Autoimmune hepatitis is a chronic disorder characterized by continuing inflammation and fibrosis of the liver that can progress to cirrhosis and liver failure. It is an autoimmune process supported by the presence of autoantibodies and other features of autoimmunity. The disease shares many similarities to chronic viral hepatitis but is autoimmune in origin as evidenced by histopathology showing predominantly cytotoxic T-cells and plasma cells, hypergammaglobulinemia, and association with other autoimmune disorders. Treatment involves immunosuppressive therapy with steroids, often in combination with azathioprine, which has been shown to be effective in improving clinical, biochemical, and histological features of severe autoimmune hepatitis.

1. AUTOIMMUNE
HEPATITIS
-

2. DEFlNlT
→ chronic disorder
(with Remissions E Relapses
]
characterized by continuing Hipgnosis
lintkmmn
W
FIBROSIS
T
progress
to iRs/ Lava failure .
→
presence
of extra hepatic features of autoimmunity G
-
Immunologic scr¥ supports an
autoimmune
process
in its pathogenesis
.
AUTOANTIBODIES
other typical feature of autoimmunity } ¥0 0am
ingalls.
- - -
-
Among categories of
"
Idiopathic
>
Ca) oupybgn.ie
chronic
- hepatitis
I
Many are autoimmune in
origin
-
→ casuinwn.ch
:::÷;:gz÷:%.
.
. . .cn .sn
.ws:1/:::::i?.::::?a.
I
Hepabtoxic drug -
a
proportion of which are
most
likely
' '
AlH

3. IMMUNO PATHOGENESIS
-
÷÷i÷÷÷÷÷ :::sis
1
Cell mediated Immunologic
T-cell / Antibody attack
n÷:÷::
involved in
this type of liver injury
is
INCOMPLETELY
DEFINED
→ The Mechanisms
-
→ Autoimmune hepatitis
has been
described in patients
who have seated AculiIB -

4. EVIDENCE TO SUPPORT AUTOIMMUNE PATHOGENESIS
→
① Histopathology
→
composed predominantly of
cytotoxic T - cells as plasma
cells
-
•
c÷:::%
.gs::'s
:
.ee/.fanconmon
.
thyroid
Rheumatoid Factor
HYPERGAMMA GLOBIN EM IA
③ Other Autoimmune
disorders such as
Autoimmune
thyroiditis
①
Rheumatoid
arthritis
occurs
with increased Altea
frequency u¥h'S
pipa N
Type
-1 DM
VITILIGO
fE
DISEASE
Sjogren
syndrome

5. ⑨ HISTOCOMPATIBILITY
HAPLOTYPES :
-
% autoimmune diseases such as HLA B1
HLA B8
HLA DR 3
HLA DR 4
Extended Haplotype HLA DRB 1 0301
-
HLA
DRBI 040
I
⑤ This type of chronic hepatitis
is responsive
to
glucocorticoid) Immunosuprcssive
Therapy
#
e in variety of aeetoimmuned.se#
CELLULAR IMMUNE MECHANISM ( cell mediated Immunity)
-
→
CDY Lymphocytes are
capable of session to Hepatocyte
mcmbvamprot-unsfdeshoyl.lk
.
→ Mokulae mimicry by aqachngaznh.ms that contain ep# similar b
hiver
is
postulated to activate there T-cell

6. → Abnormalities of Immunoregulatory control over cytotoxic
lymphocytes
(Impaired Regulator?.cz?nI/%7ess-t)
t
may play
role as
well .
Genetic predisposition : HAPLOTYPES
✓ HLA
Bl
B8
DR3
DR Y
-
DRB I 0301
DRB I 0401
-
→ polymorphism
in CTLA 4
TNF N

7. HUMORALIMMUNEMECHANISM-FExh.ae
hepatic
manifestations of autoimmune
→
play role in
- hepatitis
→ Immune complex deposition Arthralgias
- ARTHRITIS
Vasculitis
glomerulonephritis .
Nature of Immune complexes
hasnt been decked .
-
-
-
AUTOANTlB0Dl#
→ ANA ( anti Nuclear
antibodies ,
prima.ly in
HOMOGENEOUS
PATTERN
]
→ smooth muscle ( ASMA .
- directed against Iggy}Yq;µy)
→
Antibody to F -
actin
Uracil , guanine.
Adenine
→
anti - LKM
→ anti -
SLA (soluble liver antigen tgfs.hgofnpa.fm?nRNA
)
)
→
antibodies to 2-
Actinin
→ antibody to Live specific .
ASIALO
GLYCOPROTEIN
RECEPTOR (HEPATIC
LECTIN
)
→
Antibodies to other Hepatocyte Membrane proteins .

8. CLINICALFEATUREQ-smagof-din.cat
features of ALI are i to those
described for chronic
viral Hepatitis.
→
Disease may
be A (CHRONIC
present
→
The disease
may
-
initially
like q
confused with Audi
is
1
Recurrent attacks of ACUTE
HEPATITIS is common
-
→ In Yyth of saticnts → Diagnosis
is made in the
Ateneo of
typos with abnormal
DISTINCT FEATURES
→ A subset of patients have -
I
Young to middle Aged womens
MARKED HYPERGLOBULIN
EMA
{ HFI.hu of circulating ANA_
This is
the group
with SEROLOGY positivefor SLI
I
INITIALLY LABELLED AS
"
LUPOID HEPATITIS
"

9. →
Fatigue
Malaise
as::÷
:{are common
Acne
Arthralgias
Jaundice
→
ocassionally ARTHRITIS
=
Macho papular eruptions aahneodisuasulihs)
Erythema
NODOSUM
COLITIS
pleurisy
pericarditis
Anemia
Azotemia
S
Sica Syndrome
some patients presents with features of Decompensakd
→ CIRRHOSIS

10. MILD DISEASE !
-
→ In patients with mild disease Ca
) Limited histologic
lesions
(G !
piecemeal
Necrosis
w/
( without Bridging
)
progression
to cirrhosis
is limited
1
CLINICAL
monitoring is important
But even in this
subset ,
=
to identify progression
.
It
upto HALF of LEFT
untreated patients can
to
Cirrhosis
over I5years_
→ Natural history of milder disease is
with
spontaneous
Remissions as exacerbations.

11. SEVERE.tt# → 20-1.
of cases
→ ASTI ALT
- > 10X ULN
→
Marked H7PERCL0BuLlNEMl#
→
Aggressive
HISTOLOGIC
LESIONS →
BRNGe
NECROSIS
-- ad
MULTIL-OBUL.sk
COLLAPSE
→ G - month mortality without
treatment is → as high as Hot.
POOR PROGNOSTIC
SIGNS !
-
→ MULTILOBULAR
COLLAPSE Con Histology
) -
at time of presentation
Failure of Sr- Bilirubin to improve oftu.gg#
of
→ thugs
.
- -
-
→ In patients with established
cirrhosis,
HIC maybe take
complication
but occurs less#e than cirrhosis
anociatd with VIRAL HEPATITIS
#

12. LABORATORYFEATURES.LT
→
similar to those seen in CHRONIC VIRAL HEPATITIS'
→
(FT →
Abnormal → Do NOT CORRELATE
WITH
CLINICAL
SEVERITY)HISTO PATHOLOGIC
FEATURES
→
Many patients with AIH have NORMAL
BILIRUBIN
#
NORMAL
ALP
NORMAL
GLOBULIN
LEVELS
WITH
ONLY
MINIMAL ASTI ALT
N
ASTIALT levels → Elevated s Fluctuate in range
of
*
→
=
too -
1000 U
→
→ often pinged Patiala in LATE in disease
! Active phases .
In SEVERE CASES → Sv. BILIRUBIN is moderately elevated
→
( 3 - lomgldl]
-
Hypo ALBUMIN EMIA → occurs in very ACTIVE
→
#
Advance ,
} disease
→
Sr . ALP → moderately Elevated)NEAR NORMAL -
- -
→
In small proportion of patients.
s. - ALP markedly elevated
Hr
In such patients,
clinical { LAB FEATURES overlap with
those of BBE

13. AUTOANT1B0DlE#
→
RAk → is commonly present
(antibody
)
→ POLYCLONAL
HYPER GAMMA GLOBULIN EM IA
£2- 5 gm/db)
is common
in AIH
*
→ CHARECTERTICALLY ,
ANA's → in Homogeneous
staining
pattern
.
→ Smooth Muscle Antibodies → hcs-pc.rs#fic
→ seen just as trophy
chronic viral Hepatitis
→
Became of High levels of GLOBULIN 's
I
ocassionally aos may
bind nonKly in
S binding immunoassays
. for vid antibodies
to
This has been recognized most commonly in tests for
autoantibodies to Hepatitis
.

14. TYPE
-
I AIH TYPE - I AM -
⑧
→ classic syndrome occur
in
→ m/c in
CHILDREN
YOUNG
WOMAN
'
→ ABSENT
ANA -
(antibods
)
→
marked T Immunoglobulins →
positive
.
for LKMI
I
→ LUPOID
features (SLC
)
(directed against
→
HLA DR3/DR cyt
p45o2DD
especially 138 - 1310301
÷÷÷÷÷÷÷÷÷¥÷÷÷÷÷÷÷:÷÷÷.
→ lack ANA
and anti -
LKMI
→ antibodies against SLA=
⇐able liver Antigen)
I
Most of them are women
with CIF
more Severe than classic Type-
I AIM .

15. ANTl-LKMANTIB0D
Anti LKMI → Type-
I AM
"3
CHRONIC Hep
C
Anti Lkmz →
DRUG INDUCED hepatitis
anti 2km 3
→
Chronic Hep
- D
T
u
( against
Uridine Diphosphate
GLUCURONYL
TRANSFERASES
)

16. Liverpool
→
Similar to CHRONIC VIRAL
HEPATITIS
-
INTERFACE HEPATITIS) PICEMEAL
NECROSIS
#
→ Mononuclear cell Infiltrate (along E PLASMA
CELLS
)
t
Ending pots 5
Extending beyond thePI
of Pa: postal Hepatocytes into Parma '
- -
→ NECRO INFLAMMATORY activity s
indicated
by LOBULAR PARENCHYMA
→
HEPATOCELLULAR REGENERATION -
Reflected by T
"
ROSETTE formation
occurrence of Thickened cell plates
{
Regenerative PSEUDOLOBULES
→ Septal FIBROSIS
) BRIDGING FIBROSIS
)CIRRHOSIS
→ are frequent
→
In
patients with Early AIM is
presenting as Acute HEPATITIS
t
have LOBULAR S CENTRILOBULAR
Necrosis .
→ Bile duct injury / Granulomas -
UNCOMMON
.
I BlockENKA &
HISTOLOGIC
(features overlap with BBC.CC
Howwee subgroup of patients have serologic
F -

17. DlAGN0STlCCRlTER
INTERNATIONAL GROUP '
:
→
Sef of criteria for diagnosis
of Allt .
Exclusion of hiva diseases caused
by
Genetic disorders
VIRAL Hepatitis
:÷:
+
Inclusion Diagnostic
criteria
-
HYPER GLOBULIN
ENA
AUTOANTIBODIES
Hisioloaic
features}
→ Intimation group
also suggested comprehensive diagnostic
scoring system that Rarely required for typical cases 5
Helpful when Atypical
FEATURES
are present .
#
Itwau :
µ
;E¥%ii?5'm.# muscle
.
vents
→
Female gender other autoantibodies
→
PREDOMINANT Am¥fln →
concocur.cat a DISEASES
→ LEVEL OF GLOBULIN ELEVATION
→ CHARECTER
-
sik Hsiu ( I
;Yafama.
!ff?
-
→ MLA DR3/DRy markers

18. SIMPLIFIEDSCORINGSYSTEi-SAUTO.SN
TI BODIES
→
Sr.
IgG
Level
→ HISTOLOGIC
FEATURES
→
Absence of VIRAL HEPATITIS markers .
→ WEIGHING again
the diagnosis are
-
→
predominant ALP
Elevation
-
→
Milch
Antibodies
→
Markes of VIRAL HEPATITIS
-
-
→
IYO -
Hepatotoxie drugs / Excessive
Alcohol
-
→
Histologic
evidence of Buctdy
-
Atypical Histologic
features →
taotbninfilahoaalidon
g
VIRAL
INCLUSIONS -

19. -
DIFFERENTIAL
DIAGNOSIS
-
→ Acute VIRAL HEPATITIS Early in the course of disease,
AIH resemble typical Acute
viral Hepatitis.
*
→ WILSON 'S DISEASE
→
post Necrotic (CRYPTOGENIC
CIRRHOSIS E primary
Biliary
CIRRHOSIS .
→ Alcohol:c Hepatitis 8 NASH
→ chronic viral Hepatitis
→
Rheumalologicol disorders RA,
SLE
→
Hepatic Venous outflow obstruction (Budd - Chiari syndrome
]
→ CELIAC
DISEASE Ischemic
Lira disease
AIM overlap with Autoimmune Bidders (RE, PSI
]
even
more
Lardy
Mitochondrial antibody negative
AUoimagh.
→ overlap syndromes are difficult to
categorize { often ncspons-c.to
therapy may
be the Distinguish.ua Factor that establishes
the
-
-
diagnosis-

20. TREATME.INT#
STEROIDS .
→
Mainstay of TREATMENT
.
Induction :
prednisone
ALONE
} >→ Aza
alone
PRED + AZA
MAINTAIN ANCE
-
!
AZA Alone
AZA t prep
} >>> PRED Alone
CIRRHOTICS →
Prednisolone
Non -
cirrhotics → Budesonide
}

21. STEROIDS
I
→ Symptomatic ,
clinical .
Biochemical s Histological improvement
→ Increased
-
→
Therapeutic Response expected in -
8€
.
of patients .
has not been shown in clinical
→
However ,
steroids
-1¥
to prevent Ellingson
to s -
AASLD .
- Alternate approach .
start → Gomgld
-
30mg pred t Gong AZA
['
nmaonthlo It
mama. . .
we .¥g
/yoga ,
↳mouazmonm
Maintenance
-
AZA s sorry)day
PRED s long / day
AiGE : It
As course of treatment is
around 18months
1
Combination approach Reduces STERo#

22. Azathioprine :
( i -
zmgllylday
)
-
→
TPMT (Thiopurine
Methyltransferase
) allelic
variants
d
Doesnot correlate with AIA
anociatedcylopn.ca)
Efficacy E is nod.
Assessed routinely
in patients
with Autoimmune
.
G MP can be subsihehd for ALI,
but
- 5
rarely required
AZA is
prodrug
for GMP
→
AZA ALONE
Alhmatdaygluggggrhjsgid}-
7%77:b soon .

23. STERODstAZATHER.ph
→ has been shown to be Effective in
SEVERE
AIM
→
Therapy is not indicated for MILD form of AIM
-
SEvERE-
→ AST s LOX ULN
→
AST 35×02 N plus
Sr -
globulin
Z 2X
Normal
→ hiva Biopsy ( Bridging Necrosis
Ca) Multilobulae Necrosis
)
→
presence
of symptoms .
RESPONSETOTHERA.pt
→
Fatigue,
Anorexia ,
Malaise.
Jaundice Dayton
Biochemical improvement →
weeks to months
.
=
( fall in S. - Bilirubin levels (globulin levels
÷
{ increase in Sr- Albumin )
←
-

24. → Sr- AST levels → drops fusty but Improvements in
=
-
AST do not appear
to be reliable
markers of Recovery
HistologicImprovemcn# & -24 months)
Mononuclear
infiltrate and in Hepatocellular
→ Decrease in -
→
Many
societies recommend that
I
DO NOT DO SERIAL
LIVER BIOPSIES
to a_
therapeutic
^e
Ca) gains
to Attu stop therapy
.
RAPIDRESPONS.IT
→ older patients (> 69 years)
→ HLA
DR 1310403
→
Rapid Responders may progress
less slowly b cirrhosis
9 liver transplantation .
RELAPSE RATE
is like SLOW RESPONDERS .

25. therapy
→ Should continue for atleast 12-18 months
→
After stopping
s Tapering of therapy
I
RELAPSE
rate is
atleast 501.
→ Even if post treatment histology
show Millis
I
Majority of patients require therapy at MAINTENANCE
done INDEFINITELY
CONTINUING AZATHIOPRINE alone (Zmgllgldag) after
-
conation of prednisone therapy
has been
shown
-
-
to reduce the frequency of RELAPSE .
Long term Maintenance with pr felony Kay
)
is also
He with benefits of AZATHIOPRINE (Bon
mg;S%sion)
{ women of childbearing Age
# TERATOGEN 'CITY)
I - -
AZATHIOPRINE MAINTENANCE is more effective in Preserving Remission .
-

26. In REFRACTORY
CASES
-
:
to
High doe glucocorticoid monotherapy (Gomglday
)
Ca)
combination Glucocorticoid @omgld
) t AZA (50mg )day
)
H
Then closes are
Reduced to CONVENTIONAL
MAINTENANCE
doses .
I
Patients Refractory
to this Regimen
I
Treated with CYCLOSPORINE
'
i'
'
Emus }
→ TNF a -0 Inftiximab
g
Rescore therapy in
@D2DB-IymphocytiAntiguNbloclae-sRitux.mab
refractory AM
I
Put data is

27. LWERTRANSPLANTAITIONINAlf-sse.VE
RE Alk -
ALF failure of Bilirubin
to improve
offer 2wcek#
→ CIRRHOSIS
→ Decompensation
→ Recurrence of Alu in New
LIVER occurs
Rarely
→ 5 -
yeae
Patient s graft
survival exceeds 807.
patients with Ats
should be vaccinated against
Hepahts A S B before immunosuprcss.ve
-
therapy
is
begun