A N A LY S I S O F C L I N I C A L R E A S O N I N G

CHRONIC HEPATITIS C

Janine HammondDuke School of Nursing

CASE PATIENT

• 65 year old Caucasian male• Reason for visit: follow up for anemia• HPI: Pt found to be anemic with Hgb 6.3 at last

visit , 1 week ago, transfusion of 2 units PRBCs ordered and completed. His symptoms of pallor, weakness, reduced endurance, gastric pain not related to food intake and SOB are improving per pt. He reports that melena has resolved. He was started on iron therapy.

SUBJECTIVE

• PMH: Hepatitis C genotype 2 diagnosed in 2010 , 3 failed treatment regimens (2 in NJ, 1 at Duke), cirrhosis, encephalopathy 2010 & 2012, bladder cancer 2011, pulmonary HTN, gout, MVA 1979 requiring splenectomy and blood transfusion, PVD, GERD, HTN• PSH: Splenectomy 1979, reduction femur fracture

1979, TURBT 2011 & 2013, EGD 2011-no varices, liver biopsy 2012-cirrhosis• Family Hx: negative for cirrhosis or cancer.

mother: MI, HTN, died age 86, father: CVA, died age 80. One sister, 62, HTN, cardiac nurse.• Allergies: NKDA, No food allergies

SUBJECTIVE

• Social Hx: Divorced, lives alone, retired professor of psycho-biology, moved from NJ to NC after Hurricane Sandy destroyed his house. Has one son in Utah. No local family, attends Church of LDS, a few friends. He has a long alcohol abuse history with several admissions for detox. He is currently drinking 2-3 glasses of wine per day. He refuses AA. Is working with a program through the church but still struggles. Had 157 days of sobriety last year “but had the worst edema ever” which he refers to as a lack of need for cessation. Quit smoking 10 yrs ago. He denies any illicit drug use/IV drug use.

• Sexual Hx: Heterosexual, Denies sex with men

CURRENT MEDICATIONS

• Nadolol 20 mg daily• Spironolactone 50 mg bid• Torsemide 20 mg 1 or 2 daily prn edema• Lactulose 20 mg q6h prn• Xifaxan 550 mg bid• Omeprazole 20 mg daily• Aspirin EC 81 mg daily• Vitamin D3 1000 units daily• Vitamin B12 250 mcg daily

HEALTH MAINTENANCE

• Hepatitis A vaccine: received in NJ• Hepatitis B vaccines: received in NJ• Pneumovax: 02/2014• Flu vaccine: 10/2014• Colonoscopy: 2012 normal• Tetanus: 2014

REVIEW OF SYSTEMS

• General: Denies sleep disturbance. Mild fatigue improving since transfusion, no sleep disturbance, no weight change.• Eyes: No changes in vision. No yellowing of sclera

noted by pt.• Heme/Lymph: No easy bleeding, does bruise

easily. No enlarged or tender lymph nodes.• CV: No chest pain or SOB. Can climb full flight of

stairs with mild dyspnea.• Resp: No wheezing, cough or orthopnea.

REVIEW OF SYSTEMS

• GI: No nausea, vomiting, diarrhea or constipation. No heart burn or trouble swallowing.• GU: No hematuria. No dysuria, hesitancy,

frequency or incontinence.• Integumentary: No rashes or lesions. Reports

several small bruises on forearms. • Neuro: No headaches, numbness, tingling, or

tremors.• Psych: No depression, anxiety, hallucinations.• Extremities: Lower ext edema “3”(1-10). Shoes

fitting normally.

OBJECTIVE

Physical Exam• T- 98° f, HR-60 reg, RR-16, BP-102/48, wt-256 lb, ht- 69in, BMI- 37.8 kg/m2

• General: Alert, conversant, NAD.• Eyes: PERRL, No scleral icterus. Disc margins

sharp. No hemorrhages or exudates.• Heme/Lymph: No petechial hemorrhages, no

lymphadenopathy.• CV: S1S2, RRR, no murmurs, rubs or gallops. No

JVD.• Resp: Lungs clear to auscultation bilat, resp

unlabored.

OBJECTIVE

• GI: Abd soft, obese with active BS X4. No pulsations. Liver 10 cm at right MCL, palpated 3 cm below costal margin, smooth. No ascites noted.• Integumentary: No rashes or lesions. Several

small bruises in various stages of healing on forearms. No icterus.• Neuro: Alert, oriented X 4. Normal strength and

sensation. No asterixis. No tremors. • Extremities: Atraumatic, no deformities. Lower ext

edema 1+ pitting up to mid calf.

LABS/DIAGNOSTICS

• H&H- 8.8 & 29 (post transfusion)• Albumin 3.0 (3.5-4.8 g/dL)• Total Bilirubin 4.9 (0.4-1.5 mg/dL)• Alkaline Phosphatase 154 (24-110 U/L)• AST 71 (15-41 U/L)• ALT 46 (17-63 U/L)• Reticulocyte% 2.90 (0.70-2.00 %)• Immature reticulocyte 34.0 (3.1-16.0 %)• Hepatitis C viral load (2013) >1,000,000 IU/ml• Pugh Child class B cirrhosis

ASSESSMENT

• Chronic Hepatitis C 070.54• Cirrhosis 571.0• Anemia 285.9• Alcohol abuse, habitual 303.9

HEPATITIS C (HCV)• Major cause of chronic liver disease and cirrhosis• In US~ estimated 2.7 million chronically infected• SC- 3,238 chronic HCV cases reported in 2013 (CDC,

2015)• Cases expected to increase due to large numbers of

people infected in 1960’s-1970’s• 2013 cost of HCV infection ~$6.5 billion• ~80% of infections progress to chronic state• ~20% of acute infections clear completely• Transmission through blood or body fluids• 6 genotypes- in US 97% are types 1,2, or 3• Effects thought to involve direct hepatocyte damage

and immune mediated chronic inflammation(Wilkins, Akhtar, Gititu, Jalluri, & Ramirez, 2015)

HEALTH MAINTENANCE

• Protect the liver from further harm:• Consider hepatitis A and B vaccination • Reduce or discontinue alcohol consumption• Avoid new medicines, including over-the-counter and herbal

agents without first checking with health-care provider• For persons overweight (BMI ≥25kg/m2) or obese (BMI

≥30kg/m2):• Consider weight management or losing weight• Follow a healthy diet and stay physically active

• To minimize the risk for transmission to others:• Do not donate blood, tissue, or semen• Do not share appliances that might come into contact with blood,

such as toothbrushes, dental appliances, razors, and nail clippers

Smith et al., 2012

GOAL OF CIRRHOSIS MANAGEMENT

• Prevent and treat complications that lead to decompensation• Ascites• Esophageal variceal bleeding • Pulmonary vascular complications• Hepatic encephalopathy• Hepatocellular carcinoma• immunizations in cirrhotic patients

Werner, 2012

MANAGEMENT OF CIRRHOSIS• Ascites• Most common complication of ESLD• ~10% of cirrhosis patients• Associated with 50% mortality in 5 years• 2 gram sodium restriction• Diuretic therapy• Combination of distal tubule diuretic, like spironolactone, and

loop diuretic, such as furosemide, beginning at 100 mg and 40 mg with max doses of 400 mg and 160 mg

• This ratio usually sustains normokalemia• Monitor regularly for electrolyte imbalance, over-diuresis and

renal function• Refractory ascites may require paracentesis or transjugular

intrahepatic portosystemic shunt (TIPS)• Poor prognosis, consider liver transplant

Werner, 2012

MANAGEMENT OF CIRRHOSIS

• Pulmonary vascular complications• Pulmonary hypertension can lead to hepatopulmonary

syndrome (HPS) or portopulmonary hypertension (POPH). • Clinical presentation:• Dyspnea on exertion• Fatigue• Lower extremity edema• Lightheadedness• Orthopnea• Elevated jugular vein pressure• Accentuated pulmonic second heart sound• Murmur

• No treatment, send to hepatic specialist, may require liver transplant

Werner, 2012

MANAGEMENT OF CIRRHOSIS

• Hepatic encephalopathy• Occurs in 27-75% of patients with cirrhosis• Can be precipitated by sepsis, GI bleed, constipation,

protein overload, dehydration, electrolyte imbalance, use of sedatives, poor compliance with lactulose, diabetes, development of hepatocellular carcinoma

• Treatment: Lactulose 30 gm bid, titrate to 2-3 BMs/day• Enhances diffusion of ammonia (NH3) from blood to gut.

Produces osmotic effect in colon resulting in distention and increased peristalsis. (Lexicomp, 2015)

• 2nd line: rifaximin 550 mg bid, mostly for prevention• Antibiotic – inhibits bacterial RNA synthesis (Lexicomp, 2015)

• Neomycin, metronidazole, and nitazoxanide have been used

Werner, 2012

MANAGEMENT OF CIRRHOSIS

• Esophageal varices (EV)• Occur in 25-40% of patients with cirrhosis• Mortality rate following a single episode of EV bleeding

has decreased from 50% 30 years ago to 20-30% now. • EGD is used to screen for EV soon after diagnosis and is

done yearly if EV present• Small varices require no treatment• Medium to large EV should be treated with nonselective

betablocker and variceal band ligation

MANAGEMENT OF CIRRHOSIS

• Hepatocellular carcinoma• 1° cause of death in patients with cirrhosis• Annual incidence in compensated cirrhosis 1.4% and 4%

in uncompensated cirrhosis• Screening: US, CT or MRI with measurement of

alphafetoprotein every 6-12 months• Early detection is key• Treatable with surgical resection, ablation of lesions with

transarterial chemoembolization, radiofrequency or microwave technology, or liver transplant

Werner, 2012

MANAGEMENT OF CIRRHOSIS

• Moderate to heavy alcohol intake can add to or accelerate liver damage• WHO ASSIST - Alcohol, Smoking and Substance

Involvement Screening Test• Screening questionnaire for primary care, 5-10 minutes• Determination of risk score• Low risk ~ no intervention• Moderate risk ~ brief intervention• High risk ~ referral for specialist assessment and treatment

• Provides brief intervention manual for providers• Self help guide for patients

WHO, 2014, p. 51

PLAN

• Lifestyle/patient education• Abstain from or reduce alcohol intake• Weigh daily, monitor edema, call office for increase wt or

edema• Monitor mental status for early signs of encephalopathy• 2 gm sodium diet• Moderate physical activity~ work up to 150 minutes per

week• Prevention• Yearly hepatoma screening- CT• Yearly flu vaccine

PLAN

• Labs• CBC in 2 weeks to assess anemia• CMP, CBC, ammonia level, LFTs every 6 months

• Pharmacologic therapy• Continue current medical therapy• Xifaxan to prevent hepatic encephalopathy (HE)• Lactulose prn for patient’s perceived onset of HE or as

medically directed• Spironolactone and torsemide to reduce edema and prevent

ascites• Nadolol has an off-label indication for variceal hemorrhage

prophylaxis (Lexicomp, 2015)

ECONOMICS

• Pt lost home and “everything” in hurricane Sandy• This patient has Medicare and Medicaid • Office visit= $3• Labs covered• Medications• 7 covered medications X max $3 = $21/month

xifaxan~ retail cost = $1700/month Xifaxan ~ Salix patient assistance program will help with any copay for qualified people• Pt skips doses of xifaxan to postpone refills due to cost• Travel to speicialist- Duke

GoodRx, 2015, Salix, 2015

ETHICAL ISSUES

• Stigma of hepatitis C- public perception of relation to IV drug use• Shaming of patient due to continued alcohol use

despite possible increased damage to liver• Patient’s fear of putting health care workers at risk• Liver transplant requirement for 6 months

abstinence from alcohol and public perception of alcoholics receiving liver transplant (Stroh, Rosell, Dong & Forster, 2015)

REFERENCESCenters for Disease Control and Prevention (2015). Testing recommendations for chronic hepatitis C virus infection. Retrieved from http://www.cdc.gov/hepatitis/HCV/GuidelinesC.htm

Centers for Disease Control and Prevention (2015). Viral hepatitis- statistics and surveillance. Retrieved from http://www.cdc.gov/hepatitis/statistics/2013surveillance/index.htm#tabs-801919-3

GoodRx. (2015). Stop paying too much for prescriptions, compare prices, print free coupons & save up to 80%. Accessed at Goodrx.com

Lexicomp, Inc. (UpToDate). Lexicomp, Inc.; July 20, 2015.

Liou, I. (2013). Referal for liver transplantation on Hepatitis C online, University of Washington. Retrieved from http://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/liver-transplantation-referral/core-concept/all

Pugh, R. N., Murray-Lyon, I. M., Dawson, J. L., Pietroni, M. C., & Williams, R. (1973). Transection of the oesophagus for bleeding oesophageal varices. The British Journal of Surgery, 60, 646-649.

REFERENCESSmith, B. D., Morgan, R. L., Beckett, G. A., Falck-Ytter, Y., Holtzman, D., Teo, C. G., . . . Centers for Disease Control and Prevention. (2012). Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR.Recommendations and Reports : Morbidity and Mortality Weekly Report.Recommendations and Reports / Centers for Disease Control, 61(RR-4), 1-32. doi:rr6104a1 [pii]

Stroh, G., Rosell, T., Dong, F., & Forster, J. (2015). Early liver transplantation for patients with acute alcoholic hepatitis: Public views and the effects on organ donation. American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 15, 1598-1604. doi:10.1111/ajt.13176 [doi]

Werner, K. T., & Perez, S. T. (2012). Role of nurse practitioners in the management of cirrhotic patients. The Journal for Nurse Practitioners, 8(10), 816-821. doi:http://dx.doi.org.proxy.lib.duke.edu/10.1016/j.nurpra.2012.08.016

Wilkins, T., Akhtar, M., Gititu, E., Jalluri, C., Ramirez, J. (2015). Diagnosis and management of hepatitis C. American Family Physician, 91, 835-842.

World Health Organization (WHO). (2014). Guidelines for the screening, care and treatment of persons with hepatitis C infection. Geneva (Switzerland): World Health Organization (WHO).

RISKS

• Common risk factors:• Blood transfusion before July 1992• Illicit injection drug use

• Less common:• Mother-child transmission• Chronic hemodialysis• Illicit intranasal drug use• Needle stick or mucosal exposure• Incarceration • Men with HIV having sex with men• Organ transplant before 1992• Sex with partner infected with HCV• Tatoo from unregulated site

(Wilkins, Akhtar, Gititu, Jalluri, & Ramirez, 2015)

SCREENING FOR HCV• National Guidelines (WHO)• HCV antibody testing for high risk groups• CDC recommends one time testing of people born between

1945 and 1965 (2015)• If antibody (+), Nucleic acid testing (HCV RNA)• (+) = chronic HCV infection• (-) = resolved HCV infection

• Screen for alcohol use to reduce mod-high intake• Assess for liver fibrosis and cirrhosis• Aminotransferase/Platelet Ratio Index (APRI)

• Utilizes measures of platelets and AST• This pt: 0.987 (online calculator)• APRI > 1 = cirrhosis 76% sensitivity, 72% specificity• APRI > .7 = hepatic fibrosis 77% sensitivity, 72% Specificity

WHO, 2014, p 43-47, 56-59