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hepatitis(hep?a-tit'is) [ hepato- + -itis]
Damage to liver cells is caused by direct injury from the causative agent or indirectly as a result of inflammatory or autoimmune responses. During acute inflammation, the swollen hepatocytes are less able to detoxify drugs; to produce clotting factors, cholesterol, plasma proteins, bile, and glycogen; to store fat-soluble vitamins; or to perform other functions. All of the hepatitis viruses may cause fulminant hepatitis, but hepatitis B and D are the most common causes. Drug overdoses, ingestion of toxins, and shock are also responsible for rapid liver deterioration.
Patients are not generally hospitalized unless they experience significant liver damage or complications; the more severely affected need supportive medical and psychological care. Patients at home should be instructed about the nature and course of the illness, its care and treatment, and signs and symptoms of complications. When hepatitis is food-borne, thorough washing of the hands, food handling, and cleaning of dishes and silverware are necessary to prevent transmission to household members. The patient should avoid intimate contact with others until antigen and antibody levels are reduced. The patient is advised to schedule frequent rest periods and to rest between major activities. Diversionary activities should be included to help reduce anxiety. Good nutrition is encouraged (small, high-calorie, low-protein, nutrient-dense, frequent meals, and fluids to 4 qt (4 L)/day). Fluid intake and output, and weight, color, consistency, and frequency of stools should be recorded. The hospitalized patient is assessed for complications (hepatic coma, pneumonia, vascular problems, and pressure ulcers). The patient is advised to avoid alcohol during the period of acute illness and for at least 6 months after recovery. Depression may occur because of the patient’s concerns about the illness, but the depression may also be linked to changes in body chemistry or adverse drug reactions. Hepatitis is the primary reason for liver transplants, and the concerns of potential need and treatment should be explained to the patient. Emotional support and reassurance should be offered to the patient because there may be considerable interference with the patient's habits and lifestyle. See: ; hepatitis A; autoimmune hepatitis; hepatitis E; fulminant hepatitis
No drugs specifically treat hepatitis A. Immune globulin containing IgG anti-HAV antibodies may be prescribed for family members; it provides passive immunity for 6 to 8 weeks. Preventive education focuses on good personal hygiene, esp. washing of the hands; use of good judgment in choice of food and eating places; and, in some areas of the world, basic sanitation. Hepatitis A vaccine prevents infection either before or immediately after exposure to the virus and is recommended for health care workers, travelers to developing countries, day care workers, people with liver disease, and others at high risk.
CAUTION!Hepatitis A is transmitted by fecal-oral contact. To prevent the spread of the disease, those infected should not be involved in food preparation.
acute anicteric hepatitis
Metronidazole plus iodoquinol, or chloroquine phosphate plus either emetine or dehydroemetine are used to treat amebic hepatitis. These latter two drugs are toxic and should be given only if their course can be carefully observed with a cardiac monitor. The drugs should not be given to a patient who has cardiac disease or is pregnant. Needle aspiration of the abscess may be needed.
The virus is transmitted by exposure to the blood or body fluids of an infected person. The incubation period is approximately 2 to 6 months. Acute infection usually resolves in less than 6 months. When HBV surface antigen does not clear from the blood within 6 months, chronic hepatitis is said to have developed. Each year in the U.S., about 300,000 people are infected with HBV. Worldwide, chronic hepatitis affects about 300 million people.
Those at greatest risk for infection include intravenous drug abusers, people with multiple sex partners, men who have sex with men, infants born of HBV-infected mothers, and health care workers. Blood banks now routinely screen for HBV antigens, which has greatly reduced the transmission of infection by transfusion.
CAUTION!People who have not been vaccinated against HBV and receive a needlestick or have mucous membrane contact with blood or other body secretions should contact their occupational health department. Hepatitis B virus immune globulin (HBIg) can be given to provide temporary protection.
Antigens and Antibodies
The primary antigenic markers used to diagnose hepatitis B infection include the following: 1. hepatitis B surface antigen (HBsAg), the first marker to appear in the blood. It is sometimes detected before serum levels of hepatic enzymes rise; 2. hepatitis Be antigen (HBeAg) and hepatitis B DNA, markers of active viral replication and high infectivity; and 3. Hepatitis B core antibodies (antibodies against the core antigen of hepatitis B), which indicate infection of a patient with HBV. IgM antibodies against the core antigen (IgM anti-HBc) are present early in the course of infection and may sometimes be the only detectable evidence of an acute infection. IgG antibodies against the core antigen (anti-HBc) are present in any patient infected with the virus, either acutely or at some time in the past.
Protective IgG antibodies to the HB surface antigen (HBsAB), which develop late in the disease, persist for life and protect against reinfection. As hepatitis B surface antibody levels rise, HBsAg levels fall, indicating resolution of acute infection. Antibodies against hepatitis B core antigen and hepatitis Be antigen are not protective. Approx. 5% to 10% of patients develop chronic infection.
Hepatitis B vaccine, which contains the HB surface antigen, provides active immunity and is recommended for those at increased risk (children, health care workers, hemodialysis patients, intravenous drug abusers). All pregnant women should be screened for infection. Hepatitis B immune globulin, which contains antibodies against hepatitis HBV, provides passive immunity to those who have not been vaccinated and are exposed to the virus.
No drug therapy is available that controls acute HBV infection, and treatment for this phase of the illness is supportive. Interferon-alfa has been effective in some patients with chronic infection. Antiviral drugs such as adefovir, entecavir, and lamivudine are used to treat chronic hepatitis B infections.
About 30,000 to 40,000 new cases occur each year in the U.S., most of which result from needle sharing during intravenous drug abuse. A smaller number of infections are acquired as a result of exposure to tainted blood at work, e.g., in health care. About 6% of cases are the result of the transmission of the virus from mother to child during childbirth. Tattooing, body piercing, and cocaine snorting are associated with some cases. Sexual transmission of the virus seems rare. Long-term infection develops in 55% to 85% of those infected, and 5% to 20% develop cirrhosis over 20 to 30 years. Chronic hepatitis C infection has become the preeminent cause of cirrhosis, liver cancer, and death from liver failure in the U.S. The incubation period is usually 6 to 12 weeks, although it can be longer, and the acute phase lasts approx. 4 weeks. Signs and symptoms of acute infection are often milder than those of hepatitis A and B.
Infection with hepatitis C virus (HCV) is usually identified (often years after exposure) when an asymptomatic person is found to have repeatedly elevated liver enzymes on routine blood tests. Antibodies to HCV or HCV RNA in the blood confirm the infection. Antibody production is stimulated by HCV RNA, but antibodies against HCV do not destroy the virus or provide immunity.
Antiviral agents such as pegylated alpha interferon in combination with ribavirin and boceprevir may cure hepatitis C if given for prolonged courses (about 24 to 48 weeks, depending on the viral genotype). Genotype 1, the type most often found in the U.S., responds to treatment about 30% of the time. Genotypes 2 and 3 respond to combination therapy more than 60% of the time. The treatment can cause significant side effects, including high fevers, chills, malaise, muscle aches, and other flulike symptoms. Prevention of hepatitis C in health care professionals stresses using safely engineered sharps, providing safe sharps disposal, limiting contact with blood and body fluids, and properly sterilizing instruments. Public health teaching regarding prevention for the general public includes use of properly sterilized instruments for body piercing, single-use needles for tattooing, and avoiding needle sharing and taking advantage of needle-replacement programs (for intravenous drug users). Health care providers can provide invaluable education to affected patients by giving them written and verbal information on high-risk behavior, including the need to avoid needle sharing by users of intravenous drugs, having unprotected sex, or drinking alcohol. Regular consumption of alcohol increases the risk of liver cancer dramatically for a person with HCV.
Other recommendations for people infected with hepatitis C are summarized in the following list: 1. do not donate blood, blood products, tissue, or semen; 2. avoid sharing cosmetic items or personal grooming items that may be contaminated by blood, e.g., toothbrushes or razors; 3. do not use over-the-counter, herbal, or prescription medications unless they have been approved by a knowledgeable health care provider; and 4. get vaccinations for hepatitis A and B to avoid additional viral insults to the liver.
Community support groups and Internet-based resources may help those infected to learn more about disease management, e.g., http://www.liverfoundation.org. Regular professional care may help optimize health and well-being.
Because hepatitis D only occurs in people already infected with hepatitis B, vaccination against hepatitis B helps prevent the spread of this virus.