Hepatitis management

1. 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

2. 2

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

4. 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

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

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

7. How does the
liver function ?
7

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

9. What is
Hepatitis ?
9

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

11. How do we
classify hepatitis
?
11

12. Classification of Hepatitis
VIRAL
NON
VIRALAUTOIMM
UNE
BACTER
IALPARASI
TIC
12

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

14. Non viral Hepatitis
DRUG INDUCED
TOXIC HEPATITIS
14

15. Hepatitis A Virus
15

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

17. 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

18. 18

19. 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

20. 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

21. 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

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

23. 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

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

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

26. Hep b

27. Hepatitis B Virus
27

28. 28

29. 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

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

31. PATHOPHYSIOLOGY
 VIRUS ENTERS IN TO BLD STREAM
THROUG H A BREAK OR DIRECT
INOCULATION
↓
REACHES TO LIVER ,REPLICATED ( 45-180
DAYS)
↓
DESTRUCTION OF LIVER CELLS-
SYMPTOMS
31

32. CLINICAL FEATURES
32

33. 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

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

35. 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

36. 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

37. 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

38. 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

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

40. Medications

41. 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

42. 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

43. 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

44. 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

45. 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

46. contd
46

47. 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

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

49. 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

50. 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

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

52. Transmission –Bloodborne
Percutaneous
Permucosal
Sexual
Rarely
perinatal
52

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

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

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

56. 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

57. 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

58. 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

59. Immune prophylaxis
Vaccination against HBV protects Hepatitis
D
59

60. Hepatitis E Virus
60

61. 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

62. 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

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

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

65. Are there any more
types of viral
hepatitis?
65

66. 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

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

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

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

70. Non-Viral hepatitis
Toxic hepatitis
Drug induced
70

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

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

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

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

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

76. Bacterial Hepatitis
76

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

78. Complications
78

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

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

81.  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

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

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

84.  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

85.  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

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

87. 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

88. 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

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

90. 90
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