Hepatitis Flashcards
Is inflammation of the liver ?
Causes
> Viral (most common)
> Alcohol
> Rx’s
> Chemicals
> Autoimmune dz’s
> Metabolic abnormalities
Hepatitis
Types of viral hepatitis
> A, B, C, D, E
Differ in modes of transmission & clinical manifestations
Hepatitis ___
- Ranges from mild to acute liver failure
- Not chronic
- Incidence dec w/vaccination
- RNA virus transmitted via fecal-oral route
- Contaminated food or drinking water
A (HAV)
Serology - HAV
- Virus is present in feces during incubation period, so it can be carried & transmitted by persons who have undetectable, subclinical infections
- Greatest risk of transmission occurs <clinical sx’s appear
- HAV is found in feces 2 wks or more before the onset of sx’s & up to 1 wk >the onset of jaundice; present only briefly in blood
- Anti-HAV (antibody to HAV) immunoglobulin M (IgM) appears in the serum as the stool becomes negative for the virus
- Detection of hepatitis A IgM indicates acute hepatitis
- Hepatitis A IgG indicates past infection; IgG antibody provides lifelong immunity
- Hep A vaccination & thorough handwashing are the best measures to prevent outbreaks
Hepatitis ___
- Acute or chronic dz [hepatitis]
- Incidence dec w/vaccination
- DNA virus transmitted
1. perinatally
2. percutaneously
3. via small cuts on mucosal surfaces & exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva) - No evidence that urine, feces (w/o GI bleeding), breast milk, tears, & sweat are infective
B (HBV)
- At-risk populations
> Men who have sex w/men
> Household contact of chronically infected
> Pts undergoing hemodialysis
> Healthcare & public safety workers
> Organ & tissue transplant recipients
Serology - HBV
- HBV is a complex structure w/3 distinct antigens
- surface antigen (HBsAg)
- core antigen (HBcAg)
- e antigen (HBeAg)
- Each antigen along w/its corresponding antibody may appear or disappear in serum depending on the phase of infection & immune response
- Screening for HBV usually includes identifying those @ risk for infection & testing the blood for the presence of HBsAg, hepatitis B surface antibody (anti-HBs), & hepatitis B core antibody (anti-HBc)
- The presence of anti-HBs in the blood indicates immunity from the HBV vaccine or from past infection
- Detection of HBsAg in the serum for 6 mos or longer >infection indicates chronic HBV infection
Hepatitis ___
- Acute: symptomatic
- Chronic: liver damage
- RNA virus transmitted percutaneously
> IV drug use
> High-risk sexual behaviors
> Occupational exposure
> Dialysis
> Perinatal exposure (co-infection w/HIV)
> Blood transfusions <1992
C (HCV)
The most common causes of acute hepatitis C outbreaks are among injection drug users & HIV-positive MSM
Chronic HCV is the most common cause of chronic liver dz & liver failure (20-30% infected pts develop cirrhosis & eventually liver failure &/or cancer)
! Also @ risk for HBV & HIV infections
Hepatitis ___
- Also called delta virus
- Defective single-stranded RNA virus
- Cannot survive on its own
- Transmitted percutaneously
- NO vaccine
- An asymptomatic chronic carrier state to acute liver failure
D (HDV)
Hepatitis D virus requires hepatitis ___ to replicate
B
> Can be acquired @ the same time as HBV, or a person w/HBV can be infected w/HDV @ a later time
Hepatitis ___
- RNA virus
- Transmitted via fecal-oral route
- Most common mode of transmission: drinking contaminated water
- Occurs primarily in developing countries
- Few cases in US
E (HEV)
Pathophysiology
- Acute infection
> Large #’s of hepatocytes are destroyed - bile production, coagulation, blood glucose, & protein catabolism can be affected as well as detoxification of rx’s, hormones, & metabolites
> Liver cells can regenerate in normal form >resolution of infection - Chronic infection can cause fibrosis & progress to cirrhosis (& liver failure)
- Antigen-antibody complexes activate complement system
- Clinical manifestations are rash, angioedema, arthritis, fever, & malaise
____ (abnormal proteins found in the blood), glomerulonephritis, & vasculitis can occur 2° to immune complex activation
Cryoglobulinemia
Clinical Manifestations
- Classified as acute & chronic
- Many pts: asymptomatic
- Sx’s intermittent or ongoing
> Malaise
> Fatigue
> Myalgias/arthralgias
> RUQ tenderness (c/b liver inflammation)
The ___ phase is the period of maximal infectivity
> usually lasts from 1-4 mos
acute
During the ___ period, sx’s may include
- anorexia, lethargy, wt loss
- fatigue, N/V, RUQ tenderness
- distaste for cigarettes, dec sense of smell
- low-grade fever, skin rashes
- myalgias, arthralgias
incubation
Acute phase - physical exam findings
- hepatomegaly
- lymphadenopathy
- abd tenderness
- splenomegaly
- Icteric (jaundice) or anicteric
- If icteric, pt can also have
> dark urine
> light or clay-colored stools
> pruritus
___, a yellowish discoloration of body tissues, results from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct systems
- urine may darken b/c excess bilirubin being excreted by the kidneys
Jaundice
If conjugated bilirubin cannot flow out of the liver b/c obstruction or inflammation of the bile duct, stools will be light or clay-colored
Pruritus (intense chronic itching) sometimes accompanies jaundice
> Occurs as a result of the accumulation of bile salts beneath the skin
The ___ phase following the acute phase begins as jaundice disappears & lasts for wks to mos, w/an avg of 2-4 mos
Major complaints - malaise & easy fatigability
Hepatomegaly remains but splenomegaly subsides
convalescent
Recovery
- Most pts recover completely w/no complications
- Most cases of Hep A resolve
- Some HBV & majority of HCV result in chronic hepatitis
Complications
! Acute liver failure
! Chronic hepatitis (some HBV & majority of HCV infections)
! Cirrhosis
! Portal HTN
! Hepatocellular carcinoma
Acute liver failure
- Fulminant hepatic failure
- encephalopathy, GI bleeding, DIC, fever w/leukocytosis, oliguria, azotemia, ascites, edema, hypotension, resp failure, hypoglycemia, bacterial infections, thrombocytopenia, coagulopathies
- Liver transplant is usually the cure
Chronic hepatitis
- Chronic HBV is more likely to develop in infants & those <5
- HCV infection is more likely than HBV to become chronic
- Manifestations incl anemia & coagulation problems (easy bruising, bleeding), as well as skin manifestations (spider angiomas, palmar erythema, gynecomastia)
Cirrhosis - (risk factors incl)
- Male gender
- Alcohol consumption
- Concomitant fatty liver dz
- Excess iron deposition in liver
- Pts w/metabolic syndrome
___ ___
- a potentially life-threatening spectrum of neurologic, psychiatric, & motor disturbances
- results from liver’s inability to remove toxins (esp ammonia from the blood)
Hepatic encephalopathy
___
- accumulation of excess fluid in peritoneal cavity
- d/t reduced protein lvls in blood which reduces the plasma oncotic pressure
Ascites
Diagnostic Studies
! Specific antigen &/or antibody for each type of viral hepatitis
Hepatitis A
Anti-HAV ___ indicates previous infection or immunization
Anti-HAV ___ indicates acute infection
IgG
IgM
Hepatitis ___
Currently, no serologic tests to diag infection are commercially avail in the US
Diagnostic tests are avail in research labs
E
Hepatitis C
Anti-HCV (antibody to hepatitis C) is a marker for acute or chronic infection w/HCV
HCV RNA quantitation indicates active, ongoing viral replication
Hepatitis D
Anti-HDV (antibody to hepatitis D) is present in past or current infection w/hepatitis D
HDV Ag (hepatitis D antigen) is present within a few days after infection
Hepatitis B
HBsAg
anti-HBs
HBeAg
anti-Hbe
anti-Hbc IgM
anti-Hbc IgG
HBV DNA quantitation
Which of these is the best indicator of viral replication & effectiveness of therapy in pts w/chronic HBV infection?
HBV DNA quantitation
?
Indicates high infectivity & is used to determine the clinical management of pts w/chronic HBV infection
HBeAg (hepatitis B e antigen)
?
Is a marker of infectivity; present in acute or chronic infection & in chronic carriers
HBsAg (hepatitis B surface antigen)
?
Indicates prev infection w/hepatitis B or immunization
Anti-HBs (hepatitis B surface antibody)
?
Indicates previous infection
Anti-HBe [hepatitis B e antibody]
?
Indicates acute infection & does not appear after vaccination
> does not appear after vaccination
Anti-HBc IgM (antibody to hepatitis B core antigen)
?
Indicates previous infection or ongoing infection w/hepatitis B
> also does not appear after vaccination
Anti-HBc IgG
LFT’s
AST, ALT, GGT, alkaline phosphatase lvls are all elevated
γ-globulin normal or inc
albumin normal or dec
Serum total bilirubin & urinary bilirubin inc
urinary urobilinogen inc 2-5d <jaundice appears
PT prolonged
Viral genotype infection (HBV, HCV)
- 8 genotypes of HBV
- 6 genotypes & >50 subtypes of HCV
! HCV genotype 1 = 75% of HCV infections
Physical assessment
☄ hepatic tenderness
☄ hepatomegaly
☄ splenomegaly
- Liver is palpable
> Liver biopsy
FibroScan (ultrasound elastography)
FibroSure [FibroTest] (a biomarker)
Interprofessional Care - Acute & chronic
- Adequate nutrition
> Well-balanced diet (calories; fat content)
> Vitamin supplements (B-complex, K) - IV glucose solutions; supplemental enteral nutrition
- Rest (° & strictness varies)
- Avoid alcohol intake & drugs detoxified by liver
- Notification of possible contacts
Drug Therapy
Acute HAV infection: no specific
Acute HBV infection: only if severe hepatitis & liver failure
Acute HCV infection: pegylated interferon or direct-acting antivirals (DAAs) within 1st 12-24 wks of infection dec development of chronic hep C
Supportive rx therapy
⋆ Antihistamines - for generalized itching
☉ Antiemetics - for nausea
☉ prochlorperazine (Compazine)
⋆ ☉ promethazine (Phenergan)
☉ ondansetron (Zofran)
Interprofessional Care - Chronic Hepatitis B
To ↓ viral load, liver enzyme lvls, & rate of dz progression
Prevent cirrhosis, portal HTN, liver failure, & hepatocellular cancer
1st line therapies now incl primarily nucleoside (NS) & nucleotide (NT) analogs & occ interferon therapy
> NS & NT analogs don’t prevent all viral reproduction, but can substantially lower the amt of virus in the body
lamivudine (Epivir)
adefovir (Hepsera)
entecavir (Baraclude)
telbuvidine (Tyzeka)
tenofovir (Viread)
oral rx’s are indicated in treatment of chronic HBV when there’s evidence of significant active viral replication & liver inflammation
?
- Is a naturally occurring immune protein
- Antiviral, antiproliferative, & immune-modulating effects
- Pegylated ? given subcutaneous
- Blood counts, LFT’s q4-6 wks
- S/e: flu-like sx’s [fever, malaise, fatigue], depression(!)
Interferon
Pegylated interferon (PegIntron, Pegasys)
Nutritional Therapy
- No special diet required
> Emphasis on well-balanced diet that pt can tolerate
> Adequate calories are important during acute phase
> Fat content may need to be reduced
- Vitamins B-complex & K
- IV glucose or enteral nutrition
Nursing Assessment: Subjective Data
Nursing Assessment: Objective Data
- Low-grade fever
- Jaundice, lymphadenopathy
- Rash, icteric sclera
- Hepatomegaly
- Splenomegaly
- Abn lab values
Nursing Diagnoses: Viral Hepatitis
- Imbalanced nutrition: less than body requirements r/t anorexia & nausea
- Activity intolerance r/t fatigue & weakness
- Risk for impaired liver function r/t viral infection
Planning
Patient will
1. Have relief of discomfort
2. Be able to resume normal activities
3. Return to normal liver function w/o complications
___, ___, & ___:
primary immunization consists of a single dose administered IM in the deltoid muscle; a booster is recommended 6-12 mos >the primary dose to ensure adequate antibody titers & long-term protection
Havrix, Vaqta, Avaxim
Recombivax HB & Engerix-B contain HBsAg that promotes the synthesis of specific antibodies directed against HBV
For post-exposure prophylaxis, the HBV vaccine & hepatitis B immune globulin (HBIG) are used; HBIG should be given within 24 hrs of exposure & start the vax series
Health Promotion: Hepatitis C
- No vaccine to prevent HCV
- General measures to prevent transmission
1. screening of blood, organ, & tissue donors
2. use of infection control precautions
3. modifying high-risk behavior
- screen all persons born between 1945-1965
- no post-exposure prophylaxis; baseline & f/u testing
In light-skinned persons, jaundice is usually observed first in the sclera of the eyes & later in the skin
In dark-skinned persons, jaundice is observed in the hard palate of the mouth & inner canthus of the eyes
! Bleeding tendencies w/inc PT
! Manifestations of encephalopathy
! Sudden inc in wt & abd girth (may be d/t fluid retention &/or ascites)
! Bloody or tarry stools, vomiting of blood, elevated LFT’s
Evaluation - Expected Outcomes
✓ Maintain food & fluid intake adequate to meet nutritional needs
✓ Avoid alcohol & other hepatotoxic agents
✓ Demonstrate gradual increase in activity tolerance
✓ Perform daily activities with scheduled rest periods
✓Ability to explain methods of transmission & methods of preventing transmission
