Hepatitis
A fairly common systemic disease, viral hepatitis is marked by hepatic cell destruction, necrosis, and autolysis, leading to anorexia, jaundice, and hepatomegaly. In most patients, hepatic cells eventually regenerate with little or no residual damage, allowing ready recovery. However, old age and serious underlying disorders make complications more likely. The prognosis is poor if edema and hepatic encephalopathy develop.
More than 70,000 cases are reported annually in the United States. Today, six types of viral hepatitis are recognized.
Causes
The major forms of viral hepatitis result from infection with the causative viruses: A, B, C, D, E, and G.
Type A hepatitis is highly contagious and is usually transmitted by the fecal-oral route, commonly within institutions or families. However, it may also be transmitted parenterally. Hepatitis A usually results from ingestion of contaminated food, milk, or water. Outbreaks of this type are commonly traced to ingestion of seafood from polluted water.
Type B hepatitis, once thought to be transmitted only by the direct exchange of contaminated blood, is now known to be transmitted also by contact with contaminated human secretions and feces. As a result, nurses, physicians, laboratory technicians, and dentists are frequently exposed to type B hepatitis, often from wearing defective gloves. Transmission of this type also occurs during intimate sexual contact and through perinatal transmission.
Hepatitis type C is a blood-borne illness transmitted primarily through blood transfusions and by needle sharing among I.V. drug users. Transfusions cause 80% of posttransfusion hepatitis, which is seldom an acute disease, but 90% of infected persons develop chronic infections. Type C was formerly labeled non-A, non-B hepatitis.
Type D hepatitis is found primarily in patients with an acute or a chronic episode of hepatitis B. Type D infection requires the presence of the hepatitis B surface antigen; the type D virus depends on the double-shelled type B virus to replicate. For this reason, type D infection can’t outlast a type B infection.
Type E hepatitis is a form of hepatitis that is transmitted enterically and is often water-borne. Because the virus is inconsistently shed in stools, detection is difficult. Outbreaks of Type E hepatitis have occurred in developing countries.
Hepatitis G is a newly identified virus. It’s thought to be blood-borne, with transmission similar to hepatitis C.
Complications
Life-threatening fulminant hepatitis is the most feared complication. Developing in about 1% of patients, it causes unremitting liver failure with encephalopathy. It progresses to coma and commonly leads
to death within 2 weeks. (See Recognizing fulminant hepatitis.)
to death within 2 weeks. (See Recognizing fulminant hepatitis.)
Life-threatening complicationsRecognizing fulminant hepatitis
A rare but severe form of hepatitis, fulminant hepatitis rapidly causes massive liver necrosis. It usually occurs in patients with hepatitis B, hepatitis D, or enteric type E hepatitis. Although the mortality is extremely high (more than 80% of patients lapse into a deep coma), patients who survive may recover completely.
Assessment
In a patient with viral hepatitis, suspect fulminant hepatitis if you assess confusion, somnolence, ascites, and edema. Suggestive diagnostic test results include rapid liver shrinkage, a rapidly rising bilirubin level, and a markedly prolonged prothrombin time.
As the disease swiftly progresses to the terminal phase, the patient may experience cerebral edema, brain stem compression, GI bleeding, sepsis, respiratory failure, cardiovascular collapse, and renal failure.
Emergency interventions
Notify the physician immediately. Then prepare to transfer the patient to the intensive care unit.
Provide supportive care, such as maintaining fluid volume, supporting ventilation through mechanical means, controlling bleeding, and correcting hypoglycemia.
Restrict protein intake, as ordered.
Expect to administer oral lactulose or neomycin and, possibly, massive doses of glucocorticoids.
If necessary and if the patient meets the criteria, prepare him for a liver transplant.
Major complications may be specific to the type of hepatitis:
Chronic active hepatitis may occur as a late complication of hepatitis B.
During the prodromal stage of acute hepatitis B, a syndrome resembling serum sickness, characterized by arthralgia or arthritis, rash, and angioedema, may occur. This syndrome may cause misdiagnosis of hepatitis B as rheumatoid arthritis or lupus erythematosus.
Primary liver cancer may develop after infection with hepatitis B or C.
Type D hepatitis can cause a mild or asymptomatic form of type B hepatitis to flare into severe, progressive chronic active hepatitis and cirrhosis.
Weeks to months after apparent recovery from acute hepatitis A, relapsing hepatitis may develop.
Rarely, hepatitis may lead to pancreatitis, myocarditis, atypical pneumonia, aplastic anemia, transverse myelitis, or peripheral neuropathy.
Assessment
Investigate the patient’s history for the source of transmission. For example, you may learn that he was recently exposed to individuals with hepatitis A or B; underwent recent blood transfusions or used I.V. drugs; or had hemodialysis for renal failure. Look for evidence of recent ear piercing or tattooing (significant because contaminated instruments can transmit hepatitis); travel to a foreign country where hepatitis is endemic; or living conditions that are, or were, overcrowded.
Be sure to ask about alcohol consumption, which holds paramount significance in suspected cirrhosis. Remember, the alcoholic often deliberately underestimates how much he drinks, so you may need to interview family members as well.
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