Download Hepatitis B - Austin Community College

Liver Disorders
Kelle Howard, MSN, RN, CNE
Fall 2012
From the notes of:
John Nation, RN, MSN
Charlene Morris, RN, MSN
Austin Community College
Overview of Today’s Lecture
 A & P Review
 Hepatitis A
 Hepatitis B
 Hepatitis C
 Cirrhosis
 Portal Hypertension
 Esophageal Varices
 Hepatic Encephalopathy
 Hepatorenal Syndrome
 Liver Transplant
A and P Review
A and P Review
Largest internal organ
Do you know how much
it weighs?
 A Liver
 B Hepatic vein
 C Hepatic artery
 D Portal vein
 E Common bile
duct
 F Stomach
 G Cystic duct
 H Gallbladder
Blood Supply – 2 sources
 Hepatic artery:
 500ml/min of oxygenated blood
 How much of cardiac output goes to the liver?

_____________
 Portal vein:
 1000ml/min of partially oxygenated blood
 partly oxygenated blood supplies 50 - 60% O2


plus rich supply of nutrients, toxins, drugs
from stomach, small and large intestines, pancreas
and spleen
Hepatic Blood Supply
(Cont’d)
 Both empty into capillaries/sinusoids
 Liver filters the blood
 Hepatic vein to inferior vena cava
Metabolic Functions of the liver
 “Body’s Refinery”--- Over 400 functions
 Primary role in anabolism and catabolism
Metabolic Functions of the Liver
Metabolism
1. Carbohydrates
2. Fats
3. Protein
Other functions
 Immunologic
 Blood storage
 Plasma protein synthesis
 Clotting
 Waste products of hemoglobin
 Formation and secretion of bile
 Steroids and hormones
 Ammonia
 Drugs, alcohol and toxins metabolism
To Summarize….
The liver:



changes food into energy
removes alcohol and poisons from the blood
makes bile, a yellowish-green liquid that helps with digestion
Hepatitis
 Simply means inflammation of the liver
 “itis” means inflammation, “hepa” means liver.
 Viral hepatitis
 Most common cause
 Viral types include A, B, C, D, E, and G
Hepatitis
 Other possible causes
 Drugs (alcohol)




drug-induced liver injury (DILI) is now the leading cause
of acute liver failure (ALF), exceeding all other causes
combined (FDA)
Chemicals
Autoimmune liver disease
Bacteria (rarely)

Other Liver toxic drugs:
Agomelatine (antidepressant)
Allopurinol
Amitriptyline (antidepressant)
Amiodarone (antiarrhythmic)
Atomoxetine [80]
Azathioprine[81]
Halothane (a specific type of anesthetic gas)
Hormonal contraceptives
Ibuprofen and indomethacin (NSAIDs)
Isoniazid (INH), rifampicin, and pyrazinamide (tuberculosis-specific antibiotics)
Ketoconazole (antifungal)
Loratadine (antihistamine)
Methotrexate (immune suppressant)
Methyldopa (antihypertensive)
Minocycline (tetracycline antibiotic)
Nifedipine (antihypertensive)
Nitrofurantoin (antibiotic)
(acetaminophen in the United States) can cause hepatitis when taken in an overdose. The
severity of liver damage may be limited by prompt administration of acetylcysteine.
Phenytoin and valproic acid (antiepileptics)
Troglitazone (antidiabetic, withdrawn in 2000 for causing hepatitis)
Zidovudine (antiretroviral i.e., against HIV)

What other common drug is not on this list?

Usually, if you remove the drug, liver will return to normal function within months.
Hepatitis
 Other Causes
 Cytomegalovirus

Epstein-Barr virus

Herpes virus

1&2

Coxsackie virus

Rubella virus
Hepatitis A
 Hepatitis A virus (HAV)
 RNA virus

How is it transmitted?
fecal–oral route
 parenteral (rarely)


Frequently occurs in small outbreaks
Hepatitis A
(incidence)
 25,000 new cases of hepatitis A occur annually
in the United States
 1/3 of all Americans have had it
 but now have immunity
 Approx. 100 people in US die each year
 10 million cases of hepatitis A occur worldwide
 nearly universal during childhood in developing
countries
(hepatitisfoundation.org)
Hepatitis A
 Hepatitis A virus (HAV)

Found in feces:
2 or more weeks before the onset of symptoms
 up to 1 week after the onset of jaundice


Present in blood briefly

No chronic carrier state
Hepatitis A:
Incubation Period
 2-7 weeks
 Acute onset
 Mild flu-like manifestations
 Symptoms may last up to 2 months
 Children sometimes present with NO symptoms
 Liver usually repairs itself, so no permanent
effects
Hepatitis A
 Hepatitis A virus (HAV)
 Anti-HAV
Appears
immunoglobulin M (IgM)
in the serum as the stool
becomes negative for the virus
Hepatitis A
 Hepatitis A virus (HAV)
 Anti-HAV
 Presence
immunoglobulin G (IgG)
of IgG antibody provides lifelong
immunity
Hepatitis A:
Mode of Transmission
 Mainly by ingestion of food or liquid infected
with the virus
poor hygiene
 improper handling of food
 crowded housing
 poor sanitation conditions

Hepatitis A:
Mode of Transmission
(Cont’d)
 Occurs more frequently in underdeveloped
countries
 Contaminated waters

drinking water, contaminated seafood
 Food-borne Hepatitis A outbreaks usually due
to infected food handler

contamination of food during preparation
 2 doses IM
 Initial
Hepatitis A:
Vaccine
Pre-Exposure
dose
 Booster in 6 to 12 months
Children encouraged to get vaccinated
Post-exposure Prophylaxis
(PEP)
 Standard IG-immune globulin
 Given IM within 2 weeks of exposure
 Recommended for persons who:



do not have anti-HAV antibodies
& have had food borne exposure or close contact with HAV-infected
person
Provides temporary passive immunity

1-2 months
 Hepatitis A Vaccine
 Provides active immunity
Remember 2/2/2/2 Rule
 2 doses IM for vaccination
 Signs & symptoms last 2 months
 Greatest risk for transmission occurs before
clinical s/s signs & symptoms
About 2 weeks
 Also called the ‘preicteric’ phase

 Post-exposure dose of IG given within
2 weeks of exposure
Hepatitis B
(incidence)
 Nearly 1.25 million Americans infected
 350 million world wide
 5,000 Americans die from cirrhosis caused by Hep B
 100 Xs more infectious than HIV
 43,000 new cases of Hepatitis B annually in United
States

Incidence decreased due to HBV vaccine
hepatitsfoundation.org
Hepatitis B
 Hepatitis B virus (HBV)

DNA virus

Transmission occurs when infected blood or other
body fluids enter the body of a person who is not
immune to the virus
Hepatitis B
 Hepatitis B virus (HBV)
 Transmission of HBV

Perinatally
 by mothers infected
 90% of infants infected, have chronic HBV
 The younger you are the more likely chronic disease will occur
Percutaneously
 Mucosal exposure
 infectious blood, blood products
 other body fluids

Hepatitis B
 Hepatitis B virus (HBV)
 Can
live on a dry surface for 7 days
 More infectious than HIV
Who is at risk?
Source: Uptodate
See CDC & medline, medlink, NIH
Hepatitis B
Precautions
 PREVENT INFECTION OF FAMILY — Acute and chronic hepatitis B are
contagious. Thus, people with hepatitis B should discuss measures to reduce the
risk of infecting close contacts. This includes the following:
• Discuss the infection with any sexual partners and use a latex
condom with every sexual encounter.
• Do not share razors, toothbrushes, or anything that has blood on it.
• Cover open sores and cuts with a bandage.
• Do not donate blood, body organs, other tissues, or sperm.
Hepatitis B
Precautions
•Immediate family and household members should have
testing for hepatitis B.
Anyone who is at risk of hepatitis B infection should be vaccinated, if not done
previously. (See "Patient information: Adult immunizations".)
•Do not share any injection drug equipment
(needles, syringes).
•Clean blood spills with a mixture of 1 part household bleach to
9 parts water.
Source: Uptodate
See CDC & medline, medlink, NIH
Hepatitis B
Prevention
Hepatitis B cannot be spread by:
 Hugging or kissing
 Sharing eating utensils or cups
 Sneezing or coughing
 Breastfeeding
 ****Some sources say saliva can be source of transmission
Source: Uptodate
See CDC & medline, medlink, NIH
Hepatitis B
Prevention
• Vaccine-3 doses
Initial dose
Dose at 4 weeks
Dose 5 months later
Developed in the 80s
Post-exposure Hep B
 Incubation Period

6-24 weeks
 Hepatitis B Immune globulin
 IM in 2 doses


First dose within 24 hours to 7 days of exposure
Second dose 20 to 30 days post-exposure
 Provides short-term immunity
Hepatitis B
 Hepatitis B virus (HBV)

Complex structure with three antigens




Each antigen


Surface antigen (HBsAg)
Core antigen (HBcAg)
E antigen (HBeAg)
Has a corresponding antibody that may develop
In chronic carriers





Surface antigen detected 6-12months after infection
Surface antigen remains +
Can still transmit the virus
15% to 25% die from chronic liver disease
Two drugs available to suppress viral activity and decrease viral load
a-Interferon (ex. Pegasys)
 Nucleoside analogs

Hepatitis B Virus
 Presence of Hepatitis B Surface
Antibodies


Indicates immunity from HBV vaccine
Past HBV infection
Hepatitis B –Outbreaks
• Oncologist in NJ
2011 – revoked license, $30,000 in fines
Put 500 people at risk, 10 confirmed
•2 assisted living facilities
Blood glucose monitoring machines
Nurses transmitted
12 residents confirmed
Hepatitis C
 3.2 million Americans chronically infected


1.8% of the population
75-85% of those infected will remain chronically infected
 Approximately 170 million people are infected with
the hepatitis C virus (HCV)
 17,000 new cases each year in US
 8,000-10,000 Americans die each year from ESLD
s/t chronic Hep C
 Approximately 30% to 40% of HIV-infected patients
also have HCV

Source: CDC.gov
Hepatitis C
 Hepatitis C virus (HCV)
 RNA
virus
 No vaccination available
 Transmitted primarily percutaneously
Hepatitis C
 Risk Factors
IV drug use
Most common mode of
transmission in United States and
Canada
Blood
transfusions
Incidence reduced to 1/1million
However, if received blood prior
to 1992 are at risk
Hepatitis C
 Risk Factors (cont)
• High-risk sexual behavior*
more data needed on this
• Hemodialysis
• Occupational exposure
• Sharing personal care items
such as?
• Perinatal transmission
• Body piercings & tattooing *
• Up to 10% cannot identify the source
Hepatitis C
Diagnostic Studies
Anti-HCV
HCV
RNA
antibody
Hepatitis D
 Hepatitis D virus (HDV)
 Also
called delta virus
 Defective single-stranded RNA virus
 Cannot survive on its own
 Requires the helper function of HBV to
replicate
Hepatitis D
HBV-HDV
co-infection
↑ Risk of fulminant hepatitis
 Virulent
More severe acute disease

Hepatitis E
 Hepatitis E virus (HEV)
RNA virus
 Transmitted fecal–oral route
 No serological test in US
 Most common

 contaminated drinking water

occurs primarily in developing countries
Hepatitis G
 Hepatitis G virus (HGV)
 RNA virus
 Poorly characterized parenterally & sexually
transmitted virus
 Can be transmitted by blood transfusion
 Coexists with other hepatitis viruses and HIV
 Does not appear to cause liver damage by itself
Pathophysiology of Hepatitis
 Acute infection- widespread inflammation of liver tissue

Liver damage mediated by
 Cytotoxic cytokines
 Natural killer cells

Liver cell damaged


results in hepatic cell necrosis
With time & no complications
 Liver
cells will regenerate
 Eventually resume their normal appearance & function
Common Manifestations
of Hepatitis
Predictable course among all the viruses
 Incubation Phase:
 after exposure to virus

many times no symptoms
 30%
HBV & 80% HCV asymptomatic
Common Manifestations
of Hepatitis
 Acute Phase
 anicteric or icteric
 If symptoms occur



(anicteric – without jaundice)
Lasts 1-4 months
Flu-like symptoms
 General
malaise
 Fatigue
 Body
aches, headache
 GI symptoms
nausea/vomiting, diarrhea, abdominal discomfort
 Chills,
low grade fever
 Weight loss
Common Manifestations
of Hepatitis
Icteric Phase
(symtomatic, including jaundice)
 Usually 5-10 days after anicteric symptoms
 Jaundice
 results when bilirubin diffuses into tissues
 sometimes accompanied by puritis
 When jaundice occurs, fever subsides
 Liver usually enlarged and tender
Severe Jaundice
Common Manifestations
of Hepatitis
Convalescent Phase
 Healing generally within 3-16 weeks
 Begins as jaundice is disappearing
 GI symptoms minimal
 Biggest complaint

Fatigue
Hepatitis
A, B, & C
 Hep A



(summary)
Almost all cases resolve
Many are anicteric
Onset more acute, s/s flu like
 Hep B


More insidious, s/s more severe
Many result in chronic infection
 Hep C



Many asymptomatic
Many result in chronic infection
High rate of persistence & leads to chronic liver disease
Hepatitis
Complications
 Fulminant Hepatic Failure
 Chronic Hepatitis
 Cirrhosis
 Hepatocellular Carcinoma
Fulminant Hepatitis
 Results in severe impairment or necrosis of
liver cells and potential liver failure
 Develops in small percentage of patients
 Occurs because of
complications of Hepatitis B
toxic reactions to drugs and congenital
metabolic disorders
Diagnostic tests
 Liver function studies

ALT (Alanine aminotransferase)



AST (Aspartate aminotransferase)



elevates: enzyme in liver cells released into bloodstream with
injury or disease
(0 – 50) normal
elevates: enzyme in liver & heart cells released into bloodstream
(0 -41) normal
GGT – gamma glutamyltransferase

present in all cell membranes, injury or disease
 elevates in cell lysis
 (8 – 55)normal
 increases when bile ducts are blocked & hepatitis
 elevated until function returns.

Alkaline phosphatase




present in liver & bone cells
elevated in hepatitis
(44-147 IU/L) normal
CBC

low RBC, HCT, Hgb

Low WBC and Platelets

AFP


alpha fetoprotein– liver cancer marker
Lactic dehydrogenase

LDH5 specific for liver damage
Diagnostic tests
Diagnostic tests
 Coagulation

(Normal PT 12-15 seconds, INR 0.8 to 1.2)
 Hyponatremia
 Hypokalemia
 Hypophosphatemia
 Hypomagnesemia
 Bilirubin

total (2-14 umol/L)

direct/conjugated (0-4 umol/L)
Diagnostic tests
 Serum albumin

(3.3 – 5) normal
 Serum ammonia
 (0 – 150)(10 to 80 ug/l) normal
 Glucose and cholesterol
 Abdominal Ultrasound
 Esophagascopy
 Liver biopsy
 CT, MRI
Liver Biopsy
Needle biopsy
Most common in past
Laparoscopic biopsy
Used to remove tissue from specific parts of the liver.
Liver Biopsy
(Con’t)
Transvenous biopsy
Catheter into a vein in the neck and guiding it
to the liver.
A biopsy needle is placed into the catheter and
advanced into the liver.
Used for patients with blood-clotting problems
or excess fluid
Liver Biopsy
(interventions)
 Adequacy of clotting
 Type and cross match for blood
 Usually hold aspirin, ibuprofen, and
anticoagulants
 Chest x-ray
Liver Biopsy
interventions
 Consent form & NPO 4 to 8 hr.
 Vital signs & Empty bladder
 Supine position, R arm above head
 Hold breath after expiration when needle inserted
 Be very still during procedure
Complications are:
Puncture of lung or gallbladder, infection, bleeding, and pain.
After Needle Liver Biopsy
 Pressure to site, place pt on Rt side to maintain site
pressure minimum of 2 hrs. & flat up to 12-14 hrs.
 Vital signs & check for bleeding
 NPO X 2H after
 Assess for peritonitis, shock, & pneumothorax
 Rt. shoulder pain common


caused by irritation of the diaphragm muscle
usually radiates to the shoulder for a few hours or days
After Needle Biopsy (Cont’d)
 Soreness at the incision site
 Avoid aspirin or ibuprofen for pain control for the
first week
 Avoid coughing, straining, lifting x 1-2 weeks
Hepatitis Care
 Rest is a priority!
 Diet –high calorie & protein, low fat


Vitamin supplement – B complex & K
Avoid alcohol & drugs

detoxify in liver
 Life style changes
Meds for Chronic Hepatitis
 Chronic HBV
Pegylated a-interferon (Pegasys, PEG-Intron)
 Nucleoside/Nucleotide analogs
 Lamivudine (Epivir)
 Adefovir (Hepsera)
 Entecavir (Baraclude)
 Telbivudine (Tyzeka)

 Chronic HCV
Pegylated a-interferon (Pegasys, PEG-Intron)
 Ribavirin (Rebetol, Copegus)


Some can be used in children as young as 3 years old
Hepatitis
Nursing Management
Nursing assessment
 Past health history
Hemophilia
 Exposure to infected persons
 Ingestion of contaminated food or water
 Past blood transfusion (before 1992)
 Medications (use and misuse)
 APAP
 Phenytoin
 Halothane
 Methyldopa

Hepatitis
Nursing Management
Nursing assessment con’t
 IV drug and alcohol abuse
 Weight loss
 Dark urine
 Fatigue
 Right upper quadrant pain
 Pruritus
 Low-grade fever
 Jaundice
 Abnormal laboratory values
Hepatitis
Nursing Management
 Nursing diagnoses



Imbalanced nutrition: Less than body requirements
Activity intolerance
Ineffective therapeutic regimen management
 Overall goals: Planning



Relief of discomfort
Resumption of normal activities
Return to normal liver function without complications
Hepatitis
Nursing Management
 Nursing implementation (broadly summarized)
 Health

Hepatitis A




Education
Vaccination
Good hygiene practices
Hepatitis B




promotion
Vaccination
Education
Workplace safety
Hepatitis C



Education
Infection control precautions
Modification of high-risk behavior
Hepatitis
Nursing Management
Nursing implementation
 Acute intervention
Rest
 Jaundice
 Assess degree of jaundice
 Small, frequent meals
 Ambulatory and home care
 Dietary teaching
 Assessment for complications
 Regular follow-up for at least 1 year after
diagnosis
 Avoid what?

Hepatitis
Nursing Management
Evaluation
 Expected outcomes
Adequate nutritional intake
 Increased tolerance for activity
 Verbalization of understanding of follow-up care
 Able to explain methods of transmission and
methods of preventing transmission to others
