Pathophysiology of hepatitis - 7 steps.
1. virus replicates
2. atacks hepatocytes
3. Liver becomes enlarged and congested due to virus/toxin
4. inflammatiory cells - lymphocytes and edema
5. Lobular pattern becomes distorted due to inflammation, necrosis
6. swelling causes obstruction of portal circulation
7. edema causes liver bile channels to obstruct
8. recovery phase- phagocytosis, removal of damaged cell
9. regeneration - completed 2-3 months
intrahepatic obstructive jaundice
results from edema, fibrosis, or scarring of the hepatic bile channels and bile ducts, which interferes with normal bile and bilirubin excretion
Name 3 high risk groups for aquiring Hepatitis A.
1. institutions for custodial care
2. day care centers
3. travelers to developing countries
Other methods that hepatitis B spreads?
sharing tooth brushes
How is hepatitis B identified and caused by?
HbsAg(surface antigen) and Hbc Ag(Core antigen) in blood; later the anti-BcIgM (Hep Bcore antibodies) appear
Additional modes of transmission via bodily fluids of hepatitis B.
skin, mucous membrane, parenteral routes,contact with infected blood or serous fluids
High risk groups for hepatitis B.
1. users of parenteral drugs (via needle sticks)
2. fetuses of infected mothers
3. sexual partners of HBV carriers
4. anyone with pts. on hemodialysis
5. male prisoners
6. healthcare workers
Name hepatitis type with leading cause of cirrhosis & hepatocellular cancer (HCC) world wide.
Hepatitis C - causes scarring of liver and make tke up to 3 years to manifest itself.
At what age does WHO recommend people to get tested for hepatitis C? and why?
age 40, it is leading cause of liver cancer
Name coutries where hepatitis D(Delta) is an epidemic
meiditerranean basin, middle east, central Africa, Amazonian baisn and parts of Asia
What is hepatitis D caused by?
caused by HDV a defective RNA virus that seems to be only ative in the presence of HBV
What is the most common chronic blood-borne infection in the USA caused by?
hepatitis C - typical age range 29 to 49 more males than females
Mode of transmission for hepatitis C.
skin & mucous membrane or parenterally or contact with infectious blood, injecting drugs, healthcare workers, intranasal cocaine use
acute viral hepatic syndrome
caused by any virus, malaise, n/v, arthralgia, jaundice, increase of serum AST and ALT
Liver injury will produce what type of abnormal labs?
liver injury increases liver enzymes
* elevated ALT (can be as high as 20x's normal)
*elevated alkaline phosphatase
is manufacutured in bones, kidney, liver and intestine, it is excreted through biliary tact.
What does an elevated alkaline phosphate indicate?level
it is excreted through the biliary tract with obstruction levels rise
As liver becomes more damaged what other symptom may arise?
clotting factors are synthesized in the liver and will begin to decrease with liver damage, therefor clotting time will be prolonged.
*PT will be prolonged
*PTT will be prolonged with severe liver damage
failure of liver cells to regenerate, progressive necrosis & damage lead to liver failure; fatal form is rare. (most common in kids,esp. neonates. once they develop liver failure with this, life expectancy is about 1 year.)
Signs and symptoms of liver failure.
rapid weight gain from fluid collection with ascites, edema in legs, dark urine, scleral icterus, mental status changes (hepatic encephalopathy)
central nervous system dysfunction resulting from liver disease; frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma
Unconjugated bilirubin, , An increase in this form of bilirubin signifies an increase in the breakdown of red blood cells (hemolysis). Does not increase with hepatitis.
smallest of plasma protein, accounts for 60% tho, synthesized in liver, important part of osmotic pressure
What happens to the direct conjugated bilirubin level when bile flow is obstructed?
level is elevated, ie. hepatitis, cirrhosis, gallstones, tumors---anything that causes liver damage
An orange pigment which is formed by the liver as a result of heme breakdown and excreted in the bile.
How does bilirubin excreted in colon and small intestines?
Bilirubin is released when RBCs are destroyed, it flows in the blood stream attached to albumin and is conjugated (changed to a water soluble form) in the liver. conjugated bilirubin can then be secreted with bile, conjugated bilirubin can then be secreted with bile, transported to the gall bladder and released into the duodenum to aid in digestion; next it is converted to urobilinogen by bacteria in the colon & is excreted in the small intestine and returned to the liver. Eventually conjugated
Prophylaxis for Hepatitis A pre-exposure.
Havix (inactivated vaccine); provides active immunization for 1 year of age & above; used if traveling to developing countries
Prophylaxis for Hepatitis A post-exposure.
for individuals who have contact with persons with HAV; prophylaxis (HIG) must be given within 7-14 days of exposure to be beneficial, 48 hours from the first exposure is best.
With liver cell damage the following liver enzymes increases
AST (SGOT) increased
ALT (SGPT) increased
Alkaline Phosphatase increased
Nursing assessment icteric phase
*obstruction of the livers, rash and worsening symptoms: anorexia, N & V, weakness, malaise
How can you know if the liver is producing and conjugating bile?
If liver is not producing and conjugating bile, you will see an increase in direct bilirubin and total bilirubin
What does the liver do with blood?
1. clearing blood of drugs and other toxins
2. regulating blood clotting
3. processing of hemoglobin for use of its iron content (liver stores iron)
4. regulation of blood levels of amino acids, which form the building blocks of proteins
What does the liver do to help with digestion?
* production of bile helps carry away waste and break down fats in the small intestine during digestion
*production of cholesterol and special proteins to help carry fats through the body
*conversion of excess glucose into glycogen for storage
Nursing interventions when caring for hepatitis patients (comfort measures).
1. control pruritis
2. antiemetics as ordered for nausea and vomiting (Tigan, Dramamine)
What type of isolation is required for hepatitis B, C,D, G?
blood and body fluid precautions
*carefule disposal of needles
*careful labeling of blood specimens to protect personnel
*watch open cuts
What type of isolation is required for hepatitis A & E?
Contact isolation (decrease chance of contamination by oral/fecal route). wear gloves, gown, use private toilet, daily cleaning of toilet, isolation of tools, careful hand-washing
If exposed to hepatitis B
can use HBIG (hepatitis B immune globulin) within 7 days and then Recombivax series
hepatitis B immune globulin, This contain antibodies to HBV and offers prompt but short-lived protection
What labs will change with loss of liver synthesis?
PT - prolonged
PTT - prolonged
Clotting factors- decreased
Albumin - decreased
What occurs to clotting factors with loss of liver synthesis?
Manufactured in liver but will decrease with liver damage resulting in fewer clotting factors; prolonged clotting times will lead to risk of bleeding.
principal function is to provide colloid osmotic pressure, preventing plasma loss from the capillaries to the interstitial areas that can cause edema
colloid osmotic pressure
keeps fluid in the intravascular compartment by pulling H2O from the interstitial space bank into the capillaries (vascular compartment)