Hepatitis acute

ACUTE HEPATITIS

Hepatitis

bull Any disease process characterized by a diffuse inflammatory infiltrate of liver tissue with or without a degree of hepatocellular necrosis and local fibrosis

bull Etiology

Infectious Chemical Toxic and Autoimmune

Clinical Forms

bull Acute viral hepatitisbull Recent infection and inflammation of the liver

bull Chronic viral hepatitisbull Persistent viral infection of liver tissue lasting

more than 6 months

bull Causes of Acute Hepatitisbull Viruses (ABCEEBVCMV)bull Alcoholbull Toxins (Carbon tetrachloride)bull Drugs (INH PZA)

Acute Hepatitis

bull Prodromal illness (Flu like)bull 1048590 Vomitingbull 1048590 Aversion to alcohol and cigarettesbull 1048590 ABDOMINAL discomfortbull 1048590 Pale faeces and dark urinebull 1048590 Jaundice

Agents of Viral Hepatitis

bull Enterically transmitted hepatitisbull Hepatitis A and Ebull Acute diseases with no chronic phase

bull Blood-borne viral hepatitisndash Hepatitis B C and D all chronic infections

bull Systemic agents not restricted to the liverndash HSV VZV EBV CMV HIV

Hepatitis A

bull Symptomatic Illnessbull Symptomatic in 80 of adults but not children (lt3)bull Malaise Vomiting and jaundice prominent

bull Transmission patternsbull Person to person contactbull Common source outbreaks especially seafood

HAV Pathogenesis

bull Ingested orally Resistant to stomach acidbull Reaches the liver via the intestinebull Replicates in hepatocyte cytoplasmbull Secreted in the bile and excreted in faecesbull Cell mediated immune clearance and cyto-pathologybull Symptoms last 2-3 weeks

Laboratory Diagnosis of HAV

bull Serological diagnosisbull Preferred method is EIA for anti-HAV IgMbull Acute antibody response with a rise in IgMbull Simultaneous gradual rise in IgG

HAV Prevention

bullInactivated whole-virus vaccine

Treatment

bull Supportive re-hydration and nutritionbull Avoid alcohol

bull Outcomebull 1048590Recovery in gt 99 clinical relapse in 4-20bull 1048590Rarely need to hospitalize or transplantbull 1048590Fulminant hepatitis lt035

Hepatitis E

bull Epidemiologybull 1048590A major cause of sporadic and epidemic

hepatitisbull 1048590Water-bornebull 1048590Only 5 of adult cases have jaundice

HEV Pathogenesis

bull 1048590Entry across intestinal mucosa (unknown)bull 1048590Secreted in faecesbull 2 weeks before and 1 week after symptomsbull 1048590Detected in serum for two weeks after onsetbull 1048590Affects liver Kupffer cells and hepatocytesbull 1048590Cholestasis is a feature in 50 of casesbull 1048590Injury appears immune mediated

Laboratory Diagnosis of HEV

bull EIA based assays for IgM and IgG

HEV Prevention and Treatment

bull Treatmentbull Supportive therapybull No specific treatment

bull Preventionbull 1048590No vaccines availablebull 1048590Recombinant protein in animal amp human trialsbull 1048590Immune serum globulin is ineffective

bull Alcoholic Hepatitisbull Can be acute or chronicbull Risk of cirrhosis variablehellipgenetics sex (womenbull more susceptible) presence of chronic hepatitisbull possibly nutritional factorbull Presentation can range from an asymptomaticbull person to a critically ill one

bull Drug induced Liver Diseasebull 3 subtypesbull 1048590 Direct hepatotoxic groupbull 1048590 Idiosyncratic reactionsbull 1048590 Cholestatic reactions

bull Direct hepatotoxic Groupbull 1048590Dose related severitybull 1048590Latent period after exposurebull Exampleshellipacetominophen alcohol carbonbull tetrachloride niacin vitamin A

bull Idiosyncratic Reactionsbull 1048590 Sporadic and rarebull 1048590 Not dose relatedbull 1048590 Occasionally fever and eosinophiliabull suggesting an allergic type reaction

bull Cholestatic Reactionsbull 1048590 Non-inflammatory (direct effect on bilebull secretion)hellipexamples estrogens anabolic steroidsbull azathioprinebull 1048590 Inflammatory (portal areas with cholangitis) oftenbull with allergic featureshellipexamples erythromycinbull ampicillin-clavulanic and semi-synthetic penicillinsbull chlorpropamide

bull Autoimmune Hepatitisbull 1048590 Generally affects young females (less often postmenopausal)bull 1048590 ANA and anti-smooth muscle antibodies each presentbull in 70bull 1048590 Hypergammaglobulinemiabull 1048590 Extrahepatic manifestations are clueshellipamenorrheabull thyroiditis acne Sjogrens arthritis Coomb-positivebull hemolytic anemia nephritisbull 1048590 Old name was Lupoid Hepatitis

Hepatitis B

Parenteral - IV drug abusers health workers are at increased risk

Sexual - sex workers and homosexuals are particular at risk

Perinatal(Vertical) - mother(HBeAg+) rarrinfant

HBV Modes of TransmissionHBV Modes of Transmission

Pathogenesis amp Immunitybull Virus enters hepatocytes via blood bull Immune response (cytotoxic T cell) to viral

antigens expressed on hepatocyte cell surface responsible for clinical syndrome

bull 5 become chronic carriers (HBsAggt 6 months)

Clinical FeaturesIncubation period Average 60-90 days Insidious onset of symptoms Tends to cause a more severe disease than

Hepatitis APremature mortality from chronic liver disease 15-25

Possible Outcomes of HBV InfectionPossible Outcomes of HBV Infection

Acute hepatitis B infection

Chronic HBV infection

3-5 of adult-acquired infections

95 of infant-acquired infections

Cirrhosis

Chronic hepatitis

12-25 in 5 years

Liver failure Hepatocellular carcinoma

Liver transplant

6-15 in 5 years 20-23 in 5 years

DeathDeath

Prevention

bull Vaccinationbull - highly effective recombinant vaccinesbull Hepatitis B Immunoglobulin (HBIG) bull -exposed within 48 hours of the incident neonates whose

mothers are HBsAg and HBeAg positive bull Other measuresbull -screening of blood donors blood and body fluid precautions

bull

Hepatitis B Vaccine

bull Infants several options that depend on status of the mother ndash If mother HBsAg negative birth 1-2m6-18m ndash If mother HBsAg positive vaccine and Hep B immune globulin within 12

hours of birth 1-2m 6m bull Adults 01 6 months bull Vaccine recommended in

ndash All those aged 0-18 ndash Those at high risk

Hepatitis C

Pathology of HCV

bull Acute Hepatitis Cndash Generally benign

bull No jaundice (80)bull Usually asymptomatic

ndash Can be severe but liver failure rareOnly real threat of acute Hepatitis C is its ability to

reach chronic stages undetected and untreated

Pathology of HCV

bull Chronic Hepatitis Cndash 70 of patients become chronicndash Possible results

bull Cirrhosisbull End-stage liver diseasebull Hepatocellular carcinoma

Transmission

bull Direct blood or fluid exposurebull Perinatal Transmissionbull Transmissionbull Other things thought to be associated with HCV

ndash Tatoosndash Acupuncturendash Ear Piercing

bull Indications For Treatment ndash Increased ALT activityndash Liver biopsy fibrosisndash Detectible serum HCV RNA

bull Vaccinendash Difficult

bull High mutation rate

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