Adult Medical- Adult Medical- Surgical Nursing Surgical Nursing Gastro-intestinal Module: Gastro-intestinal Module:

HepatitisHepatitis

Hepatitis: ClassificationHepatitis: Classification

An acute or chronic viral infection, which An acute or chronic viral infection, which sets up an inflammatory process in the sets up an inflammatory process in the liver cellsliver cells

Leads to mild, moderate or severe liver Leads to mild, moderate or severe liver damage which is temporary or chronicdamage which is temporary or chronic

Very infectious (mode of spread according Very infectious (mode of spread according to the virus) to the virus)

At least 5 known viruses causing hepatitis: At least 5 known viruses causing hepatitis: Hepatitis A, B, C, D, E, and maybe others Hepatitis A, B, C, D, E, and maybe others

Non-viral HepatitisNon-viral Hepatitis

Certain chemicals and drugs can cause toxic Certain chemicals and drugs can cause toxic hepatitis with extensive acute liver cell hepatitis with extensive acute liver cell necrosis:necrosis:

Chemicals: Carbon-tetrachloride, Chemicals: Carbon-tetrachloride, phosphorus, chloroform, gold compoundsphosphorus, chloroform, gold compounds

Drugs: Isoniazid, Halothane, Drugs: Isoniazid, Halothane, Acetominophen, Methyldopa, certain Acetominophen, Methyldopa, certain antibiotics, anti-metabolites and anaesthetic antibiotics, anti-metabolites and anaesthetic agentsagents

Hepatitis A: (HAV)Hepatitis A: (HAV)

RNA virus; spread by faecal-oral route RNA virus; spread by faecal-oral route (contaminated food, water, hands)(contaminated food, water, hands)

Short incubation (average 30 days)Short incubation (average 30 days) Diagnosed by anti-HAV IgM in serum during Diagnosed by anti-HAV IgM in serum during

an acute attack an acute attack Anti-HAV IgG in serum indicates previous Anti-HAV IgG in serum indicates previous

infection or vaccination = now immune infection or vaccination = now immune Prevention: active immunisation to “at risk” Prevention: active immunisation to “at risk”

groups/ travellers to endemic areas. groups/ travellers to endemic areas. Immunoglobulin to contactsImmunoglobulin to contacts

Hepatitis B: (HBV)Hepatitis B: (HBV)

DNA virus (much more infectious than HIV DNA virus (much more infectious than HIV and very damaging to hepatocytes)and very damaging to hepatocytes)

Spread through blood and body fluids Spread through blood and body fluids including saliva and vertical transmission: at including saliva and vertical transmission: at birth/ post-natal, not placental transferbirth/ post-natal, not placental transfer

““At risk” groups are: drug users, sexually At risk” groups are: drug users, sexually promiscuous, health workers (also risk from promiscuous, health workers (also risk from tattoos, haemodialysis, unscreened blood/ tattoos, haemodialysis, unscreened blood/ donor organs)donor organs)

Long incubationLong incubation

Hepatitis B: (HBV) (cont)Hepatitis B: (HBV) (cont)

DiagnosisDiagnosis: HBsAg (Hep B virus surface : HBsAg (Hep B virus surface antigen) in blood or secretionsantigen) in blood or secretions

10% mortality10% mortality 10% carrier state: (HBsAg 6-12 months after 10% carrier state: (HBsAg 6-12 months after

illness): illness): Maybe no active diseaseMaybe no active disease Maybe chronic active disease may lead to Maybe chronic active disease may lead to cirrhosiscirrhosis or or liverliver cancercancer

Anti-HBsAg immunoglobulin in serum shows Anti-HBsAg immunoglobulin in serum shows previous exposure (disease/ vacc) = immune previous exposure (disease/ vacc) = immune

Hepatitis B: (HBV) (cont)Hepatitis B: (HBV) (cont)

Prevention:Prevention: Life-style changes (drugs, needles, partners, Life-style changes (drugs, needles, partners,

unprotected sex)unprotected sex) Vaccination (active or passive immunity). Vaccination (active or passive immunity).

Infants immunised in endemic areasInfants immunised in endemic areas Self-protection for health workers: gloves, staff Self-protection for health workers: gloves, staff

awareness of carriers, screening blood awareness of carriers, screening blood donors, products, disposable needles/ donors, products, disposable needles/ syringes, “sharps boxes”syringes, “sharps boxes”

Reporting “needle-stick” injury Reporting “needle-stick” injury

Hepatitis C: (HCV)Hepatitis C: (HCV)

RNA virus; also transmitted via blood and RNA virus; also transmitted via blood and body fluidsbody fluids

““At risk” groups as HBVAt risk” groups as HBV HCV becomes chronic in 85% of cases → HCV becomes chronic in 85% of cases →

cirrhosis or carcinoma of the livercirrhosis or carcinoma of the liver Prevention: As for Hepatitis B (HBV)Prevention: As for Hepatitis B (HBV) Currently no commercial vaccine and no cure. Currently no commercial vaccine and no cure.

Antivirals have delayed progression. With Antivirals have delayed progression. With HBV, this is the most common and serious HBV, this is the most common and serious form of Hepatitis form of Hepatitis

Hepatitis Delta: (HDV)Hepatitis Delta: (HDV)

Hepatitis D or Delta is a defective RNA Hepatitis D or Delta is a defective RNA virus, requiring the presence of HBVvirus, requiring the presence of HBV

Either co-infection of HBV and HDV or Either co-infection of HBV and HDV or super-infection of an HBV carrier with super-infection of an HBV carrier with HDVHDV

Transmitted as HBV in blood an body Transmitted as HBV in blood an body fluidsfluids

Prevention is as for HBVPrevention is as for HBV

Hepatitis E: (HEV)Hepatitis E: (HEV)

Enteric hepatitis (HEV) is an RNA virusEnteric hepatitis (HEV) is an RNA virus Transmitted by faecal-oral routeTransmitted by faecal-oral route Present in contaminated water, food, on Present in contaminated water, food, on

hands hands Usually responsible for epidemics in Usually responsible for epidemics in

developing countriesdeveloping countries Prevention with improved hygiene and Prevention with improved hygiene and

sanitation, isolation. Vaccination has not sanitation, isolation. Vaccination has not been effective been effective

Hepatitis: Hepatitis: PathophysiologyPathophysiology

Widespread inflammation of liver tissue Widespread inflammation of liver tissue causes degeneration and necrosiscauses degeneration and necrosis

Increased Kuppfer cells (RES) lead to Increased Kuppfer cells (RES) lead to Proliferation and enlargement of the liver Proliferation and enlargement of the liver

and cholestasis →and cholestasis → Regeneration (if no complications, should Regeneration (if no complications, should

regenerate in an orderly way and resume regenerate in an orderly way and resume normal function)normal function)

HBV and HCV may become HBV and HCV may become chronicchronic

Hepatitis: Progression of Hepatitis: Progression of DiseaseDisease

IncubationIncubation phase: phase: Varies according to virus (Hep A and E more Varies according to virus (Hep A and E more

acute onset, B and C more insidious)acute onset, B and C more insidious) ProdromalProdromal/ pre-icteric phase, before jaundice: / pre-icteric phase, before jaundice:

(most infective phase for A and E): 1 - 21 days(most infective phase for A and E): 1 - 21 days IctericIcteric phase: phase: Intra-hepatic obstructive jaundice (cholestasis): Intra-hepatic obstructive jaundice (cholestasis):

still infectious 2 - 4 weeksstill infectious 2 - 4 weeks Post-ictericPost-icteric, convalescence (weeks-months), convalescence (weeks-months) ChronicChronic state → liver failure state → liver failure

Hepatitis:Hepatitis:Clinical ManifestationsClinical Manifestations

Pain in upper right quadrantPain in upper right quadrant Enlarged tender liverEnlarged tender liver FeverFever Malaise and exhaustionMalaise and exhaustion Anorexia, nausea and vomitingAnorexia, nausea and vomiting Jaundice, skin and sclera, itchingJaundice, skin and sclera, itching Dark urine, pale stoolsDark urine, pale stools Severity of illness variesSeverity of illness varies

Hepatitis: DiagnosisHepatitis: Diagnosis

History and clinical pictureHistory and clinical picture Blood serology for specific hepatitis Blood serology for specific hepatitis

antigen or antibodyantigen or antibody Liver function tests and serum bilirubinLiver function tests and serum bilirubin Blood coagulation studiesBlood coagulation studies Liver biopsy if chronic to determine Liver biopsy if chronic to determine

extent of damage to hepatocytes (extent of damage to hepatocytes (notnot in in acute state) acute state)

Hepatitis: Medical Hepatitis: Medical Treatment Treatment

Depends on classification and severity of Depends on classification and severity of hepatitis: hepatitis:

(May require ICU and mechanical ventilation in (May require ICU and mechanical ventilation in fulminating B or C) (10% mortality)fulminating B or C) (10% mortality)

Milder forms require rest and isolation at homeMilder forms require rest and isolation at home Fluids ↑; low fat, high glucose and protein dietFluids ↑; low fat, high glucose and protein diet Vitamin B complex and vitamin K supplements Vitamin B complex and vitamin K supplements Antiviral agent (interferon) and anti-HBV (to Antiviral agent (interferon) and anti-HBV (to

prevent chronic state in Hepatitis B)/ slow HBCprevent chronic state in Hepatitis B)/ slow HBC

Hepatitis: Nursing Hepatitis: Nursing ConsiderationsConsiderations

Importance of self-protective measures Importance of self-protective measures and informing colleaguesand informing colleagues

General nursing care if on bed restGeneral nursing care if on bed rest Patient education on importance of fluids Patient education on importance of fluids

and appropriate dietand appropriate diet Patient and family education about Patient and family education about

measures to prevent spread of the virus measures to prevent spread of the virus

Review: Health Education Review: Health Education for Prevention and for Prevention and Protection Protection

Hand-washing, gloves, appropriate isolation Hand-washing, gloves, appropriate isolation and separate equipment and separate equipment

Life-style changes (drugs, needles, partners, Life-style changes (drugs, needles, partners, unprotected sex)unprotected sex)

Vaccination (active or passive immunity)Vaccination (active or passive immunity) Self-protection for health workers: gloves, staff Self-protection for health workers: gloves, staff

awareness of carriers, screening blood awareness of carriers, screening blood donors/ blood products, disposable needles/ donors/ blood products, disposable needles/ syringes, “sharps boxes”syringes, “sharps boxes”

Reporting “needle-stick” injury Reporting “needle-stick” injury