Chronic hepatitis

1. Mohit Rulaniya
•Chronic hepatitis :-
• Chronic hepatitis is a group of chronic diffuse inflammatory-dystrophic diseases of a liver
characterized by inflammation, dystrophy and necrosis of hepatocytes, while maintaining the
lobular structure of the liver.
Epidemiology :-
More than 70% of chronic hepatitis is clinically asymptomatic. In the world, about 350-400
million people suffer from chronic hepatitis B.
About 180 million people suffer from chronic hepatitis C.

2. Classification of chronic hepatitis
On etiology and pathogenesis:
• 1)chronic viral hepatitis B;
• 2)chronic viral hepatitis C;
• 3)chronic viral hepatitis D;
• 4)chronic viral hepatitis indefinite (virus F,G);
• 5)autoimmune hepatitis;
• 6)drug-induced hepatitis;
• 7)cryptogenic hepatitis (unknown etiology);
• 9)Wilson’s and Conovalov’s disease;
• 10)primary sclerosing cholangitis;
• 11)cholestasis hepatitis;
• 12)NASH and alcohol hepatitis.

3. Classification of chronic hepatitis
On activity of necroinflammatory process:
• Minimal;
• slight marked;
• moderate marked ;
• severe marked.
Stage of hepatitis (to determine by diffusion of fibrosis and forming of cirrhosis):
F0 – fibrosis is absent;
F1 – mild periportal fibrosis;
F2 – moderate fibrosis with porto-portal septs;
F3 – severe fibrosis with porto-central septs;
F4 – liver cirrhosis.

4. Classification of jaundice
Under jaundice understand the yellow
coloration of the skin, sclera and
mucous membranes as a result of
impregnation of the tissues with bile
pigment bilirubin.
Distinguish the following types of
jaundice:
- superhepatic jaundice - hemolytic
anemia.
- subhepatic jaundice:-
• tumors of large bile ducts;
• cholelithiasis;
• acute and chronic pancreatitis;
• hemoblastosis with liver infiltration.

5. intrahepatic jaundice
- enzymopathy:
a) genetically determined - Gilber's disease and others;
b) toxic - alcohol, medicines;
c) viral - predominantly chronic hepatitis C.
- hepatocellular:
a) acute viral hepatitis;
b) alcoholic hepatitis;
c) drug-induced hepatitis;
d) exacerbation of chronic hepatitis and steatohepatitis;
e) cirrhosis of the liver (including primary and secondary biliary cirrhosis);
f) heart disease (stagnant liver);
j) septic hepatitis.

6. -The routes of HBV
transmission:-
sexual;
- percutaneous (intravenous drug use);
- perinatal;
- horizontal;
- blood transfusion;
- nosocomial (can occur from patient to
patient, from patient to health care
worker);
- organ transplantation.
The routes of HDV transmission:-
• The transmission routes of hepatitis D is
the same as hepatitis B.

7. Etiology
• 1.hepatotropic viruses : B,C,D,G;
• 2.hepatotoxic drugs (antibiotics, sulphanilamids,tuberculostatic
drugs etc);
• 3.alcohol;
• 4.metabolic genetic liver diseases (hemochromatosis, Wilson’s
disease, alfa1-antitrypsin deficiency.).
• 5.NASH;
• 6.Еtiology of autoimmune hepatitis, primary biliary cirrhosis,
primary sclerosing cholangitis are not clear.

8. Pathogenesis of chronic hepatitis
Chronic course and progression of the disease is explained by the
processes:
1) the hepatitis B virus, in contrast to the hepatitis C virus, has no direct
cytopathogenic effect on hepatocytes;
2) persistence of the virus in patients with a weakening immune system;
3) development of autoimmune processes, when under the influence of
various factors hepatocytes themselves acquire antigenic properties;
4) liver cells infected with hepatitis viruses are destroyed by the cellular
immune response.
In patients infected with the hepatitis B virus in 10% develops Chronic hepatitis, and in
patients infected with the hepatitis C virus – Chronic hepatitis develops in 80-95%.

9. Clinical manifestation
• Asthenovegetative syndrome: -weakness, slackness, fatigue, irritability, decrease of activity,
loss of weight;
• Dyspeptic syndrome: loss of appetite, nausea, belching in the mouth, vomiting, epigastric
discomfort, a swelling of a stomach, unstable stool;
• Pain syndrome: pressure, heaviness or dull pain in the right hypochondrium, upper abdominal
discomfort;
• Cholestatic syndrome: icterus sclera and visible mucous membranes, skin, itchy skin, traces of
scratching on the skin, darkening of the color of urine;
• In severe forms of сhronic hepatitis - encephalopathy (memory impairment,
emotional lability, irritability).

10. laboratory research
• General blood test: decrease the level of erythrocytes, leucocytes and platelets;
• Cytolysis syndrome: an increase in the level of aminotransferases (aspartate aminotransferase -3-35 U/L, alanine
aminotransferase – 3-35 U/L, gamma-glutamyl transferase – for men 49 U/L, for women 32 U/L)
• Cholestasis syndrome - alkaline phosphatase -30-35 U/L, bile acids (common-3-17mmol/l) and bilirubin – direct (0-
5,1mmol/l) and indirect (5,1-17 mmol/l).
• Hepatodepressive syndrome: decreased level:
- albumin (the norm of 35-50 g / l)
- prothrombin index (normal 80-110%)
• Mesenchymal-inflammatory syndrome: a rise in the level is determined:
- thymol test (norm 0-7 units);
- sulum sample (norm 1.9 units and more);
- gamma globulin serum (norm 8-17 g / l).
• Alpha Fetoprotein (AFP) - the norm is 8-10 IU / l.
An increase in the level of alpha fetoprotein may indicate the development of hepatocellular carcinoma.

11. Markers of chronic viral hepatitis (B, C, D)
• Chronic hepatitis B: HBsAg, anti HBcore IgM, anti HBcore IgG, anti HBe,
The presence of hepatitis B virus in the blood (HBV DNA- deoxyribonucleic acid) is
determined by the polymerase chain reaction (PCR);
• Chronic hepatitis C: anti HCV IgM, anti HCV IgG;
The presence of the hepatitis C virus in the blood and its level is also determined by the
polymerase chain reaction. The hepatitis C virus has 6 genotypes.
Distinguish:
- phase integration - HCV RNA (ribonucleic acid) - 0,
- the replication phase - HCV RNA is above 0 to hundreds of thousands, million or more.
• Chronic hepatitis D: anti HDV IgM, anti HDV IgG.
The presence of the hepatitis D virus in the blood (HDV RNA) and its level is also
determined by the polymerase chain reaction.

12. Instrumental methods of examination
Ultrasound is the main instrumental method for studying the liver and biliary system. Ultrasound
is determined diffuse and focal changes in the liver, the size of the liver and spleen, the diameter
of the portal and splenic veins.
Computed tomography (CT) in detail determines the position, shape, size and structure of the
liver, gallbladder, large bile ducts, and also their relationship with neighboring organs and tissues.

13. Treatment of chronic viral hepatitis B
• Summary of treatment indications:
All patients with chronic hepatitis should be evaluated for treatment. Indication for treatment depends on the
level of viral replication - HBV DNA >2,000 IU/ml., corresponding to >10,000 copies/ml.
Сurrently use pegylated alpha interferons or highly effective analogues of nucleosides or nucleotides (tablet
forms):
- Pegasys 180 mkg subcutaneously 1 time per week. Duration 6-12 months;
- Entecavir 0,5 - 1 tablet per day. Duration - 1 year and more (long term);
- Tenofovir 300 mg 1 tablet per day. Duration - long term;
- Telbivudine 600 mg 1 tablet per day. Duration – long term;

14. Treatment of chronic viral hepatitis C
• Standard therapy: pegylated interferons + ribavirin (the dose of ribavirin depends on body weight).
• Currently used highly effective tablet preparations of direct antiviral action - polymerase inhibitors, protease
inhibitors.
• The scheme and duration of therapy depends on the genotype of HCV, the level of viremia and the
presence of complications.
• Sofosbuvir 400 mg, ledipasvir 90mg, daclatasvir 60 mg etc.
• With newly diagnosed chronic hepatitis (naive patients), there are short treatment regimens - 8-12 weeks.
Treatment of chronic viral hepatitis D:-
• Hepatitis D only occurs in combination with a replicating hepatitis B infection.
In clinical practice, pegylated interferons are used - pegasys 180 mkg and pegintron 1.5 mkg for 48 weeks or
more.