Viral Hepatitis PDF

Viral Hepatitis Dr. Amal Shawky Bakir Prof. of Gastroenterology & hepatology Extended Modular Program 1 Liver Functions Stores sugar needed for energy Breaks down poisons (toxins) and...

Viral Hepatitis Dr. Amal Shawky Bakir Prof. of Gastroenterology & hepatology Extended Modular Program 1 Liver Functions Stores sugar needed for energy Breaks down poisons (toxins) and drugs Makes important proteins that help build new tissue and repair broken tissue Produces bile, which helps in digestion of fats synthesizes blood coagulation factors V, VII, IX, and X, prothrombin, and fibrinogen Hepatitis Definition Hepatitis means inflammation of the liver Types: Acute hepatitis Chronic hepatitis 4 Hepatitis Acute Hepatitis: Short-term hepatitis. Body’s immune system clears the virus from the body within 6 months Chronic Hepatitis: Long-term hepatitis. Infection lasts longer than 6 months because the body’s immune system cannot clear the virus from the body. The term chronic relates to the duration of infection and not to the severity of the disease. Causes of acute hepatitis  Viral :Hepatotropic : (A,B,C,D,E and G) Non hepatotropic(CMV,EBV, herpes and HIV).  Drug: Paracetamol, alcohol and halothane. 7  Viral Hepatitis - Historical Perspectives A Enterically E transmitted Viral hepatitis Parenterall B D C y transmitted F, G, TTV ? other  VIRAL HEPATITIS VIRUS Nucleic IP TRANSMIT CHRONIC VACCINE Acid Hep A RNA 2-6 w Fecal-oral No Yes Hep B DNA 2-6m Blood Yes Yes Hep C RNA 2-6m Blood Yes No Hep D RNA 2-6m Blood Yes (HepB) Hep E RNA 2-6 w Fecal-oral No No Clinical Stages of acute viral hepatitis Incubation period (acc to type of virus) Prodromal (preicteric) phase Icteric phase convalescence 10 Prodromal Preicteric Phase Systemic &nonspecific symptoms Flue like symptoms,fever sore hroat,cough,headache anorexia,malaise,nausea, Vomiting,abdominal pain. Duration : 1-2 weeks 11 Icteric Phase Clinical jaundice a yellowing of the skin, eyes and mucous membranes Resolution of fever,Patient may feel better Pruritus Liver is enlarged,tender Splenomegaly(10-20%) 12 Symptoms and Signs: jaundice 14  The various human hepatitis viruses cause very similar illnesses. Therefore, neither the individual nor the healthcare provider can tell by symptoms or signs if a given individual is suffering from certain type of viral hepatitis unless laboratory tests are performed. Serum bilirubin:increased ALT,AST (liver enz)=marked elevation Alk.phosphatase :mild elevation ProthrombinTime(PT) is usually normal: in severe hepatitis,PT is prolonged 16 Convalescence Resolution of symptoms Complete recovery: 1-2 months A,E 3-4 months B,C 17 Transmission:Fecal-oral  Peak excretion in stool (Infectious period) occurs during the two weeks before onset of jaundice.ie.in the prodromal phase. Risk of transmission Close personal contact (e.g., household contact, child day care centers) Intake of Contaminated food, water (e.g., infected food handlers, raw shellfish) Travelers endemic countries  HAV can survive for several hours on fingertips and hands  and up to two months on dry surfaces. HAVcan be inactivated by  heating to 185°F (85°C) or higher for one minute, or  disinfecting surfaces with a 1:100 dilution of sodium hypochlorite. Laboratory Diagnosis Acute infection is diagnosed by the detection of HAV-IgM Past Infection i.e. immunity is determined by the detection of HAV- IgG.  HEPATITIS A Prophylaxis: Improve Hygiene Passive immunity Vaccine Passive immunity After Exposure to HAV but not more than 2 weeks after the last exposure. 25  Hepatitis A VACCINE Pre-exposure travelers to HAV-endemic regions Routine household and intimate contacts Selected situations institutions (e.g., day care centers) common source exposure (e.g., food handler) Post-exposure (within 14 days)  HAV has no known chronic carrier state and does not cause chronic hepatitis or cirrhosis.  Mode of transmission HBV HCV through blood and infected percutaneous exposures to bodily fluids ( semen,vaginal or infected blood. another body fluid). sexual intercourse. Sexual contact, has been shown to be an inefficient route of exposure, infected woman transfers the mother-to-child in childbirth an disease to her baby during inefficient route of exposure, childbirth. Mothers with HBeAg positive are much more likely to transmit to their offspring Presentation of the disease HBV HCV Around 30-50% of adults develop clinical illness. In most of the cases, the onset of hepatitis C infection is unrecognized because the clinical symptoms are often mild and clinically not apparent 90-95 % complete recovery. About 20–30%complete recovery. 5-10 % chronic hepatitis ends in liver cirrhosis and hepatocellular carcinoma 70–80% of persons will develop chronic HCV infection. ends in liver cirrhosis and hepatocellular carcinoma Risk factors Blood transfusion before 1992(HCV) Hemophilia i.v drug abuse Body piercing(tattoos) Needle stick injury(Health Workers are at increased risk.) Hemodialysis Vertical trasmission (HBV) Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Sexual (HBV) Ways to prevent HBV Transmission  HBV is a DNA virus The outer surface of the virus contains hepatits B surface antigen (HbsAg). HBeAg is a protein from the hepatitis B virus that circulates in infected blood when the virus is actively replicating. It encloses an inner nucleocapsid (core), which contains hepatitis B core antigen (HBc Ag not present in blood)HBc Ab. Inside the core, there is a circular double-stranded DNA and a DNA polymerase Diagnosis HBsAg - used as a general marker of infection. HBsAb - used to document recovery and/or immunity to HBV infection. HBc Ab ( IgM )- marker of acute infection. HBc Ab (IgG) - past or chronic infection. HBeAg - indicates active replication of virus and therefore infectiveness. HBV-DNA - Used mainly for monitoring response to therapy.  How long does it take for blood to test HBsAg-positive after exposure to HBV? HBsAg will be detected in an infected person’s blood an average of 4 weeks (range: 1–9 weeks) after exposure to the virus.  Prevention Passive immunity Hepatitis B Immunoglobulin – may be used to protect persons who are exposed to hepatitis B (within 48 hours). It may also be given to neonates who are at increased risk of contracting hepatitis B i.e. whose mothers are HBeAg positive. 37 Prevention Vaccination -high risk adults: Healthcare workers IV drug users Household contacts of people w/ Hep B Pts w/ multiple sexual partners Hemodialysis patients Pts who require repeated transfusions of blood products Pts w/ chronic liver disease routinely to neonates as universal vaccination in many countries. Can Hepatitis B vaccine be given after exposure to HBV? Yes., given as soon as possible but preferably within 24 hours, Laboratory Diagnosis HCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase as.In most individuals, anti-HCV antibodies appear 7 to 8 weeks after exposure HCV-RNA - PCR. used to diagnose HCV infection in the acute phase (2-4 weeks). Is there a vaccine for the prevention of HCV infection? NO In case there is an accidental exposure, to HBV or HCV follow these steps: Carefully wash the wound without rubbing for several minutes with soap and water, or using a disinfectant of established efficacy against the virus (iodine solutions or chlorine formulations). A complete detailed medical and clinical history of the patient must be recorded to rule out possible risks. What to do after needle prick from HCV patient? ALT and HCV ab at base line and 1 -3 -6 months later HCV PCR within 2-4 weeks to detect infection ALT HCV ab comment At base line +ve +ve Old infection 1-3 months +ve (was -ve at +ve (was -ve at Acute infection base line) base line) 6 months -ve (was -ve at 1- -ve (was -ve at 1- No infection 3mon) 3mon) 45  HAV: HAV IgM+ve acute hepatitis A. HBV: HBsAg ,eAg and HB DNA by PCR HCV: HCV ab and HCV RNA by PCR HDV: HDV- antibody HEV: Anti body to HEV If all tests for viral hepatitis are negative a, other viruses should be expected as CMV or EBVor others. 46 Treatment of Acute Viral Hepatitis Symptomatic treatment Bed rest Light palatable meals Patient isolation or hospitalization is rarely necessary. 47  Oral manifestations of hepatitis C infection Manifestations in the oral cavity include lichen planus, Sjögrens syndrome, xerostomia and sialadenitis, some forms of oral cancers may also be seen. Oral lichen planus  Lichen planus is a mucocutaneous disease of uncertain cause that affects the oral mucosa. It represents a cell-mediated immune response. It is classified as reticular, plaque, atrophic, erosive, or bullous according to the clinical presentation. There is a relationship between OLP and hepatitis C notably in the erosive type and asymmetric lesions on the buccal mucosa Xerostomia increases patient vulnerability to caries and oral soft tissue disorders, which, in combination with deficient hygiene, in turn facilitate the development of candidiasis.  Patient with HAV is infectious: A. When he becomes jaundiced. B. After disappearance of jaundice. C. Before appearance of jaundice. D. Non of the above.  After recent exposure to HCV , acute infection can be diagnosed within 4 ws by : A)HCV Ab B)HCV RNA C) ALT D) ALT &HCV Ab  After accidental exposure to blood from HBV +ve patient.,if you are not vaccinated you must take: HBV vaccine. HBIG HBV vaccine and HBIG. Non of the above.  All these viruses can cause chronic hepatitis except: A. HAV B. HBV C. HCV D. HDV  Increase risk of HBV transmission from mother to her infant detected by presence of : A) HBeAg B) HBsAg C) HBcAb D) HBsAb give short account on oral manifestation of hepatitis c infection ?