Hepatitis

DIAGNOSIS: Hepatitis

What Causes Hepatitis?

  • Viral Causes (most common)

    • Hepatitis Viruses A-E

  • Non-Viral Causes

    • Alcohol

    • Medications

    • Chemicals

    • Autoimmune diseases

    • Metabolic problems

Clinical Manifestations

Acute or Chronic

  • Many patients may be:

    • Asymptomatic

    • Symptomatic manifestations include:

    • Anorexia

    • Malaise

    • Fatigue

    • Lethargy

    • Myalgias (muscle pain) and arthralgias (joint pain)

    • Right upper quadrant tenderness

  • Symptoms may be intermittent or ongoing

Clinical Manifestations—Acute Phase

  • Symptoms experienced during acute phase include:

    • Nausea and vomiting

    • Right upper quadrant tenderness

    • Food aversion

    • Patients can present as:

    • Icteric (with jaundice)

    • Anicteric (without jaundice)

  • If presenting as icteric, additional symptoms may include:

    • Dark urine

    • Light or clay-colored stools

    • Pruritus (itchiness)

  • Physical examination findings may include:

    • Hepatomegaly (enlarged liver)

    • Lymphadenopathy (swollen lymph nodes)

    • Splenomegaly (enlarged spleen)

Clinical Manifestations—Convalescent Phase

  • Begins as jaundice is disappearing

  • Lasts for weeks to months

  • Major problems during this phase include:

    • Malaise

    • Easy fatigability

    • Persistent hepatomegaly

    • Subside of splenomegaly

Complications of Hepatitis

Acute Liver Failure

  • May lead to:

    • Hepatic encephalopathy (brain dysfunction due to liver failure)

    • GI bleeding

    • Disseminated intravascular coagulation (DIC)

    • Fever with leukocytosis (increase in white blood cells)

    • Renal symptoms such as oliguria (low urine output) or azotemia (high levels of nitrogen in the blood)

    • Ascites (fluid accumulation in the abdominal cavity)

Chronic Hepatitis

  • Complications may include:

    • Anemia

    • Coagulation problems resulting in bruising and bleeding

    • Dermatological signs such as spider angiomas and palmar erythema

    • Gynecomastia (breast tissue development in men)

    • Cirrhosis (scarring of the liver)

Diagnostic Studies

  • Key studies for diagnosing hepatitis:

    • Viral genotyping

    • Specific antigen and/or antibody tests for each type of viral hepatitis

    • Liver function tests

    • Physical assessment findings

    • Liver biopsy

    • FibroScan: Ultrasound to determine the degree of fibrosis

    • FibroSure (FibroTest): Biomarker used to assess the extent of fibrosis

Viral Hepatitis Subtypes

Hepatitis A Virus (HAV)

  • Characterized by:

    • Ranges from mild to acute liver failure; does not cause chronic infections

    • Incidence decreased with vaccination

    • RNA virus transmitted via fecal-oral route

    • Commonly contracted from contaminated food or drinking water

Hepatitis A—Health Promotion

  • Emphasis on:

    • Personal and environmental hygiene

    • Active immunization: HAV vaccine

    • Recommended for children at 1 year of age and high-risk adults

    • Post-exposure prophylaxis with HAV vaccine and immune globulin (IG)

    • Special precautions for health care personnel

Hepatitis B Virus (HBV)

  • Characterized by:

    • Can be either acute or chronic

    • Incidence decreased with vaccination

    • DNA virus transmitted:

    • Perinatally (from mother to child)

    • Percutaneously (through skin such as needle stick)

    • Via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids

At-Risk Persons for HBV

  • Individuals at greater risk include:

    • Men who have sex with men

    • Household contacts of chronically infected individuals

    • Patients on hemodialysis

    • Health care and public safety workers

    • IV drug users

    • Recipients of blood products

Hepatitis B Treatment

  • Treatment options include:

    • Interferon

    • Antiviral, antiproliferative, and immune-modulating effects

    • Pegylated interferon (e.g., PegIntron, Pegasys) given subcutaneously

    • Note: Side effects can complicate adherence (e.g., flu-like symptoms, depression)

    • Supportive drug therapy, including antihistamines and antiemetics

Hepatitis B—Health Promotion

  • Focus on general health measures:

    • Immunization with Recombivax HB and Engerix-B

    • Deliver in a series of three IM injections

    • Recommended for all children and high-risk adults

    • Post-exposure prophylaxis: vaccine and hepatitis B immune globulin (HBIG)

Hepatitis C Virus (HCV)

  • Characterized by:

    • Most acute cases are asymptomatic

    • Chronic infections can lead to liver damage

    • RNA virus transmitted percutaneously

At-Risk Groups for HCV

  • Individuals at risk include:

    • IV drug users

    • Individuals with high-risk sexual behaviors

    • Occupational exposure (e.g., health care workers)

    • Perinatal exposure

    • Patients who received blood transfusions before 1992

Hepatitis C Treatment

  • Treatment approaches include:

    • For acute HCV infection, utilize Direct Acting Antiviral (DAA) therapy

    • Supportive drug therapy including antihistamines and antiemetics

Hepatitis C—Health Promotion

  • No vaccine currently available for prevention

  • General measures to prevent HCV transmission include:

    • Regular screening recommendations

    • No post-exposure prophylaxis available

    • Importance of baseline and follow-up testing

Hepatitis D Virus (HDV)

  • Also referred to as delta virus

  • Characteristics include:

    • Defective single-stranded RNA virus that cannot survive independently

    • Requires HBV for replication

    • Transmitted percutaneously

    • No vaccine available

Hepatitis E Virus (HEV)

  • RNA virus characterized by:

    • Transmission via fecal-oral route

    • Most common mode of transmission: drinking contaminated water

    • Primarily occurs in developing countries with few cases reported in the United States

Nutritional Therapy

  • Specific dietary requirements include:

    • No special diet required; emphasis on a well-balanced diet that remains tolerable for the patient

    • Adequate calorie intake is crucial during acute phase

    • Potential reduction in fat content

    • Increased protein intake to counteract the catabolic effects of liver disease

    • Absolute prohibition of alcohol

    • Vitamin supplementation including B-complex and K

    • Enteral nutrition may be required for patients with malnutrition

Patient Education

  • Important teaching points include:

    • Dietary guidelines

    • Planning activities after periods of rest

    • Instruction on how to prevent transmission

    • Symptoms that should be reported immediately

    • Assessment protocol for complications

    • Importance of regular follow-ups for at least 1 year post-diagnosis

    • Prohibition of alcohol consumption

    • Medication education on how to administer interferon

    • Advisement against blood donation by patients who are HBsAg- or HCV-positive

    • Importance of contact tracing