College of Medicine and Health Sciences School of

Nursing & Midwifery

Department of Adult Health Nursing
Post Graduate program
Assignment on Hepatitis
By Melese Wagaye

ID NO SGSR 388/12

8/8/2020 By: Melese W. 1

 Outline

• Anatomy and physiology • Medical management

overview of live • Evidence based practice
• Definition on pharmacological
• Etiology management
• Prevalence • Nursing management
• Pathophysiology • Prognosis
• Sign/ symptom • Differential diagnosis
• Diagnosis • Nursing process
• Complication

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 Objective
• To explain hepatitis briefly
• To analyze pathophysiology of hepatitis
• To differentiate hepatitis from disease that has similar
feature.
• To understand and respond for actual and potential
complication
• To develop nursing care plan for patient liver disease

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Liver Anatomy and Physiology Overview

Anatomy of liver
• Located in the RUQ of the abdomen in the
peritoneal space just below the right side of the
diaphragm and under the rib cage.

• Anatomically separated into two predominant lobes:

right and left.

(Gary D. Hammer, MD, PhD, & Stephen J. McPhee, 2019)

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 Cont….

• Weighs approximately 1400 g in the adult and is

covered by a fibrous capsule.
• Receives nearly 25% of the cardiac output per
minute, via two sources:
 Portal vein, which is crucial to the performance of the
liver’s roles in bodily functions, and
 Hepatic artery, which is important for liver oxygenation
and which supplies the biliary system via the cystic artery

(Gary D. Hammer, MD, PhD, & Stephen J. McPhee, 2019)

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 Cont….

• These vessels converge within the liver, and exits via

the so called central veins (also called terminal
veins or hepatic venules) that drain into the hepatic
vein and ultimately the inferior vena cava.

(Gary D. Hammer, MD, PhD, & Stephen J. McPhee, 2019)

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 Cont….

• The portal vein carries venous blood from the small

intestine,
 Rich in freshly absorbed nutrients—as well as drugs and
poisons directly to the liver.

• Also flowing into the portal vein before its entry into
the liver is the pancreatic venous drainage, rich in
pancreatic hormones (insulin, glucagon, somatostatin,
and pancreatic polypeptide).
(Gary D. Hammer, MD, PhD, & Stephen J. McPhee, 2019)

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 Cont…..

• Because of this system of blood supply, the liver is a

prime site for the metastatic spread of cancer,
especially from the GI tract, breast, and lung.

(Gary D. Hammer, MD, PhD, & Stephen J. McPhee, 2019)

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 Cont…..

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 Cont….
Physiology of liver

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 Cont….

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 Cont….

(Gary D. Hammer, MD, PhD, & Stephen J. McPhee,

2019)
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 Definition

Hepatitis
• Is an inflammation of the cells of the liver, resulting
from infection by viral agents or exposure to drugs
toxic to the liver or occasionally from bacterial
infection.

(Williams, 2007)

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 Etiology

• Hepatitis is usually caused by one of five viruses:

 Hepatitis A virus (HAV), sometimes called infectious
hepatitis
Hepatitis B virus (HBV), sometimes called serum
hepatitis

(Williams, 2007)

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 Cont…..
 Hepatitis C virus (HCV), sometimes called non-A, non-B
(NANB) hepatitis
 Hepatitis D virus (HDV)
 Hepatitis E virus (HEV)

(Williams, 2007)

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 Prevalence

• WHO estimates that in 2015, 257 million persons, or

3.5% of the population, were living with chronic
HBV infection in the world.
• The African and Western Pacific regions accounted
for 68% of those infected.
• 2.7 million persons were coinfected with HBV and
HIV.

(World Health Organization:, 2017)

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 Cont…..

• WHO estimates that in 2015, 71 million persons were

living with HCV infection in the world, accounting
for 1% of the population.
• 2.3 million persons living with HIV also had HCV
infection.

(World Health Organization:, 2017)

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 Cont….

• HCV infection is unevenly distributed in the world.

• The European and Eastern Mediterranean regions are

more aff ected, but there are variations in prevalence
across and within countries.

(World Health Organization:, 2017)

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 Mortality in 2015

• WHO estimates that in 2015, viral hepatitis was

responsible for 1.34 million deaths.
• This number was comparable with the number of
deaths from tuberculosis, but higher than the number
of deaths from HIV.

(World Health Organization:, 2017)

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 Cont….

• Left untreated, HBV and HCV infection can lead to

cirrhosis (720 000 deaths) and hepatocellular
carcinoma (470 000 deaths).
• These long-term complications are life-threatening
and accounted for 96% of the deaths due to viral
hepatitis.

(World Health Organization:, 2017)

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 Pathophysiology

• The inflammatory process of hepatitis, whether

caused by a virus, toxin, or other mechanism,
damages hepatic cells and disrupts liver function.

(Lemone, 2011)

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 Cont….

• Cell-mediated immune responses damage

hepatocytes and Kupffer cells, leading to
hyperplasia, necrosis, and cellula regeneration.

• The flow of bile through bile canaliculi and into the

biliary system can be impaired by the inflammatory
process, leading to jaundice

(Lemone, 2011)

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 Cont….

• When the inflammatory process is mild (e.g.,

hepatitis A), the liver parenchyma is not significantly
damaged.

• The inflammatory processes associated with hepatitis

B and hepatitis C, however, can lead to severe liver
damage.

(Lemone, 2011)

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 Cont…..

• The metabolism of nutrients, drugs, alcohol, and

toxins and the process of bile elimination are
disrupted by the inflammation of hepatitis.

(Lemone, 2011)

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 Viral Hepatitis

• Is nearly always caused by one of five viruses:

hepatitis A virus (HAV), hepatitis B virus (HBV),
hepatitis C virus (HCV), the hepatitis B-associated
delta virus (HDV), and hepatitis E virus (HEV).

• With the exception of HBV, all of the hepatitis

viruses are RNA viruses; HBV is a DNA virus.

(Lemone, 2011)

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 Cont….

• The viruses differ from one another in

 Mode of transmission
 Incubation period
 Severity and type of liver damage they cause, and
 Their ability to become chronic or develop a carrier
(asymptomatic) state.

• The illnesses they cause, however, are clinically very

similar.
(Lemone, 2011)

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 Comparison of Types of Viral Hepatitis

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 Signs and Symptoms

• Hepatitis usually shows a typical pattern of loss of

liver function.
• There are generally three stages:
 Preicteric stage
 Icteric stage
 Post- icteric stage

(Lemone, 2011)

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 Cont….

1. Prodromal, or preicteric (prejaundice), stage

 lasts about 1 week.
 “Flulike” symptoms: malaise, fatigue, fever
 Gastrointestinal: anorexia, nausea, vomiting, diarrhea,
constipation
 Muscle aches, polyarthritis
 Mild right upper abdominal pain and tenderness

(Lemone, 2011)

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 Cont…..

2. Icteric stage
 peaks at 2 weeks and lasts 2 to 6 weeks.
 Jaundice
 Pruritus
 Clay-colored stools
 Brown urine
 Decrease in preicteric phase symptoms (e.g., appetite
improves; no fever)
(Lemone, 2011)

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 Cont….

3. The posticteric, or convalescent, stage

 lasts from 2 to 6 weeks with complete recovery in 6
months if relapse does not occur.
 Serum bilirubin and enzymes return to normal levels
 Energy level increases
 Pain subsides
 Gastrointestinal: minimal to absent.
(Lemone, 2011)

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 Diagnostic Tests
 Serum liver enzymes are elevated.
• ALT: Alanine aminotransferase; normal range 3 - 35 IU/L or
8 to 20 units/L.
• AST: Aspartate aminotransferase; normal range 5 - 40 units/L.
 Serum bilirubin and urobilinogen may be elevated.
 The erythrocyte sedimentation rate is usually elevated
from the inflammatory process.
(Lemone, 2011)

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 Cont…..
• In patients with severe hepatitis,
 Prothrombin time may be elevated
 Serological tests may be ordered to determine the
specific virus causing the hepatitis.
 Specific antigen markers
 Abdominal x-ray examination may show an enlarged
liver.
• A liver biopsy may be done to detect and evaluate
chronic hepatitis.
(Lemone, 2011)

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 Complications

 Chronic hepatitis
 Fulminant hepatitis
 Acute liver failure
 HBV-infected carrier patients have a greater risk of
developing cancer of the liver.

(Lemone, 2011)

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 Chronic Hepatitis

• Chronic hepatitis is chronic infection of the liver.

• Although it may cause few symptoms, it is the
primary cause of liver damage leading to cirrhosis,
liver cancer, and live transplantation.

• Three of the known hepatitis viruses cause chronic

hepatitis: HBV, HCV, and HDV.

(Lemone, 2011)

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 Cont….

• Manifestations of chronic hepatitis include malaise,

fatigue, and hepatomegaly.

• Occasional icteric (jaundiced) periods may occur.

• Liver enzymes, particularly serum aminotransferase

levels, typically are elevated.

(Lemone, 2011)

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 Fulminant Hepatitis

• Fulminant hepatitis is a rapidly progressive disease,

with liver failure developing within 2 to 3 weeks after
the onset of symptoms.

• Although uncommon, it is usually related to HBV

with concurrent HDV infection.

(Lemone, 2011)

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 Toxic Hepatitis

• Many substances, including alcohol, certain drugs,

and other toxins, can directly damage liver cells.

• Alcoholic hepatitis can result from chronic alcohol

abuse or from an acute toxic reaction to alcohol.

(Lemone, 2011)

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 Cont….

• Other potential hepatotoxins include acetaminophen,

benzene, carbon tetrachloride, halothane, chloroform,
and poisonous mushrooms.

• These substances directly damage liver cells, leading

to necrosis

(Lemone, 2011)

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 Cont…..

• The degree of damage often depends on age and the

extent of exposure (dose) to the hepatotoxin.

• Acetaminophen overdose is the leading cause of

acute liver failure.

(Lemone, 2011)

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 Autoimmune Hepatitis

• Autoimmune hepatitis is a chronic disorder in which

a cell-mediated immune response directed against
liver cells causes persistent inflammation and
necrosis with fibrosis and scarring.

• Circulating autoantibodies such as antinuclear

antibody (ANA) usually are present.

(Lemone, 2011)

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 Cont…..

• Many affected individuals have a personal or family

history of other autoimmune disorders, such as
rheumatoid arthritis or thyroiditis, suggesting a
genetic link to the disorder.

• Chronic autoimmune hepatitis can ultimately lead to

cirrhosis and liver failure.

(Lemone, 2011)

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 Medical management

• Safe and effective vaccines are widely available for

the prevention of HAV and HBV infections and an
HEV vaccine has recently been licenced in China.

(Lemone, 2011)

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 Cont…..

• Severe cases of acute hepatitis B and D may be

treated with an antiretroviral drug such as
 Lamivudine
 Adefovir
 Entecavir
 Telbivudine
• Hepatitis E
 No medication indicated
(Lemone, 2011)

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 Cont….

• Treatment is not indicated for mild to moderate cases

• Acute hepatitis C generally is treated with interferon
alpha, an antiviral agent, to reduce the risk of chronic
hepatitis C
• Combination therapy with peginterferon and ribavirin
is the treatment of choice for chronic hepatitis C.

(Lemone, 2011)

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Evidence Based Practice on Pharmacological
Management of Hepatitis
• A systematic reviews in 2017 on pharmacological
interventions for acute hepatitis B infection shows
that
 Hepatitis B immunoglobulin (a vaccine), interferon
(protein secreted in response to viral infection), and
lamivudine and entecavir (medicines) which are
considered to have antiviral effects and were compared
with placebo or no intervention.

(Br and Ks, 2017)

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 Cont….

• Systematic Reviews in 2019 on Glucocorticosteroids

for people with alcoholic hepatitis (Review) shows
 Glucocorticosteroids are considered to have anti-
inflammatory effects (relieving pain, swelling (oedema),
fever).
 They are administered to people with alcoholic hepatitis in
order to repair their liver injury.

(Cs et al., 2019)

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 Cont…..

• Systematic Reviews on pharmacological

management of hepatitis C infection in 2018 shows
 Very low quality evidence suggests that interferon-alpha
may decrease the incidence of chronic HCV infection
However, the clinical impact such as improvement in
health-related quality of life, reduction in cirrhosis,
decompensated liver disease, and liver transplantation has
not been reported.
(Kalafateli et al., 2018)

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 Nursing management

• Providing rest and adequate nutrition for liver

healing
• Patients are restricted from any alcohol or drugs that
are known to be toxic to the liver
• Prevent infection
• Treat dry itching skin
 Soft linens
 Lotions antihistamines
(Williams, 2007)

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 Prognosis

• Virtually all previously healthy patients with

hepatitis A recover completely with no clinical
sequelae.
• Similarly, in acute hepatitis B, 95–99% of previously
healthy adults have a favorable course and recover
completely.
• Certain clinical and laboratory features, however,
suggest a more complicated and protracted course.
(Fauci et al., 2009)

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 Cont….

• Patients of advanced age and with serious underlying

medical disorders may have a prolonged course and
are more likely to experience severe hepatitis

(Fauci et al., 2009)

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 Cont…..

• Initial presenting features such as ascites, peripheral

edema, and symptoms of hepatic encephalopathy
suggest a poorer prognosis.
• In addition, a prolonged PT, low serum albumin level,
hypoglycemia, and very high serum bilirubin values
suggest severe hepatocellular disease

(Fauci et al., 2009)

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 Cont…..

• Patients with these clinical and laboratory features

deserve prompt hospital admission.
• The case fatality rate in hepatitis A and B is very
low (~0.1%) but is increased by advanced age and
underlying debilitating disorders.

(Fauci et al., 2009)

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 Cont…..

• Among patients ill enough to be hospitalized for

acute hepatitis B, the fatality rate is 1%.
• Hepatitis C is less severe during the acute phase than
hepatitis B and is more likely to be anicteric; fatalities
are rare, but the precise case fatality rate is not
known.

(Fauci et al., 2009)

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 Differential diagnosis

• Viral infection
 cytomegalovirus,
 herpes simplex, and
• Bacterial infection
 Leptospirosis
 Thyphoid fever

(Fauci et al., 2009)

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Nursing process for patients with hepatitis

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 Assessment
Subjective data Objective data
• Fatigue • Yellowish of skin
• Itching • RUQ abdominal
• Nausea tenderness
• Anorexia • Weight loss
• RUQ abdominal pain
• Joint pain

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 Nursing diagnosis

1. Acute pain related to liver inflammation as

evidenced by patient verbalization
2. Imbalanced nutrition, less than body requirements
related to anorexia and vomiting as evidenced by
inappropriate weight
3. Activity intolerance related to joint pain as
evidenced by observation
4. Risk for impaired skin integrity related to itching

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 Planning
Goal Expected outcome
1. To relief pain 1. Patient will state that pain level is
acceptable with in 30 minute
2. To maintain normal
body weight 2. The patient’s weight will be stable
and appropriate for height with in 7
3. To improve activity
days
tolerance
3. Patient will report he/she is
4. To maintain skin
performing activity of daily living
integrity
with out difficulty with 3 days
4. The patient’s skin will remain intact

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 Intervention
1. -Give analgesics as ordered to control pain.
-Encourage non-pharmacological pain relief activities, such as
distraction, imagery, and relaxation
2. -Monitor weight and nutritional intake
-Provide a high-calorie, high-protein, high- carbohydrate, low-
fat diet
3. -Advice the patient to take adequate rest for hepatic healing
4. - Administer antihistamines as ordered to decrease the itching
-Encourage the patient not to scratch, but to press firmly on the
itching area.

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 Evaluation

1. Patient reported pain is relieved

2. The weight is improved
3. Patient got adequate rest
4. Skin integrity maintained

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 Reference
• Br, D. and Ks, G. (2017) ‘Pharmacological interventions for acute hepatitis B
infection (Review)’. doi:
10.1002/14651858.CD011645.pub2.www.cochranelibrary.com.
• Cs, P. et al. (2019) ‘Glucocorticosteroids for people with alcoholic hepatitis
( Review )’. doi: 10.1002/14651858.CD001511.pub4.www.cochranelibrary.com.
• Fauci, A. S. et al. (2009) Harrison’s Manual of Medicine. 17th editi.
• Gary D. Hammer, MD, PhD, & Stephen J. McPhee, M. (2019) ‘Pathophysiology
of Disease_ An Introduction to Clinical Medicine ( PDFDrive.com ).pdf’.
• Kalafateli, M. et al. (2018) ‘Pharmacological interventions for acute hepatitis C
infection (Review)’. doi:
10.1002/14651858.CD011644.pub3.www.cochranelibrary.com.
• Lemone, P. (2011) Medical Surgical Nursing critical thinking in patient care.
fifth edit.
• Williams, L. S. (2007) Medical Surgical.
• World Health Organization: (2017) Global hepatitis report, 2017.

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 Acknowledgement
• Firstly next to God, I would like to thank Merhabete
women, children and youth office and Mr. Yitbarek
supporting me through permitting the internet access
for my power point preparation.
• Next my deepest gratitude goes to Mr. Wondosen
Yimam assistant professor, Dean school of Nursing
and Midwifery who invite me to explore and prepare
PPT on hepatitis.
• Finally I thank you the audience since you listen me
attentively.
10/23/2020 BY: Melese W. 63
 THANK YOU

10/23/2020 BY: Melese W. 64