Chapter 12: Gastrointestinal Disorders 157
Management
Themanagementofacuteviralhepatitisissupportive.Bed
restisrecommendedduringtheperiodofacutesymptoms.
Antiemetics and intravenous uids are administered as
neededifnauseaandvomitingarepronounced.Incases
of fulminant hepatitis, support with intravenous uids,
electrolyte replacement, and blood products is usually
needed. Hepatic encephalopathy is treated with a low-
proteindietandeitherorallactuloseorneomycintoinduce
diarrheaandcleansingofthebowel.Sedativesshouldbe
avoided.Livertransplantationisanoptionforfulminant
hepaticnecrosis.
ChronicHBVandHCVmaybetreatedwithpegylated
interferon or a nucleoside or nucleotide analog, depending
onthepatient’slevelofviralactivity.Thisimprovesabout
35 to 40 percent of the cases of chronicHBV infection;
signicantlyfewerpeoplewithHCVexperienceimprove-
mentduringandfollowinginterferontherapy.
1,2
ForpreventionofhepatitisB,avaccineisavailableand
currentlylicensedforuseintheUnitedStates.
3
Thevaccine
consistsofarecommendedseriesofthreetofourintramus-
cularinjectionsofvaccinetoinduceprotectiveimmunity
ingreaterthan90percentofhealthyadults.TheCenters
forDiseaseControlandPrevention(CDC)AdvisoryCom-
mittee on Immunization Practices recommends vaccina-
tion of select high-risk groups, including persons with
occupationalrisk(healthcareworkers),clientsandstaffof
institutionsforthedevelopmentallydisabled,hemodialysis
patients, recipients of certain blood products, household
contactsandsexpartnersofHBVcarriers,adopteesfrom
countries where HBV infection is endemic, international
travelers, injection drug users, sexually active men and
women, and inmates of long-term correctional facilities.
The CDC also recommends vaccinating all infants and
childrenintheUnitedStates,alladultsathighriskforHBV
infection,andanyonewhorequeststhevaccine.
4
AvaccineisalsoavailableforhepatitisA.Thevaccineis
givenbyoneintramuscularinjectionfollowedbyabooster
dose6–18monthslater.TheCDCrecommendsvaccination
ofallchildrenattheageof1year.Inaddition,vaccination
isrecommendedforpersonslivinginortravelingtoendemic
areas, patients with chronic liver disease or clotting factor
disorderstreatedwithconcentrates,menwhohavesexwith
men,illicitdrugusers,personswhoworkwithHAVina
laboratory setting, and children and caregivers in day care
centers.Vaccinationof allchildrenbetweenages1and2
yearsintheUnitedStatesisalsorecommended.
4
Lifestyle Changes: Practical Tips for Your
Patients
HAVoftenoccursinepidemicswhenwaterbecomes
contaminatedwithsewage.Outbreakscanbetraced
toeatinguncookedshellsh,particularlyoystersfrom
contaminated waters. During reported outbreaks,
peopleshouldnoteatrawshellshorothercontami-
natedfoodstuffsfromtheareawheretheoutbreakis
occurring.
HBVisasexuallytransmitteddisease.Safe-sexprac-
tices,includinguseofcondomsandnotsharingbody
uids,mayreducetheriskofinfection.HCVisprimar-
ilytransmittedbyinjectiondruguse.Theriskofsex-
ual,anal,andmaternaltofetaltransmissionislow.
Pancreatitis
General Characteristics
The pancreas (Figure 12–1) has both exocrine and endo-
crinefunctions.Theexocrinefunctionistosecreteuidinto
theintestine,whichcontainsenzymesthataidinthediges-
tion of fats, carbohydrates, and proteins. The endocrine
function of the pancreas is to secrete insulin and glucagon,
whichareofprimaryimportanceinglucosemetabolism.
Pancreatitisis an inammatory condition of the pan-
creasthatmaybeanacuteorchronicprocess.Recovery
fromacutepancreatitisisusuallycomplete,withrestora-
tionofnormalpancreaticfunction.However,chronicpan-
creatitis can lead to permanent pancreatic dysfunction,
whichresultsinmalabsorptionoffood.Table 12–3 lists the
mostcommoncausesofpancreatitis.
Signs, Symptoms, and Diagnosis
Themost commonsymptom of acutepancreatitisis the
generallysuddenonsetofepigastricabdominalpainthat
radiatestothebackandcanbedescribedasintense,deep,
andsearing.
5
Thepainmayalsoradiatetotheupperquad-
rants of the abdomen and is often worse when lying
supine.Themajorityofpatientsalsoexperiencefever,nau-
sea, and vomiting. On physical examination, hypoactive
bowel sounds and abdominal tenderness are usually
present.Patientsmaybetachycardicandhypotensive.The
Table 12–3
Causes of Acute and Chronic Pancreatitis
Miscellaneous Drugs
Cholelithiasis Oral contraceptives
Alcohol use Tetracyclines
Hypertriglyceridemia Thiazide diuretics
Infections (viral, bacterial,
parasitic)
Furosemide
Abdominal trauma Pentamidine
Abdominal surgery Azathioprine
Autoimmune Simvastatin
Heredity (autosomal
dominant)
Metronidazole
Penetrating peptic ulcer
Cystic brosis

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