Download Hepatitis Liver PPT

Hepatitis and Liver
Disease
N250, CSULB
Spring 2015
Figure 38-1
Liver and biliary system.
Hepatitis
Inflammation of the liver
Acute or chronic
Causes:
– Viruses
– Bacteria
– Metabolic and vascular disorders
– Drugs, alcohol, other toxic substances
Symptoms
The same no matter the cause
– Fatigue
– Clay-colored stools
– Fever
– Loss of appetite
– Dark urine
– Jaundice
Asymptomatic > Symptomatic >
Fulminant Liver Failure > Death
Lab Tests related to Hepatitis
Alanine aminotransferase (ALT) – an enzyme found mainly in the
liver; the best test for detecting hepatitis
Alkaline phosphatase (ALP) – an enzyme related to the bile ducts;
often increased when they are blocked
Aspartate aminotransferase (AST) – an enzyme found in the liver and a
few other places, particularly the heart and other muscles
Bilirubin, a waste product made from old blood cells; it is a yellow
compound that causes jaundice and dark urine when present in
increased amounts
Albumin - measures the main protein made by the liver and tells how
well the liver is making this protein
Total Protein - measures albumin and all other proteins in blood,
including antibodies made to help fight off infections
Can also consider clotting time, such as PT, PTT, INR
Pathophysiology
Infection causes inflammatory
response
Liver edema → bile obstruction →
obstructive jaundice
Cell-mediated immune response →
– Liver cell necrosis, Kupffer cell
hyperplasia, scarring
Pathophysiology
Mild hepatitis → little parenchymal
damage
HBV and HCV → most severe liver
inflammation and damage
Acute fulminating (sudden and
severe) hepatitis → liver failure
Liver can regenerate
Pathophysiology
Asymptomatic carrier HBV and HCV
increased risk for hepatocellular
carcinoma
HBV and HCV can lead to chronic
infection
Clinical Manifestations
Three phases
– Prodromal
– Icteric
– Convalescent
Prodromal Phase
Insidious or rapid onset
Symptoms:
– Vague, flulike
– Anorexia, nausea, vomiting, malaise
– Myalgia, arthralgia, fatigue
– RUQ pain
– Low fever
Icteric Phase
Jaundice
Dark urine
Hospitalization
Convalescent Phase
After 2–3 weeks of acute illness
Increased sense of well-being and
energy level
Increased appetite; jaundice and
abdominal pain disappear
HAV resolves in 9–10 weeks; HBV
about 16 weeks
Basic Features of Hepatitis Viruses
Incubation
Period*
Chronic
Infection
Virus
Transmission
A
fecal-oral
B
parenteral
8-12 (6-24)
Yes
C
parenteral
6-9 (2-24)
Yes
D
parenteral
? (2-10)
Yes
E
fecal-oral
* Weeks
4 (2-6)
4-5 (2-9)
No
No
A, B, Cs of Viral Hepatitis
•
•
•
A
– fecal-oral spread: hygiene, drug use, men having sex
with men, travelers, day care, food
– vaccine-preventable
B
– sexually transmitted – 100x more infectious than HIV
– blood-borne (sex, injection drug use, mother-child,
and health care)
– vaccine-preventable
C
– blood borne (injection drug use primarily)
– 4-5 times more common than HIV
– NOT vaccine-preventable!
Hepatitis A Virus
HAV
Transmission
– Fecal–oral route
– Sexual
– Transfusion of infected blood
Incubation period 4–6 weeks
Anti-HAV antibodies: IgM, IgG
No chronic infection
–Protective antibodies develop in
response to infection - confers
lifelong immunity
Concentration of Hepatitis A Virus
in Various Body Fluids
Body Fluids
Feces
Serum
Saliva
Urine
100
102
104
106
Infectious Doses per mL
Source:
Viral Hepatitis and Liver Disease 1984;9-22
J Infect Dis 1989;160:887-890
108
1010
Prevention of Hepatitis A
Vaccination (pre-exposure)
Immune globulin
Good hygiene
Clean water systems;
avoidance of food
contamination
Hepatitis B Virus
Hepatitis B—United States, 1978-2006
Decline among
men who have sex with men
30000
25000
Decline among
IV drug users
Cases
20000
15000
10000
Hepatitis B vaccine licensed
5000
0
1978 1980
1985
1990
Year
1995
2000
2005
HBV
DNA virus replicates in liver
Dane particle: HBsAg, HBeAg
Asymptomatic carrier state and/or
chronic active state
– Cirrhosis and liver failure
– Increased risk for liver cancer
Incubation period: 6 weeks to 6
months
Outcome of HBV Infection
Infection
Symptomatic
acute hepatitis B
Asymptomatic
Resolved
Immune
Chronic infection
Asymptomatic
Cirrhosis
Liver cancer
Resolved
Immune
Chronic
infection
Asymptomatic
Cirrhosis
Liver cancer
HBV Modes of Transmission
Sexual – Direct sexual contact
Parenteral – Direct contact
with contaminated fluids
Perinatal -- Mother to fetus
Concentration of HBV
in Various Body Fluids
Found in blood, semen, cervical secretions,
saliva, wound drainage
High
blood
serum
wound exudates
Moderate
semen
vaginal fluid
saliva
Low/Not
Detectable
urine
feces
sweat
tears
breast milk
HBV
High-risk groups:
– Health care workers
– IV drug users
– Homosexual men; people with multiple
sex partners
Other*
15%
Injection drug use
14%
Sexual contact with
hepatitis B patient
13%
Household contact of
hepatitis B patient
2%
Men who have
sex with men 6%
Unknown 32%
Blood transfusion
0%
Medical
Employee 1%
Multiple sex partners
Hemodialysis 0%
17%
HEPATITIS C
HCV
Flavivirus
Incubation period: 35–72 days
High rate of chronic infections
Six genotypes
Found in blood, blood products,
transplanted tissue
Can be sexually transmitted
Injection drug use most common
U.S. route of transmission
Estimated Incidence of Acute Hepatitis C
United States, 1982-2000
Surrogate testing of
blood donors
20
18
16
14
12
10
8
6
4
2
0
Anti-HCV test
(1st generation)
licensed
Anti-HCV test
(2ndgeneration)
licensed
Decline among
transfusion recipients
Source: Sentinel Counties
Decline among
injection drug users
Risk Factors Associated with
Transmission of HCV
• Illegal injection drug use
• Transfusion or transplant from infected donor
• Occupational exposure to blood
– Mostly needle sticks
• Iatrogenic (unsafe injections)
• Birth to HCV-infected mother
• Sexual/household exposure to anti-HCV
positive contact
• Multiple sex partners
Chronic Hepatitis C Factors
Promoting Progression or Severity
Increased alcohol intake
Age > 40 years at time of infection
HIV co-infection
Other
– Male gender
– Chronic HBV co-infection
Injecting Drug Use and HCV
Transmission
Highly efficient
– Contamination of drug
paraphernalia, not just needles
and syringes
Rapidly acquired after initiation
– 30% prevalence after 3 years
– >50% after 5 years
Four times more common than HIV
Sexual Transmission of HCV
Occurs, but efficiency is low
– Rare between long-term steady partners (1.5-3%)
– MSM 3% (1-18% in selected STD clinic settings) –
same as heterosexuals
– Factors that facilitate transmission between
partners unknown (e.g., viral titer)
Accounts for 15-20% of acute and
chronic infections in the United States
– Sex is a common behavior
– Large chronic reservoir provides multiple
opportunities for exposure to potentially
infectious partners
Sexual Transmission of HCV
Persons with High-Risk Sexual Behaviors
At risk for sexually transmitted diseases, e.g.,
HIV, HBV, gonorrhea, chlamydia, etc.
Reduce risk
– Limit number of partners
– Use latex condoms
– Get vaccinated against hepatitis B
– MSMs also get vaccinated against hepatitis A
Perinatal Transmission of HCV
Transmission only from
women HCV-RNA positive at
delivery
– Average rate of infection 6%
– Higher (17%) if woman coinfected with HIV
– Role of viral titer unclear
No association with delivery
method
Infected infants do well
– Severe hepatitis is rare
Household Transmission of HCV
Rare but not absent
Could occur through
percutaneous/mucosal
exposures to blood
– Theoretically through
sharing of contaminated
personal articles
(razors, toothbrushes)
– Contaminated equipment used for home
therapies
► IV therapy
► Injections
Patient to HCW Transmission of HCV
Inefficient by occupational exposures
Average incidence 1.8% following
needlesticks from HCV-infected source
– Associated with hollow-bore needles
Case reports of transmission from blood
splash to eye.
Prevalence among health care workers 1-2%
– Lower than adults in the general population
– 10 times lower than for HBV infection
Reduce or Eliminate Risks for
Acquiring HCV Infection
Screening and testing donors of blood,
organs, and tissues
Virus inactivation of plasma-derived products
Risk-reduction counseling and services
– Obtain history of high-risk drug and sex behaviors
– Provide information on minimizing risky behavior, including
referral to other services
– Vaccinate against hepatitis A and/or hepatitis B
Infection control practices
Blood and body fluid precautions
Preventing HCV
Transmission to Others
Avoid Direct Exposure to Blood
Anti-HCV positive individuals should not
donate blood, body organs, other tissue or
semen
Do not share items that might have blood
on them
– personal care (e.g., razor, toothbrush)
– home therapy (e.g., needles)
Cover cuts and sores on the skin
Studies suggest that HCV can survive
on environmental surfaces at room
temperature for at least 16 hours but
not longer than 4 days
HCV Testing Routinely
Recommended
(Based on Risk for Infection)
Persons who ever injected illegal drugs
Persons with selected medical conditions
– received clotting factor concentrates produced before 1987
– ever on chronic hemodialysis
– evidence of liver disease
Prior recipients of transfusion/organs
– before July 1992
– notified that donor later tested positive
Healthcare, emergency medical, and public safety workers
after needle sticks, sharps, or mucosal exposures to HCVpositive blood
Children born to HCV-positive women
Routine HCV Testing Not Recommended
(Unless Risk Factor Identified)
Health-care, emergency medical, and
public safety workers
Pregnant women
Household (non-sexual) contacts of
HCV-positive persons
General population
Natural History of HCV Infection
100 People
Time
15%
Resolve (15)
85%
Chronic (85)
80%
Stable (68)
20%
Cirrhosis (17)
75%
Stable (13)
25%
Mortality (4)
Leading Indication for Liver Transplant
HDV
Delta virus
RNA virus; HBsAg
– Requires coinfection with HBV
Incubation period: 1–6 months
Transmission same as HBV
High rate IV drug users
HEV
RNA virus
Incubation period:
15–60 days
Transmission: fecal–oral route
Clinical manifestations similar to HAV
– Higher mortality rate for pregnant
women
Endemic in Southeast Asia, India,
North Africa, Mexico
HGV
RNA virus
Transmission:
– Percutaneously or sexual contact
Chronic viremia
Improved survival rates for HIV
patients infected with HGV
Nonviral Hepatitis
Toxic hepatitis and alcoholic hepatitis
– Etiology and risk factors
– Pathophysiology
– Clinical manifestations
– Medical and surgical management
– Nursing management
Medical Management and
Nursing Interventions
Medical Management
– Identify cause of the inflammation
– Provide symptomatic treatment
– Monitor liver damage
– Support liver's ability to regenerate
Nursing Management
– Supportive measures
– Education
Health Promotion
Prevention and reducing infection spread
Cirrhosis
Irreversible, progressive
deterioration of the liver
Caused by chronic liver disease
– Chronic hepatitis
– Alcoholism
– Right-sided CHF
– Long-term obstruction
to biliary flow
Pathophysiology
Liver cell damage, death
Cells replaced by fibrous tissue
Regenerate abnormally, creating
nodules and microcirculation distortion
May be asymptomatic until severe liver
impact
Gradual onset
Early symptoms nonspecific:
– Fatigue, weakness, anorexia, weight loss
Nursing and Medical
Management
Assessment of risk factors
Medical management
– Monitor for complications
– Maximize liver function
– Treat the underlying causes and prevent
infection
Education
–
–
–
–
Alcohol abuse
Sexual abstinence or safe sex practices
Avoidance of injection drug use
Vaccinations
Complications of Cirrhosis
Portal hypertension
Hepatic encephalopathy
Hemorrhage
Ascites
Hepatic encephalopathy