Guidelines 2016 – STDs: Hepatitis
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Hepatitis is an acute or chronic inflammation of the liver with or without permanent tissue damage and can be caused by many viruses, including influenza viruses, mononucleosis, and cytomegalovirus (CMV); there are also hepatitis viruses whose only target is the liver. At least six types of hepatitis are known at present and are designated by the letters A, B, C, D, E, and G.
II. ETIOLOGY
HEPATITIS 303
A. Causative organisms include hepatitis viruses A to E and G, mononucleosis virus, CMV, and various influenza viruses.
1. Hepatitis A virus (HAV) is transmitted enterically—fecal–oral route (rarely parenterally) with an incubation period of 15 to 50 days; 28-day average.
2. Hepatitis B virus (HBV) is transmitted parenterally or sexually through body fluids—highest concentration in the blood, perinatally, or from saliva from human bites; incubation period of 6 weeks to 6 months.
3. Hepatitis C virus (HCV) is transmitted parenterally and permucosally, with an incubation average of 1 to 3 weeks for detection of HCV RNA in blood and 8 to 9 weeks to seroconversion for the antibody; it is a major cause of posttransfusion hepatitis. It is thought that sexual and perinatal transmission may be possible, the former among HIV-infected men who have sex with men; the latter is rare unless the mother is coinfected with HIV.
4. Hepatitis D virus (HDV), also known as delta virus, only affects persons who have active hepatitis B; it is transmitted parenterally, sexually, and perinatally. The incubation period is 3 to 13 weeks.
5. Hepatitis E virus (HEV) is transmitted enterically (rarely parenterally) with incubation period 15 to 60 days, mean of 40 days. It is spread by fecally contaminated water.
6. Hepatitis G, also called GB virus—percutaneous route, posttransfusion disease; associated with chronic hepatitis C; noted especially in drug users.
III. HISTORY
A. What the patient may present with
1. Right upper quadrant pain (may be intermittent)
2. Loss of appetite
3. Malaise, fatigue (increased sleep, decreased activity level, libido)
4. Fever, often low grade
5. Flulike symptoms, including headache
6. Adenopathy
7. Jaundice
8. Nausea and vomiting
9. Rash, hives
10. Joint and muscle pain
11. Darkened urine
12. Light-colored stools
13. Taste and smell peculiarities
14. Intolerance of fatty foods, cigarettes
B. Additional information to consider
1. Use of recreational drugs
2. Alcohol use, quantity, and frequency
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3. Medication use (including nontraditional remedies, herbal preparations)
4. If partner is an injectable drug user
5. Recent transfusion of blood or blood products
6. Recent surgery
7. Eating raw or undercooked shellfish
8. Day care worker or has child/children in day care
9. Occupational risks, including exposure to body fluids, excrement; blood, blood products
10. Sexual history and habits, especially anal intercourse; number of partners; use of sex toys; human bites
11. History of STIs
12. Sexual partner and/or household member with symptoms
13. Known exposure to someone with hepatitis
14. Military or civilian service in the Middle East; travel to Africa, Asia, Central and South America, Eastern Europe, or Alaska
15. History of hepatitis B
16. Visited or from disease-endemic areas of the world
17. Hemodialysis patient; transplant recipient; hemophiliac
18. Inmate of correctional institution
19. Contraceptive history
20. History of needlestick injury, tattoos, body piercing; acupuncture, sharing toothbrushes, razors, nail files, clippers
21. Infants of HBV and HCV mothers
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Pulse
3. Respirations
4. Blood pressure
B. Abdomen
1. Liver percussion, palpation
2. Observation of skin color, turgor
3. Organomegaly, tenderness
4. Masses
5. Adenopathy
C. Complete physical examination with careful attention to
1. Skin: rash, hives, color, turgor
2. Joints: joint pain on range of motion; muscle pain
3. Adenopathy
V. LABORATORY EXAMINATION
A. Feces for virus
B. Liver function tests
C. Mononucleosis screen
HEPATITIS 305
D. Serology to determine type of HAV: IgM (immunoglobulin M) anti-HAV in serum with acute or convalescent phase (5–10 days into incubation up to 6 months); HBV: several, including HBV surface antigen (HBsAg), anti-Hepatitis B core total antibodies (IgM anti-HBc total) HCV: test for antibody with EIA or enhanced chemiluminescence assay, possible supplemental antibody test; HDV: HBsAg, anti-HDV; HEV: IgM anti-HEV, IgG anti-HEV; HGV: PCR testing, test for HAV, HBV, HCV, HDV, HEV
E. CMV
F. HIV testing
G. In severe hepatitis, serum albumin, prothrombin and partial thromboplastin times, electrolytes, glucose, complete blood cell count (CBC), platelets
H. Pregnancy test
VI. DIFFERENTIAL DIAGNOSIS
A. Infectious mononucleosis
B. Primary or secondary hepatic malignancy
C. Ischemic hepatitis
D. Drug-induced hepatitis
E. Alcoholic hepatitis
F. Acute fatty liver (acute fatty metamorphosis) of pregnancy
VII. TREATMENT
A. As needed according to laboratory report and etiology; generally referral for medical management and follow-up
B. Supportive for symptoms
1. No alcohol during acute phase of hepatitis and for 6 to 12 months thereafter
2. Adequate calories; balanced diet
C. Interferon is being used for HBV and HCV.
D. Gamma globulin to household and day care center contacts for hepatitis A within 2 weeks of exposure
E. Prevention for hepatitis B: for exposed persons, HBV hyperimmune globulin and then hepatitis B vaccination after antibody testing
F. Prevention for hepatitis D: hepatitis B vaccination; Twinrix
G. HAV recovery not aided by activity limitation; isolate food handlers with HAV; prevention for HAV with Havrix or Twinrix vaccine
VIII. COMPLICATIONS
A. Hepatitis A: rarely fatal, no chronic form, fulminant hepatitis, relapse
B. Hepatitis B: death; chronic disease in 5% to 10% of victims; of these, 50% develop chronic liver disease, leading to hepatocellular carcinoma in half of the cases; fulminant hepatitis, transmission to fetus 10% to 85%
C. Hepatitis C: More than 50% of cases become chronic; cirrhosis; hepatocellular carcinoma; perinatal transmission
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D. Hepatitis D: chronic liver disease, fulminant hepatitis
E. Hepatitis E: high mortality in pregnancy (fetus and mother); no reported chronic cases
F. Hepatitis G: little information to date
IX. CONSULTATION/REFERRAL
For medical treatment and follow-up
X. FOLLOW-UP
A. As appropriate for type of hepatitis
B. Encourage hepatitis B vaccination of those who have not had disease; schedule three-dose administration; okay in pregnancy and lactation
C. Repeat laboratory work as indicated for monitoring liver function after illness
D. Test for chronic HBV with serum assay for HBsAg
E. Encourage HAV vaccination for persons at increased risk
F. Note availability of Twinrix—HAV and HAB combined three-dose vaccine
See Bibliographies.
Website: www.cdc.gov/std/treatment/2010/default.htm