Liver Cirrhosis Outline

A. Introduction/Abstract
a. Importance of the liver in the body (major functions)
i. Process nutrients from food
1. Liver stores some of the nutrients in a form that the body can use for quick energy, while the rest will be used to make other important chemicals the body needs
2. If liver is damaged, it cannot continue to process nutrients from the blood that the body must have
ii. Create bile
1. Bile is a thick, green-yellow fluid that helps break down fats to digest food, especially fat, as it passes from the stomach to the intestines.
iii. Remove toxins from the body
1. Liver needs to pull out any bad things in the blood (drugs, damaged cells, proteins, old hormones, etc)
2. If the liver is damaged, these toxins cannot be removed and will start to accumulate, creating problems
iv. Build proteins
1. Liver builds many kinds of proteins that the body uses every day, if damaged, proteins would not be made

http://hepatitis.about.com/od/overview/a/Liver_Import.htm

b. What happens when liver is abnormal
i. If the liver is continually exposed to liver toxins it will work to repair itself. But this causes the liver to build up fibrous scars and nodules that prevent it from working correctly.
ii. This means that it can no longer filter toxins from the blood or perform any of its other vital functions (Mayo Clinic Staff, 2011). This is precisely what one sees in cirrhosis of the liver.

B. Define/ Describe Liver Cirrhosis
a. Define:
i. Cirrhosis is serious degenerative disease that occurs when healthy cells in theliver are damaged and replaced by scar tissue, usually as a result ofalcohol abuse or chronic hepatitis
http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information
b. Describe:
i. Asliver cells give way to tough scar tissue, the organ loses its ability to function properly. Severe damage can lead toliver failure and possibly death.
ii. 75% of liver tissue needed is affected and decreased function in the liver occurs.
c. Who it affects
. Every year, about 31,000 people in the U.S. die from cirrhosis, mainly due to alcoholic liver disease and chronic Hepatitis C
i. The disease cannot be reversed or cured except, in some cases, through a liver transplant. It can often be slowed or halted; however, especially if the disease is detected in the early stages of development.
B. Causes
. Viruses
a. Prolonged obstruction of bile flow
b. Long periods of exposure to drugs and other toxic substances
c. Excessive consumption of alcohol
d. Iron buildup in the body (hemochromatosis)
e. Cystic fibrosis
f. Copper accumulated in the liver (Wilson’s disease)
g. Poorly formed bile ducts (biliary atresia)
h. Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
i. Genetic digestive disorder (Alagille syndrome)
j. Liver disease caused by your body’s immune system (autoimmune hepatitis)

http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information?page=2

D. Other Influencing Factors (ie: risk factors)
a. In the U. S., people who abuse alcohol for a long time are at a very high risk for cirrhosis
i. Women who drink 2-3 alcoholic drinks per day are at a high risk for cirrhosis
ii. For men, 3-4 alcoholic drinks per day is associated with a high risk
b. People with chronic hepatitis B or C are also likely to develop cirrhosis
. The risk factors for hepatitis B or C include:
1. Exposure to blood either through blood transfusion
2. Sexual transmission
3. Intranasal or intravenous drug use
4. Improperly sterilized tattooing or piercing needles
c. Obesity
. Patients who are obese have an increased likelihood of developing nonalcoholic fatty liver disease (NAFLD)
d. Certain diseases can also put one at risk for cirrhosis
. Biliary system draining disorders- disease that can block bile ducts or destroy them
1. Primary biliary cirrhosis or primary sclerosing cholangitis occurs in adults
2. Alagille syndrome (biliary atresia) occurs in infants

http://www.niddk.nih.gov/health-information/health-topics/liver-disease/cirrhosis/Pages/facts.aspx
E. Signs
a. Abdominal distention (Ascites)
b. Abdominal hernia
c. Edema
d. Jaundice
e. Fever
f. Bruising
g. Spider angiomata (enlarged blood vessels resemble little spiders)
h. Altered mental status -confusion (possible hepatic encephalopathy)
i. Hair loss
j. Light colored stool or bloody stool
k. Brownish or orange colored urine
l. Finger nail color abnormality (terry’s nails)
m. Palmar erythema (bright red coloring of palms of hand)
http://hepatitiscnewdrugresearch.com/physical-findings-suggestive-of-cirrhosisphotos.html

F. Symptoms
a. Fatigue & loss of energy
b. Loss of appetite
c. Sensitivity to medications
d. Nausea or abdominal pain
e. Itchy skin
f. Male impotence
g. Spontaneous bacterial peritonitis
h. Thrombocytopenia (abnormal drop in blood cells-platelets)
i. Enlarged veins in esophagus and stomach (Esophageal varices)
http://hepatitiscnewdrugresearch.com/physical-findings-suggestive-of-cirrhosisphotos.html
https://www.nlm.nih.gov/medlineplus/ency/article/000255.htm
http://www.healthline.com/health/cirrhosis#Symptoms4

G. Unusual Characteristics
a. Kidney failure
b. Type 2 diabetes (insulin resistance)
c. Gallstones (interference with bile flow can cause bile to harden and form stones)
d. Increased infections
e. Bleeding (due to decreased clotting proteins)
f. Enlarged spleen (splenomegaly)
g. Breast enlargement in men (gynecomastia)
h. Premature menopause
i. Loss of muscle mass
j. Liver cancer
http://www.webmd.com/digestive-disorders/cirrhosis-liver?page=3
https://www.nlm.nih.gov/medlineplus/cirrhosis.html
http://www.healthline.com/health/cirrhosis#Complications6

H. Incidence
a. Approx. 31,000 people die in the U.S. from cirrhosis due to chronic hepatitis C and alcoholic liver disease. (Kochanek, Xu, Murphy, Miniño& Kung, 2011).

Cirrhosis of the Liver: Causes, Symptoms, Treatments. (n.d.). Retrieved March 14, 2016, from http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information
b. Twelfth leading cause of death in the U.S. (Kochanek et al., 2011).
c. Alcoholism used to be the leading cause of cirrhosis, accounting for 48.1% of the 2007 deaths from cirrhosis (Yoon & Yi, 2010).
d. Men and women aged 45-64 are most affected, fifth leading cause of death and accounted for 17,499 deaths (4%) out of 490,145 for the year (Kochanek et al., 2011).
e. Seventh leading cause of death for men and women aged 25-44 (Kochanek et al., 2011).
f. The male-to-female ratio was 2:1 (Yoon & Yi, 2010)

I. Methods of Diagnosis (Heidelbaugh, Joel J., &Bruderly, Michael, 2006)
a. No diagnostic standard
b. History, physical exam, lab studies, radiographic studies, & liver biopsy (last resort)
c. Radiographic studies: ultrasound (done 1st), CT, MRI
d. Major use of radiographic studies is to detect ascites, hepatosplenomegaly, hepatic or portal vein thromboses, and hepatocellular carcinoma, which all suggest liver cirrhosis
e. Ultrasound- less expensive, no radiation, no IV contrast/detects hepatic nodules
f. CT & MRI- not good at detecting early signs, but can accurately demonstrate nodularity and lobar atrophic and hypertrophic changes, as well as ascites and varices in advanced disease
Course of Treatment (Sanchez, William., 2014)
a. The treatment depends on the disease causing cirrhosis
b. Medication and change in lifestyle
c. Healthy diet
d. For severe liver cirrhosis, a liver transplant is the last option

M. Prognosis (Thornton, Karla., 2015) (Sanchez, William., 2014)
a. Portal hypertension (treatment: TIPS shunt)
b. Esophageal varices
c. Spleenomegaly
d. Hepatocellular carcinoma (liver cancer)
e. Jaundice
f. Ascites (treatment: Parancentesis)
g. Encephalopathy
h. Death

N. Conclusion
a. Summary of paper
O. Works Cited

Chong, Wui K. Ultrasound Clinics: Abdominal Ultrasound. Clinic Review Articles.Oct. 2014.

Heidelbaugh, Joel J &Bruderly, Michael.Cirrhosis and Chronic Liver Failure: Part 1 Diagnosis
and Evaluation. American Family Physician.Volume 74, 5. Sept. 1, 2006.

Eisenberg, Ronald L. Comprehensive Radiographic Pathology.6th ed. 2016. P. 202

Weerakkody, Dr. Yuranga and Gaillard, Frank. Cirrhosis.
http://radiopaedia.org/articles/cirrhosis

Thornton, Karla. Evaluation and Prognosis of Patients with Cirrhosis.Hepatitis C online. 2016
Retrieved from http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/evaluation-prognosis-cirrhosis/core-concept/all

Retrieved from
http://www.niddk.nih.gov/health-information/health-topics/liver-disease/cirrhosis/Pages/facts.aspx

National Institute of Diabetes and Digestive and Kidney Diseases
Retrieved from
http://hepatitis.about.com/od/overview/a/Liver_Import.htm

WebMD
Retrieved from
http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information?page=2

Mayo clinic.
Retrieved from
http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/treatment/con-20031617

William Sanchez, MD and Jayant A. Talwalkar, MD, MPH, FACG, Mayo College of Medicine, Rochester, MN – Published January 2009. Updated December 2012.
Retrieved from http://patients.gi.org/topics/liver-cirrhosis/

Kochanek, K., Xu, J., Murphy, S., & Kung, H. (2011). Deaths: Preliminary data for 2009. National Vital Statistics Reports 59 (4), 1-51. Retrieved March 10, 2016 from http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Yoon, Y., & Yi, H. (2010). Surveillance report #88: Liver cirrhosis mortality in the United States, 1970-2007, National Institute on Alcohol Abuse and Alcoholism. Retrieved March 13, 2016 from http://pubs.niaaa.nih.gov/publications/surveillance88/Cirr07.htm

Liver Cirrhosis Outline

A. Introduction/Abstract
a. Importance of the liver in the body (major functions)
i. Process nutrients from food
1. Liver stores some of the nutrients in a form that the body can use for quick energy, while the rest will be used to make other important chemicals the body needs
2. If liver is damaged, it cannot continue to process nutrients from the blood that the body must have
ii. Create bile
1. Bile is a thick, green-yellow fluid that helps break down fats to digest food, especially fat, as it passes from the stomach to the intestines.
iii. Remove toxins from the body
1. Liver needs to pull out any bad things in the blood (drugs, damaged cells, proteins, old hormones, etc)
2. If the liver is damaged, these toxins cannot be removed and will start to accumulate, creating problems
iv. Build proteins
1. Liver builds many kinds of proteins that the body uses every day, if damaged, proteins would not be made

http://hepatitis.about.com/od/overview/a/Liver_Import.htm

b. What happens when liver is abnormal
i. If the liver is continually exposed to liver toxins it will work to repair itself. But this causes the liver to build up fibrous scars and nodules that prevent it from working correctly.
ii. This means that it can no longer filter toxins from the blood or perform any of its other vital functions (Mayo Clinic Staff, 2011). This is precisely what one sees in cirrhosis of the liver.

B. Define/ Describe Liver Cirrhosis
a. Define:
i. Cirrhosis is serious degenerative disease that occurs when healthy cells in theliver are damaged and replaced by scar tissue, usually as a result ofalcohol abuse or chronic hepatitis
http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information
b. Describe:
i. Asliver cells give way to tough scar tissue, the organ loses its ability to function properly. Severe damage can lead toliver failure and possibly death.
ii. 75% of liver tissue needed is affected and decreased function in the liver occurs.
c. Who it affects
. Every year, about 31,000 people in the U.S. die from cirrhosis, mainly due to alcoholic liver disease and chronic Hepatitis C
i. The disease cannot be reversed or cured except, in some cases, through a liver transplant. It can often be slowed or halted; however, especially if the disease is detected in the early stages of development.
B. Causes
. Viruses
a. Prolonged obstruction of bile flow
b. Long periods of exposure to drugs and other toxic substances
c. Excessive consumption of alcohol
d. Iron buildup in the body (hemochromatosis)
e. Cystic fibrosis
f. Copper accumulated in the liver (Wilson’s disease)
g. Poorly formed bile ducts (biliary atresia)
h. Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)
i. Genetic digestive disorder (Alagille syndrome)
j. Liver disease caused by your body’s immune system (autoimmune hepatitis)

http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information?page=2

D. Other Influencing Factors (ie: risk factors)
a. In the U. S., people who abuse alcohol for a long time are at a very high risk for cirrhosis
i. Women who drink 2-3 alcoholic drinks per day are at a high risk for cirrhosis
ii. For men, 3-4 alcoholic drinks per day is associated with a high risk
b. People with chronic hepatitis B or C are also likely to develop cirrhosis
. The risk factors for hepatitis B or C include:
1. Exposure to blood either through blood transfusion
2. Sexual transmission
3. Intranasal or intravenous drug use
4. Improperly sterilized tattooing or piercing needles
c. Obesity
. Patients who are obese have an increased likelihood of developing nonalcoholic fatty liver disease (NAFLD)
d. Certain diseases can also put one at risk for cirrhosis
. Biliary system draining disorders- disease that can block bile ducts or destroy them
1. Primary biliary cirrhosis or primary sclerosing cholangitis occurs in adults
2. Alagille syndrome (biliary atresia) occurs in infants

http://www.niddk.nih.gov/health-information/health-topics/liver-disease/cirrhosis/Pages/facts.aspx
E. Signs
a. Abdominal distention (Ascites)
b. Abdominal hernia
c. Edema
d. Jaundice
e. Fever
f. Bruising
g. Spider angiomata (enlarged blood vessels resemble little spiders)
h. Altered mental status -confusion (possible hepatic encephalopathy)
i. Hair loss
j. Light colored stool or bloody stool
k. Brownish or orange colored urine
l. Finger nail color abnormality (terry’s nails)
m. Palmar erythema (bright red coloring of palms of hand)
http://hepatitiscnewdrugresearch.com/physical-findings-suggestive-of-cirrhosisphotos.html

F. Symptoms
a. Fatigue & loss of energy
b. Loss of appetite
c. Sensitivity to medications
d. Nausea or abdominal pain
e. Itchy skin
f. Male impotence
g. Spontaneous bacterial peritonitis
h. Thrombocytopenia (abnormal drop in blood cells-platelets)
i. Enlarged veins in esophagus and stomach (Esophageal varices)
http://hepatitiscnewdrugresearch.com/physical-findings-suggestive-of-cirrhosisphotos.html
https://www.nlm.nih.gov/medlineplus/ency/article/000255.htm
http://www.healthline.com/health/cirrhosis#Symptoms4

G. Unusual Characteristics
a. Kidney failure
b. Type 2 diabetes (insulin resistance)
c. Gallstones (interference with bile flow can cause bile to harden and form stones)
d. Increased infections
e. Bleeding (due to decreased clotting proteins)
f. Enlarged spleen (splenomegaly)
g. Breast enlargement in men (gynecomastia)
h. Premature menopause
i. Loss of muscle mass
j. Liver cancer
http://www.webmd.com/digestive-disorders/cirrhosis-liver?page=3
https://www.nlm.nih.gov/medlineplus/cirrhosis.html
http://www.healthline.com/health/cirrhosis#Complications6

H. Incidence
a. Approx. 31,000 people die in the U.S. from cirrhosis due to chronic hepatitis C and alcoholic liver disease. (Kochanek, Xu, Murphy, Miniño& Kung, 2011).

Cirrhosis of the Liver: Causes, Symptoms, Treatments. (n.d.). Retrieved March 14, 2016, from http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information
b. Twelfth leading cause of death in the U.S. (Kochanek et al., 2011).
c. Alcoholism used to be the leading cause of cirrhosis, accounting for 48.1% of the 2007 deaths from cirrhosis (Yoon & Yi, 2010).
d. Men and women aged 45-64 are most affected, fifth leading cause of death and accounted for 17,499 deaths (4%) out of 490,145 for the year (Kochanek et al., 2011).
e. Seventh leading cause of death for men and women aged 25-44 (Kochanek et al., 2011).
f. The male-to-female ratio was 2:1 (Yoon & Yi, 2010)

I. Methods of Diagnosis (Heidelbaugh, Joel J., &Bruderly, Michael, 2006)
a. No diagnostic standard
b. History, physical exam, lab studies, radiographic studies, & liver biopsy (last resort)
c. Radiographic studies: ultrasound (done 1st), CT, MRI
d. Major use of radiographic studies is to detect ascites, hepatosplenomegaly, hepatic or portal vein thromboses, and hepatocellular carcinoma, which all suggest liver cirrhosis
e. Ultrasound- less expensive, no radiation, no IV contrast/detects hepatic nodules
f. CT & MRI- not good at detecting early signs, but can accurately demonstrate nodularity and lobar atrophic and hypertrophic changes, as well as ascites and varices in advanced disease
Course of Treatment (Sanchez, William., 2014)
a. The treatment depends on the disease causing cirrhosis
b. Medication and change in lifestyle
c. Healthy diet
d. For severe liver cirrhosis, a liver transplant is the last option

M. Prognosis (Thornton, Karla., 2015) (Sanchez, William., 2014)
a. Portal hypertension (treatment: TIPS shunt)
b. Esophageal varices
c. Spleenomegaly
d. Hepatocellular carcinoma (liver cancer)
e. Jaundice
f. Ascites (treatment: Parancentesis)
g. Encephalopathy
h. Death

N. Conclusion
a. Summary of paper
O. Works Cited

Chong, Wui K. Ultrasound Clinics: Abdominal Ultrasound. Clinic Review Articles.Oct. 2014.

Heidelbaugh, Joel J &Bruderly, Michael.Cirrhosis and Chronic Liver Failure: Part 1 Diagnosis
and Evaluation. American Family Physician.Volume 74, 5. Sept. 1, 2006.

Eisenberg, Ronald L. Comprehensive Radiographic Pathology.6th ed. 2016. P. 202

Weerakkody, Dr. Yuranga and Gaillard, Frank. Cirrhosis.
http://radiopaedia.org/articles/cirrhosis

Thornton, Karla. Evaluation and Prognosis of Patients with Cirrhosis.Hepatitis C online. 2016
Retrieved from http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/evaluation-prognosis-cirrhosis/core-concept/all

Retrieved from
http://www.niddk.nih.gov/health-information/health-topics/liver-disease/cirrhosis/Pages/facts.aspx

National Institute of Diabetes and Digestive and Kidney Diseases
Retrieved from
http://hepatitis.about.com/od/overview/a/Liver_Import.htm

WebMD
Retrieved from
http://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information?page=2

Mayo clinic.
Retrieved from
http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/treatment/con-20031617

William Sanchez, MD and Jayant A. Talwalkar, MD, MPH, FACG, Mayo College of Medicine, Rochester, MN – Published January 2009. Updated December 2012.
Retrieved from http://patients.gi.org/topics/liver-cirrhosis/

Kochanek, K., Xu, J., Murphy, S., & Kung, H. (2011). Deaths: Preliminary data for 2009. National Vital Statistics Reports 59 (4), 1-51. Retrieved March 10, 2016 from http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Yoon, Y., & Yi, H. (2010). Surveillance report #88: Liver cirrhosis mortality in the United States, 1970-2007, National Institute on Alcohol Abuse and Alcoholism. Retrieved March 13, 2016 from http://pubs.niaaa.nih.gov/publications/surveillance88/Cirr07.htm