Dr kgm hep b

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Dr kgm hep b

  1. 1. Hepatitis B virus Dr. K. G. Maharjan Liver unit, Bir hospital
  2. 2. Introduction• Hepatitis is an inflammation of the liver.• It is usually caused by viral & non viral infections also due to toxins (alcohol) & drugs (mostly ATT)• In our setup it maybe due to bacterial infection but may be an autoimmune response as well.• It is characterized by anorexia , jaundice, abdominal pain, liver enlargement and sometimes fever.• Others , usually bacterial infections leading to HV&IVC thrombophlebitis, metabolic cause (Wilson disease)• Congestive causes like ( HVOO,IVC disease , CHF)• HBV can lead to cirrhosis and liver cancer.
  3. 3. Introduction• Hepatitis is an inflammation of the liver.• It is usually caused by viral & non viral infections also due to toxins (alcohol) & drugs (mostly ATT)• In our setup it maybe due to bacterial infection but may be an autoimmune response as well.• It is characterized by anorexia , jaundice, abdominal pain, liver enlargement and sometimes fever.• Others , usually bacterial infections leading to HV&IVC thrombophlebitis, metabolic cause (Wilson disease)• Congestive causes like ( HVOO,IVC disease , CHF)• HBV can lead to cirrhosis and liver cancer.
  4. 4. Viral hepatitis• The different types of viral hepatitis A,E,(virus transmitted through the faces of an infected person.• Hepatitis B,C,D are serum hepatitis• Hepatitis F,G, cryptogenic ( caused by a virus as not identified)• More hepatitis viruses are less common yellow fever, epstien barr virus(EBV), cytomegalovirus(CMV),
  5. 5. Hepatitis B virus• HBV is a serious disease ,can cause lifelong infection , liver cirrhosis ,liver cancer , and liver failure ,death.• HBV is 100 times more infectious than HIV and 10 times more infectious than HCV.• HBV is a blood borne transmitted ( body fluids , semen, saliva,vaginal fluid (high titers in the blood and lower titer in body fluids)
  6. 6. Hepatitis B virus introductions• HBV is a 42 nm,double-shelled DNA virus of the class Hepadnaviridae.• The outer surface membrane contains HBV surface antigen (HBsAg) which also circulates in blood as 22 nm spherical and tubular particles.
  7. 7. HBV virus
  8. 8. Continu…• The inner core of the virus contains HBV core antigen (HBcAg) (HBeAg)• HBV is a single molecule of partially double – stranded DNA, and DNA- dependent DNA polymerase.
  9. 9. Continu…
  10. 10. Risk groups• 1, I/V drug users Health workers• 2, Multiple sex partners• 3,Homosexuals• 4,Infant born to HBV infected mothers• 5,Hemodialysis patients• 6, Areas with high rates of HBV infections• 7,Tatooing
  11. 11. HBV transmitted• HBV is transmitted by the exchange of blood & body fluids ,eg . Blood, semen, breast milk ,saliva and vaginal secretor fluids , tears.
  12. 12. Epidemiology• Globally• 50 million new cases per year• 350-400 million chronic carriers 75% in Asia• 520,000 deaths per year
  13. 13. Epidemiology in Nepal• One epidemiology study in done in nepal• Group;1, Population No. HBsAg• a, Soldiers 922 20 (2.2%)• b, healthy people 232 2 (0.8%) from districts• c, pregnant women 81 1 (1.2%)• d, blood donors 624 5 (0.8%)• blood donors 168 1 (0.6%)
  14. 14. Continu…….• Group 2,• Hospital staff 792 7 (0.8%)• Student nurses 122 0• Relatives of CLD 388 12 (3.1%)• Patients• Group 3,• Hemophilia 4 1 (25%)• Drug addicts 72 2(3%)• Hemodialysis 41 1(2%)• HBV carriers 49 49(100%)
  15. 15. Continu…• Group 4,• Chronic liver disease 145 57 (39%)• Acute hepatitis 150 14 (9.3%)
  16. 16. Clinical course of hepatitis B infection Death Recovery 1% 99% Transient Acute 100% Subclinical hepatitis infection 25% 65% Acute HBV infection 10% 10-30% Chronic HBV 70-90% Infection Chronic Healthy Hepatitis ? HBsAg Carrier Cirrhosis Hepatocellular Carcinoma ?
  17. 17. HBsAg True Positive Negative ALT Search for other virus Raised Normal Anti-HbcIgM Positive HbcAb Negative F/u after 6 months Positive Negative F/U HBeAg HBvDNA F/UPositive Negative >105ml <105mlLiver biopsy HBcAb Rx F/U HBvDNA Negative Positive Rx Liver biopsy HBvDNA HBvDNA Absent Raised Search for other causes of ALT
  18. 18. Infection• Acute hepatitis B develops in approximately 30% to 50% of adults at the time of initial infection and is characterized by anorexia, nausea , vomiting and jaundice.• SGPT raises 2 ½ times• The risk of progression to chronic infection varies with age , being highest among young children and infants (30%-90%) and lowest among adolescents and adults (2%-6%).• Rates of progression to cirrhosis and HCC vary according to age at acquisition of chronic infections ,HBeAg status , co infection with HGV,HIV,HCV, and alcohol abuse.
  19. 19. Clinical features• The first serologic marker to appear following acute infection is HBsAg, which can be detected as early as 1 or 2 weeks and as late as 11 or 12 weeks (mode 30-60 days) after exposure to HBV• HBeAg is generally detectable in patients with acute infections, the presence of HBeAg in serum correlates with higher titers of HBV and greater infectivity.
  20. 20. Continu….• A diagnosis of acute HBV infection can be made on the basis of the detection of IgM class antibody to HBV core antigen (IgM ,anti- HBc) in serum ,It is generally detectable at the time of clinical onset.
  21. 21. Serological markers ; HBV• HBsAg: Marker of infection,presence >6months=chronic• HBeAg: active viral replication,• Anti-HBsAg: indicates recovery and /or immunity (after vaccine)• Anti-Hbe: inactive viral replication• Anti-HBc: infection or immunity
  22. 22. HBV genotypes• HBV classified into 7 genotypes (A-G)• -a: north america and western europe• B&C: asia• D: southern europe and india• E:&G: africa• F:central and south america and alaska• H: central america• B associated with less HCC, less active and more slowly progressive liver disease than C• A&B respond better to Interferon than C&D• Genotype does not predict response to oral agents
  23. 23. HBV infection• Chronic HBV: chronic necroinflammatory liver disease >6month,ALT^,HBeAg-postive or – negative, HBV DNA> 10 x4-5• Inactive HBsAg carrier : Persistent infection without necroinflammatory disease, ALT normal , HBeAg -negative HBV DNA<10 x 4-5• Resolved HBV: previous infection without virological ,biochemicalor histological evidence of active disease.
  24. 24. Continu…• Acute exacerbation HBV: elevated ALT>10 x ULN or >2 x baseline• Reactivation of HBV: reappearance of necroinflammatory disease in person known to be inactive carrier or resolved HBV
  25. 25. Liver histology ≥ Phases of chronic HBV• Immunotolerant phase: HBeAg- postive; HBV DNA high (10 x 5-10) ALT normal -candidates for therapy.Immunoactive phase: HBeAg-postive or HBeAg – negative,HBV DNA high (10 x4-10) ,ALT elevated, symptoms +/-Non replicative phase :(inactive HBV carrier)HBeAg –negative HBV DNA low(<10 x4 ) ALT normal, HBsAg may later become undectable.
  26. 26. Routine HBV carriers exam• Follow-up interval 6 months : Tests : ALT and AST; AFP. USG,• Inactive HBsAg carrier: If ALT/AST increase , re evaluate• Chronic hepatitis B: CBC,LFT,HBeAg, anti-HBe
  27. 27. HBV infected mothers• Hepatitis B immunoglobulin (HBIG 0.5 ml , I/M to new born.• Hepatitis B vaccination should have been given 12 hours of birth.
  28. 28. Post exposure prophylaxis• 1, HBIG is required• 2,the first dose of hepatitis B vaccine immediately, 0 – 1 – 6 months.
  29. 29. Hepatitis B vaccine• The standard regimen for adult is 10-20mcg initially ( depending on the formulations ) .• Schedules; 0 -1 -6 months.• Alternative schedules have been approved• 0 -1 -2 -12 months• 0- 7 and 21 days ,plus 12 months• Preferred site vaccine deltoid muscles
  30. 30. Treatment of chronic HBV• Nucleoside/nucleotide analogues: - Entecavir : 0.5-1.0 mg/d• -Lamivudine : 100 mg/d• -Adefovir dipivoxil :10mg/d• -Tenoforvir : 300mg/d• Interferon: interferon alfa-2b 5MU/d or 10MU tiw x 4 months.• Peginterferon alfa-2a (Pegasys) 180 mcg/week x 24-48 weeks.• Liver transplantation ( decompensated chronic HBV with cirrhosis.
  31. 31. Reference• Davidson principal and practice of medicine• C.M.D.T• Oxford hand book of medicine• Liver unit, Bir hospital
  32. 32. Thank youThank you

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