INFLAMMATION OF LIVER HEPAR(GREEK)=LIVER ITIS=INFLAMMATION CAN BE ACUTE(<6 MONTHS) OR CHRONIC(>6 MONTHS)

1. Topic :- Update on HEPATITIS (2020)
Dr Rahul JainDr Sharda Jain
for Gynaecologist & Surgery Specialist

2. Over 400 ppts are available on
slideshare.net ***for use of public/Doctors
www.slideshare.net / Lifecarecentre

3. BY-DR RAHUL JAIN
GUIDE-DR SHARDA JAIN

4. CONTENTS-
• DEFINITION
• ETIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• INVESTIGATIONS
• VIRAL HEPATITIS
• HEPATITIS IN PREGNANCY

5. DEFINITION-
• INFLAMMATION OF LIVER
• HEPAR(GREEK)=LIVER
• ITIS=INFLAMMATION
• CAN BE ACUTE(<6 MONTHS) OR CHRONIC(>6
MONTHS)

6. ETIOLOGY-(VITAMIN)
• VASCULAR-ISCHEMIC HEPATITIS,CONGESTIVE
HEPATITIS
• INFECTIONS-VIRAL HEPATITIS,SCHISTOSOMIASIS
• TOXINS-CCL4,AFLATOXINS,ALCOHOL
• AUTOIMMUNE HEPATITIS
• METABOLIC-WILSON,HAEMOCHROMATOSIS
• IATROGENIC-ANTI TB
• NEOPLASTIC-MALIGNANCY,METASTASIS

7. PATHOPHYSIOLOGY
• ACUTE INFECTION,LIVER DAMAGED IS
MEDIATED BY CYTOKINES AND NK CELLS.
• CYTOKINES AND NK CELLS CAUSE LYSIS OF
INFECTED HEPATOCYTES CAUSING
CHOLESTASIS
• LIVER CELLS REGENERATE AFTER ACUTE
IINFLAMMATION SUBSIDES
• CHRONIC INFLAMMATION CAUSES FIBROSIS
WHICH LEADS TO CIRRHOSIS.

8. CLINICAL FEATURES-
• NAUSEA,FATIGUE,VOMITING, FEVER, WEIGHT
LOSS,ITCHING,RUQ PAIN ANOREXIA
• JAUNDICE,DARK URINE,LIGHT STOOLS
• ABDOMINAL PAIN(RUQ PAIN)
• RUQ TENDERNESS
• HEPATOMEGALY

10. ICTERUS(JAUNDICE) AND ITS TYPES-
• YELLOWISH DISCOLORATION OF SCLERA DUE
TO HYPERBILIRUBINEMIA.
• 3 TYPES-
1. PRE HEPATIC JAUNDICE(HAEMOLYTIC)
2. HEPATIC JAUNDICE(HEPATITIS)
3. POST HEPATIC(OBSTRUCTIVE CAUSES)

11. DIFFRENTIATING TYPE OF JAUNDICE

12. INVESTIGATIONS
• SERUM BILIRUBIN(N~0.3-1.3mg/dl)
• TOTAL SERUM BILIRUBIN=UNCONJUGATED
BIL.+CONJUGATED BILIRUBIN
• SERUM ENZYMES-
• AST(SGOT)(N~10-40IU/L)-↑ IN HEPATIC
NECROSIS,MUSCLE INJURY,HEART FAILURE
• ALT(SGPT)(N~10-40IU/L)-CYTOSOLIC ENZYME
MAJORLY PRESENT IN LIVER(MORE SPECIFIC
MARKER OF LIVER INJURY)

13. INVESTIGATIONS
• AST:ALT(NORMAL RATIO~0.9-1)
1. IF ALT↑ RATIO WILL FALL EVEN FURTHER AND
INDICATES LIVER INJURY
2. IN ALCHOLIC HEPATITIS,CIRRHOSIS AST
VALUES ARE HIGHER AND RATIO REACHES 2
TO 3(DECREASED ALT PRODUCTION)
• ALP-CANALICULAR AND SINUSOIDAL WALLS
OF LIVER(N~80-240IU/L)-MARKEDLY RISE IN
OBSTRUCTIVE JAUNDICE

14. INVESTIGATIONS(CONTD)-
• GAMMA-GGT-DOESN’T ELEVATE IN BONE
DISEASE,INDICATOR OF ALCHOLISM
• PLASMA PROTEINS-
• SERUM ALBUMIN(N~3.5-5.5gm/dl)-EXCELLENT
MARKER FOR HEPATIC SYNTHESIS
FUNCTION,VERY LOW LEVELS INDICATE
SEVERE DAMAGE,RELEVANT IN CHRONIC
INFLAMMATIONS

15. INVESTIGATIONS(CONTD)-
• SERUM GLOBULINS(N~1.5-3.5gm/dl)-INCREASED
IN LIVER DISEASES,
• COAGULATION TIME(PROTHROMBIN TIME)-
• LIVER PRODUCES ALL COAGULATION FACTORS
EXCEPT FACTOR 8
• FASTING LIPID PROFILE-
CHOLESTROL,TRIGLYCERIDES,HDL,LDL LEVELS

16. VIRAL HEPATITIS
• HEPATITIS A,B,C,D,E
• CMV
• EBV
• HSV
• ADENOVIRUS
• YELLOW FEVER VIRUS
• VARICELLA ZOSTER VIRUS

17. HEPATROPIC VIRUSES
• HEPATITIS A-RNA VIRUS-FAECOORAL
TRANSMISSION
• HEPATITIS B-DNA VIRUS-VERTICAL, PERCUT &
MUCOUS MEMB.,IV ROUTE,SEXUAL CONTACT
• HEPATITIS C-RNA VIRUS-VERTICAL, PERCUT &
MUCOUS MEMB.,IV ROUTE,SEXUAL CONTACT
• HEPATITIS D-RNA VIRUS-PARENTERAL AND
SEXUAL ROUTE(COINFECTION)
• HEPATITIS E-RNA VIRUS-FAECO ORAL
TRANSMISSION

18. CLINICIAL FEATURES OF VIRAL HEP-
• DIFFT INCUBATION PERIODS
• PREICTERIC PHASE-1-2 WEEKS,CONSTITUTIONAL
SYMPTOMS
• ICTERIC PHASE-ENLARGEMENT OF
LIVER,PRURITUS,DARK URINE,PALE
STOOL,ICTERUS
• RECOVERY PHASE-APPETITE IMPROVES,JAUNDICE
DECREASES,STOOL AND URINE BECOMES
NORMAL

19. HEPATITIS A
• M/C CAUSE OF ACUTE VIRAL HEPATITIS IN
CHILDREN
• ANICTERIC PRESENTATION
• ACUTE,SELF LIMITING ILLNESS
• NO CARRIER STATE
• INCUBTION PERIOD~30 DAYS
• INVESTIGATION-igM HAV
• FORMALDEHYDE INACTIVATED VACCINE
AVAILABLE(AGE>2YRS)

20. RX OF HEP A
• HOSPITALIZATION
• SMALL HIGH CALORIE FEEDS,LOW PROTEIN
DIET,LOW FAT DIET,
• VIT K(IF PT PROLONGED)
• IV FLUIDS,ELECTROLYTES,
• ANTI EMETICS,
• PAIN MANAGEMENT

21. HEPATITIS B
• HEP B CAN CAUSE ACUTE AND CHRONIC
INFECTIONS
• CHRONIC INFECTIONS WHICH PERSIST MORE
THAN 6 MONTHS
• M/C VIRAL CAUSE OF CHRONIC HEPATITIS
• M/C VIRAL CAUSE OF HCC
• M/C CAUSE OF CARRIER STAGE
• INCUBATION PERIOD ~90 DAYS
• WORSE PROGNOSIS

22. HEPATITIS B
• HEPATITIS B IS A COMPLEX ANTIGEN WITH 3
COMPONENTS-
• HBcAg-CORE ANTIGEN
• HBsAg-SURFACE ANTIGEN
• HBeAg-REPLICATION MARKER

23. HEPATITIS B
INVESTIGATIONS-LFT,SEROLOGY
SEROLOGY-HBsAg, ANTI HBs, HBeAg, ANTI
Hbe
ANTI HBc IgG OR IgM(DIAGNOSTIC MARKER)
VACCINATION AVAILABLE IN THE FORM OF
ACTIVE AND PASSIVE IMMUNITY

24. TREATMENT OF HEP B-
• GOALS-
1. CLEARANCE OF HBV DNA
2. NORMALIZATION OF LIVER ENZYMES
3. ABSENCE OF HBeAg and APPEARANCE OF
ANTIBODY
• TREATMENT-
1. SYMPTOMATIC MANAGEMENT SIMILAR TO HEP
A
2. TENOFOVIR OR ENTECAVIR FOR VERY ILL
PATIENTS

25. CHRONIC CARRIER OF HEP B-
• ANTIVIRALS ARE GIVEN
1. PEGYLATED ALPHA 2a
INTERFERON(180microgram/week)
2. ENTECAVIR
3. TENOFOVIR
4. LAMIVUDINE
• LIVER TRANSPLANT(CLINICALLY
DECOMPENSATED PATIENT WITH CIRRHOSIS)

26. HEPATITIS C-
• CAN CAUSE BOTH ACUTE AND CHRONIC
ILLNESS
• INCUBATION PERIOD~50 DAYS
• M/C VIRAL CAUSE OF CIRRHOSIS
• INVESTIGATIONS-LFT,SEROLOGY
• HCV-RNA-MOST SENSITIVE INDICATOR
• ANTI HCV-SCREENING OF HCV
• NO VACCINE AVAILABLE

27. TREATMENT OF HEPC-
• SYMPTOMATIC MANAGEMENT
• PEGYLATED INTERFERON TO AVOID
PRGRESSION TO CHRONIC STATE

28. HEPATITIS AND PREGNANCY
• HEPATITIS B IS M/C VIRAL HEPATITIS IN
PREGNANCY
• HEPATITIS E IN PREGNANCY ASSOCIATED WITH
HIGHEST MORTALITY
• HEPATITIS ASSOCIATED WITH-
• GDM
• LOWER APGAR SCORES
• PRETERM DELIVERY
• DX-AST,ALT~2000IU/L,S BILIRUBN-5-20MG/DL

29. HEPATITIS AND PREGNANCY
• HEP E SEROLOGY-IgM HEV
• IF A BABY IS BORN TO HEP B + MOTHER THEN
1. HB Ig-0.5ml I.M. IS GIVEN SOON AFTER BIRTH
2. START Hep B VACCINE 1ST DOSE GIVEN WITH
IN 12 HRS

30. • THANK YOU
• ANY QUESTIONS?