T3: Hepatitis
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| Inflammation of the liver. | hepatitis
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| Causes of hepatitis | viruses (common); drugs (alcohol); chemicals; autoimmune diseases; metabolic abnormalities
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| Type of viral hepatitis | A, B, C, D, E
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| Mild to acute liver failure, not chronic, incidence dec. w/vaccination, RNA virust transmitted by fecal-oral rte or by contaminated foor or drinking water. | Hepatitis A Virus (HAV)
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| Cause acute or chronic disease, incidence dec. w/vaccination, DNA virus transmitted: perinatally, percutaneously, mucosal exposure to infectious blood, or body fluids. | Hepatitis B Virus (HBV)
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| Who is at risk for HBV? | Men who have sex w/men; household contact of chronically infected; pts undergoing hemodialysis; health care & public safety workers; transplant recipients
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| How long can HBV live on a dry surface? | For at least 7 days, HBV is much more infectious than HIV.
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| Can be acute (asymptomatic) or chronic (liver damage), RNA virus transmitted percutaneously: IV drug use, high risk sexual behaviors, occupational exposure, dialysis, perinatal exposure blood transfusions before 1992. | Hepatitis C Virus (HCV)
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| Also know as delta virus, is a defective single-stranded RNA virus that can't survive on its own; requires HBV to replicate; transmitted percutaneously; no vaccine. | Hepatitis D Virus (HDV)
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| An RNA virus, transmitted by fecal oral rte, most common mode of transmission: drinking contaminated water; occurs primarily in developing countries; few cases in US. | Hepatitis E Virus (HEV)
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| Liver damage by cytotoxic cytokines & natural killer cells that cause lysis of infected hepatocytes. Inflammation can interrupt bile flow (cholestasis). After resolution liver cells can regenerate back to normal function & appearance. | acute hepatitis infection
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| Can cause fibrosis and progress to cirrhosis. | chronic hepatitis infection
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| CM of viral hepatitis | Can be acute and chronic. Acute usually no symptoms but may have intermittent or ongoing malaise, fatigue, myalgias, arthralgias, and hepatomegaly.
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| CM during the incubation period of the acute phase of hepatitis | Malaise, anorexia, wt loss, fatigue, N/V, abdominal discomfort, distaste for cigarettes (smokers), dec. sense of smell, headache, low-grade fever, arthralgias, skin rashes
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| Physical examination may reveal what? | Hepatomegaly, lymphadenopathy, splenomegaly; may be icteric (jaundice) or anicteric; if icteric pt can have dark urine, light or clay colored stools, pruritus.
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| A yellowish discoloration of body tissues, results from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct systems. | jaundice
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| Why would the urine darken with jaundice? | B/c of excess bilirubin being excreted by the kidneys.
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| Why are the stools light or clay colored with jaundice? | B/c conjugated bilirubin cannot flow out of the liver b/c of obstruction or inflammation of the bile ducts.
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| Intense chronic itching. | pruritus
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| Why does pruritus occur with jaundice? | B/c of the accumulation of bile salts beneath teh skin.
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| The convalescent phase follows the acute phase and begins when? | Jaundice disappears and lasts for weeks to months, with an average of 2 to 4 months.
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| What is the patient's major complaints during the convalescent phase? | Malaise and easy fatigability. Hepatomegaly remains for several weeks, but splenomegaly subsides during this period.
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| Complications of hepatitis | acute liver failure, chronic hepatitis, cirrhosis, hepatocellular carcinoma
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| What is the only definitive way to distinguish among the various forms of viral hepatitis? | By testing the patient's blood for the specific antigen and/or antibody.
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| Many liver function tests show abnormalities in what? | AST, ALT, GGT (liver enzymes) & alkaline phosphatase levels all elevated. Serum proteins: y-globulin level normal or inc. Albumin normal or dec. Bilirubin (total) & urinary levels inc. PT prolonged.
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| Diagnostic studies for hepatitis | liver function tests, viral genotype test: HBV, HCV; physical assessment findings; liver biopsy; FibroScan; FibroSure (FibroTest)
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| When caring for patients with hepatitis what measures would you emphasize? | To rest the body and assist the liver in regenerating. Adequate nutrition & rest seem to be most beneficial for healing and liver cell regeneration. If anorexia, N/V are severe, IV sol. of glucose or supple. enteral nut. therapy. Maintain F&E balance.
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| Why is rest so important with hepatitis? | It reduces the metabolic demands on the liver and promotes cell regeneration.
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| What should you teach the pt with hepatitis to avoid? | Alcohol intake and drugs detoxified by the liver.
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| What drug therapies are used for HAV? | no specific drug therapy
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| What drug therapy is used for HCV? | Pegylated interferon within the first 12-24 wks of infections markedly reduces the development of chronic hep C
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| Supportive drug therapy for hepatitis | antiemetics for nausea such as prohlorperazine (Compazine), promethazine (Phenergan), or ondansetron (Zofran)
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| Drug therapy for chronic HBV infection is focused on what? | Decreasing the viral load and liver enzyme levels, and slowing the rate of disease progression.
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| What are the long term goals for chronic HBV? | Prevention of cirrhosis, hepatic failure, and hepatocellular cancer.
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| What are the drug therapies for chronic HBV and how do they work? | First line therapy are peglyated interferon and nucleoside and nucleotide analogs. They don't eradicate the virus but work well to suppress viral replication and prevent complications of Hep B.
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| Functions of interferons on viral replication. | After binding to receptors on host cell membranes, the drug blocks viral entry into cells, synthesis of viral proteins, and viral assembly and release.
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| What are the 2 forms of interferons? | standard and pegylated
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| This interferon has a short half-life, necessitating frequent subcutaneous administrations (3x/wk). | standard (conventional) interferon (Intron A)
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| This interferon are long acting preparations that are administered subq once per week, making them more convenient plus the blood levels remain high b./t doses so clinical responses are better. | pegylated interferons
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| How are the long acting interferons made? | By conjugation of a standard interferon with polyethylene glyco (PEG), in a process known as pegylation.
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| What is the function of the PEG component? | To delay elimination of the drug.
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| Why are pegylated interferons preferred over standard interferons in the treatment of HBV and HCV? | They are more convenient and have superior efficacy.
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| Patients receiving interferon should have what performed every 4-6 weeks? | blood counts and liver function tests
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| What are the side effects of interferon? | flu-like symptoms, depression, irritability, insomnia, neutropenia, thrombocytopenia
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| How does the Hepatitis B virus reproduce? | By making copies of its viral DNA nucleosides and nucleotides.
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| What is the function of nucleoside/nucleotide analog drugs? | Masquerade as normal building blocks for DNA thereby "fooling" the Hep B virus. Thus the virus is unable to reproduce.
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| T/F: Nucleoside/nucleotide analogs prevent all viral reproduction. | False. They do not prevent all viral reproduction but they can substantially lower the amount of virus in the body.
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| Examples of nucleoside/nucleotide analogs | lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), and tenofovir (Viread)
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| When are nucleoside/nucleotide analogs used? | Long term treatment of chronic HBV when there is evidence of active viral replication.
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| What are the beneficial effects of nucleoside/nucleotide analogs? | reduce viral load, decrease liver damage, and decrease liver enzymes
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| Treatment of chronic hepatitis C is individualized by what? | Based on the genotype, the severity of liver disease, potential side effects, presence of co-morbid conditions, patient's readiness for treatment, and presence of other health problems (HIV).
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| Drug therapy for chronic Hepatitis C is directed at what? | Eradicating the virus and preventing HCV related complications.
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| What is the treatment for HCV? | Includes pegylated interferon (PEG-Intron, Pegasys) given with ribavirin (Rebetol, Copegus). PEG interferon is injected once a week & ribavirin is taken orally twice daily. This has a synergistic effect & reduces relapse after Hep C treatment.
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| What should be warned about taking Ribavirin? | It is teratogenic so pregnancy must be avoided, both by women taking the drug and by women whose male partners are taking the drug.
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| What protease inhibitors can be taken for patients who have HCV genotype 1? | telaprevir (Incivek), boceprevir (Victrelis)
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| What past health history is important to obtain when diagnosing hepatitis? | History of hemophilia, exposure to infected persons, ingestion of contaiminated food or water, ingestion of toxins, past blood transfusion (before 1992), and other risk factors. Also use/misuse of acetaminophen, OTC or herbal meds
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| What objective data would you note upon assessment of hepatitis? | low-grade fever, lethargy, lymphadenopathy, rash or other skin changes, jaundice, icteric sclera; hepatomegaly, splenomegaly, abnormal labs
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| What are some preventive measures for HAV? | Personal & environmental hygiene & health education promote good sanitation. Hand washing important precaution esp after BM & before eating. Control & screening (S/S) of food handlers. Vaccination prophylaxis & immune globulin postexposure prophylaxis.
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| What is the best protection against HAV? | vaccination
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| Should a person with HAV be put in isolation? | No use infection control measures but isolation is not required.
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| Immune globulin (IG) provides what type of immunity for HAV and when should it be given? | Temporary (1-2 mths) passive immunity and is effective if given w/i 2 wks after exposures.
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| When is IG recommended? | For people who do not have anti-HAV antibodies & are exposed as a result of close (household, day care center) contact w/persons who have HAV or foodborne exposure.
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| Patients with HAV are most infectious when? | Just before the onset of symptoms (the preicteric phase).
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| What is Twinrix? | a combined HAV and HBV vaccine
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| What individuals should be given Twinrix? | People who are at high risk, including pts w/chronic liver disease, users of ilicit IV drugs, pts on hemodialysis, men who have sex w/men, & persons w/clotting factor disorders who receive therapeutic blood products.
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| What are some preventive measures for HBV? | Identify those at risk, screen for HBV, & vaccinate. Good hygienic practices (handwashing & use gloves when contact w./blood), don't share razors toothbrushes, etc; use condoms & vaccinate.
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| What is used as postexposure prophylaxis for HBV? | HBV vaccine & hepatitis B immune globulin (HBIG)
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| When is HBIG recommended? | For postexposure prophylaxis in cases of needle stick, mucous membrane contact, or sexual exposure & for infants born to mothers who are HBsAg-positive.
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| What are the primary measures to prevent HCV? | Screen blood, organ, & tissue donors; use infection control precautions; modify high-risk behavior.
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| What does the CDC recommend for postexposure prophylaxis for HCV? | Following acute exposure (needle stick) the person should ahve anti-HCV testing done, baseline anti-HCV & ALT levels should be measured. F/u testing for anti-HCV & ALT done at 4-6 mths. Test for HCV RNA performed at 4-6 wks.
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| What should be assessed for in patients with hepatitis? | Assess for jaundice (usu observed first in sclera of eyes & later in skin); for dark skin people observe jaundice in hard palate of mouth & inner canthus of eyes; urine may be dark brown or brownish red color.
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| Nursing interventions for hepatitis. | Comfort measures to relieve pruritus (if present), headache, & arthralgias. Ensure pt receives adeq. fluid & nutrition (small, freq meals), stimulate appetite (mouth care, antiemetics); carbonated drinks or avoid very hot/cold foods helps w/anorexia.
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| What is essential & an important factor in promoting hepatocyte regeneration? | rest (physical, psychologic, & emotional);
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