Hepatitis

Hepatitis

• Inflammation of the liver • Types of viral

• Causes hepatitis
• Viral (most common): • A [HAV]
acute or chronic • B [HBV]
• Drugs (alcohol), some • C [HCV]
herbs • D [HDV]
• Chemicals [Table 39-6] • E [HEV]
• Autoimmune diseases • Non A-E
• Metabolic abnormalities
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
TOXIC & DRUG-INDUCED
HEPATITIS
• Exposure to hepatotoxins
[industrial toxins, alcohol, drugs]
• Secondary infection during the
course of infections w/other viruses;
i.e Epstein-Barr, herpes simplex,
VZV, cytomegalovirus
Hepatitis A Virus (HAV)

• Ranges from mild to acute liver failure

• Not chronic
• Incidence decreased with vaccination
• RNA virus transmitted via fecal-oral
route
• Person-person contact: oral-anal sexual
• Contaminated food or drinking water
• Survives on human hands
• Destroyed by chlorine bleach & high
temps
Serologic Events in HAV Infection

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Hepatitis B Virus (HBV)

• Acute or chronic disease

• Incidence decreased with vaccination
• DNA virus transmitted
• Perinatally
• Percutaneously: needle sticks, sharps
• Via mucosal exposure to infectious blood,
blood products, or other body fluids
• Carriers: infect others even if not sick & no
obvious signs of Hep B
• Chronic: high risk for liver cancer and cirrhosis
 Hepatitis B Virus (HBV)

• At-risk populations
• Men who have sex with men
• Household contact of chronically
infected
• Patients undergoing hemodialysis
• Health care and public safety workers
• Transplant recipients
Serologic Events in HBV Infection

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hepatitis C Virus (HCV)
• Acute: asymptomatic
• Chronic: liver damage
• Not transmitted by
• RNA virus transmitted casual contact or
percutaneously
• IV drug use: highest incidence
intimate household
• High-risk sexual behaviors: contact
multiple partners
• Occupational exposure • Should not share
• Dialysis razors,
• Perinatal exposure
• Blood transfusions before toothbrushes,
1992 pierced earrings
• Sharing intranasal cocaine
paraphernalia • NO vaccine at
present
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hepatitis D Virus (HDV)
• Also called delta virus
• Defective single-stranded RNA virus
• Cannot survive on its own
• Requires HBV to replicate
• Transmitted
parenterally/percutaneously
• IVDA; high risk sexual contact w/HDV
infected person
• No vaccine
Hepatitis E Virus (HEV)
• RNA virus
• Transmitted via fecal-oral route
• Most common mode of transmission:
drinking contaminated water/food
• Self-limiting; resolves on own
• Incubates 15-64 days
Pathophysiology

• Acute infection
• Liver damage: lysis of infected cells
• Cholestasis
• Liver cells can regenerate in normal
form after resolution of infection
• Chronic infection can cause fibrosis
and progress to cirrhosis {Hep B/C]
Pathophysiology
• Antigen-antibody complexes
activate complement system
• Systemic manifestations
• Rash • Malaise
• Angioedema • Cryoglobulinemia
• Arthritis • Glomerulonephritis
• Fever • Vasculitis
Clinical Manifestations
• Classified as acute and chronic
phases
• Many patients: asymptomatic
• Symptoms intermittent or ongoing
• Malaise
• Fatigue
• Myalgias/arthalgias
• Hepatomegaly
Clinical Manifestations
• Acute phase
• Maximal infectivity; lasts 1–4 months
• Symptoms during incubation
• Malaise • ↓ Sense of smell
• Anorexia • Headache
• Weight loss • Low-grade fever
• Fatigue • Arthralgias
• Nausea/vomiting • Skin rashes
• Abdominal discomfort: RUQ
• Distaste for cigarettes
Clinical Manifestations
• Acute phase
• Physical examination findings
• Hepatomegaly
• Lymphadenopathy
• Splenomegaly
• Icteric (jaundice) or anicteric
• If icteric, patient can also have
• Dark urine
• Light or clay-colored stools
• Pruritus
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations
• Convalescent phase
• Begins as jaundice is disappearing
• Lasts weeks to months
• Major complaints
• Malaise
• Easy fatigability
• Hepatomegaly persists
• Splenomegaly subsides
Recovery
• Homologous immunity to HAV or
HBV
• Patient can be reinfected with other
types of viral hepatitis, as well as
different strains of HCV
• Most patients recover completely
with no complications
Complications
• Acute liver failure: Fulminant
Hepatitis: fatal
• Chronic hepatitis
• Some HBV and majority of HCV
infections
• Cirrhosis
• Hepatocellular carcinoma
Diagnostic Studies
• Specific antigen and/or antibody for
each type of viral hepatitis
• Anti-HAV IgM , anti-HAV IgG
• HBsAg, anti-HBs, HBeAg, anti-Hbe,
anti-HBc IgM, anti-HBc IgG, HBV DNA
quantitation
• Anti-HCV, HCV quantitation
• Anti-HDV, HDV Ag
• None currently for HEV
Diagnostic Studies
• Liver function tests
• Viral genotype testing
• HBV
• HCV
• Physical assessment findings
• Liver biopsy
• FibroScan
• FibroSure (FibroTest)
Collaborative Care
• Acute and chronic
• Well-balanced diet
• Increased calorie
• Low fat if not tolerated
• Vitamin supplements
• Rest: degree varies with severity
• Avoid alcohol intake and drugs
detoxified by the liver
• Notification of possible contacts
Collaborative Care: Drug Therapy
• Acute hepatitis A: no specific
• Acute hepatitis B: only if severe
• Acute hepatitis C
• Pegylated interferon to reduce
progression to chronic infection
• Support therapy
• Antiemetics
Collaborative Care
Chronic Hepatitis B
• To ↓ viral load , liver enzyme levels,
and rate of disease progression
• Prevent cirrhosis, hepatic failure,
and cancer
• Pegylated interferon
• Nucleoside and nucleotide analogs
• SCREENING: liver CA: screen every
6-12 months
Drug Therapy
Chronic Hepatitis B
• Interferon
• Multiple effects on viral replication
• Two forms: standard and pegylated
• Must be administered subcutaneously
• Varied response to treatment
• Side effects
• Flu-like symptoms, depression,
irritability, insomnia, neutropenia,
thrombocytopenia
Drug Therapy
Chronic Hepatitis B
• Nucleoside/nucleotide analogs
• Decrease viral replication by inhibiting
normal DNA synthesis
• Lamivudine (Epivir)
• Adefovir (Hepsera)
• Entecavir (Baraclude)
• Telbivudine (Tyzeka)
• Tenofovir (Viread)
• Long-term treatment
Drug Therapy
Chronic Hepatitis C
• Individualized treatment regimens
• Pegylated a-inteferon: SubQ
• Pegylated α-interferon with ribavirin
(Rebetol, Copegus)
• Ribavirin: teratogenic
• Take as prescribed
• Protease inhibitors for genotype 1
• Telaprevir (Incivek)
• Boceprevir (Victrelis)
 Collaborative Care
• Health promotion: hepatitis A
• General measures
• Vaccination best protection
• All children at 1 year of age should receive
vaccine
• Adults at risk
• Infection control measures; isolation not
required
• Post-exposure prophylaxis with vaccine and
immune globulin (IG)-temporary passive
immunity
Collaborative Care
• Health promotion: hepatitis B
• General measures
• Immunization
• Recombivax HB, Engerix-B
• Series of three IM injections
• All children and at-risk adults
• Postexposure prophylaxis: vaccine and
hepatitis B immune globulin (HBIG)
Collaborative Care
• Health promotion: hepatitis C
• No vaccine to prevent HCV
• General measures to prevent HCV
transmission
• Screen all persons born between 1945
and 1965
• No postexposure prophylaxis; baseline
and follow-up testing
Nursing Implementation
• Acute care
• Assess for jaundice
• Comfort measures
• Adequate nutrition
• Small, frequent meals
• Measures to stimulate appetite
• Carbonated beverages
• Adequate fluid intake
Nursing Implementation
• Acute care
• Physical rest
• Psychologic and emotional rest
• Diversional activities
Nursing Implementation
• Ambulatory and home care
• Dietary teaching
• Activity restrictions
• Teach how to prevent transmission
• What to report
• Assessment for complications
• Regular follow-up for at least 1 year after diagnosis
• No alcohol
• Medication education
• How to administer interferon
• Side effects
• No blood donation by HBsAg- or HCV-positive
patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation
• Ambulatory and home care
• Regular follow-up for at least 1 year
after diagnosis
• No alcohol
• Medication education
• How to administer interferon
• Side effects
• No blood donation by HBsAg- or HCV-
positive patients
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Evaluation
• Expected outcomes
• Adequate nutritional intake
• Increased tolerance of activity
• Performing daily activities with
scheduled rest periods
• Ability to explain methods of
transmission and methods of
preventing transmission
Review
• Chart 58B: Best Practice for Patient
Safety & Quality Care
• Patient and Family Education:
Health Practices to Prevent Viral
Hepatitis
• DRUG Therapy for Chronic B/C
• Preparing for Self-Management: 58-
5: Viral Hepatitis