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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