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 Hepatitis

Hepatitis is a viral infection of the liver associated with a broad spectrum of clinical manifestations from non-symptom-producing infection through icteric hepatitis to hepatic necrosis. Five types of viral hepatitis have been identified.

Pathophysiology and Causes

Type A Hepatitis Pathophysiology and Causes

 1. Hepatitis A (HAV) is caused by a ribonucleic acid (RNA) virus of the enterovirus family.

 2. Mode of transmission is primarily faecal-oral, usually through the ingestion of food or liquids contaminated with the virus.

     a. Prevalent in underdeveloped countries or in instances of overcrowding and poor sanitation.

     b. Infected food handler can spread the disease and people can contract it by consuming water or shellfish from contaminated waters.

     c. Commonly spread by person-to-person contact and, rarely, by blood transfusion.

 3. Incubation period is 3 to 5 weeks, with the average being 4 weeks.

 4. Occurrence is worldwide, usually among children and young adults.

 5. Mortality is 0% to 1%, with recovery as the rule.

Type B Hepatitis Pathophysiology and Causes

 1. Hepatitis B (HBV) is a double-shelled particle containing deoxyribonucleic acid. This particle is composed of the following:

    a. HBcAg—hepatitis B core antigen (antigenic material in an inner core).

    b. HBsAg—hepatitis B surface antigen (antigenic material in an outer coat).

    c. HBeAg—an independent protein circulating in the blood.

2. Each antigen elicits a specific antibody:

    a. Anti-HBc—persists during the acute phase of illness; may indicate continuing HBV in the liver.

    b. Anti-HBs—detected during late convalescence; usually indicates recovery and development of immunity.

    c. Anti-HBe—usually signifies reduced infectivity.

3. Significance:

    a. HBcAg—found only in liver cells, not serum.

    b. HBsAg—usually detected transiently in blood of 80% to 90% of infected people; may be noted in blood for months or years, indicating that the patient has acute or chronic hepatitis B or is a carrier.

    c. HBeAg—if absent, the patient is an asymptomatic carrier.  If present, it indicates highly infectious period of acute, active hepatitis. If it persists, it indicates progression to chronic state.

4. Mode of transmission is primarily through blood (percutaneous and per mucosal route).

    a. Oral route through saliva or through breastfeeding.

    b. Sexual activity through blood, semen, saliva, or vaginal secretions. Hepatitis B is recognized as a sexually transmitted disease.

    c. Homosexual men are at high risk.

5. Incubation period is 2 to 5 months.

6. Occurrence is for all ages, but mostly affects young adults worldwide.

7. Mortality can be as high as 10%, with another 10% of patients progressing to carrier status or developing chronic hepatitis. It is the main cause of cirrhosis and hepatocellular carcinoma worldwide.

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Type C Hepatitis Pathophysiology and Causes

1. Hepatitis C (HCV) was formerly called non-A, non-B hepatitis; an RNA virus.

2. Mode of transmission in most cases is through blood or blood products; prior to 1992, commercial blood was not routinely tested; now, the rate of transmission through blood transfusions is less than 1%.

    a. Found among IV drug users and renal dialysis patients.

    b. Can be transmitted through sexual intercourse and from mother to fetus (vertical transmission).

    c. Can theoretically be transmitted through contaminated piercing and tattooing tools and ink, but transmission by this route has not been proven.

3. Incubation period varies from 1 week to several months.

4. Occurs in all age groups.

    a. Most common form of posttransfusion hepatitis.

    b. May occur sporadically or in epidemic proportions.

Type D Hepatitis (Delta Hepatitis) Pathophysiology and Causes

1. Hepatitis D virus (HDV) is a defective RNA agent that appears to replicate only with the hepatitis B virus. It requires HBsAg to replicate.

    a. Occurs along with HBV or may superinfect a chronic HBV carrier.

    b. Cannot outlast a hepatitis B infection.

    c. May be acute or chronic.

2. Mode of transmission and incubation are the same as for HBV.

3. Occurrence in the United States is primarily in IV drug abusers or multiple-transfused patients. The highest incidence exists in the Mediterranean, Middle East, and in South America.

4. Mortality—causes about 50% of fulminant hepatitis, which has a high mortality.

Type E Hepatitis Pathophysiology and Causes

1. A recently identified, nonenveloped, single-strand RNA virus.

2. Mode of transmission is fecal−oral, but because this virus is inconsistently shed in feces, detection is difficult.

3. Incubation is the same as for HAV.

4. Occurrence is primarily in India, Africa, Asia, and Central America, but may be found in recent travelers to these areas and is more common in young adults and more severe in pregnant women.

Autoimmune Hepatitis Pathophysiology and Causes

1. In addition to viral hepatitis, autoimmune hepatitis (AIH) has also been identified. It is a chronic form of hepatitis that is progressive and fluctuates with degree of liver damage.

2. Although the cause of AIH is unknown, it is thought to be self-antigen mediated.

3. Treatment usually consists of anti-inflammatory or immuno-suppressive agents, which may need to be taken throughout the patient’s life.

4. AIH may lead to chronic or fulminant liver failure and transplantation.

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Symptoms of Hepatitis ( Type A, B, C, D, E)

Symptoms Type A Hepatitis 

 1. May have no symptoms.

 2. Prodromal symptoms: fatigue, anorexia, malaise, headache, low-grade fever, nausea, and vomiting.

 3. Highly contagious during this period, usually 2 weeks before the onset of jaundice.

 4. Icteric phase: jaundice, tea-coloured urine, clay-coloured stool, and right upper quadrant tenderness.

 5. Symptoms may be mild in children; adults are more likely to have severe symptoms and a prolonged course of disease.

Symptoms Type B Hepatitis

 1. Symptom onset usually more insidious and prolonged compared with HAV.

 2. May be asymptomatic.

 3. One week to 2 months of prodromal symptoms: fatigue, anorexia, transient fever, abdominal discomfort, nausea and vomiting, headache.

 4. Extrahepatic manifestations may include myalgias, photophobia, arthritis, angioedema, urticaria, maculopapular eruptions, skin rashes, vasculitis.

 5. Jaundice in icteric phase.

 6. In rare cases, it may progress to fulminant hepatic failure, also called fulminant hepatitis.

 7. May become chronic active or chronic persistent (asymptomatic) hepatillness.

Symptoms Type C Hepatitis

1. Similar to those associated with HBV but usually less severe.

2. Symptoms usually occur 6 to 7 weeks after transfusion but may be attributed to another viral infection and not diagnosed as hepatitis.

3. Approximately 60% to 85% of people infected with HCV go on to develop a chronic infection. (Complications of chronic HCV include cirrhosis, decompensated liver disease, and hepatocellular carcinoma.)

4. In patients with HCV, the estimated risk of developing hepatocellular carcinoma after 20 years is 1% to 5%.

5. It is recommended that high-risk individuals be tested for HCV because many may remain asymptomatic for approximately 20 years.

Symptoms Type D Hepatitis

1. Similar to HBV but more severe.

2. With superinfection of chronic HBV carriers, causes sudden worsening of condition and rapid progression of cirrhosis.

Diagnostic Evaluation of Hepatitis ( Type A, B, C, D, E)

1. Elevated serum transferase levels (aspartate transaminase [AST], alanine transaminase [ALT]) for all forms of hepatitis.

2. Radioimmunoassays that reveal immunoglobulin (Ig)M antibodies to hepatitis virus in the acute phase of HAV.

3. Radioimmunoassays to include HBsAg, anti-HBc, and anti HBsAg detected in various stages of HBV (see Figure 19-1).

4. Hepatitis C antibody—may not be detected for 3 to 6 months after onset of HCV illness; antibody test used for screening purposes.

5. Polymerase chain reaction test to confirm viral activity in HIV illness

6. Antidelta antibodies of HBsAg for HDV or the detection of IgM in acute disease and IgG in chronic disease.

7. Hepatitis E antigen (with HCV ruled out).

8. Liver biopsy to detect chronic active disease, progression, and response to therapy.

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Management of Hepatitis ( Type A, B, C, D, E)

All Types of Hepatitis

1. Rest according to patient’s level of fatigue.

2. Therapeutic measures to control dyspeptic symptoms and malaise.

3. Hospitalization for protracted nausea and vomiting or life-threatening complications; enteral feedings may be necessary.

4. Small, frequent feedings of a high-calorie, low-fat diet; proteins are restricted when the liver cannot metabolize protein by-products, as demonstrated by symptoms.

5. Vitamin K injected subcutaneously if PT is prolonged.

6. IV fluid and electrolyte replacement, as indicated.

7. Administration of antiemetics for nausea.

8. After jaundice has cleared, gradual increase in physical activity. This may require many months. Patients with HBV

1. First-line therapy is pegylated interferon, entecavir, or tenofovir. Treatment with nucleoside analogues is no longer considered first-line therapy due to drug resistance and viral breakthrough.

2. All patients should be vaccinated for hepatitis A.

Patients with HCV

1. Treatment of the virus with long-acting injectable interferons, such as peginterferon alfa-2a, in combination with the oral antiviral ribavirin may induce a sustained response of undetectable viral levels in about 41% to 50% of people with genotype 1 and 70% to 80% of people with genotypes 2 and 3.

2. Direct-acting antiviral agents recently received FDA approval for use in patients with chronic hepatitis C. These drugs include boceprevir and telaprevir and are used in addition to pegylated interferon and ribavirin to improve viral response and clearance.

3. Close monitoring, including complete blood count, liver function tests, and HCV viral load during the long treatment period is imperative.

4. Patients should be vaccinated against hepatitis A and B if they do not have immunity.

Complications of Hepatitis ( Type A, B, C, D, E)

1. Dehydration, hypokalemia.

2. Chronic “carrier” hepatitis or chronic active hepatitis.

3. Cholestatic hepatitis.

4. Fulminant hepatitis (liver transplantation may be necessary).

5. HBV and HCV carriers have a higher risk of developing hepatocellular carcinoma.

Nursing Assessment of Hepatitis ( Type A, B, C, D, E)

1. Assess for systemic and liver-related symptoms.

2. Obtain history, such as IV drug use, sexual activity, travel, and ingestion of possible contaminated food or water to assess for any mode of transmission of the virus.

3. Assess size and texture of liver to detect enlargement or characteristics of cirrhosis.

4. Obtain vital signs, including temperature.

Nursing Diagnoses of Hepatitis ( Type A, B, C, D, E) 

All Types of Hepatitis

￾ Imbalanced Nutrition: Less Than Body Requirements related to effects of liver dysfunction

￾ Deficient Fluid Volume related to nausea and vomiting.

￾ Activity Intolerance related to anorexia and liver dysfunction.

￾ Deficient Knowledge related to transmission.

Patients with HBV

￾ Risk for Bleeding related to coagulopathy because of impaired liver function.

￾ Acute confusion related to encephalopathy because of impaired liver function.

Nursing Interventions of Hepatitis ( Type A, B, C, D, E)

Maintaining Adequate Nutrition

1. Encourage frequent small feedings of high-calorie, low-fat diet. Avoid large quantities of protein during acute phase of illness.

2. Encourage eating meals in a sitting position to decrease pressure on the liver.

3. Encourage taking pleasing meals in an environment with minimal noxious stimuli (odors, noise, interruptions).

4. Administer or teach self-administration of anti-emetics, as prescribed.

Maintaining Adequate Fluid Intake

 1. Provide frequent oral fluids, as tolerated.

 2. Administer IV fluids for patients with inability to maintain oral fluids.

 3. Monitor intake and output.

Maintaining Adequate Rest and Activity

 1. Promote periods of rest during symptom-producing phase, according to level of fatigue.

 2. Promote comfort by administering or teaching self-administration of analgesics as prescribed.

3. Provide emotional support and diversional activities when recovery and convalescence are prolonged.

4. Encourage gradual resumption of activities and mild exercise during convalescent period.

Ensuring Prevention of Disease Transmission

1. Educate patient about disease and about disease transmission.

2. Emphasize the self-limiting nature of most forms of hepatitis and the need for follow-up of liver function tests.

3. Stress importance of proper public and home sanitation and of proper preparation and dispensation of foods.

4. Encourage specific protection for close contacts.

    a. Immune globulin as soon as possible to household contacts of HAV patients.

    b. Hepatitis B immune globulin as soon as possible to blood or body fluid contacts of HBV patients, followed by HBV vaccine series.

5. Explain precautions to patient and family about transmission and prevention of transmission to others.

    a. Good handwashing and hygiene after using bathroom.

    b. Avoidance of sexual activity (especially for HBV) until free of HBsAg.

    c. Avoidance of sharing needles, eating utensils, and tooth brushes to prevent blood or body fluid contact (especially for HBV and HCV).

6. Report all cases of hepatitis to public health officials.

Preventing and Controlling Bleeding

1. Monitor and teach patient to monitor and report signs of bleeding.

2. Monitor PT and administer vitamin K, as ordered.

3. Avoid trauma that may cause bruising, limit invasive procedures, if possible, and maintain adequate pressure on needlestick sites.

Monitoring Thought Processes

1. Monitor for signs of encephalopathy—lethargy and somnolence with mild confusion and personality changes, such as excessive sexual or aggressive activity and loss of usual inhibitions. Lethargy may alternate with excitability, euphoria, or unruly behaviour.

2. Monitor for worsening of condition, from stupor to coma; assess for asterixis, the irregular flapping of the forcibly dorsi-flexed outstretched hands.

3. Maintain calm, quiet environment and reorient patient, as needed.

Patient Education and Health Maintenance

1.Educate adolescents about the risk of piercing and tattooing in transmission of HCV.

3. Encourage vaccination for HBV with series of three shots (initial shot at birth, 1, and 6 months) for high-risk patients, such as health care workers or institutionalized persons, as well as vaccination of all children from birth or at adolescence.

4. Instruct all patients who have received a blood transfusion to refrain from donating blood for 6 months (the incubation period of HBV). After hepatitis infection, blood should never be given if patient is an HBV carrier or was infected with HCV.

5. Stress the need to follow precautions with blood and secretions until the patient is deemed free of HBsAg.

6. Explain to HBV carriers that their blood and secretions will remain infectious.

7. For additional information, refer to the local public health department or the Centers for Disease Control and Prevention.