Introduction
Hepatitis is a major health threat to our environment because of the associated effects on liver and the mode of transmission. Hepatitis C which is one of the types of hepatitis that has become a major challenge since the discovery. Different factors have contributed to these challenges. One of those major challenges is the inability of researchers to discover suitable vaccine for the infection. The prolonged inactive period of the causative organism in the body before clinical manifestation is another factor (Department of health). The infectious course usually leads to enlargement of the liver and this in turn affects the functions of the liver with associated signs and symptoms (Department of health). The term hepatitis depicts a medical view of enlargement of the liver which is tagged medically as inflammation. Liver is major body organ, once is affected serious problems set in for the body. The culprit in this infection is a virus known as hepatitis C Virus and it is usually transmitted in a blood-to-blood contact mode of infection.
The implicated virus ‘hepatitis C’ was first identified in 1989. Most of the post-discovery serological investigations conducted on the newly identified agents revealed that the virus to be responsible for almost all the cases of hepatitis that occur. About 90% of those previously identified transfusion-related cases of hepatitis were then considered to be from the newly discovered virus (Croft). Another major facts about the management of the virus is that there has been availability of various agents that can be used to perform commercial assay needed to test for the hepatitis C virus since 1990 globally but vaccine is yet to be developed (Department of Health).
An estimated 130-170 million are infected with the virus worldwide. The condition has been found to be commonly co-infected with HIV hence common with those countries with higher rates of HIV infections. This form of hepatitis is also common in Egypt, Pakistan and China. A factor such as injection drug use is another major contributory factor to increase prevalence among these highlighted countries.
“This is a case study of a 32-year-old female that was referred to a hepatologist for a liver biopsy. This was as a result of her presentation to an emergency department which occurred earlier. At the emergency department during her presentation she complained of fever and flank pain. This was found to be as a result of pyelonephritis occurring from obstructive renal calculi. She had a history of a needle stick injury that was sustained 10 years earlier (1982) from a patient that was believed to be infected with non-A, non-B hepatitis.
Six weeks after the injury was sustained, she became ill having a mild flu-like syndrome. During that period, she was not icteric. The routine investigation conducted shows irregular elevations in the results of liver function tests (LFTs). Since then, no further workup was obtained” (Hepatitis C Education & Prevention Society).
“On physical exam, the patient was found to well nourished, and no acute distress. She was anicteric. Negative Lymph nodes and examined chest was clear. The liver and spleen were not enlarged. There was no pedal oedema, she was very active and no issue with fatigue or malaise. No evidence of decompensated liver or cirrhosis. Laboratory results shows a remarkably high level of white blood cell count, haematuria, urine contain is positive for white blood cells and bacteria”(Hepatitis C Education & Prevention Society).
“The laboratory investigation reveal an abnormal liver function tests were abnormal (AST of 49 U/L and ALT of 62 U/L), with an aspartate aminotransferase (AST). Complete hepatitis profile conducted for the patient reveals to be hepatitis C (HCV) antibody positive and subsequently tested positive for HCV by PCR reaction” (Hepatitis C Education & Prevention Society).
Signs and symptoms
In most cases, affected individuals usually have no symptoms. This occurs in about 75 per cent of cases. In such situations there is a later clinical manifestation of those associated signs and symptoms. In other people i.e. 25 per cent of populations, they tend to present with some associated symptoms when they are infected with the virus. Common signs and symptoms include: fatigue, fever, jaundice, and loss of appetites. According to Hepatitis Australia information, those patient that usually presents with signs and symptoms when infected are likely to have their presentation come on before six months (Hepatitis Australia).
Majority tend to have their presentation after the six months period that is what is seen in the case study that was presented above. The affected nurse presented several years after getting infected with the virus. The implication of this is that she has been a carrier for several years without any form of clinical manifestation. It is also very important to note that those people that usually presents with those symptoms associated with the chronic form might have been living with the disease for several years which could be up to 20 years before presentation. The associated major signs and symptoms with the chronic form include: severe tiredness, loss of appetite, nausea, fever, joint pain, vomiting, depression, and soreness below ribs in the upper right side of the stomach (Better Health Channel).
History and Risk Factors
Taking a critical evaluation of the presented case, it can be seen that the history of the patient is related to that of those that present with the chronic form of the hepatitis C infection. This has been attributed to the duration of the infection and the onset of symptoms for presentation. The nature of the presentation also contributes to the chronicity of condition. She had a history of needle injury 10 years earlier before presentation. This alone supports the classification of the infection as a chronic form considering the earlier stated categories which are related to 6 months after infection. This patient present with an initial flu-like syndrome 6 weeks after the infection but had nothing special done regarding the treatment but a laboratory investigation showing raised liver function tests. She is now presenting with fever and flank pain secondary to pyelonephritis from obstructive renal calculi.
The laboratory investigations that were not worked up for her then were now conducted to actually understand what is going with her. The laboratory investigation then reveal sporadic elevated Liver function tests as routine physical exams during the flu-like syndrome. In recent presentation, no history of fatigue or malaise, no evidence of cirrhosis, anicteric, lymph nodes were negative, clear chest sounds, no hepatosplenomegaly, no spider angioma or palmar erythema and no pedal edema.
Laboratory results were high = elevated white blood cell count, urinalysis was positive for blood, white blood cells and bacteria. Abnormal liver function test which include: raised aspartate aminotransferase (AST) of 48 U/L and alanine aminotransferase (ALT) of 60 U/L.
Disease progression
Acute phase
The progression of hepatitis C can be described under 3 major subclasses/phases: Acute phase, sub-acute phase, chronic phase. The acute phase of infection occurs within the first 12 weeks of infection with the hepatitis C virus. Majority suffers no symptoms at this period of infection. However, few tend to present with some form of acute infection which is characterized by decreased appetite, fatigue, abdominal pain, jaundice, itching and sometimes flu-like symptoms. During this acute phase of infection, the use of polymerase chain reaction can actually help detect the virus within the blood within one to three weeks of infection. Why the detection of antibodies that developed against the virus will be detected at a later period. The liver enzymes will also increase during the phase.
Sub-acute phase
In cases of sub-acute phase of infections, it is just the phase that is between the chronic and the acute phase of infection. It represents that stage whereby there is sub-acute hepatic necrosis. It is being referred to as a variant of the acute phase of viral hepatitis. Their course is usually within 6 months and there is no fully delineation between the acute and sub-acute phase of hepatitis.
Chronic Phase
In chronic cases, the duration for presentation is longer than the acute phase. This is the most common form of presentation people tend to present with. Once the infection persists for more than 6 months then, it’s a chronic phase. The natural course of the infection has been found to vary from one individual to another. Cirrhosis remains the most important features that associated with chronic hepatitis and once it occurs, all other major signs and symptoms will set in. Those signs and symptoms are mostly due to decreased liver functions or increased pressure in the liver caused by the cirrhosis.
Prevention of hepatitis
Preventive measures against hepatitis can be personal or institution based. Sharing of sharps in cases of injection drug users or blades should be avoided. In cases of hospitals, preventive measures must be provided so as to prevent contact with sharps or patient’s fluid that lead to infection. This will be achieved in the hospital by providing various guidelines and policy for the health care workers. The following highlighted modes can also help achieve some form of preventive measures in the community as a whole: this involve instituting various health campaigns over the media and sporting activities, educating the younger generations, and planning for programs that can help engage student more.
Medical management/treatment
In managing this viral infection, the main goal is to clear the virus from the patient's blood (Education resource centre). This is mainly achieved by the use of ribavirin and interferon as a combination therapy or changing the interferon to pegylated interferon (Education resource centre). Current researches in the management shows that affected individual’s treatment must start and monitored together to know how the management is progressing. Different strains or types of the hepatitis C virus have been found hence making the response to treatment varies (Education resource centre). Another major consideration in the management is that which relates to the rate of clearance of the virus from the blood. It has also been found that the clearance rate from blood is dependent on the number of viral types in the patient's blood. It level when treatment starts and factors such as the age of the patient and sex also contribute to the outcome of the management. The combination therapy form of management with pegylated type of interferon has been found to be very effective. This is because of its ability to help in the quick reduction of the associated inflammation (Department of health). Apart from the drugs used, eating healthy foods, having enough sleep, and avoiding smoking and alcohol have been found to help infected patients (Communicable Disease Control Directorate).
Physical therapy diagnosis
Acute phase
Sub-acute phase
Chronic phase
As regards to this infection, the associated signs and symptoms that could be used as a physical therapist is the same throughout the progression of the infection. This is because the only differences between the phases of progression of infection are that which relates to time of presentation. However such patients presenting with fatigue and generalized body weakness will reveal an underlying factor that needs to be diagnosed by the physical therapist. Palpation of the abdominal pain for tenderness could also reveal if there are any forms of liver enlargement in the patient. If a patient also present with jaundice and loss of appetite then, the physical therapist can then start to conclude on making a diagnosis of hepatitis based on the available information.
Investigations
The major investigations that need to be conducted for full diagnoses to be made are that which relates to the laboratory analysis of the liver enzymes. The blood will also be analysed for the virus to know the actual virus the patient is infected with. This will also help in the effective management of the patient both from the medical and the physical therapist perspective. Some of the liver enzymes are always checked for and these include: aminotransferase (AST) and alanine aminotransferase (ALT).
Physical therapy interventions
An important management of such patient include: highlighting those diet the patient must avoid which include; Animal fats (cold meat or any products from pork), smoked, salted or fried foods, hot foods or spicy foods, tobacco, alcohol, and coffee. The implication of these items is that they could overwhelm the liver that is already impaired hence affecting the functions. Due to the presence of fatigue and generalised body weakness, the physical therapist could also design different modes or activities that could help the patient increase his or her muscle strength and tone. The therapist will achieve the goals by teaching the patient about the disease process, symptoms, complications, and treatments. The therapist can also encourage graded exercise that will help the patient cope with the condition.
Summary and conclusions
In cases hepatitis C, there is no cure for the disease yet however people can be prevented from it by getting vaccinated or ensuring they follow all the applicable safety guidelines in the hospital if he or she is a hospital worker. Avoiding the use of non-sterilize instrument or sharing of sharps will also go a long way in preventing the contact with the virus. As highlighted earlier, the use of medications prescribed by the physician and getting involve in eating planned diet with good exercise with help reduce the progression of the infection and will also help live a good life.
Work Cited
Barbara et al. Acute Hepatitis C virus infection in incarcerated injection drug users. Clinical infectiious Diseases. 2006. Web. 26 November, 2011.
Better Health Channel. Hepatitis C. Digestive system-liver. 2011. Web. 25 November, 2011
Communicable Disease Control Directorate. Hepatitis C. 2008. Web. 25 November, 2011 .
Crofts, Nick. Epidemiology of the hepatitis C virus. National Library of Australia, Catalogue. 1999. Web. 26 November, 2011.
Department of Health, Australia. Hepatitis C- the facts. Epidemiology and surveillance. 5 August 2009. Web. 25 November, 2011.
Education resource centre. Ribavirin/pegylated interferon combination Therapy for people with hepatitis C. Fact sheet. Alfred. September 2002. Web. 25 November, 2011.
HepatitisAustralia. Unlike hepatitis A & B, there is no vaccine for hepatitis C. 2010. 2010. Web. 25 November, 2011.
Hepatitis C Education & Prevention Society. Clinical Review. Case Study 1. 1997. Web. 25 November, 2011.
Maddrey et al. The Clinician's companion VII: Expert Perspectives on Contemporary Clinical Issues in Hepatitis C. Projects in Knowledge. 2005 26 November, 2011.
