Hepatitis - 3 Nursing CEs

Author: Kristi Hudson RN MSN CCRN

Written: 1/4/05

Updated: September 11, 2009

Course Description:

This course is designed to provide information regarding the care and management of the patient with Hepatitis. Differentiating the different types of Hepatitis (A through E) will be presented. Facts such as transmission signs and symptoms as well as statistic and trends will also be presented. Nursing assessment and patient/family education for the patient with Hepatitis will be the final focus of this course.

Course Objectives:

Upon completion of this course the student will be able to:

• Differentiate different types of Hepatitis (A –E)
• Describe the transmission process of Hepatitis
• List specific groups and risk factors for contracting Hepatitis
• Discuss the signs and symptoms surrounding Hepatitis
• List treatment options for the different types of Hepatitis
• State key patient/family education that nursing can provide to patients with Hepatitis

 Hepatitis in General:

Hepatitis is a liver disease that is caused by the Hepatitis virus (there have so far been 5 different strains of the Hepatitis virus established and they have been listed as A, B, C, D and E). The virus causes an inflammation to the liver that is either acute (in cases of A, B and E) or chronic (in cases of B, C and D) Note: Hepatitis B can be both acute and chronic. Non-viral Hepatitis can also occur from drug toxicity and or alcoholism. The pathologic lesions of hepatitis are similar to those caused by other viral infections. Hepatic cell necrosis, scarring, Kupffer cell hyperplasia and infiltration by mononuclear phagocytes occur with varying severity.

Hepatitis “A” Virus (HAV):

Transmission – Hepatitis A is transmitted from person to person by coming into contact with feces. The following modes of transmission are the most common:

• Food preparers who are infected can pass the virus on if they do not wash their hands with soap and water after having a bowel movement; especially when they prepare uncooked foods.
• Fecal contamination of food and water.
• Anal/oral contact, by putting something in the mouth that had been contaminated with infected feces.
• Diaper changing tables, if not cleaned properly or changed after each use, may facilitate the spread of HAV.
• Fecal residue may remain on the hands of people changing soiled diapers.
• Eating raw or partially cooked shellfish contaminated with HAV.

People at Risk – Some of the higher-risk groups for contracting Hepatitis A include:

·         Travelers to countries with high rates of Hepatitis A.

·         Men who have sex with other men.

·         Injecting-drug users.

·         People with clotting-factor disorders.

·         People with chronic liver disease.

·         Children living in communities with high rates of disease.

Signs and Symptoms – Clinical Manifestations of Hepatitis A in children are usually absent; but in adults symptoms may come on strong and sudden and include:

• Jaundice
• Fatigue
• Abdominal pain
• Loss of appetite
• Nausea
• Fever
• Diarrhea

Diagnosis – Diagnoses cannot be made on symptoms alone. A blood test that is conclusive for IgM anti-HAV is required for diagnoses of Hepatitis A.

Treatment – There is no medical treatment required for Hepatitis A. Physicians suggest rest and a healthy diet (avoiding dehydration) until the virus runs it course.  

Trends and Statistics – The following trends and statistics surround Hepatitis A:

• It occurs in epidemics both nationwide and in local communities.
• During epidemic years, the number of reported cases reached 35,000.
• In the late 1990s, Hepatitis A vaccine was more widely used and the number of cases reached historic lows.
• One-third of Americans have evidence of past infection and immunity.

Hepatitis “B” Virus (HBV):

Transmission – Hepatitis B is transmitted in the following ways:

• Occurs when blood from an infected person enters the body of another
• It is spread through having sex with an infected person without using a condom.
• By sharing needles when shooting drugs.
• Needle sticks (sharps exposures on the job).
• From an infected mother to her baby during birth.

People at Risk – The following is a list of people at risk for being infected by the Hepatitis B virus:

• People who has sex with someone with HBV.
• Men who have sex with another man.
• People who live in the same house with someone who has chronic HBV infection.
• People who have jobs that involves contact with human blood.
• People who inject illegal substances/drugs.
• People with hemophilia.
• People who travel to areas where HBV is common (this includes all countries except Northern and Western Europe, Japan, Australia, New Zealand, and North America except Mexico).

Signs and Symptoms – The following is a list of clinical manifestations that are often associated with Hepatitis B;

• Jaundice
• Fatigue
• Abdominal Pain
• Nausea
• Fever
• Joint Pain

Diagnosis – There are three standard blood tests for the diagnoses of HBV and they include:

• HBsAG (hepatitis B surface antigen):
  When this test is positive or reactive, you are infected with HBV and can pass it on to others.
• Anti-HBc (antibody to hepatitis B core antigen):
  When you test positive, it means you are currently infected with HBV or have been infected at some point in the past.
• Anti-HBs (antibody to HbsAg):
  When this test is positive, it means that you are immune to hepatitis B either as a result of having had the disease or from having been given the vaccine.

Treatment – The following are commonly prescribed medications for the treatment of Hepatitis B:

• Adefovir – This is an experimental antiviral medication that is able to inhibit enzymes necessary for Hepatitis B Virus (HBV) and HIV to reproduce.  
• Interferon alfa-2b – This is a protein made by white blood cells. The drug is produced in the lab through recombinant gene technology.
• Lamivudine –This class of medications called nucleoside reverse transcriptase inhibitors. It works by stopping the spread of the HIV and hepatitis B viruses.

Note: These medications should not be used by pregnant women and drinking alcohol while taking these medications can make your liver disease worse.

Trends and Statistics – The following are the latest trends and statistics for HBV:

Hepatitis “C” Virus (HCV):

Transmission – Hepatitis C virus is transmitted by the following:

• Occurs when blood from an infected person enters the body of a person who is not infected. 
• HCV is spread through sharing needles when using drugs.
• Through needle sticks or sharps exposures on the job.
• From an infected mother to her baby during birth.
• People at Risk – Approximately one in ten people contract Hepatitis C with no identifiable risk factors. The following are known to be risk factors of Hepatitis C:
• Intravenous (IV) drug users – even IV use in the distant past.
• Those with multiple sex partners or sex partners who have other sexually transmitted diseases.
• Those with tattoos or body piercing done with less then sterile instruments.
• Anyone who has had a blood transfusion prior to 1992 or clotting factors produced prior to 1987.
• Hemodialysis patients.
• Potential for transmission from an HCV infected mother to her newborn occurs approximately 5% of the time.

Signs and Symptoms – The clinical manifestations of HCV include:

• Jaundice
• Fatigue
• Dark Urine
• Nausea
• Abdominal Pain
• Loss of Appetite

Diagnosis – HCV infection can be determined by lab testing for HCV antibodies. The current enzyme immunoassay test (EIA) that detects anti-HCV has a sensitivity of about 95% in chronic HCV.

Treatment – Though there are three different types of interferon that can be prescribed for Hepatitis C, the following medication regimen is thought to be the most effective:

• Pegylated interferon alfa-2a (injection) with 800 mg Ribavirin (oral) is thought by the National Health Institute to be a good combination for non-responders and relapsers to previous Interferon and Ribavirin therapy.  

Note: Women or the male partners of women, who are pregnant or those who are planning pregnancy, should not take Ribavirin. Pregnancy should not be attempted until six months after treatment is ended.

Trends and Statistics – The following are the latest trends and statistics for HCV:

• The number of new HCV has declined form an average of 240,000 in the 1980’s to about 30,000 in 2003.
• Most infections of HCV are transmitted by illegal drug use (injections).
• Transfusion related cases of transmission now occur less then one in 2 million.
• It is estimated that 3.9 million (1.8%) of Americans have been infected with HCV (2.7 million have chronic HCV).
• The risk for perinatal transmission of HCV is about 4%.
• If co-infected with HIV the risk for perinatal transmission of HCV is about 19%.

Hepatitis “D” Virus (HDV):

Transmission – Hepatitis D virus is a virus that is present in conjunction with Hepatitis B. Transmission of Hepatitis D is similar to transmission of Hepatitis B and is as follows:

• Occurs when blood from an infected person enters the body of another.
• It is spread through having sex with an infected person without using a condom.
• By sharing needles while using drugs.
• Needle sticks (sharps exposures on the job).
• From an infected mother to her baby during birth.

People at Risk – The following are people and groups of people who are at risk for contracting Hepatitis D:

• Men who have sex with other men.
• Hemophiliac patients.
• People who have multiple sex partners or sex with someone who is infected.
• Health care and public safety workers.
• Though very rare, infants born to infected mothers.

Signs and Symptoms – The following are clinical manifestations seen with HDV:

• Jaundice
• Nausea/Vomiting
• Fatigue
• Abdominal pain
• Loss of appetite
• Joint pain
• Dark (tea colored) urine

Diagnosis – Hepatitis D virus is diagnosed through a blood test that shows a positive HDV anti-body.

Treatment – For an acute episode of HDV supportive care including rest and a healthy diet are recommended. For chronic HDV interferon-alfa is recommended and in severe cases liver transplant.

Trends and Statistics – According to the Centers for Disease Control data there is no data available regarding HDV.

Hepatitis “E” Virus (HEV):

Transmission – Hepatitis E (HEV) is found most commonly in feces and contaminated animals. Transmission occurs in the following manner:

• Eating or drinking contaminated food.
• Though rare, transmission from person to person.
• Most outbreaks in developing countries has been attributed to contaminated drinking water.

People at Risk – Cases of Hepatitis E are rare in the United States but most cases are attributed to travel to developing countries; specifically South Asia and North Africa.

Signs and Symptoms – The following are clinical manifestations of Hepatitis E:

• Jaundice
• Fatigue
• Dark Urine
• Nausea
• Abdominal Pain
• Loss of Appetite

Diagnosis – Testing for anti-HEV is usually reserved for returning travelers from the developing world in whom hepatitis is present but other hepatitis viruses cannot be detected.

Treatment – Supportive care including rest and healthy diet are recommended for patients with Hepatitis E. There is currently there is no treatment for HEV.

Trends and Statistics – Because Hepatitis E is so rare in the United States the Centers of Disease Control do not have current trends and or statistics on this disease.

Nursing Assessment:

Nursing assessment is based on taking a detailed patient history, observing for signs and symptoms for Hepatitis virus (jaundice is the most prevalent symptom) and then drawing labs for anti-body conformation for Hepatitis. Once the diagnosis of Hepatitis has been confirmed: (depending on the type of Hepatitis) treatment can be prescribed.

Patient/Family Education:

Patient education is important for patients who have been diagnosed with Hepatitis because often the disease processes becomes chronic. All of the following should be included in patient education:

• The need for increasing hydration, exercise, nutrition.
• Avoiding alcohol.
• Emphasizing the mode of transmission.
• Assuring that the patient take responsibility for not spreading the disease.
• Emphasis on improved hand washing and other hygiene if necessary.
• The importance of adhering to drug regimens.
• Encourage patients to join support groups.
• Understanding the possible side effects of antiviral therapy and when to seek assistance for symptoms.

References

Center for Disease Control. (2009). Viral Hepatitis. Retrieved on September 9, 2009 at: http://www.cdc.gov/hepatitis/

Centers for Disease Control. (2005). Viral hepatitis. Retrieved on January 1, 2006 at: http://www.cdc.gov/ncidod/diseases/hepatitis/

Gujral, H., Viscomi, C., & Collantes, R. (2002). The role of physician extenders in caring for patients with chronic hepatitis C. Retrieved on January 4, 2005 at:

www.ccjm.org/PDFFILES/hepadGujral.pdf

Hepatitis Foundation International. (2005). Living with hepatitis. Retrieved on January 1, 2006 at:

http://www.hepfi.org/living/liv_diagnosis.html

McCance, K., L. & Huether, S., E. (1998). Pathophysiology the biologic basis for disease in adults and children. (3^rd ed.) Mosby. St. Louis

University of Washington. (2005). UniAIDS Clinical trials group drug information sheet. Retrieved on January 3, 2006 at:

http://depts.washington.edu/actu/drugs/adefovir.htm