HEPATIC ENCEPHALOPATHY

& VIRAL HEPATITIS

Adrian B. Arenas
BSN 3-1
 HEPATIC ENCEPHALOPATHY

Hepatic encephalopathy or portosystemic

encephalopathy, is a life-threatening
complication of liver disease that occurs with
profound liver failure.
Hepatic encephalopathy is the
neuropsychiatric manifestation of hepatic
failure associated with portal hypertension
and the shunting of blood from the portal
venous system into the systemic blood
circulation.
 PATHOPHYSIOLOGY
Despite the frequency with which the hepatic
encephalopathy occurs, the precise pathophysiology
is not fully understood
To major alterations underlie its development in
acute and chronic liver disease:
Hepatic insufficiency may result in encephalopathy
because of the inability of the liver to detoxify toxic
by-products of metabolism.
Portosystemic shunting, in which collateral vessels
develop as a result of portal hypertension allows
elements of the portal blood to enter the systemic
circulation
 PATHOPHYSIOLOGY
Ammonia is considered the major etiologic factor in the
development of encephalopathy.

Ammonia enters the brain

Excites peripheral benzodiazepine -type receptors on astrocyte

cells

Stimulates gamma-aminobutyric acid neurotransmission

Producing sleep and behavior patterns associated with hepatic

encephalopathy
 CLINICAL MANIFESTATION

The earliest symptoms of hepatic

encephalopathy include mental status
changes and motor disturbances.
Confused
Unkempt
Alterations in mood and sleep patterns
Asterixi, an involuntary flapping of the hands,
may be seen in stage II encephalopathy
 ASSESSMENT AND
DIAGNOSTIC FINDINGS
Electroencephalogram shows generalized
slowing, an increase in the amplitude of brain
waves, and characteristic triphasic waves.
The survival rate after a first episode of overt
hepatic encephalopathy in patients with
cirrhosis is approximately 40% at 1 year.
Patients should be referred for liver
transplantation after this initial episode
 MEDICAL MANAGEMENT
Lactulose is administered to reduce serum ammonia
levels. It acts by trapping and expelling the ammonia
in the feces
Two or three soft stools per day are desirable; this
indicates that lactulose is performing as intended.
Possible side effects of lactulose include intestinal
bloating and cramps, which usually disappear within
a week.
Other management strategies include:
IV Administration of glucose to minimize protein breakdown
Administration of vitamins
Antibiotics may also be added to the treatment regimen
 NURSING MANAGEMENT

The nurse is responsible for maintaining a

safe environment to prevent injury, bleeding,
and infection.
The potential for respiratory compromise is
great given the patients depressed neurologic
status.
The nurse encourages deep breathing and
position changes
 VIRAL HEPATITIS
Viral hepatitis is a systemic, viral infection in which
necrosis and inflammation of liver cells produce a
characteristic cluster of clinical, biochemical, and
cellular changes.
To date, five definitive types of viral hepatitis that
cause liver disease have been identified:
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Hepatitis A and E are similar in mode of
transmission, whereas hepatitis B, C, and D share
many other characteristics
 HEPATITIS A VIRUS

Hepatitis A, formerly called infectious

hepatitis, is caused by an RNA virus of the
enterovirus family.
This form of hepatitis is transmitted primarily
through the fecal-oral route.
Hepatitis A can be transmitted during sexual
activity; this is more likely with oral-anal
contact or anal intercourse and with multiple
sex partners.
 CLINICAL MANIFESTATIONS

Many patients are anicteric and symptomless

When symptoms appear, they resemble those
of a mild, flulike upper respiratory tract
infection, with low-grade fever
Anorexia, an early symptom, is often severe.
Later, jaundice and dark urine may become
apparent
Indigestion is present in varying degrees,
marked by vague epigastric distress, nausea,
heartburn, and flatulence.
 ASSESSMENT AND
DIAGNOSTIC FINDINGS
The liver and spleen are often moderately
enlarged for a few days after onset; other than
jaundice, there are few other physical signs
Hepatitis A antigen may be found in the stool
7 to 10 days before illness and for 2 to 3
weeks after symptoms appear
 PREVENTION
Scrupulous hand hygiene, safe water supplies, and
proper control of sewage disposal are just a few of
these prevention strategies
Effective and safe HAV vaccines include Havrix and
Vaqta
Hepatitis A vaccine is recommended for people
traveling to locations where sanitation and hygiene
are unsatisfactory
Vaccination is also recommended for those from
high-risk groups, such as homosexual men, IV or
injection drug users, staff of day care centers, and
health care personnel
 MEDICAL MANAGEMENT

Bed rest during the acute stage and a

nutritious diet are part of the treatment and
nursing care
During the period of anorexia, the patient
should receive frequent small feedings,
supplemented if necessary by IV fluids with
glucose
 NURSING MANAGEMENT

Management usually occurs in the home

unless symptoms are severe
The nurse assists the patient and family in
coping with the temporary disability and
fatigue that are common in hepatitis and
educates them to seek additional health care
if the symptoms persist or worsen
 HEPATITIS B VIRUS

Unlike HAV, the hepatitis B virus (HBV) is

transmitted primarily through blood
HBV can be found in blood, saliva, semen, and
vaginal secretions and can be transmitted
through mucus membranes and breaks in the
skin
Screening of blood donors has greatly reduced
the occurrence of hepatitis B after blood
transfusion
 GERONTOLOGIC
CONSIDERATIONS
The immune system is altered in the aged
A less responsive immune system may be
responsible for the increased incidence and
severity of hepatitis B among older adults and
the increased incidence of liver abscesses
secondary to decreased phagocytosis by the
Kupffer cells
The older patient with hepatitis B has a
serious risk of severe liver cell necrosis or
fulminant hepatic failure, particularly if other
illnesses are present
 CLINICAL MANIFESTATIONS
Clinically, HBV closely resembles hepatitis A, but the
incubation period is much longer
Fever and respiratory symptoms are rare; some
patients have arthralgias and rashes
Patient may also have:
Loss of appetite
Dyspepsia
Abdominal pain
Generalized aching
Malaise
Weakness
 ASSESSMENT AND
DIAGNOSTIC FINDINGS
HBV is a deoxyribonucleic acid (DNA) virus
composed of the following antigenic particles:
HBcAg hepatitis B core antigen
HBsAg hepatitis B surface antigen
HBeAg an independent protein circulating in the
blood
HBxAg Gene product of X gene of HBV DNA
Antibodies
Anti-HBc antibody to core antigen of HBV
Anti-HBs antibody to surface determinants on HBV
Anti-Hbe antibody to hepatitis B e-antigen
Anti-HBxAg antibody to the hepatitis B x-antigen
 PREVENTION

Prevention Transmission
Continued screening of blood donors for the presence of
hepatitis B antigen (HBAg) further decreases the risk of
transmission by blood transfusion
The use of disposable syringes, needles, and lancets and the
introduction of needleless IV administration systems have
reduced the risk of spreading this infection from one patient to
another or to health care personnel

Active Immunization: Hepatitis B Vaccine

Active immunization is recommend for people who are at high
risk for hepatitis B
In addition, people with hepatitis C and other chronic liver
diseases should receive the vaccine
 PREVENTION

Passive Immunity: Hepatitis B

Immune Globulin
Hepatitis B immune globulin (HBIG) provides passive
immunity to hepatitis B and is indicated for people
exposed to HBV who have never had hepatitis B and
have never received hepatitis B vaccine
Both active and passive immunization are
recommended for people who have been exposed to
hepatitis B through sexual contact
 MEDICAL MANAGEMENT
Goals are to minimize infectivity and liver
inflammation and decrease symptoms.
Of all the agents that have been used to treat
chronic type B viral hepatitis, Alpha-interferon is the
single modality of therapy that offers the most
promise.
Two antiviral agents, lamivudine and adefovir, which
are oral nucleoside analogues, have been approved
for use in chronic hepatitis B in the United States
Bed rest may be recommended until the symptoms
of hepatitis have subsided
Adequate nutrition should be maintained
 NURSING MANAGEMENT

Convalescence may be prolonged, with

complete symptomatic recovery sometimes
requiring 3 to 4 months or longer.
The nurse identifies psychological issues and
concerns, particularly the effects of
separation from family and friends if the
patient is hospitalized during the acute and
infective stages
 HEPATITIS C VIRUS
Blood transfusions and sexual contact once
accounted for most cases of hepatitis C in the
United States, but other parenteral means,
such as sharing of contaminated needles by IV
or injection drug users and unintentional
needlesticks and other injuries in health care
workers now account for a significant
numbers of cases.
The incubation period is variable and may
range from 15 to 160 days.
 HEPATITIS C VIRUS

The clinical course of acute hepatitis C is

similar to that of hepatitis B
However, a chronic carrier state occurs
frequently, and there is an increased risk of
chronic liver disease
Studies have demonstrated that a
combination of two anti-viral agents
peginterferon and ribavirin is effective in
producing improvement in patients with
hepatitis C and in treating relapses
 HEPATITIS D VIRUS
Hepatitis D virus infection occurs in some cases of
hepatitis B
Hepatitis D is common among:
IV or injection drug users
Hemodialysis patients
Recipients of multiple blood transfusions
Sexual contact with those who have hepatitis B is
considered to be an important mode of transmission
of hepatitis B and D
The incubations period varies between 30 to 150
days
 HEPATITIS E VIRUS

It is believed that hepatitis E (HEV) is

transmitted by the fecal-oral route
Incubation period is variable, estimated to
range between 15 and 65 days
In general, hepatitis E resembles hepatitis A
Avoiding contact with the virus through good
hygiene, including hand washing, is the major
method of prevention of hepatitis E
 HEPATITIS G AND GB VIRUS-C
Incubation period for posttransfusion hepatitis is 14
to 145 days, too long for hepatitis B or C
Another form of hepatitis, referred to as hepatitis G
virus or GB virus-C.
The clinical significance of this virus remains
uncertain
Risk factors are similar to those for hepatitis C