Hepatitis management

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 5 th -12 th rib. It weighs 1800gms in men and 1400 in women. It is divided into 4 lobes and multiple lobules. 1

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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 H epatocytes P our secretions into small bile duct Larger bile duct 5

6. Hepatic duct +cystic duct J oins 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 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 e nterovirus 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

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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 A version 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,( Twinrix )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

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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. Mortality - 10%.leads to cirrhosis and Ca 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 1/3 rd 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 THANK YOU