HepatitisHarindu Udapitiya,Temporary Lecturer,Division Of Pharmacology

Overview….1. What is hepatitis

2. Causes

3. Viral hepatitis

3.1. General viral Hepatology

• phases

• Symptoms

• Signs

3.2. Specific viral Hepatology

Hepatitis A-E

- Incubation period

- Transmission

- Investigation

- Treatments

1.What is Hepatitis?

• Inflammation of the liver characterized by patchy or diffuse necrosis.

2.Causes

1. Hepatitis virus

2. Alcohol

3. Drugs and toxines- paracetamol, methyldopa,isoniazid

4. Autoimmune

5. Hereditary- Wilson’s disease, haemochromatosis

6. Other viruses-IMN, CMV

7. Some systemic diseases-IBD

3.Viral hepatitis

• Hepatitis virus A-E

• Can be classified as,

1. Acute

2. Chronic-is defined as any hepatitislasting for 6 months or longer

3.1. General Viral hepatology

Symptoms

• The clinical presentation of infectious hepatitis varies with the individual, as well as with the specific causative virus.

• The classic presentation of acute infectious hepatitis involves 4 phases.

1. Phase 1 (viral replication phase) – Patients are asymptomatic during this phase; laboratory studies demonstrate serologic and enzyme markers of hepatitis

2. Phase 2 (prodromal phase)-

– Anorexia

– Ausea

– Vomiting

– alterations in taste

– arthralgias,

– malaise, fatigue

– urticaria

3. Phase 3 (icteric phase)-

• Yellowish discoloration of eyes

• Dark urine

• RHC pain

4. Phase 4 (convalescent phase) – Symptoms and icterus resolve, and liver enzymes return to normal

Signs• Physical findings in patients with hepatitis vary with

the type of hepatitis and the time of presentation.

• General Ex-

– Ill looking

– Febrile to touch

– Signs of dehydration

– Icterus

– Cervical lymphadenopathy

– urticarial rashes

CVS Ex

– Tachycardia

Abdominal

– RHC tenderness

– Tender hepatomegaly

– Splenomegaly

3.2. Specific Viral hepatology

Source of

virus

feces blood/

blood-derived

body fluids

blood/

blood-derived

body fluids

blood/

blood-derived

body fluids

feces

Route of

transmission

fecal-oral percutaneous

permucosal

percutaneous

permucosal

percutaneous

permucosal

fecal-oral

Chronic

infection

no yes yes yes no

Prevention pre/post-

exposure

immunization

pre/post-

exposure

immunization

blood donor

screening;

risk behavior

modification

pre/post-

exposure

immunization;

risk behavior

modification

ensure safe

drinking

water

Type of Hepatitis

A B C D E

Hepatitis A

Incubation period: Average 30 days

Range 15-50 days

Complications: Fulminant hepatitisCholestatic hepatitisRelapsing hepatitis

Post hepatic syndrome

Chronic sequelae: None

Laboratory Diagnosis

Acute infection is diagnosed by the detection of HAV-IgM in serum.

Past Infection i.e. immunity is determined by the detection of HAV-IgG.

Cell culture – difficult and take up to 4 weeks, not routinely performed

Direct Detection – EM, RT-PCR of faeces. Can detect illness earlier than serology but rarely performed

Treatment

No specific Tx.

-Bed rest

-Symptomatic Rx

Fever-Antipyretics

Vomiting-Antiemetics

Pruritus-colestyramine

Prevention

Pre-exposure

travelers to intermediate and high HAV-endemic regions

Post-exposure (within 14 days)

• Routine

-household and other intimate contacts

• Selected situations

-institutions (e.g., day care centers)

-common source exposure (e.g., food prepared by infected food handler)

Hepatitis B

Incubation period: Average 60-90 daysRange 45-180 days

Spectrum

– Chronic Persistent Hepatitis - asymptomatic

– Chronic Active Hepatitis - symptomatic exacerbations of hepatitis

– Cirrhosis of Liver

– Hepatocellular Carcinoma

Laboratory Diagnosis• HBsAg - used as a general marker of infection.

• HBsAb - used to document recovery and/or immunity to HBV infection.

• anti-HBc IgM - marker of acute infection.

• anti-HBc IgG - past or chronic infection.

• HBeAg - indicates active replication of virus and therefore infectiveness.

• Anti-Hbe - virus no longer replicating. However, the patient can still be positive for HBsAg which is made by integrated HBV.

• HBV-DNA - indicates active replication of virus, more accurate than HBeAg especially in cases of escape mutants. Used mainly for monitoring response to therapy

Treatment

• 1. Symptomatic

• 2. Antivirals

– Indications

• HBeAg +ve carriers with chronic active hepatitis

• Decompensated cirhosis

• Detection of HBV DNA by PCR

– Drugs

• alpha-interferon

• Lamivudine

• Adefovir

• Entecavir

Prevention

• Active immunization

– Recombinant HbsAg vaccine

– For individuals at risk and for neonates

• Passive immunization

– Hep B immunoglogulines

– Following acute post exposure and neonates who born to hep B + mothers.

• Other measures

– - screening of blood donors, blood and body fluid precautions.

Hepatitis C

Incubation period: Average 6-7 wks

Range 2-26 wks

Spectrum

Chronic hepatitis-80%

Cirrhosis-20-30%

Laboratory Diagnosis

1. HCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase.

2. HCV RNA-by PCR

3. HCV-antigen

Treatment

• Acute- No specific Tx, Supportive Mx

• Chronic-

– Interferon

– Ribavirin

Prevention

• Screening of blood, organ, tissue donors

• High-risk behavior modification

• Blood and body fluid precautions

• No vaccine available.

Hepatitis D

• A defective virus, may only co-infect with HBV or superinfect person with hep B.

Hepatitis E

Incubation period: Average 40 daysRange 15-60 days

Spectrum

Fulminant hepatitis-1-2%

No chronic form

From past papers….2014 Jan

Summery….• Hepatitis causes

Viral hepatitis

Symptoms & Signs

Transmission Diagnosis Treatment Prevention

Further reading….• Autoimmune Hepatitis

• Wilson’s disease

• Haemochromatosis

References….• Kumar & clerk 8th edition

• Medscape

Questions…

Thank you….