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Cirrhosis is a chronic condition that impairs the normal functioning of liver cells and increases the resistance of the liver to blood flow. It is causes by liver fibrosis (scarring) and sometimes referred to as hepatic biliary disease. Three common causes of cirrhosis are alcoholism, chronic viral hepatitis, and ingestion of toxic substances including drugs. The type of cirrhosis that results from hepatitis and toxic substances is called postnecrotic cirrhosis, while the type that is usually associated with chronic alcoholism is called Laennec's cirrhosis or portal cirrhosis. Laennec's cirrhosis is more common in men than women, and it is especially prevalent in Hispanic, African-American, and Native American males.

Symptoms of cirrhosis develop gradually over a period of years but can eventually be found in all body systems. These symptoms are related to scar tissue formation; increased blood pressure in the portal vessels (blood vessels carrying blood to and from the liver); poor absorption of various fat-soluble vitamins including A,D,E and K; and the inability of the liver to detoxify waste products such as those produced by protein catabolism.

General- Fatigue, general weakness, and malaise may occur, often in relation to anemia.

Cardiovascular- Abdominal ascites (fluid) may develop as a result of portal hypertension in relation to restricted blood flow through the liver. Ascites is often the symptom that prompts the patients to seek help because of associated discomfort including difficulty breathing. Esophageal varices (dilated blood vessels in the esophagus) may also develop as a result of portal hypertension.

Respiratory- The thoracic cavity may not be able to fully expand because abdominal ascites or hepatomegaly (enlargement of the liver) may push the diaphragm into the chest cavity. This can cause shortness of breath.

Neurological- A condition called hepatic encephalopathy may develop; this is characterized by changes in mood, personality, and level of consciousness, and it may result in hepatic coma.

Gastrointestinal- The patient may experience nausea, dyspepsia, change in bowel movements, early satiety (feeling of fullness from food), and anorexia with weight loss.

Integumentary- The skin may become jaundiced and pruritus may develop in relation to a buildup of bile pigments in the skin. Bruises and other evidence of bleeding may also be present; these include bleeding gums, ecchymoses, and spider angiomas, or spider-shaped capillaries that are visible on the skin. These symptoms are related to high estrogen levels and decreases absorption of vitamin K.

Endocrine- Women may experience menstrual irregularities; men may experience atrophy of the testicles, gynecomastia (enlarged breasts), and loss of chest and axillary hair.

With cirrhosis, levels of certain liver enzymes are elevated due to cellular death or necrosis; such enzymes include aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Both AST and ALT are part of routine bloodwork when a complete metabolic panel is ordered. Liver function test reveal low albumin level in the blood and high level of bilirubin in the blood. The patient's prothrombin times (clotting times) may be prolonged and his or her hemoglobin and hematocrit may be low. Folic acid levels are also often below normal in patients with Laennec's cirrhosis. In addition to these measurements, a liver biopsy may be used to diagnose cirrhosis

The primary treatment for cirrhosis is liver transplantation. Since tissue rejection can occur after this surgery, immunosuppressant medications like cyclosporine are given immediately following the transplant. Of course, liver transplantation is only possible when a donated liver becomes available. Thus, much of the medical care of patients with cirrhosis is targeted toward symptom control.

If ascites and edema are present, diuretic therapy will be ordered. If the excess fluid is not removed from diuretic therapy, a procedure called a paracentesis will be ordered. This involves a needle attached to a catheter inserted into the abdomen to drain fluid from the peritoneal cavity.

Patients that have cirrhosis should use soft toothbrushes and electric razors instead of straight razors. Anyone taking care of the patient should be alert for any signs of bleeding including: restlessness and anxiety, weakness, lowered blood pressure, rapid pulse, feelings of epigastric fullness, blood in stools.

Esophageal varicies are a common complication of cirrhosis. If these varices causue esophageal bleeding, a triple-lumen Sengstaken-Blakemore tube may be inserted into one of the patient's nostrils. Two of the tube's lumens have balloons that press against areas in the stomach and the esophagus and control bleeding when inflated; this is called a double-balloon tamponade. The tube's third lumen removes blood and other secretions directly from the stomach. The primary nursing concern related to the use of this device is aspiration since swallowing is not possible once the balloons are inflated. In addition to the Sengstaken-Blakemore tube, the patient will have a second nasal tube that removes secretions from the esophagus itself. One primary medical concern related to this tube is perforation and necrosis of the esophagus; thus, this tube is generally used on a short-term basis, but it may need to be reinserted at a later date if medications cannot stop the patient's bleeding.

If portal hypertension is present, a surgical procedure may be necessary. This would consist of a portacaval shunt, where the portal vein and vena cava are cut and them connected to each other in order to allow blood to bypass or avoid the liver.

People that have cirrhosis will benefit from eating a variety of foods that are high in carbohydrates, including pasta, rice, and starchy vegetables. The patient's diet may also be lower in protein since metabolism of this substance is decreased due to liver damage; the greater the degree of damage, the lower the protein intake should be. If the patient has esophageal varices, a soft diet may be necessary to prevent bleeding and rupture. If edema and ascites are present, the patient must follow a low-sodium diet (500-1,000mg/day) and fluid restriction.

In addition to the dietary modifications, patients may need to supplement with vitamins inlcuing A, B 12, D, E, K, calcium, zinc, thiamine and folic acid to treat anemia. Alcohol in any form must be avoided. Also, some medications, such as acetaminophen, can contribute to liver damage and should be avoided.

Portal-systemic encephalopathy (PSE) is a brain disorder that can result from chronic liver disease. When the liver functions normally, it detoxifies various chemicals in the foods and beverages we ingest. When the liver is damaged, however, these chemicals can either bypass or fail to be detoxified by the liver. An example of this is protein wastes that are usually converted to ammonia then urea by the liver before they are excreted in urine; if the liver is unable to convert ammonia to urea, unhealthy levels of ammonia can build up in the blood and PSE can develop. Other contributing factors are hypokalemia (low potassium in the blood) and internal bleeding.

Early symptoms of PSE are similar those of dementias and include confusion, disorientation, memory impairment, difficulty reasoning and making judgements, and abnormalities in speech and language. Advanced symptoms of PSE include involuntary jerking or flapping movements of the hands; this is called asterixis or flapping tremor. As the ammonia level in the blood continues to rise, the patient may become delirious and eventually unresponsive to any external auditory or tactile stimuli. This final stage of PSE is called hepatic coma.

Since bacteria in the intestine produce ammonia, a number of oral medications may be used to kill bacteria and acidify the bowel. Such medications include hyperosmotic laxatives like lactulose and sorbitol, both of which increase peristalsis and produce diarrhea. Side effects may include increased gas in the bowel and hypokalemia; rectal tubes may be inserted to relieve the gas- electrolytes need to be monitored, especially potassium levels. The antibiotic Neomycin may also be given orally or by enema to cleanse the bowel. Finally, dietary management for PSE is similar to that for cirrhosis and may include foods that are low in protein but high in carbohydrates.