This Presentation is on Viral Hepatitis, The types discussed include: Hepatitis A, B, C, D and E viruses.

1. LIVERS DISORDERS
MR MULUNDANO
BSC NS-UNZA
LECTURER-KCN

2. INTRODUCTION
• The liver is the largest organ of the body
situated in the upper abdominal cavity
immediately below the diaphragm. It is divided
into four lobes and is highly vascular, receiving
its blood supply from two sources. The portal
vein carries blood from the stomach,
intestines, spleen and pancreas into the liver.
The hepatic artery delivers blood from the
aorta. The blood from both sources leaves the
liver by a common pathway, the hepatic vein,
which joins the inferior vena cava.

3. INTRODUCTION
• Like any other organ in our body, the
liver is prone to infections as well.
• Therefore, in this presentation we will
discuss the following disorders of the
liver;
1. Hepatitis A, B, C Viruses
2. Toxic hepatitis
3. Drug induced hepatitis
4. Fulminant hepatic failure
5. Hepatic cirrhosis

4. Anatomy of the biliary
system

6. The lobes of the liver

8. HEPATITIS
• An inflammatory disease of the liver
that may be caused by, drugs, alcohol,
chemicals, autoimmune diseases and
viruses and is usually characterized by
impaired hepatic functions.
• It is the inflammation of the liver cell
usually resulting in impaired liver
function

9. Classification
• It is usually classified according to the
cause and duration i.e.:
Toxic hepatitis
Auto immune hepatitis
Drug induced hepatitis
Viral hepatitis caused by:
i. Hepatitis A Virus
ii. Hepatitis B Virus

10. Classification cont
iii. Hepatitis C Virus
iv. Hepatitis D Virus
v. Hepatitis E Virus
vi. Hepatitis F and G have been
identified but are uncommon
However the commonest forms of viral
hepatitis are Hepatitis A, B, and C
It may also be called acute or chronic

11. VIRAL HEPATITIS

12. Chx of hepatitis viruses
Type Duration Route Structure
HAV ACUTE Faecal Oral No envelope, single stranded
RNA (+)
HBV Acute &
Chronic
Sex, blood, perinatal Enveloped, double stranded
DNA.
HCV Acute &
Chronic
Sex, blood, perinatal Enveloped, single stranded
RNA (+)
HDV Acute &
Chronic
Sex, blood, perinatal.
Needs HBV to infect the
cell (co-infection or
superinfection)
Enveloped, circular single
stranded RNA(-)
HEV Acute Faecal Oral No envelope, single stranded
RNA(+)

13. Hepatitis A (infective)
• It is the type of hepatitis that is
caused by hepatitis A virus (an
RNA picornavirus).
• The incubation period is 2-6weeks
• It is a contagious viral infection

14. MODE OF SPREAD
It is spread by the fecal oral route
that is;
• 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.

15. Hepatitis A Mode of
spread cont
• 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.

16. Possible out comes of the
disease
• Hepatitis A will clear up on its own in a
few weeks or months with no serious
after effects.
• Once recovered, an individual is then
immune for life to HAV through the
presence of the IgG antibody .
• About 1 in 100 HAV sufferers may
experience a sudden and severe (i.e.,
"fulminant") infection.

17. Pathophysiology
• Hepatitis virus invade the liver cells
• It take hostage of the liver cell and
destroy it after reproducing
• The body attacks the HAV with
antibodies
• This leads to the regeneration and
resuming of normal function of the liver
• A person who recovers remains
protected for life

18. Signs and symptoms
• It is possible to experience mild or no
symptoms whatsoever, but even if this is the
case the person’s faeces will still be infectious
to others. Many people who become infected
with HAV will have symptoms that include
 - fatigue.
- Nausea, vomiting and diarrhea.
- Loss of appetite.
- Weight loss.
- Fever
- Joint pains
 NOTE: These symptoms are seen in the pre-
icteric phase(before onset of jaundice)

19. Signs and symptoms
The icteric period will have the following
symptoms:
 Jaundice (yellow skin and whites of eye)
 Dark yellow urine
 Pale feces (clay colored stool).
 Itchy skin.
 Abdominal pain especially around the right
hypochondriac region
 Diarrhea
 The infection usually clears up in to 2
months, but may occasionally recur or
persist longer in some people.

20. Diagnosis
• Obtain a thorough patient history to assess
the likelihood of hepatitis A infection.
• Use clinical evaluation to support the
diagnosis of hepatitis A.
• Confirm the diagnosis of hepatitis A with
appropriate laboratory testing. IgM anti body
to HAV
• Use serologic testing to exclude HAV
infection in persons with unexplained acute
liver failure.

21. Diagnosis cont
• Blood to r/o hepatitis B and C
• liver function (laboratory evaluation of: urine
bilirubin and urobilinogen, total and direct
serum bilirubin, ALT and/or AST, alkaline
phosphatase, prothrombin time, total
protein, albumin, IgG, IgA, IgM
• Liver scan will show change in the liver
• Stool for electro microscopy
• Urine for urobilinogen

22. Treatment
• No specific treatment is necessary for
hepatitis A. Disease
• IV fluids to prevent dehydrated, 5%
Dextrose 1 litre /24hours.
• Anti emetics to counteract nausea and
vomiting, e.g. phenegan 10mg bd
• Anti histamine to control itching phenegan
5-10mg
• Enough rest to promote recovery

23. • A balanced diet is given (low fat high
carbohydrate is well tolerated)
• Vitamin C in high doses may help to
quicken recovery 40-100mg orally
• Glucose drink for energy

24. Treatment cont
• Glucose to promote rest of the liver
there by promoting recovery
• Vitamin B complex
• Vitamin A 10mg im
• Prednisolone 30mg od for 14/7 then
reduce till you stop
• Analgesics for pain e.g. panadol
500mg tds for 3/7

25. Prevention
• Vaccination against hepatitis A is the
most effective method where available
• Good hand hygiene may prevent
spread during out breaks
• Using clean utensil can prevent spread
• Cooking food well
• Prophylaxis with anti hepatitis immunal
globulin

26. Hepatitis B
• Hepatitis B is an inflammatory liver
disease caused by the hepatitis B
virus (HBV) which is a DNA
hepadevirus, that results in liver
cell damage.
• This damage can lead to scarring
of the liver (cirrhosis) and
increased risk of liver cancer in
some people.

27. Mode of transmission
• HBV can be spread in the following ways:
 By unprotected (without a condom)
penetrative sex (when the penis enters the
anus, vagina or mouth) with someone who
is infectious. Also by sex that draws blood
with someone who is infected.
 By sharing contaminated needles or other
drug-injecting equipment.
 By using non-sterilised equipment for
tattooing, acupuncture or body piercing.

28. Mode of transmission
cont
From an infected mother to her baby,
most commonly during delivery.
Immunisation of the baby at birth
prevents the transmission of hepatitis
B.
Through a blood transfusion in a
country where blood is not screened.
INCUBATION PERIOD
• 4-24weeks

29. Phases of the infection
• This infection has 2 phases: acute and
chronic.
Acute (new, short-term) hepatitis B occurs
shortly after exposure to the virus. A small
number of people develop a very severe,
life-threatening form of acute hepatitis called
fulminant hepatitis.
Chronic (ongoing, long-term) hepatitis B is
an infection with HBV that lasts longer than 6
months. Once the infection becomes
chronic, it may never go away completely.

30. Phases of the infection
cont
About 90-95% of people who are
infected are able to fight off the
virus so their infection never
becomes chronic.
Only about 5-10 percent of adults
infected with HBV go on to develop
chronic infection.

31. Pathophysiology
• Viral hepatitis causes diffuse inflammatory
infiltration of the hepatic tissue with
mononuclear cells, spotty or singular
necrosis
• The liver may be swollen
• There is no collapse of lobules, no loss of
lobular architecture, and minimal or no
fibrosis
• Inflammation and regeneration occur
simultaneously distorting the normal lobular
pattern and creating pressure within and
around the portal vein and obstruction the
normal bile channel

32. Pathophysiology cont
• The pathological change in the
hepatocytes is not always related to
the effect of the virus itself but rather
the injurious response of the body’s
own immune system attempting to
clear out the virus
• This changes will lead to impaired liver
functions

33. Signs and symptoms
• Half of all people infected with the
hepatitis B virus have no symptoms.
• Symptoms develop within 30-180 days
of exposure to the virus.
• The symptoms are often compared to
flu.
• Most people think they have flu and
never think about having HBV
infection.

34. Sign and symptoms
cont
 loss of appetite
Feeling tired (fatigue)
Nausea and vomiting
Itching all over the body
Pain over the liver (on the right side of the
abdomen, under the lower rib cage)
Fever
Jaundice - A condition in which the skin and the
whites of the eyes turn yellow in color
Urine becomes dark in color (like cola or tea).
Stools are pale in color (grayish or clay
colored).

35. Sign and symptoms
cont
• Fulminant hepatitis is an unusual
illness. It is a severe form of acute
hepatitis that can be life threatening if
not treated right away. The symptoms
develop very suddenly.
Mental disturbances such as confusion,
lethargy, extreme sleepiness or
hallucinations (hepatic encephalopathy)
Sudden collapse
Jaundice
Swelling of the abdomen

36. Sign and symptoms
cont
• Prolonged nausea and vomiting can cause
dehydration. If Patient has been vomiting
repeatedly, you may notice these symptoms:
Feeling tired or weak
Feeling confused or having difficulty
concentrating
Headache
Not urinating
Irritability

37. Sign and symptoms
cont
• Symptoms of liver failure may include the
following:
Fluid retention causing swelling of the belly
(ascitis) and sometimes the legs
Weight gain due to ascitis
Persistent jaundice Loss of appetite, weight
loss, wasting
Vomiting with blood in the vomit
Bleeding from the nose, mouth, or rectum or
blood in the stool
Hepatic encephalopathy (excessive
sleepiness, mental confusion, and in
advanced stages, development of coma

38. Diagnosis
• History to assess the likelihood of hepatitis
B infection.
• Clinical picture will demonstrate jaundice.
• Confirm the diagnosis of hepatitis B with
appropriate laboratory testing. IgM anti body
to HBV
• Use serologic testing to exclude HBV
infection in persons with unexplained acute
liver failure. Blood to r/o hepatitis A and C
• liver function (laboratory evaluation of:
urine bilirubin and urobilinogen, total and
direct serum bilirubin, ALT and/or AST
alkaline phosphatase, prothrombin time,
total protein, albumin, IgG, IgA, IgM
• Hepatic scan may show inflammation

39. Treatment
• Acute hepatitis B usually goes away by itself
and does not require medical treatment.
• There are no medications that can prevent
acute hepatitis B from becoming chronic
• Glucose to promote rest of the liver there by
promoting recovery
• Vitamin B complex 2 tablets
• Vitamin A 200000iu
• Prednisolone 30mg od for 14/7 then reduce till
you stop
• Analgesics for pain e.g. panadol 500mg tds
for 3/7

40. Treatment cont
• The most severe effect of acute hepatitis B
is dehydration from vomiting and diarrhea.
• If you are dehydrated, your doctor may
prescribe IV fluid such as Ringer’s lactate
2000ml in 24 hours.
• If patient is experiencing significant nausea
and vomiting anti emetics will be given e.g.
phenegan 10mg.
• There is no treatment that can prevent acute
HBV infection from becoming chronic

41. Disease out come
Either you develop immunity to HBV
• 95% of adults infected develop antibodies
and recover spontaneously within six
months.
• Upon recovery, they develop immunity to
the virus and they are not infectious to
others.
• Blood tests will always test positive for the
HBV antibody.
• Blood banks will not accept donations of
blood from HBV-immune people.

42. Disease out come
OR you become chronically infected.
• About 5% of the time, the virus does not
clear the body within six months.
• If so, a person is considered a carrier – or
chronically infected.
• Chronically infected people may or may not
show outward signs or symptoms.
• The HBV virus remains in blood and body
fluids, and can infect others.

43. Prevention
• Practice safe sex (use latex condoms).
• Don't share anything that could have
an infected person's blood on it, i.e.
toothbrushes, razors, nail clippers,
body piercing instruments.
• Don't share drug needles, cocaine
straws or any drug paraphernalia.

44. Prevention
• Cover all sores and rashes and do not touch
them.
• Clean up any blood spills with a 10%
solution of household bleach. Infected
persons should not pre-chew food for
babies.
• If exposed to hepatitis B, get an HBIG
(hepatitis B immune globulin) injection within
14 days following exposure.
• Vaccination against hepartitis

45. Hepatitis C
• It is the inflammation of the liver that is
caused by Hepatitis C virus. Hepatitis C
virus a member of the Flaviviridae family of
viruses which are RNA viruses
• Mode of transmission: The hepatitis C virus
(HCV) usually is spread by
 shared needles among drug abusers,
 blood transfusion,
 hemodialysis, and
 needle sticks
 Un protected sex with an infected person

46. Signs and symptoms
• At the beginning of an hepatitis C virus
infection, only about 25% of patients
exhibit the characteristic symptoms of
acute (rapid onset) hepatitis.
• These symptoms include;
 fatigue,
muscular aches,


47. Signs and symptoms
cont
poor appetite, and
low-grade fever.
Rarely, yellowing of the skin and/or
eyes (jaundice) also occurs.
However, most patients (about 75%)
experience minimal or no symptoms at
the onset of hepatitis C virus.

48. Dianonosis
• As for other form of viral hepatitis
• Additionally do Blood for HCV
antibodies

49. Progression of chronic hepatitis
C virus
• Our understanding of the natural
progression (history) of hepatitis C infection
is still evolving.
• About 15% of patients with acute hepatitis C
virus infection spontaneously recover (clear
the virus).
• 85%, however, develop chronic liver
disease.
• Patients with chronic hepatitis C infection
are at risk for developing cirrhosis, liver
failure, and liver cancer

50. Treatment
• As for hepatitis B
• Prevention as for hepatitis B

51. Toxic hepatitis
• The inflammation of the liver caused by toxic
agent.
• The toxic agent may include:
Drugs like acetaminophen, pyrazinamide,
etc
Alcohol
Industrial toxins such as carbon
tetrachloride from dry cleaning agents.
Insecticides.
Plant poisons like mushroom, and bush teas

52. Treatment
• Identify and remove the damaging
agent e.g. by gastric lavage
• Where there is a known treatment for
the poison it may be given
• For instance for Acetaminophen over
dose, Acetyl cysteine will be given

53. Complications of
hepatitis
• Chronic hepatitis
• Hepatic coma
• Liver cirrhosis
• Cancer of the liver
• Acute hepatic necrosis

54. Hepatitis D
• It is a type of viral hepatitis that is
caused by hepatitis D virus which is
caused by a defective RNA virus that
needs the helper function of HDV co-
infection
• It needs the presence of HBV to
replicate
• Can not occur on its own.

55. Nursing care
• AIMS:
To promote optimal functioning of the
liver and prevent spread of the
infection
Improve patient’s knowledge about the
condition
Alley anxiety

56. Environment
• Patient will be nursed in an isolation ward to
prevent infection spread
• Patient will be nursed in a well ventilated
room to allow free air circulation and
promote comfort
• Patient will be nursed in a well lit room for
easy observation and for orientation to time
and place
• I will include all equipment needed in the
care of the patient such as the drip stand
for intravenous fluids

57. Position
• Patient will be nursed in fowlers
position to promote lung expansion
and relieve dyspnea
• I will change the patient’s position two
hourly to prevent development of
pressure sores
• As the condition improves I will let the
patient adopt any position of comfort to
promote rest

58. Rest and activity
• I will play the radio at low volume to avoid
disturbing the patient thereby promote rest
• I will answer all phone calls promptly to
prevent disturbing the patient there by
promote rest
• I will do related procedures at the same time
to prevent disturbing patient unnecessarily
• I will administer prescribed analgesics in
order to relieve pain thereby promoting rest
• I will ensure that squeaking trolleys which
may disturb patient rest are worked on.

59. Activity
• If my patient is confined to bed i will do
passive exercises like limb movement and
massage in order to prevent muscle atrophy
and promote blood circulation
• I will encourage the patient to do deep
breathing exercises in order to promote lung
expansion
• I will encourage early ambulation as soon as
the condition permits in order to prevent
deep vein thrombosis and other
complications of immobility

60. Observations
• I will do vital sign and BP to act as the base
line data in order to know if the condition is
improving or deteriorating
• I will observe jaundice if improving or
getting worse
• I will observe for the itching if present I will
offer ant histamines
• I will observe the pressure area to detect on
set of pressure sore development

61. Observations
• I will observe the stool and urine for colour
and note any improvement towards normal
and report the physician
• I will observe the patient’s facial expressions
to detect pain and administer prescribed
analgesics like panadol
• I will observe the feeding pattern of my
patient and take measures like giving small
frequent meals to promote appetite
• I will observe the respirations to detect
tachycardia and report accordingly

62. Psychological support
• I will explain the disease process in order to
raise the knowledge levels and thereby alley
anxiety
• I will encourage the patient to ask question and
I will answer accordingly and refer those I will
unable to answer to the physician in order to
clear misconceptions thereby allaying anxiety
• I will explain all procedures to my patient in
order to allay anxiety and gain cooperation.
• I will involve a successfully managed case to
come and talk to my patient in order to allow the
patient ask pressing question and get answer
this will improve the patients out look on his
condition

63. Psychological support
cont
• I will explain the reason for isolation to alley
anxiety
• I will provide diversional therapy in order to
shift the patient’s mind from the hospital
routine and his condition
• I will involve him in planning his own care in
order for him.
• I will explain to him that as the health care
team we are doing everything possible to
ensure that he get better in order to promote
co-operation

64. Hygiene
• I will encourage the patient to take plunge
baths in order to remove dead epithelium
and promote comfort
• I will do hair care to promote self esteem
and also prevent pediculosis
• I will do nail care to prevent auto infection
• I will do mouth care to prevent halitosis
• Any soiled linen and clothes will be changed
to promote comfort

65. Elimination
• I will provide privacy if my patient asks
for a bed pan in order to promote
bowel motions
• I will administer priscribed fluids in
order to promote renal wash out and
maintain hydration
• I will offer a bed pan if he is confined to
bed to ensure bowel movement

66. Nutrition
• I will provide energy giving foods like nshima
to provide the energy needed for the
metabolic processes and promote recovery
of the liver.
• I will provide protein foods like fish and
beans to promote replacement of worn out
tissues
• Food rich in vitamin C such as Vegetables
and fruits will be provided to raise the
immunity and promote skin and mucous
membrane integrity

67. Nutrition cont
• I will provide a lot of oral fluids to
prevent dehydration due to excessive
sweating and promote bringing up of
phlegm
• I will serve small frequent meals to
promote appetite
• I will do regular mouth washes in order
to promote appetite

68. Medication
• I will administer prescribed analgesic like
panadol at the right time to promote rest
• I administer prescribe fluids to prevent
dehydration
• I will ensure that the drugs are swallowed in
my presence to avoid drug withholding by
the patient.
• I will sign on the treatment sheet to avoid
for smooth continuity of care

69. Health education
• I will educate the patient about his condition
in order to create awareness and prevent
recurrence of the condition
• I will explain the need for taking the
medication in order to promote compliance
• I will educate the patient about the sign and
symptoms of the condition for early
diagnosis and treatment
• I will educate the patient about the need to
keep the review dates so that his progress is
monitored to ensure full recovery

70. Health education cont
• I will advise the patient to avoid over
crowding to prevent spread of infection
• I will talk to the patient about the need
to take a balanced diet using locally
available foods in order to boost the
immunity

71. THE END
THANK
YOU!
71