03.03 Hepatitis (Liver Disease)

In this lesson we’re going to explore hepatitis.

As the name suggests, hepatitis is inflammation of the liver. This can be caused by viruses, which is the most common type of hepatitis you’ll see in clinical practice and on the NCLEX, but just know it can also be caused by alcohol abuse, toxins like acetaminophen overdoses, and other autoimmune conditions. Severity of hepatitis can range from mild, where it’s actually self-limiting and we see healthy liver cells regenerating over time, to severe where we see liver cell necrosis and cell death within weeks of onset. Now we’re going to talk mostly about the viral type hepatitis, so one important thing to note is that they could have what’s called an incubation period. That means they may be contagious, but completely asymptomatic for up to two weeks before they start showing symptoms. So we always want to be alert and taking precautions to prevent transmission of these viruses.

So let’s take a quick look at the types of Viral hepatitis. There are 5 types, A, B, C, D, and E, but you will mainly see A, B, and C, especially considering those are the ones that healthcare workers are at risk for. Now, we’ve created a great cheatsheet for you guys with this information on it, so be sure to check it out. So let’s talk about each one of these. Hepatitis A is transmitted via Fecal-Oral route. This doesn’t necessarily mean you’re eating poop, but it does mean that somehow the bacteria have made their way into your mouth. Usually what happens is someone doesn’t wash their hands, then they handle your food or silverware or even doorknobs, and eventually you put the food or silverware or your own hands in your mouth. So to prevent Hep A, we focus hugely on hand hygiene and safe food handling - we see this being transmitted by food workers a lot. There’s also a vaccine for Hepatitis A.

Now, Hepatitis B is transmitted via blood and body fluids. This means any body fluid getting into your bloodstream either from a needle stick or even if it gets into your mucus membranes like your eyes or mouth. It can also be transmitted sexually, so we want to educate our patients on safe sex practices. We also focus largely on hand hygiene and needle safety - never recapping bloody needles, etc. We will also screen at-risk patients and screen donated blood to make sure we aren’t inadvertently transmitting this in blood transfusions. There is also a vaccine for Hepatitis B.

Hepatitis C is the most common one you’ll see and it’s transmitted via blood. Usually through needle sticks or IV drug use. Again we focus on handwashing and needle safety, as well as screening blood donations and high-risk patients like IV drug users. Notice there is NO vaccine for Hepatitis C. One big thing to note here about Hepatitis is that there are NO special precautions, this is all standard precautions. Gloves when in contact with blood or body fluids, and hand washing. Of course if you are about to change a wound dressing or start an IV on a patient with Hepatitis B or C, I always recommend a face shield for extra protection.

You don’t need to know much about Hepatitis D and E except that there are no vaccines for either - hepatitis D is an opportunistic virus that ONLY occurs with Hep B and Hep E is common in underdeveloped countries.

Now, let’s talk assessment. Hepatitis presents in stages. The preicteric stage is when they’re only just starting to feel bad. They may have flu like symptoms like fatigue or body aches, some pain in their right upper quadrant and a low-grade fever. These are pretty nonspecific, so a lot of times they are overlooked. When they patient progresses into the icteric stage, that’s when we start to realize something more severe is going on. We begin to see jaundice, that’s what icteric means. The liver isn’t able to conjugate the bilirubin like it should, so it ends up in our system and shows up as yellow skin, like you see here. This increased bilirubin will also cause dark urine and pruritus which is super itchy skin. We’ll also see their AST, ALT, and ammonia elevate - together these lab values are known as the LFT’s or Liver Function Tests. We’ll also see clay-colored stools because the liver isn’t making bile like it should. As their liver begins to regenerate, they’ll transition into the posticteric stage which is the recovery phase of hepatitis. We’ll see their lab values return to normal, their pain decreases, and their energy levels will increase. It could take anywhere from 2 weeks to 6 months for them to fully feel like themselves again.

While patients are in the icteric stage, we want to manage their symptoms. This means giving lactulose to bind to the ammonia and excrete it in stool, antiemetics for nausea and antihistamines for the itching. We’ll also give antiviral therapy specific to the virus they have. Ultimately, if they don’t recover and their liver progresses to liver failure or cirrhosis, they may require a liver transplant.

Our priorities for a patient with Hepatitis is GI/Liver metabolism - because we know they’re going to lose some of the normal liver function while they’re in the acute stages - infection control - because we want to prevent transmission and treat the virus - and patient education. We know that excessive alcohol consumption or even overuse of acetaminophen can be toxic to the liver, so we need to educate our patients to avoid those, as well as educate them on how to prevent transmission to their loved ones.

So let’s recap quickly. Hepatitis is inflammation of the liver caused by various sources like viruses or toxins and can range from mild to severe, depending on the liver’s ability to regenerate. When it comes to viral hepatitis, prevention of transmission needs to be a top priority. Hepatitis presents in stages and we know that the icteric stage is when they’re showing actual symptoms related to impaired liver function. We are going to support their symptoms during that time with lactulose, antihistamines, antiemetics, and antivirals. If they don’t recovery or progress to liver failure, they may require transplant. And finally, we want to make sure that we educate our patients on things to avoid that could cause damage to their liver and how to prevent transmitting the virus to those around them.

So, that’s it for hepatitis. Be sure to check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!