Treating fulminant hepatitis

Fulminant hepatitis is a rare syndrome usually associated with hepatitis B but very rarely occurring in people with hepatitis A or hepatitis E. It is characterized by a rapid development of jaundice and the onset of brain swelling and nervous system deterioration, likely to have been caused by the buildup of toxins that cannot be removed by the diseased liver. Confusion, disorientation, dementia, and coma may develop within hours in some cases. Areas of liver tissue die, and there is marked decrease in the size of the organ. Liver failure, vascular bleeding in the brain and elsewhere, infections, and kidney failure may develop.

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Viral hepatitis is the leading cause of fulminant hepatitis throughout the world. An unusually large load of hepatitis A virus and severe infection may result in fulminant hepatitis. Other factors that increase the likelihood of this complication include infection in individuals over 40 years of age, hepatitis A superimposed on pre-existing liver disease, other chronic illnesses, and travel to countries with widespread contamination of food and water with the hepatitis A virus.

Careful management and painstaking nursing care provide the best hope for recovery from this complication. Regular monitoring of blood glucose levels with constant glucose infusion is essential, because dangerously low blood sugar is a constant threat. Monitoring of weight and serum electrolytes is crucial because reduction in sodium and potassium in the blood can lead to heart irregularities. Early in the course of fulminant hepatitis, potassium supplementation is usually required. Other treatments may be necessary to prevent kidney or other organ failure.

Intracranial pressure monitoring is frequently useful in fulminant hepatitis. As brain swelling increases, intracranial hypertension becomes a serious problem. The risk of brain damage begins when ICP is too high, and interventional procedures are needed to reduce pressure. Intracranial hypertension management may include head elevation, administration of diuretics, rapid ventilation, reducing core body temperature, and drug-induced coma. Abnormally low blood pressure is also a frequent problem in the management of patients with fulminant hepatic failure. Drugs are often used to maintain blood pressure in order to sustain life.

Ultimately, the degree of brain and nervous system deterioration is an indicator of prognosis. Some 80 percent of patients who progress to coma die from this complication. As a result, liver transplantation has become the standard of care in many institutions: It offers a survival rate of close to 90 percent in patients where transplantation appears feasible.