6.4 Liver Disease (Hepatitis B, Cirrhosis, Hepatic Encephalopathy) & Thyroid Disorders
Key Takeaways
- Ghana gives hepatitis B vaccine in the pentavalent vaccine at 6, 10 and 14 weeks, and the GHS schedule now lists a hepatitis B birth dose.
- A positive HBsAg indicates current hepatitis B infection, while a positive HBeAg indicates active replication and high infectivity.
- Hepatic encephalopathy in cirrhosis causes confusion and a flapping tremor and is treated with lactulose and correction of triggers.
- Carbimazole can cause agranulocytosis, so patients must report sore throat, mouth ulcers or fever immediately.
- After thyroidectomy, nursing priorities are airway, haemorrhage including behind the neck, voice changes and signs of hypocalcaemia.
6.4 Liver Disease (Hepatitis B, Cirrhosis, Hepatic Encephalopathy) & Thyroid Disorders
Quick Answer: The Ghana Health Service describes hepatitis B as a major public health concern, and its immunisation schedule now lists a hepatitis B birth dose. Know the serology—HBsAg means current infection, anti-HBs means immunity, HBeAg means high infectivity. In cirrhosis, watch for ascites, variceal bleeding and hepatic encephalopathy (confusion, flapping tremor), treated with lactulose and removal of triggers. For the thyroid, remember carbimazole can cause agranulocytosis (report sore throat or fever) and that after thyroidectomy the priorities are airway, haemorrhage, voice and calcium.
Viral Hepatitis at a Glance
| Virus | Main transmission | Vaccine | Chronic infection? | Key point |
|---|---|---|---|---|
| Hepatitis A | Faecal-oral (food, water) | Yes | No | Hand hygiene and safe water |
| Hepatitis B | Blood, sexual, mother-to-child | Yes (Penta at 6, 10, 14 weeks; birth dose being introduced) | Yes—especially if infected at birth | A leading cause of chronic liver disease and liver cancer in Africa |
| Hepatitis C | Blood (unsafe injections, transfusion) | No | Often | Curable with direct-acting antivirals |
| Hepatitis D | Only with hepatitis B | Prevented by HBV vaccine | Yes | Worsens HBV disease |
| Hepatitis E | Faecal-oral | Not routine | Rarely | Dangerous in pregnancy |
Ghana's Expanded Programme on Immunization gives hepatitis B vaccine inside the pentavalent vaccine at 6, 10 and 14 weeks, and the Ghana Health Service schedule now lists a hepatitis B birth dose (0.5 mL IM, left thigh); check whether your facility has started giving it.
Hepatitis B Serology
| Marker | Meaning |
|---|---|
| HBsAg (surface antigen) | Current infection (acute or chronic); positive for more than 6 months = chronic |
| Anti-HBs (surface antibody) | Immunity from vaccination or recovery |
| HBeAg | Active viral replication and high infectivity |
| Anti-HBc IgM | Recent (acute) infection |
| HBV DNA (viral load) | Level of virus; guides treatment decisions |
Nursing care for a person with hepatitis B:
- Standard precautions; the person does not need isolation for routine contact;
- Screen and vaccinate household and sexual contacts; encourage condom use until partners are immune;
- Avoid alcohol and unprescribed herbal or hepatotoxic drugs; keep paracetamol within safe limits;
- Refer for assessment—selected patients receive antiviral therapy such as tenofovir, prescribed and monitored by a doctor;
- Pregnant women who are HBsAg-positive need a plan for newborn vaccination (and immunoglobulin where available) within hours of birth (section 11.1).
Cirrhosis and Its Complications
Causes: chronic hepatitis B or C, alcohol, fatty liver disease and other chronic liver injury.
Features: fatigue, jaundice, ascites, leg oedema, spider naevi, palmar erythema, dilated abdominal veins, gynaecomastia, easy bruising, and the complications below.
| Complication | What happens | Nursing actions |
|---|---|---|
| Ascites | Fluid in the peritoneal cavity from portal hypertension and low albumin | Daily weight and abdominal girth; sodium restriction; give prescribed diuretics (spironolactone ± furosemide) and monitor potassium; assist with paracentesis and record volume |
| Oesophageal varices | Dilated veins that can bleed massively | Treat as an upper GI bleed (section 6.3); two large-bore IV lines; prepare for endoscopy |
| Hepatic encephalopathy | Ammonia and other toxins affect the brain | See below |
| Spontaneous bacterial peritonitis | Infected ascites | Report fever, abdominal pain or new confusion |
| Coagulopathy | Low clotting-factor production | Bleeding precautions; give vitamin K as prescribed |
| Hepatocellular carcinoma | Liver cancer, often linked to chronic HBV | Specialist surveillance, often 6-monthly ultrasound |
Hepatic Encephalopathy
Signs: altered sleep pattern, confusion, drowsiness, a flapping tremor (asterixis), sweet musty breath (fetor hepaticus), progressing to coma.
Common precipitants to look for: GI bleeding, infection, constipation, dehydration, electrolyte imbalance (especially low potassium), sedatives and alcohol.
Nursing management:
- Give lactulose as prescribed, aiming for about 2–3 soft stools a day (it traps ammonia in the gut and speeds its removal);
- Avoid sedatives and opioids where possible;
- Treat the trigger (e.g., bleeding, infection);
- Maintain nutrition—routine protein restriction is no longer recommended;
- Keep the patient safe (side rails, supervision) and monitor neurological status.
Thyroid Disorders
| Feature | Hyperthyroidism (e.g., Graves' disease, toxic nodular goitre) | Hypothyroidism |
|---|---|---|
| Metabolism | Weight loss despite good appetite, heat intolerance, sweating | Weight gain, cold intolerance |
| Heart | Tachycardia, palpitations, atrial fibrillation | Bradycardia |
| Nervous system | Anxiety, tremor, irritability | Slowness, depression, poor memory |
| Other | Diarrhoea, exophthalmos (Graves'), goitre | Constipation, dry skin, hoarse voice, puffy face |
| Treatment | Carbimazole or propylthiouracil, beta-blocker (propranolol), radioactive iodine, thyroidectomy | Levothyroxine daily, usually lifelong, taken on an empty stomach |
Carbimazole warning: it can cause agranulocytosis. Teach the patient to stop the drug and report at once if they develop a sore throat, mouth ulcers or fever, so a white cell count can be checked.
Thyroid storm (severe thyrotoxicosis with high fever, marked tachycardia, agitation) is an emergency: cooling, IV fluids, and prescribed antithyroid drugs, beta-blocker and steroids.
Iodine deficiency causes goitre; Ghana promotes universal salt iodisation—teach families to use iodised salt.
Nursing After Thyroidectomy
- Airway: keep a tracheostomy set and suction at the bedside; position semi-Fowler's with the head and neck supported.
- Haemorrhage: check the dressing and behind the neck; a tense, swelling neck with breathing difficulty is an emergency (the surgeon may need to release sutures).
- Voice: ask the patient to speak—hoarseness can mean recurrent laryngeal nerve injury.
- Calcium: tingling around the lips or fingers, muscle cramps, Chvostek's or Trousseau's sign suggest hypocalcaemia from parathyroid injury; have IV calcium gluconate ready and report immediately.
- Thyroid storm and pain control; teach neck exercises and wound care.
Exam Traps at a Glance
- HBsAg positive + HBeAg positive = infected and highly infectious.
- Confusion + flapping tremor in cirrhosis = hepatic encephalopathy → lactulose, find the trigger.
- Sore throat on carbimazole = check the white cell count before the next dose.
- Tingling lips after thyroidectomy = hypocalcaemia.
A blood donor's screening shows HBsAg positive and HBeAg positive. How should the nurse interpret these results?
A patient with cirrhosis becomes confused and drowsy and has a flapping tremor of the outstretched hands. Which prescribed medication should the nurse expect to give first?
Twelve hours after a total thyroidectomy, a patient reports tingling around the lips and fingers, and the nurse elicits Trousseau's sign. What should the nurse prepare?