1. Hepatitis and Liver Disease
N250, CSULB
Spring 2015

2. Figure 38-1 Liver and biliary system.

3. Hepatitis Inflammation of the liver Acute or chronic Causes: Viruses
Bacteria
Metabolic and vascular disorders
Drugs, alcohol, other toxic substances

4. Symptoms The same no matter the cause Fatigue Clay-colored stools
Fever
Loss of appetite
Dark urine
Jaundice
Asymptomatic > Symptomatic > Fulminant Liver Failure > Death

5. Lab Tests related to Hepatitis
Alanine aminotransferase (ALT) – an enzyme found mainly in the liver; the best test for detecting hepatitis
Alkaline phosphatase (ALP) – an enzyme related to the bile ducts; often increased when they are blocked
Aspartate aminotransferase (AST) – an enzyme found in the liver and a few other places, particularly the heart and other muscles
Bilirubin, a waste product made from old blood cells; it is a yellow compound that causes jaundice and dark urine when present in increased amounts
Albumin - measures the main protein made by the liver and tells how well the liver is making this protein
Total Protein - measures albumin and all other proteins in blood, including antibodies made to help fight off infections
Can also consider clotting time, such as PT, PTT, INR

6. Pathophysiology Infection causes inflammatory response
Liver edema → bile obstruction → obstructive jaundice
Cell-mediated immune response →
Liver cell necrosis, Kupffer cell hyperplasia, scarring

7. Pathophysiology Mild hepatitis → little parenchymal damage
HBV and HCV → most severe liver inflammation and damage
Acute fulminating (sudden and severe) hepatitis → liver failure
Liver can regenerate

8. Pathophysiology
Asymptomatic carrier HBV and HCV increased risk for hepatocellular carcinoma
HBV and HCV can lead to chronic infection

9. Clinical Manifestations
Three phases
Prodromal
Icteric
Convalescent

10. Prodromal Phase Insidious or rapid onset Symptoms: Vague, flulike
Anorexia, nausea, vomiting, malaise
Myalgia, arthralgia, fatigue
RUQ pain
Low fever

11. Icteric Phase
Jaundice
Dark urine
Hospitalization

12. Convalescent Phase After 2–3 weeks of acute illness
Increased sense of well-being and energy level
Increased appetite; jaundice and abdominal pain disappear
HAV resolves in 9–10 weeks; HBV about 16 weeks

13. Basic Features of Hepatitis VirusesD E
Incubation
Period*
4 (2-6)
8-12 (6-24)
6-9 (2-24)
? (2-10)
4-5 (2-9)
Transmission
fecal-oral
parenteral
* Weeks
Chronic
Infection No
Yes

14. A, B, Cs of Viral Hepatitis
fecal-oral spread: hygiene, drug use, men having sex with men, travelers, day care, food
vaccine-preventable B
sexually transmitted – 100x more infectious than HIV
blood-borne (sex, injection drug use, mother-child, and health care) C
blood borne (injection drug use primarily)
4-5 times more common than HIV
NOT vaccine-preventable!

15. Hepatitis A Virus
Hepatitis A is caused by infection with HAV, a 27-nm RNA virus that is classified as a picornavirus. The virus can produce either asymptomatic or symptomatic infection in humans after an average incubation period of 28 days. HAV infection appears to induce lifelong protection against subsequent infection. Only one serotype has been observed among HAV isolates collected from various parts of the world. Several hepatitis A vaccines have been developed and evaluated in clinical trials and proven long-term protection against HAV infection.

16. HAV
Transmission
Fecal–oral route
Sexual
Transfusion of infected blood
Incubation period 4–6 weeks
Anti-HAV antibodies: IgM, IgG
No chronic infection
Protective antibodies develop in response to infection - confers lifelong immunity
Hepatitis A Virus Transmission
Transmission of HAV generally occurs as a result of a susceptible person ingesting virus that has been shed in the feces of an infected person. Close personal contact is the most common mode of HAV transmission as demonstrated by high rates of infection among household and sex contacts of persons with hepatitis A and among children in day care center outbreaks. Contaminated food and water can also serve as vehicles of HAV transmission; the vehicles of transmission in foodborne outbreaks are most often uncooked foods or foods touched by human hands after cooking, but outbreaks have been reported in association with foods contaminated before wholesale distribution. Because HAV can survive for 12 weeks or more in water, infection can occur by ingestion of a variety of raw shellfish harvested from sewage-contaminated areas. Waterborne outbreaks have occasionally been associated with drinking fecally contaminated water and with swimming in contaminated swimming pools and lakes. In addition, HAV transmission can occur as a result of blood exposures such as injecting drug use or blood transfusion because viremia can occur prior to onset of illness in infected persons; however, such transmission is rare.

17. Concentration of Hepatitis A Virus
in Various Body Fluids
Feces
Serum
Body Fluids
Saliva
Urine
Concentration of Hepatitis A Virus in Various Body Fluids
Feces can contain up to 108 infectious virions per ml and are the primary source of HAV. Viremia occurs during the prodromal phase of illness and HAV has been transmitted on rare occasions by transfusion. Virus has also been found in saliva during the incubation period in experimentally infected animals, but transmission by saliva has not been reported to occur.
100
102
104
106
108
1010
Infectious Doses per mL
Source: Viral Hepatitis and Liver Disease 1984;9-22
J Infect Dis 1989;160:

18. Prevention of Hepatitis A
Vaccination (pre-exposure)
Immune globulin
Good hygiene
Clean water systems;
avoidance of food
contamination
Pre-exposure
travelers to intermediate and high HAV-endemic regions
Post-exposure (within 14 days)
Routine
household and other intimate contacts
Selected situations
institutions (e.g., day care centers)
common source exposure (e.g.,
food prepared by infected food handler)

19. Hepatitis B Virus 28

20. men who have sex with men
Hepatitis B—United States,
Decline among
men who have sex with men
Decline among
IV drug users
Hepatitis B vaccine licensed
The reduction of reported cases in the late 1990s is not likely due to vaccine. An estimated 100k infections continue to occur annually, primarily in young adults.
Year

21. HBV DNA virus replicates in liver Dane particle: HBsAg, HBeAg
Asymptomatic carrier state and/or chronic active state
Cirrhosis and liver failure
Increased risk for liver cancer
Incubation period: 6 weeks to 6 months

22. Outcome of HBV Infection
Asymptomatic
Symptomatic
acute hepatitis B
Resolved
Immune
Chronic infection
Cirrhosis
Liver cancer
Chronic
infection

23. HBV Modes of Transmission
Sexual – Direct sexual contact
Parenteral – Direct contact with contaminated fluids
Perinatal -- Mother to fetus 2 2 2

24. Low/Not High Moderate Detectable Concentration of HBV
in Various Body Fluids
Found in blood, semen, cervical secretions, saliva, wound drainage
Low/Not
High
Moderate
Detectable
semen
serum
vaginal fluid
blood
wound exudates
saliva
urine
feces
sweat
tears
breast milk 1 1 1

25. HBV High-risk groups: Health care workers IV drug users
Homosexual men; people with multiple sex partners

26. HEPATITIS C

27. HCV Flavivirus Incubation period: 35–72 days
High rate of chronic infections
Six genotypes
Found in blood, blood products, transplanted tissue
Can be sexually transmitted
Injection drug use most common U.S. route of transmission
Incubation period: Average wks (Range wks)
Acute illness (jaundice) Mild (≤20%)
Case fatality rate Low
Chronic infection %-85%
Chronic hepatitis %
Cirrhosis 5%-20%
Mortality from CLD : 3%

28. Estimated Incidence of Acute Hepatitis C United States, 1982-20002 4 6 8 10 12 14 16 18 20 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
2000
Cases per 100,000
Decline among
transfusion recipients
injection drug users
Surrogate testing of
blood donors
Anti-HCV test
(1st generation)
licensed
(2ndgeneration)
Estimated Incidence of Acute Hepatitis C United States,
The estimated incidence of acute clinically diagnosed hepatitis C remained constant through much of the 80’s but declined by >80% between 1989 and The number of cases of transfusion-associated acute hepatitis C declined significantly after 1985 but this change had little impact on overall disease incidence. The substantial decline observed since 1989 correlates to a decrease in acute cases associated with injection drug use. Since clinical disease is apparent in 30% of acute HCV infections, the estimated total number of acute HCV infections ranges from 240,000 in the mid-80’s to 40,000 in Most acute cases of hepatitis C occur in young adults, 20 – 39 years old.
Source: Sentinel Counties

29. Risk Factors Associated with
Transmission of HCV
Illegal injection drug use
Transfusion or transplant from infected donor
Occupational exposure to blood
Mostly needle sticks
Iatrogenic (unsafe injections)
Birth to HCV-infected mother
Sexual/household exposure to anti-HCV positive contact
Multiple sex partners
Risk Factors Associated with Transmission of HCV
Percutaneous exposures, including transfusion and transplantation from an infectious donor and injecting drug use, are the most efficient modes of HCV transmission. The overall prevalence of anti-HCV among persons with these exposures generally exceeds 60%. Other types of percutaneous exposures, including hemodialysis and needlestick injuries, have also been associated with HCV transmission. The risk of HCV transmission following a needlestick exposure to an anti-HCV‑positive patient is approximately 5% to 10%. Other risk factors that have been associated with HCV transmission include sexual or household exposure to an anti-HCV‑positive contact, having multiple sex partners, and being an infant of an HCV-infected mother. However, the magnitude of the risk associated with these exposures has not been well defined.

30. Chronic Hepatitis C Factors Promoting Progression or Severity
Increased alcohol intake
Age > 40 years at time of infection
HIV co-infection
Other
Male gender
Chronic HBV co-infection

31. Injecting Drug Use and HCV Transmission
Highly efficient
Contamination of drug
paraphernalia, not just needles
and syringes
Rapidly acquired after initiation
30% prevalence after 3 years
>50% after 5 years
Four times more common than HIV

32. Sexual Transmission of HCV
Occurs, but efficiency is low
Rare between long-term steady partners (1.5-3%)
MSM 3% (1-18% in selected STD clinic settings) – same as heterosexuals
Factors that facilitate transmission between partners unknown (e.g., viral titer)
Accounts for 15-20% of acute and chronic infections in the United States
Sex is a common behavior
Large chronic reservoir provides multiple opportunities for exposure to potentially
infectious partners

33. Sexual Transmission of HCV
Persons with High-Risk Sexual Behaviors
At risk for sexually transmitted diseases, e.g., HIV, HBV, gonorrhea, chlamydia, etc.
Reduce risk
Limit number of partners
Use latex condoms
Get vaccinated against hepatitis B
MSMs also get vaccinated against hepatitis A

34. Perinatal Transmission of HCV
Transmission only from women HCV-RNA positive at delivery
Average rate of infection 6%
Higher (17%) if woman co-infected with HIV
Role of viral titer unclear
No association with delivery method
Infected infants do well
Severe hepatitis is rare

35. Household Transmission of HCV
Rare but not absent
Could occur through percutaneous/mucosal exposures to blood
Theoretically through sharing of contaminated personal articles (razors, toothbrushes)
Contaminated equipment used for home therapies
IV therapy
Injections

36. Patient to HCW Transmission of HCV
Inefficient by occupational exposures
Average incidence 1.8% following needlesticks from HCV-infected source
Associated with hollow-bore needles
Case reports of transmission from blood splash to eye.
Prevalence among health care workers 1-2%
Lower than adults in the general population
10 times lower than for HBV infection

37. Reduce or Eliminate Risks for Acquiring HCV Infection
Screening and testing donors of blood, organs, and tissues
Virus inactivation of plasma-derived products
Risk-reduction counseling and services
Obtain history of high-risk drug and sex behaviors
Provide information on minimizing risky behavior, including referral to other services
Vaccinate against hepatitis A and/or hepatitis B
Infection control practices
Blood and body fluid precautions

38. Preventing HCV Transmission to Others
Avoid Direct Exposure to Blood
Anti-HCV positive individuals should not donate blood, body organs, other tissue or semen
Do not share items that might have blood on them
personal care (e.g., razor, toothbrush)
home therapy (e.g., needles)
Cover cuts and sores on the skin
Studies suggest that HCV can survive on environmental surfaces at room temperature for at least 16 hours but not longer than 4 days

39. HCV Testing Routinely Recommended (Based on Risk for Infection)
Persons who ever injected illegal drugs
Persons with selected medical conditions
received clotting factor concentrates produced before 1987
ever on chronic hemodialysis
evidence of liver disease
Prior recipients of transfusion/organs
before July 1992
notified that donor later tested positive
Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV- positive blood
Children born to HCV-positive women

40. Routine HCV Testing Not Recommended (Unless Risk Factor Identified)
Health-care, emergency medical, and public safety workers
Pregnant women
Household (non-sexual) contacts of HCV-positive persons
General population
Uncertain Need
Recipients of transplanted tissue
Intranasal cocaine or other non-injecting illegal drug users
History of tattooing, body piercing
History of STDs or multiple sex partners
Long-term steady sex partners of HCV-positive persons

41. Natural History of HCV Infection
100 People
Resolve (15)
15%
Chronic (85)
85%
Cirrhosis (17)
Stable (68)
80%
75%
Stable (13)
Mortality (4)
25%
Time
20%
Leading Indication for Liver Transplant

42. HDV Delta virus RNA virus; HBsAg Incubation period: 1–6 months
Requires coinfection with HBV
Incubation period: 1–6 months
Transmission same as HBV
High rate IV drug users

43. HEV RNA virus Incubation period: 15–60 days
Transmission: fecal–oral route
Clinical manifestations similar to HAV
Higher mortality rate for pregnant women
Endemic in Southeast Asia, India, North Africa, Mexico

44. HGV RNA virus Transmission: Chronic viremia
Percutaneously or sexual contact
Chronic viremia
Improved survival rates for HIV patients infected with HGV

45. Nonviral Hepatitis Toxic hepatitis and alcoholic hepatitis
Etiology and risk factors
Pathophysiology
Clinical manifestations
Medical and surgical management
Nursing management

46. Medical Management and Nursing Interventions
Identify cause of the inflammation
Provide symptomatic treatment
Monitor liver damage
Support liver's ability to regenerate
Nursing Management
Supportive measures
Education
Health Promotion
Prevention and reducing infection spread

47. Cirrhosis Irreversible, progressive deterioration of the liver
Caused by chronic liver disease
Chronic hepatitis
Alcoholism
Right-sided CHF
Long-term obstruction
to biliary flow

48. Pathophysiology Liver cell damage, death
Cells replaced by fibrous tissue
Regenerate abnormally, creating nodules and microcirculation distortion
May be asymptomatic until severe liver impact
Gradual onset
Early symptoms nonspecific:
Fatigue, weakness, anorexia, weight loss

49. Nursing and Medical Management
Assessment of risk factors
Medical management
Monitor for complications
Maximize liver function
Treat the underlying causes and prevent infection
Education
Alcohol abuse
Sexual abstinence or safe sex practices
Avoidance of injection drug use
Vaccinations

50. Complications of Cirrhosis
Portal hypertension
Hepatic encephalopathy
Hemorrhage
Ascites