Viral Hepatitis

  • transmissiontable-hepatitisIs a viral infection of the liver associated with a broad spectrum of clinical manifestations from asymptomatic infection through icteric hepatitis to hepatic necrosis.

Five forms of viral hepatits:

Type A Hepatitis (HAV)

  • Is caused by an RNA virus of the enterovirus family.
  • It spreads primarily by fecal-oral route, usually through the ingestion of infected food or liquids.
  • It may also spread from person-to-person contact and, rarely, by blood transfusion.
  • Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.

Type B Hepatitis (HBW)

  • Is caused by a double-shelled virus containing DNA.
  • It spreads primarily through blood (percutaneous and permucosal route).
  • It can also spread by way of saliva, breast feeding, or sexual activity (blood, semen, saliva, or vaginal secretions.
  • Male homosexuals are at high risk for infection.
  • After acute infection, 10% of patients progress on to carrier status or develop chronic hepatitis.
  • HBV is the main cause of cirrhosis and hepatocellular carcinoma.

Type C Hepatitis (HCV)

  • Formerly called non-A, non-B hepatitis, usually spreads through blood or blood product transfusion, usually from asymptomatic blood donors.
  • It may also be transmitted through unsterile piercing or tattooing tools or dyes.
  • It commonly affects I.V. drug users and renal dialysis patients and personnel.
  • HCV is the most common form of postransfusion hepatitis.

Type D Hepatitis (HDV)

  • Also known as Delta hepatitis.
  • Is caused by a defective RNA virus that requires the presence of hepatitis B-specifically, hepatitis B surface antigen (HBsAg) – to replicate.
  • HDV occurs along with HBV or may superinfect a chronic HBV carrier, and cannot outlast a hepatitis B infection.
  • It occurs primarily in I.V. drug abusers or those who have had multiple blood transfusions, but the highest incidence is in the Mediterranean, Middle East, and South America.

Type E Hepatitis (HEV)

  • Is caused by a nonenveloped, single-strand RNA virus.
  • It transmitted by the fecal-oral route but is hard to detect because it is inconsistently shed in the feces.
  • Its occurence is primarily in India, Africa, Asia, or Central America.

Fulminant Hepatitis

  • Is a rare but severe complication of hepatitis, which may require liver transplantation.

Assessment:

Type A hepatitis

  • Incubation period, 3 to 5 weeks.
  • Prodromal symptoms: fatigue, anorexia, malaise, headache, low-grade fever, nausea, vomiting. Highly contagious at this time, usually 2 weeks before onset of jaundice.
  • Icteric phase: jaundice, tea-colored urine, clay0colored stools, right upper quadrant pain and tenderness.
  • Symptoms often milder in children.

Type B hepatitis

  • Incubation period, 2 to 3 months.
  • Prodronal symptoms (insidious onset): fatigue, anorexia, transient fever, abdominal discomfort, nausea, vomiting, headache.
  • May also have myalgias, photophobia, arthritis, angioedema, urticaria, maculopapular rash, vasculitis.
  • Icteric phase occurs 1 week to 2 months after onset of symptoms.

Type C hepatitis

  • Incubation period, 6 weeks to several months.
  • Similar to HBV but less severe.

Type D hepatitis

  • Unclear incubation period.
  • Similar to HBV but more severe.

Applicable to all type:

  • Obtain a patient history. Ask about I.V. drug use, blood transfusions, contact with infected persons (including sexual activity), travel to endemic areas, and ingestion of possible contaminated food or water to help determine cause of hepatitis.

Diagnostic Evaluation:

  1. All forms of hepatitis; elevated serum transferase levels (aspartate aminotransferase, lanine aminotransferase); may have abnormal clotting tests.
  2. HAV: radioimmunoassay detects immunoglobulin M (IgM) antibodies to hepatitis A virus in the acute phase.
  3. HBV: radioimmunoassays detect hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc), anti-HBsAg in various stages of hepatitis B infection.
  4. HCV: hepatitis C antibody may not be detected for 3 to 6 months after onset of illness (used for screening); polymerase chain reaction testing evaluates viral activity.
  5. HDV: anti-delta antibodies in the presence of HBsAg, or detection of IgM in acute disease and IgG in chronic disease.
  6. Hepatitis E antigen (with HCV ruled out).
  7. If indicated, prepare the patient for liver biopsy to detect chronic active disease, track progression, and evaluate response to therapy.

Pharmacologic Interventions:

  1. Vitamin K injected subcutaneously (S.C.) if prothrombin time is prolonged.
  2. I.V. fluid and electrolyte replacements as indicated.
  3. Antiemetic for nausea.
  4. Long-term interferon therapy in combination with oral ribavirin may produce remission inHCV patients. Peginterferon alfa-2b is a long-acting preparation given S.C., once per week, and ribavirin is taken twice daily.
  5. Antiviral treatment is being investigated for HBV.

Nursing Interventions:

  1. Monitor hydration through intake and output.
  2. Monitor prothrombin time and for signs of bleeding.
  3. Encourage the patient to eat meals in a sitting position to reduce pressure on the liver.
  4. Encourage pleasing meals in an environment with minimal noxious stimuli (odors, noise, and interruptions).
  5. Teach self-administration of antiemetics as prescribed.
  6. Encourage rest during symptomatic phase, according to level of fatigue.
  7. Encourage diversional activities when recovery and convalescence are prolonged.
  8. Encourage gradual resumption of activities and mild exercise during convalescent period.
  9. Stress importance of proper public and home sanitation and proper preparation and dispensation of foods.
  10. Encourage specific protection for close contacts.
  11. Explain precautions about transmission and prevention of transmission to others to the patient and family.
  12. Warn the patient to avoid trauma that may cause bruising.
  13. Stress the need to follow precautions with blood and secretions until the patient is deemed free of HBsAg.
  14. Emphasize that most hepatitis is self-limiting, but follow up is needed for liver function tests.

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