Hepatitis PowerPoint Presentation PDF

HEPATITIS  Introduction to Hepatitis Hepatitis refers to the inflammation of the liver. It can be caused by various factors, including viral infections, toxins, alcohol abuse, medications, and autoimmune conditions. If left untreated, hepatitis can lead to liver fibrosis, cirrhosis, or li...

HEPATITIS  Introduction to Hepatitis Hepatitis refers to the inflammation of the liver. It can be caused by various factors, including viral infections, toxins, alcohol abuse, medications, and autoimmune conditions. If left untreated, hepatitis can lead to liver fibrosis, cirrhosis, or liver cancer.  Abbreviations ELISA - enzyme linked immunosorbent assay HAV - hepatitis A virus HBeAg - hepatitis B “e” antigen HBsAg - hepatitis B surface antigen HBV - hepatitis B virus HCV - hepatitis C virus LFTs - liver function tests RIBA - recombinant immunoblot assay RT‐PCR - reverse transcriptase‐ polymerase chain reaction  Hepatitis is an inflammation of the liver with multiple aetiologies. It may present as an acute illness with jaundice and altered liver function tests. When symptoms, signs or laboratory abnormalities persist for more than 6 months it is considered that the hepatitis is chronic  Types of Hepatitis  Viral Hepatitis (most common cause): o Hepatitis A (HAV) o Hepatitis B (HBV) o Hepatitis C (HCV) o Hepatitis D (HDV) o Hepatitis E (HEV)  Non-viral Hepatitis:  Alcoholic Hepatitis:  Drug-Induced Hepatitis:  Autoimmune Hepatitis:  Toxic Hepatitis  ACUTE HEPATITIS CAUSES  Viruses (Hepatitis A, B, C, D and E, Yellow Fever etc.)  Drugs (allopathic, alternative and herbal preparations)  SIGNS & SYMPTOMS Right hypochondrial pain  Fever (occurring 1 to 4 weeks before the jaundice appears) Malaise Anorexia Nausea  Yellow or dark coloured urine and pale stools  Itching Fatigue  Jaundice  Right hypochondrial tenderness  Hepatomegaly  INVESTIGATIONS  History and Physical Examination: o Assess risk factors: Travel, alcohol use, drug use, sexual history. o Signs: Jaundice, hepatomegaly, spider angiomas. · FBC  Abdominal Ultrasound  Investigations/Diagnosis Laboratory Tests:  Liver function tests (LFTs): Elevated ALT, AST, bilirubin. Serologic tests:  HAV: Anti-HAV IgM.  HBV: HBsAg, anti-HBc IgM, anti-HBs.  HCV: Anti-HCV antibodies, HCV RNA.  HDV: Anti-HDV antibodies, HDV RNA.  HEV: Anti-HEV IgM, HEV RNA. Imaging:  Ultrasound: Assess liver size, structure.  Fibroscan: Measure liver stiffness (fibrosis).  Liver Biopsy (optional): Assess severity and extent of liver damage.  TREATMENT Treatment objectives  To identify and eliminate the precipitating cause  To relieve symptoms  Non-pharmacological treatment  Rest  High calorie fluids especially glucose drinks, fruit juice, light porridge, koko, rice-water, mashed kenkey  Any food that the patient can tolerate  Avoid alcohol  pharmacological treatment  Vitamin B preparations  CHRONIC HEPATITIS This refers to chronic inflammation of the liver of more than 6 months duration, with persistently elevated liver function tests. Chronic hepatitis can progress to liver cirrhosis, portal hypertension with upper gastrointestinal bleeding, hepatic encephalopathy and hepatocellular carcinoma.  CAUSES  Chronic infection of the liver with hepatitis B and C viruses  SIGNS & SYMPTOMS · Usually asymptomatic · Chronic fatigue Malaise · Ascites · Gynaecomastia · Palmar erythema · Parotid enlargement · Testicular atrophy · Spider naevi · Jaundice  INVESTIGATIONS · Hepatitis B s antigen, Hepatitis B e antigen, Viral DNA load · Hepatitis C antigen · HIV testing · Abdominal Ultrasound  TREATMENT Treatment objectives · To prevent disease progression and complications · To prevent hepatic encephalopathy Non-pharmacological treatment Avoid alcohol Avoid hepatotoxic agents and drugs e.g. Paracetamol  Hepatitis A Hepatitis A, formerly called infectious hepatitis,  It is caused by ribonucleic acid(RNA) virus of the enterovirus family.  RNA virus is a virus—other than a retrovirus—that has ribonucleic acid (RNA) as its genetic material.  A highly contagious liver infection caused by the hepatitis A virus(HAV).  It can cause acute hepatitis with jaundice. Also cause acute liver failure. It does not cause long term infection.  The mode of transmission  This disease is the fecal–oral route, primarily through the ingestion of food or liquids contaminated by the virus. The virus has been found in the stool of infected patients before the onset of symptoms and during the first few days of illness.  Hepatitis A can be transmitted during sexual activity; this is more likely with oral–anal contact, anal intercourse, and a greater number of sex partners  Typically, a child or a young adult acquires the infection at school by poor hygiene, hand-to- mouth contact, or close contact at play.  Poor sanitation.  An infected food handler can spread the disease, and people can contract it by consuming water or shellfish from sewage- contaminated waters.  NB : It is rarely, if ever, transmitted by blood transfusions. Incubation period The incubation period is estimated to be 15 to 50 days, with an average of 30 days. Hepatitis A confers immunity against itself, but the person may contract  Clinical Manifestations Many patients are an icteric (without jaundice) and symptomless. Low-grade fever. Anorexia, Later, jaundice and dark urine may become apparent. Indigestion is present in varying degrees,  Vague epigastric distress,  Nausea,  Heartburn, and  Flatulence.  Strong aversion (dislike) to the taste of cigarettes or the presence of cigarette smoke and other strong odors.  Prevention  Educate public on proper community and home sanitation to prevent the spread of the disease.  Educate public on maintaining good personal hygiene  Food vendors should be educated to ensure safe practices for preparing and dispensing food  Ensure effective health supervision of schools, dormitories, extended care facilities, barracks, and camps  Embark on community health education programs on the disease condition to prevent the infection.  Encourage vaccination for travellers to developing countries, illegal drug users (injection and non injection drug users), men who have sex with men, and persons with chronic liver disease  HEPATITIS B  This is caused by Hepatitis B virus (HBV)  HBV can live on a dry surface for at least 7 days;  it is much more infectious than human immunodeficiency virus (HIV).  Mode of Transmission  Hepatitis B is transmitted primarily through blood (percutaneous and permucosal routes).  HBV has been found in blood, saliva, semen, and vaginal secretions and can be transmitted through mucous membranes and breaks in the skin.  There is no evidence that urine, feces (without GI bleeding), breast milk, tears, and sweat are infective.  Sexual transmission is a common mode of HBV transmission.  Men who have sex with men (especially those practicing unprotected anal intercourse) are at risk for HBV infection.  Although the risk of transmission is much lower, kissing and sharing food items may spread the virus via saliva.  HBV is also transferred from carrier mothers to their babies usually not via the umbilical vein, but from the mother at the time of birth and during close contact afterward (vertical transmission).  Organ and tissue transplantation is another potential source of infection. Incubation period  28–160 days Average: 70–80 days Homologous  People at risk Health workers (surgeons, clinical laboratory workers, dentists, nurses, and respiratory therapists) Patients in hemodialysis and oncology units Sexually active, homosexual and bisexual men   Clinical Manifestations  Loss of appetite,  Dyspepsia,  Abdominal pain,  Generalized aching,  Malaise, and  Weakness  Jaundice If jaundice occurs, light-colored stools and dark urine accompany it Liver may be tender and enlarged Spleen is enlarged and palpable in a few patients; The posterior cervical lymph nodes may also be enlarged  Investigations of Viral Hepatitis  FBC  Liver function tests  Hepatitis Bs Ag + Hepatitis C  Abdominal Ultrasound  Prothrombin time (PT): a test that measures how long it takes for a clot to form in a blood sample  Blood culture  Urinalysis  Treatment for chronic hepatitis B infection  Most people diagnosed with chronic hepatitis B infection need treatment for the rest of their lives.  Treatment helps reduce the risk of liver disease and prevents you from passing the infection to others.  Treatment for chronic hepatitis B may include: Antiviral medications. Several antiviral medications can help fight the virus and slow its ability to damage the liver. These drugs are taken by mouth. Entecavir (Baraclude), Tenofovir (Viread), Lamivudine (Epivir), Adefovir (Hepsera) And Telbivudine (Tyzeka)  NURSING MANAGEMENT OF VIRAL HEPATITIS Nutrition  The nurse should plan diet with patient so that is appealing to him to tolerate  Provide well balanced diet/nourishing diet and provide adequate nutrients and calories base on patient size and age  The nurse should ensure the diet is high in carbohydrate  Serve patient small meals but frequent for him to tolerate  Restrict the patient’s fat intake as they are poorly tolerated  Alcohol beverages should be avoided because they are metabolised in the liver  Control of Pruritus / itching  Educate the patient to use cool, light, and non restrictive clothing  The nurse should ensure that patient uses soft, dry, and clean bedding  Educate him to use warm, not hot, bath OR use tepid water for bathing  Educate patient to apply emollient cream and lotion to skin  Educate him/her to use super fat soaps  Educate patient to avoid activities that promote sweating and increase body temperature  The nurse should ensure and maintain a cool environment for patient. The nurse should administer anti histamine as ordered. The nurse should employ diversional activities /therapies such as reading, Television, Radio to reduce the patient’s perception of purities Trim the fingernails short and hands clean to decrease the likelihood of excoriation or infection if scratching occurs If patient must scratched provide a soft cloth to protect the skin from excoriation Assess patient skin daily for signs of breakdown or excoriation from scratching  PREVENTING TRANSMISSION Continued screening of blood donors for the presence of hepatitis B antigens will further decrease the risk of transmission by blood transfusion. The use of disposable syringes, needles, and lancets reduce the risk of spreading this infection from one patient to another. Ensure good personal hygiene because it is fundamental to infection control. In the clinical laboratory, work areas should be disinfected daily.  Gloves should be worn when handling all blood and body fluids as well as HBAg positive specimens, or when there is potential exposure to blood (blood drawing) or to patients’ secretions.  Eating and smoking are prohibited in the laboratory and in other areas exposed to secretions, blood, or blood products.  Educate patient regarding the nature of the disease, its infectiousness, and prognosis to prevent transmission and protecting contacts. In the ward the nurse should decontaminate all used items of the infected persons in the ward before use Decontaminate the excreta of infected person’s and properly dispose Ensure proper hand washing before and after every procedure  Bleeding Control The nurse should avoid IM and SC injection if possible to prevent bleeding The nurse should use smallest guage needle if possible when giving an injection The nurse should administer vitamin K as ordered The nurse should also use or instruct patient to use a soft brittle tooth brush or cotton swabs for oral hygiene Educate patient not to strain on defecation and avoid vigorous blowing of nose or coughing  Educate patient to avoid foods (spicy, hot, or raw) that can traumatize oesophageal varices  The nurse should provide patient assistant to avoid falls that will lead to injuries and bleeding  The nurse should make sure that room is free from clutter, floors are dried, and shoes or slippers are worn to prevent injuries and bleeding  Observe the patient’s stools, and orifices to detect any bleeding and intervene Incubation Sources of Infectivity Period and Infection Mode of Transmission Hepatitis A Crowded Most Virus (HAV) conditions infectious 15-50 days (e.g., day care, during 2 wk (average 30) nursing home). Fecal-oral Poor before onset (primarily fecal personal of symptoms. contamination hygiene. Poor Infectious and oral sanitation. until 1-2 wk ingestion) Contaminated after food, the start of milk, water, shellfish. symptoms. Persons with subclinical Mode of Sources of Transmission Infection Infectivity Hepatitis B Contaminated Before and Virus (HBV) needles, after Percutaneous syringes, and symptoms (parenteral) or blood products. appear. permucosal Sexual activity Infectious for exposure to with infected 4-6 mo. blood or blood partners. Carriers products Asymptomatic continue to be Sexual contact carriers. infectious for Perinatal Tattoos or body life. transmission piercing with contaminated needles. Incubation Sources of Period and Infection Infectivity Mode of Transmission Hepatitis C Blood and 1-2 wk before Virus (HCV) blood products. symptoms 14-180 days Needles and appear. (average 56) syringes. Continues Percutaneous Sexual during (parenteral) or activity with clinical course. mucosal infected 75%-85% go exposure to partners. on to develop blood or blood chronic products hepatitis High-risk C and remain sexual contact infectious. Incubation Sources of Period and Infection Infectivity Mode of Transmission Hepatitis D Same as HBV. Blood Virus (HDV) Can cause infectious at all 2-26 wk infection only stages of HBV must when HBV is HDV infection. precede HDV present. Chronic Routes of carriers of HBV transmission always at risk same as for HBV. Incubation Sources of Period and Infection Infectivity Mode of Transmission Hepatitis E Contaminated Not known. Virus (HEV) water, poor May be similar 15-64 days sanitation. to (average 26-42 Found in Asia, HAV. days) Africa, and Fecal-oral Mexico route Outbreaks associated with contaminated water supply THANKS HEPATIC CIRRHOSIS / LIVER CIRRHOSIS Cirrhosis is the result of chronic liver disease that causes scarring of the liver and liver dysfunction. OR Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated), leading to progressive loss of liver function. Cirrhosis is generally irreversible once it occurs, and treatment generally focuses on preventing progression and complications.  Causes Cirrhosis has many possible causes; sometimes more than one cause is present in the same patient. In the Western World, chronic alcoholism and hepatitis C are the most common causes.  Alcoholic liver disease (ALD). Alcoholic cirrhosis develops in 15% of individuals who drink heavily for more than a decade.  Infections (Chronic hepatitis C., hepatitis B. infections. The hepatitis B virus is probably the most common cause of cirrhosis worldwide, Hepatitis B causes liver inflammation and injury that over several decades can lead to cirrhosis. Non-alcoholic steatohepatitis (NASH). In NASH, fat builds up in the liver and eventually causes scar tissue. Idiopathic cirrhosis has no known cause. Primary biliary cirrhosis. May be asymptomatic or complain of fatigue, pruritus, and non-jaundice skin hyperpigmentation with hepatomegaly.  Primary sclerosing cholangitis.  Autoimmune hepatitis. This disease is caused by the immunologic damage to the liver causing inflammation and eventually scarring and cirrhosis.  Chronic right sided heart failure which leads to liver congestion.  Drugs or toxins  Certain parasitic infections [such as schistosomiasis]  Types of Cirrhosis Laennec’s portal cirrhosis; - this is due to alcoholism and malnutrition Postnecrotic cirrhosis; - massive necrosis from hepatotoxins, usually viral hepatitis Biliary cirrhosis;-occurs as a result of inflammation of intrahepatic bile ductules resulting in biliary obstruction in liver and common duct, cholangitis Cardiac cirrhosis; - as a result of right- sided congestive heart failure Nonspecific metabolic cirrhosis; also as a result of metabolic problems, infectious diseases, infiltrative diseases, or GI diseases.  Clinical Manifestations of Cirrhosis Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly Ascites Impotence and loss of interest in sex confusion Jaundice Weakness Muscle wasting Weight loss  Continuous mild fever  Clubbing of fingers  Purpura (due to decreased platelet count)  Spontaneous bruising  Purities  Hypotension  Sparse body hair  White nails  decrease urine output  Gonadal atrophy  INVESTIGATIONS Hepatitis B s antigen, Hepatitis B e antigen, Viral DNA load Hepatitis C antigen HIV testing Abdominal Ultrasound FBC Liver function tests Prothrombin time, INR Blood culture Urinalysis  Medical Management  The management is usually based on the presenting symptoms.  Vitamins and nutritional supplements promote healing of damaged liver cells and improve the general nutritional status.  Potassium-sparing diuretics to decrease ascites, if present.  An adequate diet and avoidance of alcohol are essential.  Preliminary studies indicate that colchicine, an anti-inflammatory agent used to treat the symptoms of gout, may increase the length of survival in patients with mild to moderate cirrhosis.  NURSING MANAGEMENT Promoting Rest Improving Nutritional Status If there is no ascites or oedema and patient exhibits no signs of impending hepatic coma he/she should receive a nutritious meals, high-protein diet (of high biologic value) if tolerated,. A diet containing 1 to 1.5 g of protein per kilogram of body weight per day is required unless the patient is malnourished. Protein is restricted if encephalopathy develops. If the patient shows signs of impending or advancing coma, the amount of protein in the diet is decreased temporarily. The nurse should make every effort to encourage the patient to eat because proper nutrition is as important as any medication.  Serve patient meals in bits but frequent because often small and frequent meals are tolerated better than three large meals due to the abdominal pressure exerted by ascites.  Serve patient’s preferences meals if not contra indicated.  Patients with prolonged or severe anorexia, or those who are vomiting or eating poorly for any reason, may receive nutrients parenteral nutrition. Patients with fatty stools (steatorrhea) should receive watersoluble forms of fat- soluble vitamins—A, D, and E (Aquasol A, D, and E). Sodium restriction is also indicated to prevent ascites. A high-calorie intake should be maintained, and supplemental vitamins and minerals should be provided (eg, vitamins (B complex, vitamins A, C, K and folic acid, oral potassium if the serum potassium level is normal or low and if  Providing Skin Care Providing careful skin care is important because of subcutaneous oedema, the patient’s immobility, jaundice, and increased susceptibility to skin breakdown and infection. Frequent position changes are necessary to prevent pressure ulcers.  Instruct patient to avoid irritating soaps and the use of adhesive tape to prevent trauma to the skin.  Lotion may be soothing to irritated skin therefore the nurse should assist patient to apply the lotion  The nurse should educate the patient on measures to take to minimize scratching by the patient  Reducing Risk of Injury  The nurse should nurse the patient on a low bed to protect him from falls and other injuries.  The side rails should be in place and padded with blankets in case the patient becomes agitated or restless to protect him from falls and other injuries.  To minimize agitation, the nurse should orient the patient to time and place and explains all procedures.  The nurse should also instruct the patient to ask for assistance to get out of bed. In addition, the nurse should carefully evaluate any injury because of the possibility of internal bleeding. Educate patient that because of the risk for bleeding from abnormal clotting, he should use an electric rather than a safety razor. Inform patient that he should use a soft- bristled toothbrush because it will help to minimize bleeding gums. The nurse should apply pressure to all venipuncture sites to minimize bleeding. Trim the patient’s nails short to prevent injury and minimize bleeding.  Fluid Volume Excess  Assess the patient level of oedema to serve as baseline for future comparison.  Administer prescribed diuretics eg furosemide and observe the effects  Assess the patient regularly for signs of dehydration and electrolyte imbalance and intervene  The nurse should implement fluid restrictions making sure you maintain fluid balance  Restrict sodium intake because it retains fluid  Monitor intake and output accurately to ensure fluid balance,  Weigh the patient on daily basis with same scale, same or similar clothing , same time of the day (preferably early morning ) to know the progress of the oedema  Measure the abdominal girth, record and compare subsequently to know the progress of the oedema. Teaching Patients Self-Care / education on discharge  During the patient’s hospital stay, the nurse and other health care providers prepare the patient with cirrhosis for discharge, focusing on dietary instruction. Of greatest importance is Educate patient to exclude or avoid alcohol intake.  Educate and assist the patient if he needs referral to Alcoholics Anonymous, psychiatric care, counselling or spiritual advisor for support.  Educate patient that sodium restriction will continue for a considerable time, if not permanent and encourage him to cooperate.  The nurse should also ensure that the patient gets written instructions, teaching, reinforcement, and support from the staff as well as the family members.  The nurse should educate and convince the patient on the need to adhere completely to the therapeutic plan (rest, lifestyle changes, adequate dietary intake, and the elimination of alcohol). The nurse also needs to instruct the patient and family about the symptoms of impending encephalopathy, possible bleeding tendencies, and susceptibility to infection. The nurse should ensure that the patient and family understand that recovery is neither rapid nor easy; there are frequent setbacks and apparent lack of improvement in many patients, and encourage them. THANKS  HEPATIC ENCEPHALOPATHY This describes a syndrome with neuropsychiatric features reflecting a state of disordered central nervous system function, due to inability of the liver to detoxify ammonia and other chemicals as a result of severe liver disease and failure. It may be a complication of either acute or chronic liver disease.  CAUSES  Viral hepatitis Cirrhosis of the liver Fatty liver of pregnancy  Drugs e.g. halothane, isoniazid, paracetamol overdose, herbal concoctions  Longstanding cholestasis  Precipitating factors including: Hypotension Infection Fluid and electrolyte imbalance (excessive use of loop diuretics)  Sedatives Increased gastrointestinal tract (GIT) protein load e.g. heavy GIT bleeding Alcoholic binge  SIGNS & SYMPTOMS · Jaundice · Fever · Disturbed consciousness which progresses as follows: disorder of sleep, hypersomnia and inversion of sleep rhythm, apathy and eventually coma · Personality changes · Intellectual deterioration · Cyanosis · Fetor hepaticus/ breath of the dead · Speech impairment · Features of chronic liver disease Neurological abnormalities: Asterixis (a flapping tremor) indicates precoma and strongly supports the diagnosis of encephalopathy Inability to draw or construct objects e.g. a 5-pointed star Incoordination Impaired handwriting Encephalopathy: Grade 1: Mild confusion, irritable, tremor, restless Grade 2: Lethargic responses, decreased inhibitions, disorientation, agitation, asterixis Grade 3: Stuporous but arousable, aggressive bursts, inarticulate speech and marked confusion Grade 4: Coma  INVESTIGATIONS · FBC · Blood glucose · Liver function tests · Blood urea and electrolytes · Hepatitis BsAg, Hepatitis C · Prothrombin time, INR  TREATMENT Treatment objectives To identify and correct precipitating factors  Non-pharmacological treatment · Place in the coma position if unconscious · Daily tap water enemas may be used to further reduce enteric bacteria · Avoid protein feeds, sedatives and drugs metabolized by the liver. Increase protein intake slowly on recovery. · Encourage intake of high carbohydrate diet by mouth or NG tube · Maintain fluid and electrolyte balance. · Monitor temperature, pulse and respiratory rate, blood pressure, pupils, urine output and blood glucose regularly · Avoid paracetamol and other hepatotoxic drugs and agents  Pharmacological treatment  Prevent worsening coma by emptying the bowel with: · Magnesium sulphate, oral, Or Lactulose liquid, oral. (Aim for 2 soft stools /day and no diarrhoea) · Glucose 5-10%, IV, · High potency Vitamin B, IV, (formulated as two separate vials ) added to glucose IV solution  Metronidazole, oral, Or  Neomycin, oral,  If the patient starts bleeding or INR >1.5, administer: · Vitamin K (Phytomenadione) , IV or oral, avoid IM injections Platelets, fresh frozen plasma and blood should be given as needed cautiously  Treat stress ulceration with: · Omeprazole, IV, Or Ranitidine, IV, THANKS