Updates

1. Narrative (Part II)
of
Clinical Workshop on HIV & Hepatitis
(attended in KTM on NOV 20-22, 2018, organized by WHO & NCASC)
by:
Dr. Pawan KB Agrawal,
MBBS, MDGP (IOM, Maharajgunj), Distance Fellowship in Diabetes Management (CMC, Vellore)
Consultant, General Practice & Emergency, Nyaya Health Nepal-Possible
9th January, 2019, Wednesday

2. Children Adult

3. Acute Viral Hepatitis
• Inflammation of liver due to a recent infection with hepatotropic virus
• Duration of days to weeks
• Characterized by jaundice and elevation in liver enzymes ALT/AST
without features of chronic liver disease.
• 3 stages:
• Prodrome
• Icteric
• Convalescent
• D/D: Malaria, Leptospirosis, Biliary obstruction, Drug induced liver injury

4. Acute Viral Hepatitis
• D/D:
• Malaria, Leptospirosis, Biliary obstruction, Drug induced liver injury
• Treatment:
• Reassurance & Symptomatic treatment for fever, vomiting and
dehydration.

5. Acute Liver Failure
• acute liver injury with encephalopathy and impaired prothrombin
time (INR of ≥1.5) in a patient without cirrhosis or preexisting liver
disease.
• Common Causes: Acute viral hepatitis; paracetamol poisoning,
alcoholic hepatits, acute fatty liver of pregnancy, autoimmune
hepatitis and Wilson’s disease.

6. Acute Liver Failure
• Clinical manifestation:
• malaise, fatigue, anorexia, nausea, vomiting, jaundice, pruritis, RUQ pain
• Hepatic encephalopathy
• Hepatorenal syndrome
• Labs:
• INR >1.5
• ALT/AST increases
• Bilirubin increases
• Platelet <150,000
•

7. Acute Liver Failure
• Management:
• Supportive
• Treatment of underlying cause
• Liver transplantation.
•

8. Chronic Viral Hepatitis
• Could present as
• Asymptomatic
• Acute hepatitis
• Acute liver failure
• Chronic hepatitis

9. Chronic Viral Hepatitis
• Could present as
• Asymptomatic
• Acute hepatitis
• Acute liver failure
• Chronic hepatitis
• Features of Chronic liver disease:
• Spider naevi, palmar erythema, gynaecomastia, hypoalbuminemia and
prolonged prothrombin time.

10. Chronic Viral Hepatitis
• Radiological features of chronic liver disease
• Coarse echotexture, shrunken nodular surface with irregular margins,
portal vein diameter >12 mm, splenomegaly >12 cm and ascites.
• Cirrhosis:
• Advanced stage of chronic liver disease characterized by
• Extensive fibrosis
• Nodular regeneration
• Loss of liver architecture.
• Symptoms: ascites, esophageal varices and splenomegaly
• Investigation : USG, low platelets, APRI index, FIB 4 index

11. Child Pugh Turcot Scoring
• Key population:
• Similar to HIV (sex workers and clients, MSM, TGs, PWID)
• Transfusion dependent (Thalassemia, Hemophilia)
• Chronic kidney disease patients on maintenance hemodialysis

12. Aspartate aminotransferase (AST) to platelet
ratio index (APRI)
APRI = ((AST/Top normal AST)/Platelets) * 100
APRI <=0.3: Unlikely cirrhosis or significant fibrosis
APRI >0.3 and <=0.5: Unlikely cirrhosis, significant fibrosis possible
APRI >0.5 and <=1.5: Significant fibrosis or cirrhosis possible
APRI >1.5 and <=2: Likely significant fibrosis, cirrhosis possible
APRI >2: Likely cirrhosis
APRI = ((AST/Top normal AST)/Platelets) * 100

14. 6 genotypes: 1,2,3,4,5 & 6

15. Hepatitis C lab interpretation
• Key population:
• Similar to HIV (sex workers and clients, MSM, TGs, PWID)
• Transfusion dependent (Thalassemia, Hemophilia)
• Chronic kidney disease patients on maintenance hemodialysis

16. Lab Investiations
Cheaper, easier, scalable
compared to HCV RNA
Initial screening test

17. Hepatitis C lab interpretation

18. Hepatitis C
• Management
• Assess stage (acute Vs Chronic)
• Assess fibrosis (cirrhotic or not)
• Assess liver function (compensated or decompenasated)
• Implications of cirrhosis
• Longer duration of treatment and life long follow up.
• Higher risk of complications and relapse
• Adddition of ribavirin could provide additional benefit in terms of response
and duration of treatment

19. Hepatitis C
• Treatment
Pan genotypic: Sofosbuvir + Velpatasvir
Genotype specific:
Genotype 1: Sofosbuvir + Ledipasvir
Genotype 2: Sofosbuvir + Daclatasvir
Adolescents (12-17 yrs with weight ≥ 35 kg): Sofosbuvir + Ledipasvir (G1,4,5,6)
Sofosbuvir + Ribavirin (G2,3*)
• Duration of treatment: 12 weeks but *could extend to 24 weeks in cases of
G3 and in cirrhotic patients.

21. Contraindications
• Advantage of Pan genotypic treatment
• Cost saving
• Simplified protocol and hence easy to dispense at local level
• Shorter duration
• Assess for cure at end of 12 weeks.
• Follow patients with cirrhosis every 6 months with USG for HCC and
portal HTN.

23. Hepatitis C
• Advantage of Pan genotypic treatment
• Cost saving
• Simplified protocol and hence easy to dispense at local level
• Shorter duration
• Monitor with CBC, LFT & RFT
• Assess for cure at end of 12 weeks.
• Follow patients with cirrhosis every 6 months with USG for HCC and portal
HTN.

26. Case

28. Workup
• Stage
• Compensation
• Treatment
• Followup