HEPATIC DISORDERS

ACUTE HEPATITIS

Hepatitis is an acute or chronic inflammation of the liver that can result from infection or non-infectious
reasons. There are 5 types of hepatitis caused by 5 different types of hepatitis virus. E.g, hepatitis A
virus, Hep B virus, Hep C virus, Hep D virus and Hep E virus.

HEPATITIS A

The virus is spread directly or indirectly by the fecal-oral route by ingestion of contaminated foods,
direct exposure to infected fecal material or dose contact with an infected person. The virus is prevalent
in developing countries with poor living conditions, inadequate sanitation, crowding and poor personal
hygiene practices. The average incubation period is about 28days with a range of 15-50 days.

Fecal shadding of the virus can occur for 2 weeks before and after 1 week after the onset of jaundice.
During this time, the individual is asymptomatic the virus is most likely to be transmitted. Infants with
HAV infection are likely to be asymptomatic (anicteric hepatitis). Children often have diarrhea and their
symptoms are frequently attributed to gastroenteritis. The prognosis of HAV is usually good and the
complications are rare.

HEPATITIS B

HBV can be acute or chronic infection, ranging from asymptomatic limited infection to fatal, fulminant
(rapid or severe) hepatitis. Human are the main source of infection. HBV can be transmitted
parenterally, percutaneously or transmucosally. Hepatitis B surface Antigen (HBsAg) has been found in
all body fluids e.g. feces, bile, breastmilk, sweat, tears, vaginal secretions and urine, but only blood,
semen and saliva have been found to contain infectious HBV particles.

Most HBV infection in children is acquired perinataly. Transmission from mother to infant during
perinatal period results in chronic infection in upto 90% of infants in mothers who is positive for HBsAg.
HBV infection occurs in children and adolescents in specific high-risk groups which are;

1. Individuals with hemophi;ia or other disrders who have received multiple transfusions.
2. Children/adolescents involved in IV drug abuse
3. Institutional children
4. Pre-school children in endemic areas.
5. Individuals engaged in sexual activity with an infected partner.

The incubation period of HBV infection ranges from 45-160 days with a range of 120 days.

HEPATITIS C

HCV is the most common cause of chronic liver disease with an estimated 4 million people in the
unitated states. It is transmited parenterally through exposure to blood products from HCV infected
person, whereas perinatal transmission is the most common mode of transmission of children. The
incubation period for HCV ranges from 2-24 weeks with an average of 7-9 weeks. The natural history of
the disease in children is not well defined. Some children maybe asymptomatic, but hepatitis C can
become a chronic condition and can cause cirrhosis and hepatocellular carcinoma.
HEPATITIS D

Occurs rarely in children and must occur in individuals already infected with HBV. HDV is a defective RNA
virus that requires the helper function of HBV. The incubation period is 2-8 weeks but with co-infection
of HBV, the incubation period is similar to an HBV infection. Can occur through blood and sexual contact
and commonly occurs among drug abusers, individuals with hemophilia and persons immigrating from
endemic areas.

HEPATITIS E

HEV was formerly known as non A and non B hepatitis. Transmission may occur through the fecal-oral
route from contaminated water. Incubation period ranges from 15-60 days with average of 40 days. The
illness is uncommon in children, does not cause chronic liver disease, is not a chronic condition and has
no carrier state.

PATHOPHYSIOLOGY

Pathologic changes occur primarily in the parenchymal cells of the liver and results in variables degree of
swelling; infiltration of liver cells by mononuclear cells and subsequent degeneration, necrosis and
fibrosis. Structural changes within the hepatocytes account for altered liver functions, such as impaired
bile secretion, elevated transaminases levels, and decreased albumin synthesis. The disorder maybe self-
limiting with regeneration of liver cells without scarring, leading to a complete recovery. However in
fulminant hepatitis does not result in complete recovery of liver function, characterized by severe, acute
course with massive destruction of the liver tissue causing liver failure and high mortality within 1-2
weeks. The progression of liver disease is characterized pathologically by four stages;

1. Stage one: characterized by mononuclear inflammatory cells surrounding small bile ducts.
2. Stage two: characterized by proliferation of small bile ducts
3. Stage three: characterized by fibrosis or scarring
4. Stage four: cirrhosis

CLINICAL MANIFESTATION

Uncomplicated acute viral hepatitis

Prodromal/anicteric phase (absence of jaundice) last 5-7 days. Presents with; anorexia, malaise,
lethargy, and easy fatigability are common symptoms. Fever presents in adolescents. Nausea and
vomiting and epigastric or right upper quadrant abdominal pain/ tenderness may occur. Arthralgia and
skin rashes common in HBV. Hepatomegaly may present.

Chronic acute hepatitis

Maybe asymptomatic, malaise, fatigue, lethargy, weight loss, abdominal pain, hepatomegaly,
transaminases high level.

Fulminant hepatitis.

Liver failure, encephalopathy, coagulation defects, ascites, deepening jaundice, increased WBCs count.
COMPLICATIONS

GI bleeding, sepsis, renal failure, disseminated coagulopathy

DIAGNOSTIC EVALUATIONS

History taking, physical examination and serologic markers for hepatitis A, B and C.

No LFTS is specific for hepatitis.

Histologic evidence from liver biopsy.

Antibody test; Anti-HAV immunoglobulin G (Ig G) and immunoglobulin M.

THERAPEUTIC MANAGEMENT

Use of steroid drugs (chronic autoimmune hepatitis)

Hospitalization in coagulopathy events.

Human interferon alpha in treatment of chronic HBV/HCV

LAMUVIDIN (HBV) children older than 3 years.

ADENOFOVIR (HBV) older than 12 years.

ENTECAVIR (HBV) 16years and older.

NURSING MANAGEMENT

Educate on proper sanitation.

Encourage mouth care before and after meals.

Monitor hydration through input and out put.

Encourage the patient to eat meals in a sitting position to reduce pressure in the liver.

Encourage rest during symptomatic phase according to level of fatigue.

Explain precaution about transmission and prevention of transmission to patients and family.

PREVENTION

Proper hand washing and standard precautions.

Prophylactic use of standard immune globulin and HBV vaccination

Routine serologic testing for anti-HCV.

NURSING DIAGNOSIS

Imbalanced nutrition less than body requirement related to anorexia

Risk for deficient fluid volume related to vomiting and diarrhea.

Fatigue related to episodes of discomfort

Risk for impaired skin integrity related to bile salt accumulation in the tissues.

PROGNOSIS

Depends on the type of virus and the child age and immunocompetency. Hepatitis A and E are usually
mild, brief illness with no carrier state. HBV can cause a wide spectrum of acute and chronic illness.
Infants are more likely than older children to develop chronic hepatitis. Hepatitis C frequently becomes
chronic and cirrhosis may develop in this children.

REFFRENCE

Hockenberry M. Wongs Essentials of Pediatric Nursing 8TH Ed. Ed. Mosby 2009.