Download Hepatitis File

Hepatitis
Jane E. Binetti DNP MSN RN
Objectives
• Describe the pathophysiological principles that occur wit liver
disease
• Compare normal structure and function
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Identify clinical decision making and pharmacological management
Discuss Collaborative interventions identified by the physician
Describe diagnostic tests and therapeutic interventions
Identify appropriate teaching/learning strategies
Utilize holism to assess, plan, implement and evaluate care
Liver
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Largest internal organ
Built on a framework of lobes
Right and left lobes are predominant
100,000 lobules made of hepatocytes
• Each have capillaries (sinusoids) in rows
of hepatocytes
• Lined with Kupffer cells
• Hepatic cells secrete bile to canaliculi
and bile ducts
Liver Vascularity
• Hepatic Artery
• Carries blood from the heart to the
liver to provide nourishment
• Portal Vein
• Carries blood that has circulated through
the abdominal organs and processes it to
take both nutrients and toxins
• Hepatic Vein
• Carries blood away from the liver and connects
to the inferior vena cava to go back to the heart
Liver Functions
• Metabolic Functions
• Carbohydrate metabolism
• Glycogenesis, glycogenolysis, gluconeogenesis
• Protein metabolism
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Synthesis of non essential amino acids
Synthesis of plasma proteins
Formation of urea from ammonia
Synthesis of clotting factors
• Vitamins
• A,D,E,K; B1, B2, B9 and B12, Iron
Liver Functions
• Bile synthesis
• Production
• Excretion
• Storage
• Mononuclear Phagocyte System
• Kupffer cells
• Clotting Factors
• Synthesizes fibrinogen, prothrombin, vitamin K dependent clotting factors
Hepatitis
• General term for inflammation of the entire liver
• Causes:
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Viruses
Drugs
Chemicals
Auto immune disease
Metabolic abnormalities
Viral Hepatitis – What Happens?
• With infection, cytotoxic cytokines and killer cells lyse infected
liver cells
• Inflammation interferes with bile flow
• Chronic hepatitis causes chronic inflammation and fibrosis that
over time leads to cirrhosis
• Antigen-antibody complexes activate the compliment system:
• Antigen is foreign, antibody tries to neutralize it.
• Rash, angioedema, arthritis, fever, malaise,
• Cryoglobinemia leads to glomerulonephritis and vasculitis
Viral Hepatitis
• Types of viral hepatitis differ by:
• Mode of transmission
• Clinical manifestation
• All types can cause:
• Acute or chronic liver disease
• We will review one at a time
Hepatitis A (HAV)
• What is it?
• RNA virus
• How is it transmitted?
• Fecal-oral route
• Poor food handling or contaminated drinking water
• Poor hygiene, crowded living, institutions, day care
• Incubation period
• 2 weeks prior to symptoms found in stool; 1-2 weeks after
More on HAV
• Symptoms:
• Range from flu-like illness to acute hepatitis with jaundice
• Diagnostics:
• Anti HAV IgM acute hepatitis;
• Anti HAV IgG means history of infection, lifelong immunity
• Treatment:
• No specific treatment for acute cases, usually managed at home with rest
• No drug therapies
• Prognosis:
• Can relapse in 2-3 months, most recover completely
Nursing
• What do you do?
• Focus on prevention and control
• HAV vaccines are dead viruses
• Havrix, Vaqta, Avraxim: IM dose with booster 6-12 months later
• IgG can be given after suspected exposure
• Teaching
• Vaccination and handwashing are important
Hepatitis B Virus (HBV)
• What is it?
• DNA virus
• “Serum” hepatitis
• How is it transmitted?
• Infected blood/body fluids in someone not vaccinated
• Prenatal mothers, IV drug users, needles, tattoos, piercings, sex – infected
semen and saliva, GI Bleeds
• Risk to hemodialysis pts, living with Hep B pts, healthcare workers
• HBV can live on dry surfaces up to seven days!
More on HBV
• Incubation period
• Before and after symptoms appear
• Infectious 4-6 months after start of symptoms
• Carriers are infectious for life
• Symptoms
• Anorexia, nausea, vomiting
• Abdominal pain, malaise, fever
• Arthralgia, dark urine, clay stools
HBV Diagnostics
• Diagnostics – 3 distinct antigens
• HBV surface antigen (HBsAG)
• Acute and presence 6 mo or more means chronic infection
• HBV core antigen (HBcAG)
• Made by IgM in active stages
• HBV e antigen (HBeAG)
• Reflects replication and infectivity
• HBV DNA
• Viral replication and effectiveness of therapy for chronic HBV
• Genotype testing is done for patients during drug therapy
• 8 different genotypes that are great predictor of tx and prognosis
HBV Antibody Testing
• Indicative of past infections
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AntiHBs – means immunity
AntiHBe
AntiHBc IgG
AntiHBC IgM
• IgG and IgM do not appear in the person who has been vaccinated
HBV Treatment
• Acute and is only treated for severe hepatitis and failure
• Chronic tx is to decrease viral load, reduce transaminitis, and slow
progression disease
• Interferon: blocks viral entry to cell, blocks protein synthesis and assembly
• Standard: Intron A – short half life means 3 doses/ week, subcu
• Pegylated Interferon: PegIntron, Pegasys – long half life, weekly doses, subcuc
• 1/3 of patients will have reduced HBV DNA and decreased ALT and HBeAg loss
• Nucleoside and Nucleotide analogs: decrease viral replication
• Lamivudine (Epivir), adefovir (Hepsera), entevacir (Baraclude)
• Oral meds, treatment is long, non-compliance causes exacerbation
Nursing – What do you do?
• Identify at risk populations, screen and vaccinate
• HBV vaccine (Recombivax HB or Energix B) series of 3 injections are highly
effective
• Children are vaccinated but high risk populations should be too
• Dialysis patients should be vaccinated
• Post exposure, Vaccine and HBIG (Hep B immunoglobin) are given within 24 hrs
• Teach
• Handwashing, don’t share personal items, safe sex
• Prognosis
• In healthy adults the infection resolves
• 15-25% of chronically infected pts die from chronic liver disease
Hepatitis C Virus (HCV)
• What is it?
• RNA virus
• How is it transmitted?
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Sex with infected partners
Blood and blood products, needles and syringes
10% is occupational, dialysis or perinatal
Transfusions before 1992 place people at higher risk
Many will not know their source
Can be 15-20 years between infection and symptoms
Chronic HBV and HCV are 80% of HCC cases
30-40% of HIV pts also have HCV
More on HCV
• Incubation period
• 1-2 weeks before symptoms appear
• 75-85% develop chronic HCV and remain infectious
• Symptoms
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Initially asymptomatic
Mild but persistent
Most are unaware; the majority will be chronic
May have hepatomegaly, splenomegaly and hepatic tenderness
20-30% lead to Cirrhosis
Most common cause of liver transplantation in US
HCV Diagnostics
• RIBA: HCV recombinant immunoblot assay (RIBA)
• Confirms an Anti-HCV is a true positive
• Enzyme Linked Immunosorbent Assay (ELISA) - confirms anti-HCV
• Anti-HCV
• Marker of acute or chronic infection
• HCV RNA quantitation
• Active ongoing viral replication
• HCV genotyping
• 6 genotypes with 50 subtypes
• Helps with treatment and prognosis
• Liver Biopsy can be done if patient is a candidate
• Non-invasive: Fibroscan, and FibroSure
HCV Treatment
• Drug therapy aims at killing virus and preventing complications
• Treatment is dictated by :
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Genotyping of Hep C
Co-morbitidies of the patient
Possible side effects
Patient willingness to comply
• Pegylated Interferon (Pegasys, PegIntron) with Ribavirin (Rebetol,
Copegus)
• Pegylated interferon is taken once a week, sc
• Ribavirin is taken orally twice a day
More HCV Treatment
• Protease Inhibitors for specific genotypes:
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Telaprevir (Incivek), Boceprevir (Victrelis)
Protease inhibitors are taken every 8 hours – compliance!
Treatment will depend on ability of liver to compensate
Depression and mood swings are common for patients with HCV treatment
• Screening prior to and during treatment is important
Nursing
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No vaccine is available
Screening is essential for blood, organ and tissue donation
Infection control precautions
Identify at risk groups:
• CDC recommends all people born between 1945-1965 be tested
• No post exposure prophylaxis
• If exposed, anti-HCV and ALT levels should be drawn and repeated
in 4-6 weeks
Hepatitis D (HDV)
• What is it?
• RNA virus – single stranded so it cannot exist on its own
• Needs HBV to replicate
• How is it transmitted?
• Transmitted transcutaneously like HBV
• Often contracted along with HBV, needs HBV to exist
• Incubation period
• 2-26 weeks, constantly infectious
Diagnostics
• Anti-HDV
• Present in in past or current infection with HDV
• HDV Ag
• Present a few days after infection
• Treatment
• No vaccination but Hep B vaccination reduces risk of co-infection
• No pharmacologic treatment for HDV has been approved
• Prognosis
• HBV infected patients always at risk for Delta
• HDV can be an acute, short-term, infection or a long-term, chronic infection
Hepatitis E (HEV)
• What is it?
• RNA virus
• How is it transmitted?
• Fecal-oral route
• Usually from contaminated drinking water
• Common in developing countries, epidemics noted in India, Mexico, Africa
and Asia
• Cases in US usually people who have traveled to the above countries
More on HEV
• Incubation period
• 2 weeks-3 months; infective time frame not known
• 15-60 days after innoculation
• Symptoms
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Fever, fatigue, loss of appetite
Nausea, vomiting, abdominal pain
Jaundice, dark urine, clay-colored stool
Joint pain
Diagnostics and Treatment
• Diagnostics
• Cases of Hepatitis E are not clinically distinguishable from other types of acute virus
• No serologic tests to diagnose HEV infection have been approved by FDA in the US.
• Anti HEV IgG and IgM
• Present 1 week to 2 months after onset
• HEV RNA quantitation
• Indicative of active ongoing viral replication
• Blood tests are most definitive for the antigen or antibody
• Treatment
• HEV usually resolves on its own without treatment. No specific antiviral therapy for HEV
• Rest, get adequate nutrition and fluids, avoid alcohol
Other Viral Sources of Hepatitis
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Cytomegalovirus (CMV)
Epstein-Barr Virus (EBV)
Herpesvirus
Coxsackievirus
Rubella virus
What can happen?
• Most cases of acute viral hepatitis recover completely
• Mortality for acute viral hepatitis is less than1%
• Complications:
• Acute liver failure, chronic Hepatitis, Cirrhosis and Hepatocellular Ca (HCC)
• Fading jaundice is not indicative of resolution
• HBV and HCV can cause chronic viral infection
Drug and Chemical Causes
• Alcohol is a common cause of acute and chronic Liver Disease and
can cause
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Elevated liver enzymes (AST, ALT)
Acute hepatitis
Advanced fibrosis
Cirrhosis
• Acute Alcoholic Hepatitis
• Hepatomegaly
• Jaundice, elevated ALT, AST, low grade fever, ascites and prolonged PT
• Cessation of ETOH, may improve symptoms
Chemical
• Chemical Hepatotoxicity
• Caused by systemic poisons
• Carbon tetrocholoride or gold compounds
• Not see much anymore since restrictions
• Drug Induced Liver Injury (DILI)
• Caused by Prescription, OTC drugs and herbal remedies
• Acetaminophen is most common cause of DILI
• Safe at recommended doses
Autoimmune and Metabolic Causes
• Autoimmune Hepatitis
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Chronic inflammatory condition with unknown etiology
Autoantibodies work against normal hepatocytes
Increased serum immunoglobulins
Often seen with other auto immune disorders
Lab tests differentiate from other forms of hepatitis
• ANA’s and anti-DNA antibodies
Autoimmune continued
• Often cause chronic hepatitis or acute liver failure
• Treatment is prednisone with azathioprine (Immuran) for active hepatitis
• If no response
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Cyclosporine (Gengraf)
Tacrolimus (Prograf)
Methotrexate
Mycophenolate(Cellcept)
• All are hepatotoxic!
Metabolic Causes of Hepatitis
• Wilsons’s Disease – genetic – copper transport
• Hemochromocytosis – iron overload
• Primary Biliary Cirrhosis
• Primary Sclerosing Cholangitis
• NAFLD or NASH
Collaborative Care
• No specific treatment; rest allows liver to regenerate
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Adequate nutrition; increased calories in acute phase
Rest to reduce metabolic demands
Parameters of care depend on severity of symptoms
Counseling for alcohol avoidance
Diversional activities
Compliance with follow up care
Education about treatment
What do you do?
• Assess your patient!!!
• History
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Onset of symptoms
Exposure to infected individuals
Medications
Chemical exposure
• Teach risks
• Support the patient
• Standard Precautions
Nursing Diagnoses
• Imbalanced Nutrition: Less than body requirements related to
anorexia and nausea
• Activity Intolerance related to fatigue and weakness
• Risk for impaired liver function related to viral infection
• Goals of Care:
• Relief of discomfort
• Resumption of normal activities
• Normal liver functions
Liver Transplantation
• Option for patients with
• End Stage Liver Disease (ESLD)
• Localized Hepatocellular Carcinoma (HCC)
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Chronic viral Hepatitis is primary indicator in US
About 6,000 are done annually in US
Intense screening for co-morbidities
Contraindications
• Metastatic disease
• Non compliance
• Ongoing ETOH/Drug use
Cadaver vs Split Liver Transplants
• Cadaver transplants are most common
• Split liver transplants are live donations
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Biliary disease
Hepatic artery thrombosis
Pneumo, wound infections, ileus
Success rate lower than cadavers
• Complications
• Bleeding, infection, rejection
• Survival is best within 5 year window
• Depends on need for transplant
Anti-rejection Therapy
• Prednisone
• Calcineurin inhibitor
• Cyclosporine
• Tacrolimus
• Azathioprine
• Two months following transplant are critical
• Infection – any kind
• Emotionally
• Reinfection of virus
Nursing Care
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ICU until extubated and stable
Neuro status
Watch for bleeding
IV fluids
Prevent respiratory complications
I&O and electrolytes
Drains
• JP, NG,T-tubes
• UOP