Hepatitis refers to inflammation of the liver, which is commonly caused by viral infections. There are 5 main types of hepatitis viruses - A, B, C, D and E. Hepatitis A and E are typically spread through contaminated food or water, while hepatitis B, C and D usually occur through contact with infected body fluids. Acute hepatitis may present with few or no symptoms, while chronic hepatitis can progress to fibrosis, cirrhosis or liver cancer over many years if left untreated. Diagnosis involves physical exam, imaging, liver function tests and blood tests to detect viral antibodies.

1. Hepatitis
Ahmed Essam Elsayed Farrag
3rd year Medical Student
Mansoura Faculty Of Medicine - Egypt

2. What is HEPATITIS ?
Hepatitis refers to an
inflammatory
condition of the liver
commonly caused by a viral infection

3. There are 5 main hepatitis viruses, referred to as
types A, B, C, D and E. These 5 types are of
greatest concern because of the burden of
illness and death they cause and the potential
for outbreaks and epidemic spread ..

5. Hepatitis A and E are typically caused by ingestion of contaminated food or
water. Hepatitis B, C and D usually occur as a result of parenteral contact
with infected body fluids. Common modes of transmission for these viruses
include receipt of contaminated blood or blood products, invasive medical
procedures using contaminated equipment and for hepatitis B transmission
from mother to baby at birth, from family member to child, and also by
sexual contact.
Acute infection may occur with limited or no symptoms, or may include
symptoms such as jaundice (yellowing of the skin and eyes), dark urine,
extreme fatigue, nausea, vomiting and abdominal pain.

6. Alcohol
Hepatitis can be caused by liver damage from excessive
alcohol consumption. This is sometimes referred to as alcoholic
hepatitis. The alcohol causes the liver to swell and become
inflamed. Other toxic causes include overuse of medication or
exposure to poisons.
Autoimmune Disease
The immune system may mistake the liver as a harmful object
and begin to attack it, hindering liver function.
Causes of Non-viral Hepatitis

7. The condition can be self-limiting or
can progress to fibrosis (scarring),
cirrhosis or liver cancer .

14. Types of Viral Hepatitis :

16. Hepatitis A virus (HAV) is present in the faeces of infected
persons and is most often transmitted through consumption of
contaminated water or food. Certain sex practices can also
spread HAV. Infections are in many cases mild, with most
people making a full recovery and remaining immune from
further HAV infections. However, HAV infections can also be
severe and life threatening. Most people in areas of the world
with poor sanitation have been infected with this virus. Safe and
effective vaccines are available to prevent HAV.
HAV

17. No treatment is needed for hepatitis A since the
infection almost always resolves on its own. Nausea is
common, though transient, and it is important to stay
hydrated. It is recommended that strenuous exercise
be avoided until the acute illness is over.

18. Hepatitis B virus (HBV) is transmitted through exposure to
infective blood, semen, and other body fluids. HBV can be
transmitted from infected mothers to infants at the time of birth
or from family member to infant in early childhood. Transmission
may also occur through transfusions of HBV-contaminated
blood and blood products, contaminated injections during
medical procedures, and through injection drug use. HBV also
poses a risk to healthcare workers who sustain accidental
needle stick injuries while caring for infected-HBV patients. Safe
and effective vaccines are available to prevent HBV.
HBV

19. For hepatitis B, treatment is aimed at controlling the
virus and preventing damage to the liver. Antiviral
medications are available that will benefit most
people, but the medications need to be chosen
carefully, and the treatment needs to be monitored in
order to assure successful treatment and prevent or
treat medication-related side effects. For some
individuals, the risks of treatment may not be justified.

20. Hepatitis C virus (HCV) is mostly transmitted through exposure to
infective blood. This may happen through transfusions of HCV-
contaminated blood and blood products, contaminated
injections during medical procedures, and through injection
drug use. Sexual transmission is also possible, but is much less
common. There is no vaccine for HCV.
HCV

22. World map of HCV prevalence

23. Treatment of chronic hepatitis C has evolved, rendering many
earlier drugs obsolete. The drugs currently used (as of March
2016) include pegylated interferon, ribavirin, elbasvir,
grazoprevir, ledipasvir, sofosbuvir, paritaprevir, ritonavir,
ombitasvir, dasabuvir, simeprevir, daclatasvir. These are always
used in various combinations, never alone. Interferon is given by
injection while the other medications are pills. Studies have
shown that combinations of these drugs can cure all but a small
proportion of patients; however, serious side effects of
treatment can occur.

24. Hepatitis D virus (HDV) infections occur only in those who are
infected with HBV. The dual infection of HDV and HBV can result
in a more serious disease and worse outcome. Hepatitis B
vaccines provide protection from HDV infection.
HDV

25. Hepatitis E virus (HEV) is mostly transmitted through consumption
of contaminated water or food. HEV is a common cause of
hepatitis outbreaks in developing parts of the world and is
increasingly recognized as an important cause of disease in
developed countries. Safe and effective vaccines to prevent
HEV infection have been developed but are not widely
available.
HEV

26. Although structurally quite different, the Hepatitis Viruses produce similar
morphological and clinical pictures. Three basic clinico-pathological
pictures can develop depending on the timescale of infection which is
largely determined by the exuberance of the immune response to the virus.
oClinico-pathological Patterns
• Acute Viral Hepatitis : Strong Immune Response
• Chronic Viral Hepatitis : Absent or Low Immune Response
• Fulminant Hepatitis : Catastrophically exuberant immune response

27. Acute Viral Hepatitis refers to a clinico-pathological
pattern of disease caused by infection with Hepatitis
Viruses that results in short-term inflammation
of the liver.
Definition
Acute Viral Hepatitis

28. Infection with any of the Hepatitis Viruses (HAV, HBV,
HCV, HDV) can initiate acute viral hepatitis.
Generally speaking, HAV only produces acute viral
hepatitis, HBV produces acute syndromes in adults
but rarely when infection occurs in infants, and HCV
produces acute syndromes in a minority of cases.
Etiologies
Acute Viral Hepatitis

29. • Gross Appearance
The liver may be enlarged and slightly reddened.
• Histological Appearance
Hepatocytes respond to injury in a number of ways including cytoplasmic
vacuolation (Termed "Ballooning Degeneration"), cellular rupture, or simply
apoptosis. In severe cases, areas of hepatic tissue may undergo necrosis. The
hepatic tissue displays striking inflammation in acute viral hepatitis which
manifests with proliferation of kupffer cells as well as parenchymal infiltration
with mononuclear cells, especially lymphocytes. Within this inflammatory war
zone, areas of hepatocyte regeneration can be observed. Finally, in the case
of HBV infection, the cytoplasm of hepatocytes may appear full of granules,
giving them a characteristic "Ground-Glass Appearance", representing dense
granules of HBV Surface Antigen (HBsAg).
Morphology
Acute Viral Hepatitis

30. Classic Clinical Syndrome
Incubation
Period
prodrome
Icteric
Phase
Recovery
Phase
Acute Viral Hepatitis

31. • Incubation Period
All of the Hepatitis Viruses possess an incubation period
where there is no clinical or serological evidence of
infection. The incubation periods vary for each virus but
generally last between one to two months.
Classic Clinical Syndrome
Acute Viral Hepatitis

32. • Prodrome
The prodromal period is characterized by nonspecific
symptoms associated with systemic infection. The prodrome
characterizes rapid viral proliferation prior to the development
of an immune response. During this period serological markers
of viral proteins as well as serum aminotransferase (ALT and AST)
levels will skyrocket. Clinically, constitutional symptoms along
with malaise, fatigue, and anorexia may be present.
Classic Clinical Syndrome
Acute Viral Hepatitis

33. • Icteric Phase
During this phase clinical signs of jaundice and scleral icterus
will appear and some right upper quadrant tenderness may
develop due to enlargement of the liver. However, this phase
coincides with a building immune response which begins to
bring the virus under control .
During this period IgM antibodies to certain viral antigens begin
to develop and viral protein levels will decline. Constitutional
symptoms also decrease in intensity and serum
aminotransferases begin to fall.
Classic Clinical Syndrome
Acute Viral Hepatitis

34. • Recovery Phase
During this phase clinical signs of jaundice subside as
do most constitutional symptoms. The immune
response also matures and many of the anti-viral IgM
antibodies begin to class switch to the IgG subtype.
Levels of serum aminotransferases also return to
normal.
Classic Clinical Syndrome
Acute Viral Hepatitis

35. Chronic Viral Hepatitis refers to a clinico-pathological
pattern of disease caused by infection with certain
Hepatitis Viruses that results in greater than 6 months
of hepatic inflammation and injury .
Definition
Chronic Viral Hepatitis

36. • Hepatitis A Virus
Almost never results in chronic infection.
• Hepatitis B Virus
If transmission occurs in neonates via mother-to-child transmission: Nearly 99% of individuals
display chronic infection
If transmission occurs in immunocompetent adults: Only 1% of individuals display chronic
infection
If transmission occurs in immunocompromised adults: Rate of chronic infection is significantly
higher than 1%
• Hepatitis C Virus
Nearly 80% of infected adults will display chronic infection.
• Hepatitis D Virus
If acquired through co-infection with HBV, follows same pattern as HBV. If
acquired on top of chronic HBV infection, will result in chronic HDV infection.
Etiology
Chronic Viral Hepatitis

37. Long-term infection with hepatitis viruses results in variable
degrees of low-grade inflammation. In many cases,
inflammation is so minute and pathological changes so
nuanced that clinical consequences are not observed. In
other cases, inflammation smolders sufficiently that over
time extensive fibrosis is observed that ends in a picture of
cirrhosis. Finally, in some individuals the immune system may
suddenly and spontaneously mount a stronger response to
the virus leading to a syndrome of acute viral hepatitis.
Pathogenesis
Chronic Viral Hepatitis

38. The morphology of chronic hepatitis is extremely variable.
When mild, a predominantly lymphocytic infiltrate may
occur just within the portal tracts. Frequently, steatosis is
observed along with lymph node-like aggregations within
the hepatic parenchyma
When severe, hepatocyte necrosis may be apparent.
Progression to cirrhosis is manifested by increasing fibrosis.
Morphology
Chronic Viral Hepatitis

39. Fulminant Hepatitis is a complication of
acute viral hepatitis that manifests as
rapid functional decompensation of
the liver.
Definition
Fulminant Hepatitis

40. Fulminant Hepatitis occurs in the context of
acute viral hepatitis. It is rare during hepatitis
A or C virus infection. Most cases are due to
Hepatitis B Virus infection with or without
Hepatitis D Virus. It is most likely the result of
a massive, overly-exuberant immune
response to the presence of virus, resulting in
rapid inflammatory damage to the liver.
Etiology and Pathogenesis
Fulminant Hepatitis

41. • Overview
Fulminant Hepatitis is characterized by certain signs of hepatic failure that can
manifest rapidly and thus does not include those that require chronic timescales to
develop.
• Symptomology
Hepatic Encephalopathy: Characterized by altered mental status, confusion, somnolence, or coma
Brain Edema: May occur, possibly resulting in cerebral herniation
Hepatorenal Syndrome: Which may result in acute renal failure
Generalized Edema: Due to rapid hypoalbuminemia
Prolonged Prothrombin Time (PT) : Due to reduced synthesis of coagulation proteins
Jaundice: Due to hyperbilirubinemia
ARDS may result
• Prognosis
Fulminant Hepatitis has a high degree of mortality and is rapidly fatal.
Clinical Consequences
Fulminant Hepatitis

42. Very frequently the onset of hepatitis, the acute phase, is not
associated with symptoms or signs, but when they do occur
they are usually general and include fatigue, nausea,
decreased appetite, mild fever, or mild abdominal pain.
Later signs more specific for liver disease may occur,
specifically yellowing of the skin and eyes (jaundice) and
darkening of the urine. If the infection becomes chronic as is
the cause with hepatitis B and C, that is, lasting longer than
months, the symptoms and signs of chronic liver disease may
begin. At this point the liver often is badly damaged.
Symptoms of Hepatitis

45. How Is Hepatitis Diagnosed ?
Physical Exam
Liver Biopsy
Liver Function Tests
Ultrasound
Blood Tests
Viral Antibody Testing

47. Thank you ..