1. Adult Medical- Surgical Nursing
Gastro-intestinal Module:
Hepatitis

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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): days
Icteric phase:
Intra-hepatic obstructive jaundice (cholestasis): still infectious weeks
Post-icteric, convalescence (weeks-months)
Chronic state → liver failure

13. 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

14. 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)

15. 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

16. 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

17. 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