Adult Medical- Surgical Nursing Gastro-intestinal Module: Hepatitis

Hepatitis: Classification An acute or chronic viral infection, which sets up an inflammatory process in the liver cells Leads to mild, moderate or severe liver damage which is temporary or chronic Very infectious (mode of spread according to the virus) At least 5 known viruses causing hepatitis: Hepatitis A, B, C, D, E, and maybe others

Non-viral Hepatitis Certain chemicals and drugs can cause toxic hepatitis with extensive acute liver cell necrosis: Chemicals: Carbon-tetrachloride, phosphorus, chloroform, gold compounds Drugs: Isoniazid, Halothane, Acetominophen, Methyldopa, certain antibiotics, anti-metabolites and anaesthetic agents

Hepatitis A: (HAV) RNA virus; spread by faecal-oral route (contaminated food, water, hands) Short incubation (average 30 days) Diagnosed by anti-HAV IgM in serum during an acute attack Anti-HAV IgG in serum indicates previous infection or vaccination = now immune Prevention: active immunisation to “at risk” groups/ travellers to endemic areas. Immunoglobulin to contacts

Hepatitis B: (HBV) DNA virus (much more infectious than HIV and very damaging to hepatocytes) Spread through blood and body fluids including saliva and vertical transmission: at birth/ post-natal, not placental transfer “At risk” groups are: drug users, sexually promiscuous, health workers (also risk from tattoos, haemodialysis, unscreened blood/ donor organs) Long incubation

Hepatitis B: (HBV) (cont) Diagnosis: HBsAg (Hep B virus surface antigen) in blood or secretions 10% mortality 10% carrier state: (HBsAg 6-12 months after illness): Maybe no active disease Maybe chronic active disease may lead to cirrhosis or liver cancer Anti-HBsAg immunoglobulin in serum shows previous exposure (disease/ vacc) = immune

Hepatitis B: (HBV) (cont) Prevention: Life-style changes (drugs, needles, partners, unprotected sex) Vaccination (active or passive immunity). Infants immunised in endemic areas Self-protection for health workers: gloves, staff awareness of carriers, screening blood donors, products, disposable needles/ syringes, “sharps boxes” Reporting “needle-stick” injury

Hepatitis C: (HCV) RNA virus; also transmitted via blood and body fluids “At risk” groups as HBV HCV becomes chronic in 85% of cases → cirrhosis or carcinoma of the liver Prevention: As for Hepatitis B (HBV) Currently no commercial vaccine and no cure. Antivirals have delayed progression. With HBV, this is the most common and serious form of Hepatitis

Hepatitis Delta: (HDV) Hepatitis D or Delta is a defective RNA virus, requiring the presence of HBV Either co-infection of HBV and HDV or super-infection of an HBV carrier with HDV Transmitted as HBV in blood an body fluids Prevention is as for HBV

Hepatitis E: (HEV) Enteric hepatitis (HEV) is an RNA virus Transmitted by faecal-oral route Present in contaminated water, food, on hands Usually responsible for epidemics in developing countries Prevention with improved hygiene and sanitation, isolation. Vaccination has not been effective

Hepatitis: Pathophysiology Widespread inflammation of liver tissue causes degeneration and necrosis Increased Kuppfer cells (RES) lead to Proliferation and enlargement of the liver and cholestasis → Regeneration (if no complications, should regenerate in an orderly way and resume normal function) HBV and HCV may become chronic

Hepatitis: Progression of Disease Incubation phase: Varies according to virus (Hep A and E more acute onset, B and C more insidious) Prodromal/ pre-icteric phase, before jaundice: (most infective phase for A and E): 1 - 21 days Icteric phase: Intra-hepatic obstructive jaundice (cholestasis): still infectious 2 - 4 weeks Post-icteric, convalescence (weeks-months) Chronic state → liver failure

Hepatitis: Clinical Manifestations Pain in upper right quadrant Enlarged tender liver Fever Malaise and exhaustion Anorexia, nausea and vomiting Jaundice, skin and sclera, itching Dark urine, pale stools Severity of illness varies

Hepatitis: Diagnosis History and clinical picture Blood serology for specific hepatitis antigen or antibody Liver function tests and serum bilirubin Blood coagulation studies Liver biopsy if chronic to determine extent of damage to hepatocytes (not in acute state)

Hepatitis: Medical Treatment Depends on classification and severity of hepatitis: (May require ICU and mechanical ventilation in fulminating B or C) (10% mortality) Milder forms require rest and isolation at home Fluids ↑; low fat, high glucose and protein diet Vitamin B complex and vitamin K supplements Antiviral agent (interferon) and anti-HBV (to prevent chronic state in Hepatitis B)/ slow HBC

Hepatitis: Nursing Considerations Importance of self-protective measures and informing colleagues General nursing care if on bed rest Patient education on importance of fluids and appropriate diet Patient and family education about measures to prevent spread of the virus

Review: Health Education for Prevention and Protection Hand-washing, gloves, appropriate isolation and separate equipment Life-style changes (drugs, needles, partners, unprotected sex) Vaccination (active or passive immunity) Self-protection for health workers: gloves, staff awareness of carriers, screening blood donors/ blood products, disposable needles/ syringes, “sharps boxes” Reporting “needle-stick” injury