Hepatitis; types, signs and symptoms, management and complication

Introduction

Hepatitis is an inflammation of the liver characterized by abdominal pain, vomiting, hepatomegaly (enlarged liver) and jaundice (yellowing of the skin and eye) etc. Apart from the hepatitis viruses, other viruses can also cause hepatitis, including cytomegalovirus, Epstein-Barr, yellow fever, etc.

The most common viral hepatitis are; Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D and Hepatitis E.

Types of Hepatitis

According to Pathology

  • Acute Hepatitis; having a severe and rapid onset, a short course and pronounce symptoms.
  • Chronic Hepatitis; this is when hepatitis progress for more than six months. There are two types of chronic hepatitis. These include;
    • Chronic Progressive Hepatitis.
    • Chronic Active Hepatitis.

According to Aetioloogy

Viral Hepatitis, Alcohol Hepatitis, Toxic Hepatitis, Hepatobilliary Hepatitis, Metabolic Hepatitis, Viral Hepatitis.

  • Viral Hepatitis

HEPATITIS A VIRUS (INFECTIOUS HEPATITIS)

This is infectious hepatitis caused by RNA virus (hepatitis A virus-HAV), specifically picornavirus. It is transmitted by the orofecal route, transmitted to humans through methods such as contaminated food, water, conditions of poor hygiene, intimate contact with carrier of the virus is also a source of transmission. It is rare to be transmitted through blood transfusion. It causes an acute form of hepatitis and does not have chronic stage.

The patient's immune system makes antibodies against hepatitis A that confer immunity against future infection.

People with hepatitis A are advised to rest, stay hydrated and avoid alcohol.

A vaccine is available that prevent infection from hepatitis A for life.

Strict personal hygiene and the avoidance of raw and unpeeled foods help prevent an infection.

Infected person begin excreting the hepatitis A virus with their stool two weeks after appearance of the first symptoms.

Incubation period is 2-6weeks.

HEPATITIS B VIRUS (SERUM HEPATITIS)

This is caused by DNA virus, known as hepadnavirus. This virus can cause both acute and chronic forms of hepatitis.

Identified methods of transmission include blood (blood transfusion now rare). Tattoos, sexually (through sexual intercourse) or through contacts with blood or bodily fluids, or in utero (from mother to her unborn child, as the virus can cross the placenta). Blood contacts can occur by sharing syringes in intravenous drugs use. Shaving accessories such as razor blades, or touching wounds of infected persons. Kissing is another mode of transmission.

Causative organism: Hepatitis B virus.

Incubation period: between 45 and 180 days.

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HEPATITIS C VIRUS

It was formally known as hepatitis NON A, NON B and is caused by an RNA virus. Transmitted parentally (needle pricks, blood transfusion) and through sexual contact where two parties blood is mixed. Patients with hepatitis C are prone to severe hepatitis if they contract either hepatitis A or B. so all hepatitis C patient should be immunized against hepatitis A and B if they are not already immune. Hepatitis C virus itself is a very lethal virus, most people who have gotten hepatitis C have died.

  • Hepatitis C can lead to chronic form of hepatitis.
  • It can remain asymptomatic for 10-20 years.
  • No vaccine is available for hepatitis C.
  • The virus can cause cirrhosis of the liver.
  • The virus, if detected early can be treated by a combination of interferon (a protein formed by animal cells in the presence of a virus or other inducing agents that prevent viral production) and antiviral drug ribavirin (ribofuranosyl).
  • The incidence has reduced since 1990 when screening of donated blood for hepatitis C virus (HCV) antibodies started.

Incubation period is between 5 and 10weeks.

HEPATITIS D VIRUS OR DELTA HEPATITIS

  • This is caused by an RNA virus. Methods of transmission include; blood transfusion, tattoos, sexually (through sexual intercourse), kissing and through contact with blood or bodily fluid. Blood contacts can also occur by sharing syringes and needles during intravenous drugs use, shaving accessories such as razor blades or touching wounds of infected persons. Mode of transmission is the same as those of HBV.

Incubation period is not known.

HEPATITIS E VIRUS

It is caused by RNA virus, it is transmitted through orofecal route (by taking contaminated drinking water or food) it occurs in economically underdeveloped countries where inadequate sanitation and unsafe drinking water are present.

Hepatitis E produces symptoms similar to hepatitis A. although it can take a fulminate or sudden and severe course in some patients, particularly pregnant women.

Incubation period is between 14-63 days.

HEPATITIS G VIRUS

Another type of hepatitis, hepatitis G virus, has been identified to spread by blood and sexual contact.

There is however, doubt about whether it causes hepatitis or is just associated with hepatitis.

  • Alcohol Hepatitis

Alcohol hepatitis can result from chronic alcohol abuse or acute toxic reaction to alcohol. This results in necrosis of hepatocytes and inflammation of the liver parenchyma. Without ongoing abstinence from taking alcohol, progression to cirrhosis is common. Ethanol, mostly in alcoholic beverages, is an important cause of hepatitis.

Alcohol hepatitis is characterized by a variable constellation of symptoms, which may include feeling unwell and enlargement of the liver with inflammation and development of jaundice. It can occur in patient with chronic alcoholic liver disease and alcohol cirrhosis.

  • Toxic Hepatitis (Drug Induced Hepatitis)

There are chemicals or drugs and other substance that cause hepatitis in the individual. Potential hepatoxic agents includes acetaminophen, chloroform, methyldopa and Nifedipine (antihypertensive) Rifampicin, isoniazid and pyrazinamide.

Others are Brufen and indomethacin (NSAIDs), phenytoin (antiepileptic), Mitriptyline (antidepressant), nitofurantoin (antibiotic) and ketoconazole (antifungal). Some herbs and poisonous mushrooms are also very toxic.

  • Hepatobilliary Hepatitis

This is produced by obstruction of the hepatobiliary tract. It results from cholestasis stoppage or slowing flow in biliary channels especially in the small intrahepatic branches and if longstanding, it leads to destruction and inflammation of the liver tissue.

In other words, when bile flow is disrupted inflammation of the liver parenchyma may result.

The condition can also result from obstruction of the hepatic duct from bile stones.

  • Metabolic hepatitis

Some metabolic disorder cause different forms of hepatitis. Hemochromatosis (due to iron accumulation) and Wilson’s disease (copper accumulation) can cause liver inflammation and necrosis.

Pathophysiology

The major pathophysiologic event in viral hepatitis is destruction of hepatocytes with inflammation. The virus invades the portal tract, and lobules of the liver, causes inflammation of the liver and destruction of the liver parenchyma cells. This results in necrosis, degeneration and autolysis of individual hepatocytes. Infiltration of the liver by leukocytes occur.

Liver enzymes e.g. gamma glutamyltransferase (GGT) is released and liver function decrease. The damage hepatocytes are removed by phagocytosis and regeneration of the cells occurs.

Clinical Manifestation

The clinical features of acute hepatitis can be labeled as pre-icteric, icteric and post-icteric depending on whether jaundice is present or not.

The most common clinical features which may manifest are;

  • malaise
  • right upper abdominal pain
  • vomiting
  • loss of appetite
  • dark urine
  • fever
  • hepatomegaly
  • jaundice (yellowing of the skin and the eyes). etc.

Some chronic forms of hepatitis show very few of the above signs and only present when the longstanding inflammation has led to the replacement of the liver cells by connective tissue. The disease process is referred to as cirrhosis of the liver.

  • Pre-icteric phase or prodromal stage

Eliciting manifestation of malaise, gastrointestinal complaints include nausea, vomiting, diarrhea and anorexia. Client may also complain of headache and fatigue.

Right upper abdominal pain may be elicited upon palpation.

  • Icteric phase

The second phase is manifested by jaundice of the mucous membrane and skin. The jaundice occurs because inflammation of the liver and bile duct prevents bilirubin from being excreted into the small intestine.

As a result, the bilirubin (principal pigment of bile) is elevated in the blood, causing yellowish skin and mucous membrane. Pruritus may then be caused by the deposit of bile salts on the skin.

The client frequently has light brown or clay-coloured stools because the pigment is not excreted through the normal fecal pathway. Instead, the pigment is excreted by the kidneys, causing the urine to turn brown.

  • Post-icteric phase or convalescence phase

This lasts several weeks, during this time, manifestation gradually improve, hepatic pain decreases, and gastrointestinal symptoms and weakness subsides.

Serum bilirubin levels return to normal and energy level increases.

Investigations and Diagnosis

Diagnosis may be based on health history and physical examination.

Several investigations are also available to test for hepatitis.

  1. Anti-HAV is the antibody to HAV and is found from the onset of symptoms and persists throughout person's life.
  2. HBAg is the hepatitis B surface antigen. Several types have been discovered. Its presence indicates active disease or a carrier case.
  3.  HDAg is a delta antigen and detectable in early acute infection.
  4. Anti-HCV is the antibody to HCV (formerly non A. non-B) and seems to be most accurate in detecting chronic state of hepatitis C.
  5. Alkaline phosphate (ALP) a non-specific test of liver is frequently elevated in destructive jaundice or hepatitis.
  6. Gamma glutamyltransferase (GGT) is a more specific test of the liver function but alcohol or hepatotoxic drugs also cause GGT to be elevate.
  7. Bilirubin levels may be elevated in viral hepatitis when serum bilirubin level in checked.
  8. The liver may not able to manufacture the protein needed for blood coagulation.

Medical Management

Both pre-exposure and post -exposure pharmacology are important.

Pre-exposure prophylaxis

  • Hepatitis A clinical illness can be avoided in up to 90% of cases when immune globulin (IG) is given either before or during the early incubation period. People travelling to developing countries, needs to receive IG. Those who remain for prolonged periods should receive IG for every month.
  • Hepatitis B prophylaxis is recommended for people at risk of developing hepatitis e.g. nurses and other health care workers. It is also recommended that infants receive immunization against hepatitis B to achieve lifelong prophylaxis.

Post -exposure prophylaxis

  • Hepatitis A prophylaxis is obtained with single dose of IG given as soon after exposure as possible. Indications for IG vary with the degree of probable contact with hepatitis A virus. IG is recommended for all persons with household or sexual contact with a person known to be infected with hepatitis A.
  • Hepatitis B post exposure prophylaxis is indicated for persons exposed to the hepatitis B virus. This usual method of treatment is hepatitis B immune globulin (HBIG) for short term immunity. With perinatal exposure, infants are given HBIG vaccine within 12months of birth. Following sexual contact, adults are given HBIG vaccine within 14davs of sexual contact.

Secondary Treatment

  • IV fluid e.g. Dextrose water + B-co injection.
  • Liberal oral fluids if the patient can tolerate e.g. glucose drinks.
  • Bed rest.
  • Low fat diet.
  • Vitamin supplementation is usually not necessary during acute hepatitis, however the client’s condition may call for vitamin supplementation. Vitamin K for example may be administered if the client is bleeding or prothrombin time is prolonged.

Complications of Hepatitis

  • Hepatic coma; is brain and nervous damage that occur as a complication of liver disorders.
  • Hepatic encephalopathy; is caused by disordered affecting the liver. These include disorders that reduce liver function such as cirrhosis or hepatitis etc. The exact cause of hepatic encephalopathy is not known. However, when the liver cannot properly metabolize and turn poisons into harmless substances in the body, these poisons build up in the blood stream. One substance believed to be particularly harmful to the central nervous system is ammonia which is produced by the body when proteins are digested. Ammonia is normally made harmless by the liver.
  • Bleeding disorders.
  • Many other substances may accumulate in the blood if the liver does not function and cause other complications to the patient.

Nursing Care/Management

Risk for infection transmission. One of the important goals of care for client with acute hepatitis is preventing the spread of infection through:

    • Universal precaution (proper aseptic technique) and meticulous hand washing.
    • For clients with hepatitis A or E etc. use strict barrier nursing (isolation). Place them in private room if fecal incontinence is present. Clients with hepatitis B who is bleeding should also be isolated.
  • Activity intolerance: fatigue, sometimes accompanied by weakness is common in client with hepatitis. Ensuring adequate period of rest and limitation of activities may be necessary. Client may then resume activity gradually.
  • Altered nutrition: sufficient energy is required for healing. Adequate carbohydrate can spare protein.
  • Body image: jaundice, rashes and purities may cause client embarrassment. Prevent skin break down and improve image by encouraging or providing skin care.

Client teaching

  • Teach about disease.
  • Methods to prevent transmission.
  • Follow up care (review) discharge planning.
  • Explain that until serological indications returns to normal, sexual and close personal contact with others (e.g. wife and husband) should be avoided.

Read Also

General Nursing Management of Patients with Medical Pathology

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