coagulopathies worsen, treatment may require whole-blood or fresh-frozen plasma to maintain the hematocrit and hemoglobin. If alcohol is the primary etiologic factor in liver cirrhosis, strongly encourage the patient to cease drinking. If patients are able to ambulate, they are encouraged to walk as much as possible to prevent muscle wasting.

INTERVENTIONAL RADIOLOGY A transjugular intrahepatic portosystemic shunt (TIPS) is a bypass used to collect two veins within the liver for patients with portal hypertension and severe ascites. The shunt is placed by an interventional radiologist who uses a guided image to open a pathway to connect the portal vein to the hepatic vein and then threads a stent through the pathway to keep it open. TIPS may reduce internal bleeding in the gastrointestinal (GI) tract and lessen ascites.

SURGICAL The medical team will consider liver transplantation for patients with decompensated cirrhosis. Candidates for liver transplantation fall into three categories: those with irreversible chronic liver disease, those with malignancies of the liver and biliary tree, and those with fulminant hepatic failure. Approximately 7,000 liver transplants occur each year in the United States. Approximately 15% of patients on the liver transplant waiting list will die while waiting for a transplant because of a shortage of organs. As surgeons have gained more experience with both the surgical procedure and the postoperative management, survival rates have increased. The 1-year survival rate is approximately 90%, and the 5-year survival rate is 70% or more. Patients with alcohol-related liver disease are considered for transplantation after a medical and psychological evaluation that includes the potential for long-term alcohol abstinence. Posttransplantation care is complex and includes careful monitoring for infection, rejection, and hemorrhage as well as assessing the function of the donor liver.

Pharmacologic Highlights:

Medication or Drug Class	Dosage	Description	Rationale
Zinc sulfate	220 mg PO BID	Mineral supplement	May improve muscle cramps, stimulate appetite, and improve taste sensitivity

Other Drugs: To remedy itching, an antihistamine can be administered. If a patient has nausea and vomiting, antiemetics may be prescribed. Use caution when administering antiemetics and acetaminophen to patients with liver damage because many medications are cleared through the liver. For primary biliary cirrhosis, the following may be used: ursodeoxycholic acid to slow the progression of the disease; immunosuppressive agents, corticosteroids. For autoimmune hepatitis, prednisone and azathioprine may be used, whereas interferon and other antiviral agents may be used for hepatitis B and C. Patients with chronic liver disease should receive a vaccination to protect against hepatitis A.

Independent

Nursing considerations in the cirrhotic patient are to avoid infection and circulatory problems. Turn the patient and encourage coughing and deep breathing every 2 hours to prevent pneumonia. Because bleeding can occur, monitor the patient closely for signs of hypovolemia. Test any stool and emesis for blood. Follow closely any break in the patient’s skin integrity for increased bleeding and apply pressure to injection sites. Warn the patient against straining at stool, blowing the nose, or sneezing too vigorously. Suggest the patient use a soft toothbrush and an electric razor.

Because of fatigue, muscle atrophy, and wasting, the patient needs to rest. Plan activities to include regular rest periods. To prevent breakdown of the skin, place the patient on an eggcrate or air mattress. Avoid using soap to bathe the patient; use moisturizing agents or lubricating lotion and massage areas of the skin that are potential breakdown sites. Use pressure-reducing mattresses or specialty beds to prevent skin breakdown. If patients are strong enough, assist them with ambulation to prevent muscle wasting.

Encourage the patient to verbalize questions, anxieties, and fears. In conversation, note any behavioral or personality changes, including increasing stupor, lethargy, or hallucinations. Arouse the patient periodically to determine the patient’s level of consciousness. Emotional and psychological support for the patient and family are important to eliminate anxiety and poor self-esteem. Involve the family members in the patient’s care as a means of improving the patient’s morale.

Evidence Based Practice Health Policy

Bosch, J., Gracia-Sancho, J., & Abraldes, J. (2020). Cirrhosis as new indication for statins. Gut, 69, 953-962. [PMID:32139553]

The authors noted that in recent years, patients with advanced chronic liver disease have been increasingly treated with statin drugs. With increased use, reports of favorable effects on a range of liver ailments have increased, and the authors aimed to provide an overview of recent developments. The authors reviewed the current knowledge about the applications of statins in chronic liver diseases and described their effects.
They noted that evidence shows that statins might improve outcomes in cirrhosis, but evidence from randomized trials is limited. Therefore, they note that there is no strong enough evidence for recommending statins for the treatment of cirrhosis.

Documentation Guidelines

Physical findings: Bleeding, abdominal enlargement, weight gain or loss, fluid intake and output, easy respirations, breath sounds, heart sounds, level of consciousness, GI status (nausea, vomiting, anorexia, diarrhea), color of skin and sclera
Laboratory results: White blood cell count, hemoglobin and hematocrit, albumin, serum electrolytes, ALT, AST
Nutrition: Tolerance of diet, appetite, ability to maintain body weight
Response to treatment: Medications, surgery, transplantation

Discharge and Home Healthcare Guidelines

ALCOHOL ABUSE TREATMENT Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in alcohol abuse treatment. Assist the patient in obtaining counseling or support for their alcoholism.

FOLLOW-UP Encourage the patient to seek frequent medical follow-up. Visits from a community health nurse to monitor the patient’s progress and to help with any questions or problems at home are also helpful. Transplant patients will need lifelong follow-up by a transplant clinic and extensive teaching. When patients are discharged, make sure the patient and family understand all aspects of their medical regime, including medications, nutrition, protection from infection, signs of rejection, activity limits, and schedule of follow-up visits.

SUPPORT GROUPS Refer the patient to an alcohol support group or liver transplant support group. Refer the patient and family to hospice for palliative care if appropriate in end-stage disease.