Acute

Viral
Hepatitis
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SUMATERA
UTARA
2013

WHAT IS VIRAL
HEPATITIS ?

A serious disease caused by

virus that attacks the liver .
There are various strains of viral
hepatitis which can cause
lifelong infection, cirrhosis
( scarring) of the liver , liver
cancer , liver failure, and death.

Etiology
Major
agents:
HAV
HBV

HGV

HCV

TTV

HDV

HFV

HEV

Minor agents:
EBV,CMV
HSV,VZV
Rubella,Measles
Coxsackie

B
Adenovirus

Transmission
HAV HBV HCV

HDV HE
V

Fecal-oral

Percutan.

Perinatal

Sexual

Epidemiology
HAV:fecal-oral
HEV:fecaloral
Rarely bloodborne
HBV:percutaneous contact
Mucous membrane
contact
Sexual contact
Perinatal:third trimester

Epidemiology

HCV:
Percutaneous transmission
Transfusion(0.1 %),needle
stick(1.8 %)
Mucousal transmission (rare)
Sexual transmission is
rare(monogamy) Perinatal
transmission is uncommon

Sexual transmission of
HCV
Multiple

sexual partner
HIV and STD
Anal sex
Open sore
Sex during menstruation

Pathology
Infiltration

of mononuclear

cells
Hepatic cells necrosis
Kupfer cells hyperplasia
Variable degrees of
cholestasis
In more severe cases;

Clinical Stages
Incubation

period
Prodromal (preicteric)
phase
Icteric phase
Convalescence

Variation in
staging

Asymptomatic
Anicteric
Fulminant
Chronic

Incubation
Period

HAV:15-45

days(30)
HBV: 30-180 days(60-90)
HCV: 15-160 days(50)
HDV: 30-180 days(60-90)
HEV: 14-60 days(40)

Preicteric Phase
Systemic & nonspecific
symptoms
Flu-like syndrome & dyspepsia
Fever, sore throat, cough,
headache
Fever, anorexia, malaise, nausea,
vomiting, abdominal pain

Icteric Phase
Clinical

jaundice
Dark urine : 1-5 days before
jaundice
Patient may feel better
Resolution of fever
Pruritus

Icterus

Icterus

Jaundice

Icteric Phase
Liver

is enlarged,tender
Cervical adenopathy(10-20%)
Splenomegaly(10-20%)
Fever is absent
Encephalopathy :Irritability,
lethargy, confusion

Convalescence
Resolution

of symptoms
Liver is enlarged
Pruritus
Complete recovery:
1-2 months A,E
3-4 months B,C (3/4)

Laboratory
Findings

CBC

:leukopenia,
lymphocytosis
Normal Hb; except
haemorrhage
Normal platelet; except DIC
ESR is normal

 Serum

bilirubin : 5-20 mg/dl

Direct bil indirect bil
SGOT/SGPT = 400-4000 IU
ALP : mild elevation
PT is usually normal :
Severe hepatitis prolonged
PT
Hypoglycemia

 Ig

Serologic
Diagnosis

M anti-HAV
HBs Ag and Ig M anti-HBc
HCV Ab, HCV RNA PCR
anti-HDV
anti-HEV

Complications
Hepatitis

A : Relapsing

hepatitis
Cholestatic hepatitis
Chronicity : HBV,HCV,HDV
Fulminancy : HAV, HBV, HDV,
HEV

Diferential
Diagnosis

Viral

hepatitis by minor
agent
Gram negative Sepsis
Cholangitis, cholecystitis
Acute on chronic hepatitis
Drug-related hepatitis
Ischemic hepatitis

Management
Indication of admission:
Bilirubin>20 mg/dl
Hypoglycemia
Abnormal PT
Hypoalbuminemia

 Poor

oral intake
Mental change,letargy
Low compliance
Other chronic disease

Management
Restriction

activity
Drug &Alcohol avoidance
Isolation is not necessary,
unless special cases
Symptomatic

Monitoring
Regular

physical
examination
Liver size, mental state,
icterus
Check of LFT, PT, Bilirubin
Serial check of HBsAg and
HCVAb

Prevention
Hand

washing, hygiene
Universal percaution
No sharing of personal
items (razor, toothbrush,
nail clipper)
Sexual barrier

Chronic Viral
Hepatitis

Chronic hepatitis (CH)

Definition:

chronic

necroinflammatory

injury

characterized by liver cell necrosis

and inflammation lasting more than
6 months that can lead insidiously
to liver cirrhosis, end-stage liver
disease
carcinoma.

and

hepatocellular

Major causes of chronic

hepatitis

Chronic hepatitis C (70-80%)

Chronic hepatitis B (10-20%)
Chronic hepatitis D
Chronic autoimmune hepatitis (<10%)
Wilsons disease
Haemochromatosis

1-Antitrypsin deficiency

Drug-induced chronic hepatitis

Cryptogenic hepatitis (non-A-E
hepatitis)

Clinical appearance of
CH

mostly asymptomatic
~20%: mild fatique; rarely: mild
RUQ pain

discovered by screening lab tests:

- mildly elevated ALT and AST
(<10x ULN);
- ALT>AST
- AP and -GT: normal or minimally
elevated

Late symptoms of CH

Marked symptoms only in the

stage of cirrhosis:
marked fatique, muscle weakness
and wasting,
poor appetite, nausea, weight loss;
dark urine, jaundice, itching;
abdominal swelling, ascites, edema,
UGI bleeding,
hepatic encephalopathy, etc.

Diagnostic tests for chr. hepatitis

Hepatitis C

Chronic hepatitis C
(CHC)

Hepatitis C is a common infection with

variable course
170 million infected pts worldwide
CHC can led to liver cirrhosis and
hepatocellular carcinoma (HCC)
2nd or 3rd most common cause of liver
cirrhosis and HCC
No effective vaccine at present
Prevention: avoidandance of high-risk
behaviors

Risk Factors Associated with

Transmission of HCV
Illegal injection drug use
Transfusion or transplant from infected donor
Occupational exposure to blood
Mostly needle sticks

Iatrogenic (unsafe injections)

Birth to HCV-infected mother
Sexual/household exposure to anti-HCV
positive contact

Multiple sex partners

Natural history of HCV

infection
Acute hepatitis
85%
15%
Persistent infection

Recovery and clearance

of HCV-RNA

60-70%
Chronic hepatitis
20-30%
Liver cirrhosis

~5%
HCC

Factors promoting the

progression of CHC

High viral dose, genotype 1, quasispecies

Older age, male sex

Immunodeficiency

Alcohol abuse

Co-infection with HBV, HIV

Iron overload

Environmental contaminants, geography

Hepatitis B

Epidemiology of HBV

HBV is a common cause of viral

hepatitis

400 million carriers worldwide

Prevalence in the population of

developed countries:
carriers: 1%, anti-HBsAg +: 10 %;
incidence: 35 per 100 000 in a year;
in the 3rd world (Far/Middle East):
carriers: 8%; anti-HBsAg +: 50 %

Transmission of HBV
HBV is present in all body fluids and secretions!

Highly contagious! Blood cc. may be as

high as 1013/ml

Vertical transmission: in the perinatal

period; > 90%

Horizontal transmission:
by blood, blood products, surgery
injection-drug abuse, needle-stick injury
sexual activity,
occupational exposure
household contact

Natural history of HBV

infection
1%

Acute hepatitis
10%
Persistent infection

Fulminant hepatitis
90%
Recovery and clearance
of HBV-DNA

2-3%
Chronic active hepatitis
1%
Liver cirrhosis

Carrier state
100-fold risk
HCC

Natural History of Chronic

HBV Infection
Resolution

Acute
Infection

Stabilisation

Chronic
Hepatitis

Chronic
Carrier

Compensated
Cirrhosis

Cirrhosis

Liver
Cancer

Progression Decompensated
Cirrhosis
(Death)

3050 Years
Adapted from Feitelson, Lab Invest 1994

Death

Healthy Liver

Cirrhosis

Liver Fibrosis

Liver Cancer

Diagnosis of CHC

Screening for liver disease

elevated se ALT (<10x UNL)

Screening for HCV infection

se anti-HCV (enzyme immunoassay)

Confirmation: detection of viremia

se HCV RNA (rtPCR)

Diagnosis of CHB

Follow-up of patients with acute HBV

infection

Screening for liver disease (elevated se

ALT)

Screening for HBV infection

se HBsAg (enzyme immunoassay)

Confirmation: detailed serology;

detection of viremia se HBV-DNA

erological markers in hepatit

Evaluation of patients with

CHB and C

Clinical: signs and symptoms of chronic

hepatitis;
evaluation of coexisting diseases

Laboratory: se ALT, bilirubin, albumin,

prothrombin
(se AP, GGT , Fe, transferrin saturation,
ferritin, renal function tests,
autoimmune markers)

Virological:
HBV: serology, se HBV-DNA; antiHDV

CHC: current therapies

Interferon-: may eradicate

HCV infection;
antiviral, immunoregulator, antiinflammatory;
may inhibit fibro- and
carcinogenesis;
costly, unpleasant (injection!); 520% efficacy
Interferon- + ribavirin
doubled efficacy in HCV clearance

CHB: current therapies

Interferon-: may eradicate HBV

infection;
antiviral, immunoregulator, antiinflammatory;
may inhibit fibro- and carcinogenesis;
costly, unpleasant, 20-30% efficacy

Lamivudine, adefovir, entecavir

(virostatic drugs):
advantages: oral administration; well
tolerable;

Side effects of therapy

Interferon-alpha:
Early: flu-like illnes, fatique, cytopenias
Late: depression with suicidal risk,
psychosis, anorexia, weight loss, sepsis,
thyroid dysfunction, deteoriation of
liver disease, hair-loss
Ribavirin:

Dose-dependent, mild, reversible

hemolytic anemia

Therapy of end-stage CHB

and C:
liver transplantation

CHC is the leading indication for

OLT
Antiviral pretreatment is advised
Recurrence of the infection is
universal;
a great problem in hepatitis B
infection;
survival rate is less affected by
HCV

THANK YOU