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Hepatitis management
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Anatomy and physiological overview of Liver
It is the largest gland of the bodyLocated behind the ribs in the right upper quadrant, from 5th-12th rib.
It weighs 1800gms in men and 1400 in women.
It is divided into 4 lobes and multiple lobules.
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What’s special about the blood supply to the liver ?
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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.
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Secretions movement
Hepatocytes Pour secretions into small bile
duct
Larger bile duct
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Hepatic duct +cystic duct
Joins to form common bile duct
Empties into small intestine & spincter of oddi
controls the emptying into the intestine
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How does the liver function ?
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Functions of the liver
Glucose metabolismAmmonia conversionProtein metabolismFat metabolismVitamin and iron storage Drug metabolismBile formationBilirubin excretion
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What is Hepatitis ?
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Hepatitis
Inflammation of liver cells producing a characteristic cluster of cellular changes
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How do we classify hepatitis ?
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Classification of HepatitisVIRALNON
VIRALAUTOIMMUNEBACTERIALPARASITIC
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Viral
HAVHBVHCVHDVHEVHGV
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Non viral Hepatitis
DRUG INDUCED
TOXIC HEPATITIS
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Hepatitis A Virus
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Hepatitis A
It accounts for 20-25% of clinical hepatitis in developed countries.
Etiology -RNA virus of the enterovirus family.
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TransmissionFeco-oral routeIngestion of food infectedFound with over crowding and poor sanitation
Poor hand hygiene, hand to mouth contact
Infected food handlerOral & anal intercourse
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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
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Clinical manifestations
Anicteric and symptomlessLow grade fever,headacheAnorexia ,abd painNauseand vomiting(due to toxins released to
detoxify virus)Jaundice and dark urine, claycolured stoolsIndigestion, heart burn and flatulenceAversion to strong odorsGeneralized weaknessAll these clear within 10 days
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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
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contd
Raised IgM,IgG AtibodiesElevated liver enzymesUltrasoundCT scanMRI
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Prevention Scrupulous hand washingSafe food and water supplyVaccine(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.
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Medical management
Bedrest during acute stageIV fliuds with glucoseRestrict activities to prevent fatigue worsening
AntiemeticsImmunoglobulin
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Nursing management
Guidelines about Diet(low fat, fluid balance) Rest Followup of blood work Importance of avoiding of alcohol Sanitation Teach family members
Hep b
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Hepatitis B Virus
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Hepatitis BTransmission-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
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Risk factors
Exposure to blood and blood products.Health care workersHemodialysisMale homosexualIV drug usersMultiple sex partnersBlood transfusions
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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
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CLINICAL FEATURES
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Clinical manifestations
Insidious onset because of long prolonged incubation
Fever and respiratory symptoms are rareArthralgia and rashesLoss of appetite & dyspepsiaAbdominal pain and generalized achesMalaise and weaknessJaundice may or may not be evident
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Cont…
Light colored feces and dark urine(if jaundice occurs)
Hepatomegaly 12-14 cms vertically and tenderness
Splenomegaly in fewPosterior cervical lymphnodes
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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
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Prevention
Preventing transmissionScreening of blood donorsUse of disposable needlesGood protection during blood collectionWork areas disinfected daily Use protective devices when neededPatient educationDiscourage blood donation
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Cont…….
Active immunizationRecommended for high risk individualsCombined hepatitis A &B vaccine for >18
yrsTwinrix- 3 dosesRecombivax HB-yeast recombinant Hep B
vaccineIM in 3 doses with 6 months intervalDeltoid muscle universal response for all
new born
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Cont…..
Passive immunityHepatitis B immune globulin Used for those exposed to virus and not taken vaccine before
Used for needle stick injuries,perinatal exposure
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What is the best choice of treatment for hepatitis B ?
Medications
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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 1/3rd patients Prolonged course might have additional benefits Side effects-fever,nausea,myalgia,fatigue,bone
marrow suppression, thyroid dysfunction,alopecia and delayed infection
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Cont…..
Antiviral agents-Lamivudine,Adefovir,oral nucleoside analogues.
Drugs help control disease progression by supressing viral reproduction in liver
Once daily for yearsBedrest-Until hepatomegaly and serum
bilirubin falls.Antacids and antiemeticsFluid therapyNutritious diet
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Nursing management
Symptomatic supportGradual resumption of physical activity
Advice avoidance of sexual activity
Minimize social isolationReduce fear and anxiety by proper explanation of treatment plans
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Hepatitis C
Prevalence –adults,40-59 yrs African-AmericansCause for death –hepatocellular carcinoma
People at risk -IV drug users Multiple sex partners
frequent blood trasfusions
Health care personnel
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Incubation period -15-60 daysClinical course of diseaseIt is similar to Hep B Symptoms are mildChronic carrier state occurs frequently
Increased risk of cirrhosis and cancer
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contd
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Risk factors
Exposure to blood and blood products.Health care workersHemodialysisMale homosexualIV drug usersMultiple sex partnersBlood transfusionsBorne to hep C –infected mother
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Do we have medications to treat Hepatitis C !!!
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Treatment
Avoid alcoholAvoid hepatotoxic drugsCombination of antiviral -ribavarin interferon is effective-pegylated interferon-I inj each week
Screening blood donors reduces risk
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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.
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Risk groupIntravenous drug usersHomosexual and multiple sex aprtners
Unscreened blood transfusionsHemphiliacs and other clotting disorders patient
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Transmission –Bloodborne Percutaneous
Permucosal Sexual Rarely perinatal
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Pathogenesis
Limited only to liver
Can replicate only in liver
Histological changes results in hepatocellular necrosis and inflammation
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Clinical features
Found only in acute phase of diseaseMild feverJaundiceMuscle acheDark urineNauseaVomitiingLoss of appetite
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Cont……
HeadacheDizzziness light colored stools & may contain pus
SpleenomegalyPrurituis
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DIAGNOSIS
Serological tests-using radioimmunoassay or enzyme immunoassay kits
PCR-can detect 10-100 copies of HDV genome
IgM in serumAnti HDV antibodies present
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Prevention
Informing sex partner and safe sex
Hepatitis B vaccineDon’t share razor,toothbrush and personal articles
Immunization with recombinant purified HDAg-S provide complete protection
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Treatment
Massive doses of Interferon9-12 million units 3 times a wk*12 months
5 million units daily*12 monthsAntivirals are ineffectiveLiver transplantation
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Immune prophylaxis
Vaccination against HBV protects Hepatitis D
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Hepatitis E Virus
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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 meatEpidemiology- highest among
adolescence and adults.
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Clinical features
WeaknessFatigueFeverRt upper abd pain,abd tendernessNausea,vomiting,diarrhoeaSore throatJoint painMalaise Wt lossJaundice, brown urine, clay stools
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Diagnostic
Elevated antibodies of hep E- RT-PCR
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Prevention-Improving sanitation Proper disposal of human waste Good standards of public water supply Personal hygiene & sanitary food
preparationVitamin supplementsDiet- highcoh-
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Are there any more types of viral hepatitis?
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Hepatitis G
Cause-Hepatitis G virus a distant relative of hepatitis C virus
People at risk-Those getting repeated transfusionsIV drug usersMother to newbornSexual transmission
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Diagnosis-DNA testingTreatment-No specific treatmentBedrestAvoid alcoholBalanced diet
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Prognosis –It is mild illness and doesnot last long.
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Hepatitis TT virus
Found in the year 1997Found in patient in Japan with post
transfusion hepatitis
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Non-Viral hepatitis
Toxic hepatitis Drug induced
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Causes
Alcohol overuseDirect hepatotoxicityIdiosyncratic hepatotoxicityCholestatic reactionsMetabolic & autoimmune disorders
Infectious agents
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s/s
AnorexiaNausea and vomitingJaundiceDark urineHepatomegalyAbdominal painClay colored stoolsPruritus
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Diagnosis
WBC countIncreased eosinophil countLiver biopsy
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Treatment
Remove the causative agent by lavage
Catharsis and hyperventilationAntidote-Eg acetyl cysteineCorticosteroids if drug induced
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Autoimmune hepatitis
Body’s immune system attacks liver cells
Treatment CorticosteroidsAzathioprine Liver transplant
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Bacterial Hepatitis
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Pathophysiology of hepatitis
Damage to liver parenchyma Persistent inflammation
Hepatocyte fibrosis
Cirrhosis
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Complications
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Nursing care
Pain in upper right quadrant related to inflammation of liver and arthralgia
?
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Activity intolerance ,fatigue and tiredness related to the disease process
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Nausea related to stimulation of vomiting centre associated with inflammation of GIT, gaseous distension due to impaired fat digestion and obstruction of bile flow.
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Risk for fluid volume deficit related to decreased oral intake associated with vomiting and diaphoresis.
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Risk for imbalanced nutrition less than body requirement related to nausea,vomiting,decreased appetite and inability to digest.
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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
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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.
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Deficient knowledge regarding disease process,treatment and home care related to ignorance
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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
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Cont…..
Donot donate bloodAvoid alcohol atleast for 6 months-1 year
Avoid contact with industrial toxinsTake acetaminophen only as prescribed
Hepatitis immune globulin and vaccine for family members
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Bibliography
Suzanne.C.Smeltzer.,& Brenda.G.Bare.,&Janie.L.Hinkle.,& kerry.(2008).Brunner and Suddarths textbook of Medical and Surgical Nursing.Philadelphia:Lippincott .
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