Hepatitis management

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Information about Hepatitis management
Health & Medicine

Published on April 27, 2014

Author: bimelk

Source: slideshare.net


Hepatitis management

Anatomy and physiological overview of Liver  It is the largest gland of the body  Located behind the ribs in the right upper quadrant, from 5th-12th rib.  It weighs 1800gms in men and 1400 in women.  It is divided into 4 lobes and multiple lobules. 1


What’s special about the blood supply to the liver ? 3

Blood supply  2 sources mainly *75% from portal vein which is rich in nutrients *25% from hepatic artery which is rich in O2 *A mixture of venous and arterial blood bathes the hepatocytes. 4

Secretions movement Hepatocytes Pour secretions into small bile duct Larger bile duct 5

Hepatic duct +cystic duct Joins to form common bile duct Empties into small intestine & spincter of oddi controls the emptying into the intestine 6

How does the liver function ? 7

Functions of the liver  Glucose metabolism  Ammonia conversion  Protein metabolism  Fat metabolism  Vitamin and iron storage  Drug metabolism  Bile formation  Bilirubin excretion 8

What is Hepatitis ? 9

Hepatitis Inflammation of liver cells producing a characteristic cluster of cellular changes 10

How do we classify hepatitis ? 11


Viral  HAV  HBV  HCV  HDV  HEV  HGV 13


Hepatitis A Virus 15

Hepatitis A It accounts for 20-25% of clinical hepatitis in developed countries. Etiology -RNA virus of the enterovirus family. 16

Transmission Feco-oral route Ingestion of food infected Found with over crowding and poor sanitation Poor hand hygiene, hand to mouth contact Infected food handler Oral & anal intercourse 17


Incubation-15-50 days with a mean of 28-30 days period. Illness period is 4-8 wks Mortality rate -0.5% in <40 yrs 1-2% in > 40 yrs Carrier-No carrier state 19

Clinical manifestations  Anicteric and symptomless  Low grade fever,headache  Anorexia ,abd pain  Nauseand vomiting(due to toxins released to detoxify virus)  Jaundice and dark urine, claycolured stools  Indigestion, heart burn and flatulence  Aversion to strong odors  Generalized weakness  All these clear within 10 days 20

Assessment and diagnostic findings  Hepatomegaly and splenomegaly for few days Hepatitis A virus found in stool for 7-10 days before illness and 2-3 weeks after symptoms appear. HAV antibodies detected in serum 21

contd  Raised IgM,IgG Atibodies  Elevated liver enzymes  Ultrasound  CT scan  MRI 22

Prevention Scrupulous hand washing Safe food and water supply Vaccine(Havrix,Vaqta)HAV,(Twinr ix)HAV+HBV *Immunoglobulin given IM within 2 wks of exposure for those who never had vaccine- 0.02-0.05mi/kg bodywt. 23

Medical management Bedrest during acute stage IV fliuds with glucose Restrict activities to prevent fatigue worsening Antiemetics Immunoglobulin 24

Nursing management  Guidelines about  Diet(low fat, fluid balance)  Rest  Followup of blood work  Importance of avoiding of alcohol  Sanitation  Teach family members 25

Hep b

Hepatitis B Virus 27


Hepatitis B Transmission-Blood ,percutaneous and permucosal,mother to child. Incubation period 1-6 months. People at risk- surgeons, lab workers, nurses, dentist, respiratory therapist and staff working in hemodialysis and oncology unit. Recovery-90% recovery spontaneously. 29

Risk factors Exposure to blood and blood products. Health care workers Hemodialysis Male homosexual IV drug users Multiple sex partners Blood transfusions 30



Clinical manifestations  Insidious onset because of long prolonged incubation  Fever and respiratory symptoms are rare  Arthralgia and rashes  Loss of appetite & dyspepsia  Abdominal pain and generalized aches  Malaise and weakness  Jaundice may or may not be evident 33

Cont…  Light colored feces and dark urine(if jaundice occurs)  Hepatomegaly 12-14 cms vertically and tenderness  Splenomegaly in few  Posterior cervical lymphnodes 34

Assessment and diagnosis  specific antibody in serum like HBcAg,HBsAg,HBeAg,HBxAg  HBsAg appears in the circulation in 80%-90% of infected patients,1-10 wks after exposure & 2-8 wks before the onset of symptoms  HBV DNA detected  HBcAg Is not always detected in serum 35

Prevention  Preventing transmission Screening of blood donors Use of disposable needles Good protection during blood collection Work areas disinfected daily Use protective devices when needed Patient education Discourage blood donation 36

Cont…….  Active immunization Recommended for high risk individuals Combined hepatitis A &B vaccine for >18 yrs Twinrix- 3 doses Recombivax HB-yeast recombinant Hep B vaccine IM in 3 doses with 6 months interval Deltoid muscle universal response for all new born 37

Cont….. Passive immunity Hepatitis B immune globulin Used for those exposed to virus and not taken vaccine before Used for needle stick injuries,perinatal exposure 38

What is the best choice of treatment for hepatitis B ? 39


Medical management  Alpha interferon as the single modality of therapy.- Enhance bodys immune activity  5 million units daily/10 million units 3 times a wk for 4-6 months  Results in remmission in 1/3rd patients  Prolonged course might have additional benefits  Side effects-fever,nausea,myalgia,fatigue,bone marrow suppression, thyroid dysfunction,alopecia and delayed infection 41

Cont…..  Antiviral agents-Lamivudine,Adefovir,oral nucleoside analogues.  Drugs help control disease progression by supressing viral reproduction in liver  Once daily for years  Bedrest-Until hepatomegaly and serum bilirubin falls.  Antacids and antiemetics  Fluid therapy  Nutritious diet 42

Nursing management Symptomatic support Gradual resumption of physical activity Advice avoidance of sexual activity Minimize social isolation Reduce fear and anxiety by proper explanation of treatment plans 43

Hepatitis C Prevalence –adults,40-59 yrs African-Americans Cause for death –hepatocellular carcinoma People at risk -IV drug users Multiple sex partners frequent blood trasfusions Health care personnel 44

Incubation period -15-60 days Clinical course of disease It is similar to Hep B Symptoms are mild Chronic carrier state occurs frequently Increased risk of cirrhosis and cancer 45

contd 46

Risk factors Exposure to blood and blood products. Health care workers Hemodialysis Male homosexual IV drug users Multiple sex partners Blood transfusions Borne to hep C –infected mother 47

Do we have medications to treat Hepatitis C !!! 48

Treatment Avoid alcohol Avoid hepatotoxic drugs Combination of antiviral - ribavarin  interferon is effective- pegylated interferon-I inj each week Screening blood donors reduces risk 49

Hepatitis D  Cause- *Small circular RNA virus,delta virus. * It is also called subviral satellite * Can propogate only with the help of another virus. *It can occur with HBV and by superinfection. 50

 Risk group Intravenous drug users Homosexual and multiple sex aprtners Unscreened blood transfusions Hemphiliacs and other clotting disorders patient 51

Transmission –Bloodborne Percutaneous Permucosal Sexual Rarely perinatal 52

Pathogenesis  Limited only to liver  Can replicate only in liver  Histological changes results in hepatocellular necrosis and inflammation 53

Clinical features  Found only in acute phase of disease  Mild fever  Jaundice  Muscle ache  Dark urine  Nausea  Vomitiing  Loss of appetite 54

Cont……  Headache  Dizzziness  light colored stools & may contain pus  Spleenomegaly  Prurituis 55

DIAGNOSIS Serological tests-using radioimmunoassay or enzyme immunoassay kits PCR-can detect 10-100 copies of HDV genome IgM in serum Anti HDV antibodies present 56

Prevention  Informing sex partner and safe sex  Hepatitis B vaccine  Don’t share razor,toothbrush and personal articles  Immunization with recombinant purified HDAg-S provide complete protection 57

Treatment  Massive doses of Interferon  9-12 million units 3 times a wk*12 months  5 million units daily*12 months  Antivirals are ineffective  Liver transplantation 58

Immune prophylaxis Vaccination against HBV protects Hepatitis D 59

Hepatitis E Virus 60

Hepatitis E  Caused by hepatitis E virus.It is a positive single stranded RNA  Transmission –feco oral Animals as reservoirs Consuming wild boar and deer meat  Epidemiology- highest among adolescence and adults. 61

Clinical features  Weakness  Fatigue  Fever  Rt upper abd pain,abd tenderness  Nausea,vomiting,diarrhoea  Sore throat  Joint pain  Malaise  Wt loss  Jaundice, brown urine, clay stools 62

Diagnostic  Elevated antibodies of hep E- RT-PCR 63

Prevention- Improving sanitation  Proper disposal of human waste  Good standards of public water supply  Personal hygiene & sanitary food preparation Vitamin supplements Diet- highcoh- 64

Are there any more types of viral hepatitis? 65

Hepatitis G  Cause-Hepatitis G virus a distant relative of hepatitis C virus  People at risk- Those getting repeated transfusions IV drug users Mother to newborn Sexual transmission 66

 Diagnosis-DNA testing  Treatment- No specific treatment Bedrest Avoid alcohol Balanced diet 67

 Prognosis –It is mild illness and doesnot last long. 68

Hepatitis TT virus  Found in the year 1997  Found in patient in Japan with post transfusion hepatitis 69

Non-Viral hepatitis Toxic hepatitis Drug induced 70

Causes Alcohol overuse Direct hepatotoxicity Idiosyncratic hepatotoxicity Cholestatic reactions Metabolic & autoimmune disorders Infectious agents 71

s/s  Anorexia  Nausea and vomiting  Jaundice  Dark urine  Hepatomegaly  Abdominal pain  Clay colored stools  Pruritus 72

Diagnosis WBC count Increased eosinophil count Liver biopsy 73

Treatment Remove the causative agent by lavage Catharsis and hyperventilation Antidote-Eg acetyl cysteine Corticosteroids if drug induced 74

Autoimmune hepatitis Body’s immune system attacks liver cells Treatment Corticosteroids Azathioprine Liver transplant 75

Bacterial Hepatitis 76

Pathophysiology of hepatitis Damage to liver parenchyma Persistent inflammation Hepatocyte fibrosis Cirrhosis 77

Complications 78

Nursing care  Pain in upper right quadrant related to inflammation of liver and arthralgia 79

 Activity intolerance ,fatigue and tiredness related to the disease process 80

 Nausea related to stimulation of vomiting centre associated with inflammation of GIT, gaseous distension due to impaired fat digestion and obstruction of bile flow. 81

 Risk for fluid volume deficit related to decreased oral intake associated with vomiting and diaphoresis. 82

 Risk for imbalanced nutrition less than body requirement related to nausea,vomiting,decreased appetite and inability to digest. 83

 pruritus related to stimulation of itch fibers in the skin by bile acid metabolites which accumulate in the blood as a result of bile flow obstruction 84

 Potential for complications of hepatitis,bleeding, progressive liver degeneration(fulminant hepatitis,chronic acute hepatitis) related to decreased production of clotting factors and continued degeneration and necrosis of hepatocytes. 85

Deficient knowledge regarding disease process,treatment and home care related to ignorance 86

Home care teaching  Wash hands after urinating and having a bowel movement.  Donot share personal articles eg brush,razor.  Donot share utensils,cigarettes and food  Use disposable syringes eg vit B12 injections  Use condom for sexual intercourse 87

Cont…..  Donot donate blood  Avoid alcohol atleast for 6 months-1 year  Avoid contact with industrial toxins  Take acetaminophen only as prescribed  Hepatitis immune globulin and vaccine for family members 88

Bibliography  Suzanne.C.Smeltzer.,& Brenda.G.Bare.,&Janie.L.Hinkle.,& kerry.(2008).Brunner and Suddarths textbook of Medical and Surgical Nursing.Philadelphia:Lippincott . 89


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