Viral hepatitis

• Hepatitis means inflammation of the liver. Many illnesses and conditions can cause
inflammation of the liver, for example, drugs, alcohol, and diseases.
There are several hepatitis viruses
• Hepatitis A virus ( HAV )
• Infectious hepatitis caused by RNA virus of enterovirus family
• Transmitted through fecal-oral by ingestion of food or liquid contaminated by the virus.
• Incubation period: 15 to 50 days: mean of 28 to 30 days.
Etiology
• Hepatitis A virus
Signs and symptoms
• Influenza- like such as headache
• Severe anorexia
• Abdominal discomfort/ pain
• Nausea and vomiting
• Fever
• Late : jaundice and dark urine
Assessment
• Moderate enlargement of spleen and liver
• Hepatitis A antigen found in stools 7 to 10 days before illness and 2 to 3 weeks after
symptoms appears
• IgM indicates recent infection; positive up to 6 months
Diagnostic
• Blood tests
There are three types of blood tests for evaluating patients with hepatitis:

Liver enzymes - Among the most sensitive and widely used blood tests for evaluating patients
with hepatitis are the liver enzymes, called aminotransferases. They includeaspartate
aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). These enzymes
normally are contained within liver cells. If the liver is injured (as in viral hepatitis), the liver
cells spill the enzymes into the blood, raising the enzyme levels in the blood and signaling that
the liver is damaged.
The normal range of values for AST is from 5 to 40 units per liter of serum (the liquid part of the
blood). The normal range of values for ALT is from 7 to 56 units per liter of serum. Patients with
acute viral hepatitis (for example, due to hepatitis A or hepatitis B) can develop very high AST
and ALT levels (sometimes in the thousands of units per liter range). These high AST and ALT
levels will become normal in several weeks or months as the patients recover completely from
their acute hepatitis. In contrast, patients with chronic hepatitis B and hepatitis C infection
typically have only mildly elevated AST and ALT levels, but these abnormalities can last years or
decades. Since most patients with chronic hepatitis are asymptomatic (no jaundice or nausea),
their mildly abnormal liver enzymes are often unexpectedly encountered on routine blood
screening tests during yearly physicals or insurance physicals.
Elevated blood levels of AST and ALT only means that the liver is inflamed, and elevations can
be caused by many agents other than hepatitis viruses, such as medications,
alcohol, bacteria, fungus, etc. In order to prove that a hepatitis virus is responsible for the
elevations, blood must be tested for antibodies to each of the hepatitis viruses as well as for their
genetic material.
Viral antibodies -  Antibodies are proteins produced by white blood cells that attack invaders
such as bacteria and viruses. Antibodies against the hepatitis A, B, and C viruses usually can be
detected in the blood within weeks of infection, and the antibodies remain detectable in the blood
for decades thereafter. Blood tests for the antibodies can be helpful in diagnosing both acute and
chronic viral hepatitis.
In acute viral hepatitis, antibodies not only help to eradicate the virus, but they also protect the
patient from future infections by the same virus, that is the patient develops immunity. In chronic
hepatitis, however, antibodies and the rest of the immune system are unable to eradicate the
virus. The viruses continue to multiply and are released from the liver cells into the blood where
their presence can be determined by measuring the viral proteins and genetic material. Therefore
in chronic hepatitis, both antibodies to the viruses and viral proteins and genetic material can be
detected in the blood.

Medical management:

• bed rest during the acute stage

• frequent small feeding during anorexia

• optimal food and fluid levels to counteract weight loss

• gradual and progressive ambulation

Nursing Management
 • Good personal hygiene

• Hand washing

• Environmental sanitation

• Hepatitis B virus

• HBV is transmitted primarily through blood ( percutaneous and permucosal routes ) ,

breaks in the skin, and from carries mothers to this babies.

• Found in the blood, saliva, semen, and vaginal secretions.

Signs and symptoms
• Loss of appetite
• Abdominal pain
• Jaundice may or may not be evident
• Liver is tender and enlarged to 12 to 14 cm
• Spleen is enlarged and palpable
Diagnostic test
HBsAg
The presence of hepatitis B surface antigen (HBsAg) in the blood indicates that the patient is
currently infected with the virus. HBsAg appears an average of four weeks after initial exposure
to the virus. Individuals who recover from acute hepatitis B infections clear the blood of HBsAg
within approximately four months after the onset of symptoms. These individuals develop
antibodies to HBsAg (anti-HBs). Anti-HBs provides complete immunity to subsequent hepatitis
B viral infection. Similarly, individuals who are successfully vaccinated against hepatitis B
produce anti-HBs in the blood.
Patients who fail to clear the virus during an acute episode develop chronic hepatitis B. The
diagnosis of chronic hepatitis B is made when the HBsAg is present in the blood for at least six
months. In chronic hepatitis B, HBsAg can be detected for many years, and anti-HBs does not
appear.

Anti-HBc
In acute hepatitis, a specific class of early antibodies (IgM) appears that is directed against the
hepatitis B core antigen (anti-HBc IgM). Later, another class of antibody, anti-HBc IgG,
develops and persists for life, regardless of whether the individual recovers or develops chronic
infection. Only anti-HBc IgM can be used to diagnose an acute hepatitis B infection.
Medical management:
• Goals of treatment are to minimize infectitivity and liver inflammation and decrease
symptoms.
• Anti viral: lamivudile ( epivir ) and adefovir ( hepsera ), oral nucleoside analogues have
been approved by FDA for chronic hepatitis B.
• Bed rest until symptoms subside with restricted movement until enzymes disappear.
• Maintenance of adequate nutrition.
Nursing management
• Ensure adequate rest and nutrition
• Avoid all forms of the alcohol and eating raw shellfish
• Follow-up visits may be needed

• Hepatitis C virus

Infectious disease affecting the liver, caused by the hepatitis C virus (HCV)

Signs and symptoms

Acute

Acute hepatitis C refers to the first 6 months after infection with HCV. Between 60% to 70% of
people infected develop no symptoms during the acute phase. In the minority of patients who
experience acute phase symptoms, they are generally mild and nonspecific, and rarely lead to a
specific diagnosis of hepatitis C. Symptoms of acute hepatitis C infection include decreased
appetite, fatigue, abdominal pain, jaundice, itching, and flu-like symptoms. The hepatitis C
virus is usually detectable in the blood within one to three weeks after infection by PCR, and
antibodies to the virus are generally detectable within 3 to 15 weeks.
Chronic

Chronic hepatitis C is defined as infection with the hepatitis C virus persisting for more than six
months. Clinically, it is often asymptomatic (without symptoms) and it is mostly discovered
accidentally (e.g. usual checkup).

The natural course of chronic hepatitis C varies considerably from one person to another.
Although almost all people infected with HCV have evidence of inflammation on liver biopsy,
the rate of progression of liver scarring (fibrosis) shows significant variability among
individuals. Accurate estimates of the risk over time are difficult to establish because of the
limited time that tests for this virus have been available.

Diagnostics
• HCV antibody - generally used to diagnose hepatitis C
infection. Not useful in the acute phase as it takes at least 4
weeks after infection before antibody appears.
• HCV-RNA - various techniques are available e.g. PCR and
branched DNA. May be used to diagnose HCV infection inthe acute phase. However, its main
use is in monitoring theresponse to antiviral therapy.
• HCV-antigen - an EIA for HCV antigen is available. It is used in the same capacity as
HCV-RNA tests but is much easier to carry out

Medical and Nursing Management

Alpha Interferon
The therapy for chronic hepatitis C has evolved steadily since alpha interferon was first approved
for use in this disease more than 10 years ago. At the present time, the optimal regimen appears
to be a 24- or 48-week course of the combination of pegylated alpha interferon and ribavirin.
Alpha interferon is a host protein that is made in response to viral infections and has natural
antiviral activity. Recombinant forms of alpha interferon have been produced, and several
formulations (alfa-2a, alfa-2b, consensus interferon) are available as therapy for hepatitis C.
These standard forms of interferon, however, are now being replaced by pegylated interferon
(peginterferon).
Peginterferon is alpha interferon that has been modified chemically by the addition of a large
inert molecule of polyethylene glycol. Pegylation changes the uptake, distribution, and excretion
of interferon, prolonging its half-life. Peginterferon can be given once weekly and provides a
constant level of interferon in the blood, whereas standard interferon must be given several times
weekly and provides intermittent and fluctuating levels. In addition, peginterferon is more active
than standard interferon in inhibiting HCV and yields higher sustained response rates with
similar side effects. Because of its ease of administration and better efficacy, peginterferon has
replaced standard interferon both as monotherapy and as combination therapy for hepatitis C.

Ribavirin
Ribavirin is an oral antiviral agent that has activity against a broad range of viruses. By itself,
ribavirin has little effect on HCV, but adding it to interferon increases the sustained response rate
by two- to three-fold. For these reasons, combination therapy is now recommended for hepatitis
C, and interferon monotherapy is applied only when there are specific reasons not to use
ribavirin.
 • Hepatitis D Virus
The delta agent is a defective virus which
shows similarities with the viroids in plants.
The agent consists of a particle 35 nm in diameter
consisting of the delta antigen surrounded by an
outer coat of HBsAg.
The genome of the virus is very small and consists
of a single-stranded RN

• Hepatitis E virus

• HEV is transmitted through fecal oral route

• Incubation period is variable from 15 to 65 days

• Prevention is good hygiene through hand washing

• Hepatitis G

• Post transfusion hepatitis with incubation period of 14 to 145 days

• Clinical significant is still unknown