A COMPLETE OVERVIEW

1. HEPATITIS
S/L DR AAMIR HUSSAIN
ASSTT PROFESSOR

2. OBJECTIVES
 AT THE END OF LECTURE,THE SECOND YEAR MBBS
STUDENT WILL BE ABLE TO UNDERSTAND
 THE DIFINITION OF HEPATITIS
CAUSES RESPONSIBLE FOR HEPATITIS
CLINICAL FEATURES OF ACUTE AND CHRONIC
HEPATITIS
COMPLICATIONS
PREVENTION &
TREATMENT OF HEPATITIS

3. INTRODUCTION

4. HEPATOCYTE AND LIVER LOBULE

5. DEFINITION
 INFLAMMATION OF LIVER
 DAMAGE TO HEPATOCYTES
 RAISED ALT

6. TYPES
 ACUTE
 Temporary, self-limiting
 CHRONIC(>6 MONTHS)
 Persistent, leads to Fibrosis, Cirrhosis or malignancy
 FULMINANT(WITHIN 8 WEEKS)
 jaundice, encephalopathy and cerebral edema
 PRESENTS AS JAUNDICE, YELLOW DISCOLORATION OF EYES
AND SKIN

7. CAUSES OF ACUTE HEPATITIS
 VIRAL HEPATITIS
 HAV,HBV,HCV,HDV,HEV,CMV,EBV,HSV,YFV
 NON-VIRAL INFECTION(LEPTOSPIROSIS etc)
 ALCOHOL
 TOXINS(amanita phalloides, carbon tetrachloride)
 DRUGS(paracetamol, isoniazid)
 ISCHEMIC HEPATITIS
 AUTOIMMUNE
 METABOLIC/HEREDITARY DISEASES
 PREGNANCY
 REYE’S SYNDROME

8. CAUSES OF CHRONIC HEPATITIS
 VIRAL HEPATITIS
 HBV & HCV
 ALCOHOL
 DRUGS
 NON-ALCOHOLIC FATTY LIVER DISEASE
 AUTOIMMUNE
 HEPATOCYTE INJURY
 BILE DUCT INJURY
 PRIMARY BILIARY CIRRHOSIS
 PRIMARY SCLEROSISNG CHOLANGITIS
 HAEMOCHROMATOSIS
 WILSON’S DISEASE
 ALPHA 1 ANTITRYPSIN DEFICIENCY
 CRYPTOGENIC/UNKNOWN

9. CLINICAL FEATURES
 LOW-GRADE FEVER
 LOSS OF APPETITE
 NAUSEA
 VOMITING
 MALAISE
 DIARRHOEA
 YELLOW DISCOLORATION
 DARK URINE
 TENDER HEPATOMEGALY

10. CLINICAL PRESENTATION OF CHRONIC LIVER DISEASE
 JAUNDICE
 ASCITES
 HEMETEMESIS AND MELENA
 HEPATIC ENCEPHALOPATHY
 PALMAR ERYTHEMA,DUPYTRENS CONTRACTURE OR
FLAPPING TREMORS
 PORTAL HYPERTENSION & SPLENOMEGALY
 PLEURAL EFFUSION
 LEG EDEMA
 RENAL FAILURE

11. COMPLICATIONS
 CHRONIC
 FULMINANT(8 WKS)
HYPERACUTE(< 1 WK)
ACUTE(<4 WKS)
 HYPOGLYCAEMIA
 METABOLIC ACIDOSIS
 INFECTIONS/SEPSIS
 RENAL FAILURE

12. INVESTIGATIONS
 LIVER BIOCHEMICAL TESTS
ALT
AST
ALKALINE PHOSPHATASE
GAMMA GT
BILIRUBIN
ALBUMIN
PT & INR

13. INVESTIGATIONS
 HEPATITIS VIRAL PROFILE
 ANTI HAV
 ANTI HEV
 HBs Ag and IgM ANTI HBc
 ANTI HCV
 ANTI HDV if HBs Ag positive
 AUTOANTIBODIES
 ANA
 AMA
 ASMA
 ANTI LKM

14. INVESTIGATIONS
 IRON PROFILE
IRON
FERRITIN
TIBC
TRANSFERRIN SATURATION
 CAERULOPLASMIN,SERUM AND URINARY COPPER
 ALPHA 1 ANTITRYPSIN
 TOXICOLOGY SCREEN OF BLOOD AND URINE

15. ADDITIONAL INVESTIGATIONS
 RANDOM BLOOD ALCOHOL
 IMMUNOGLOBULINS
 HFE GENE TEST
 ALPHA 1 ANTITRYPSIN GENOTYPE
 ANTI TTG
 ANCA
 BIOPSY
 LIVER
 SMALL BOWEL
 LARGE BOWEL

16. ADDITIONAL INVESTIGATIONS
 COMPLETE HEPATITIS B PROFILE
HBs Ag & ANTI HBs Ag
ANTI HBc IgM & TOTAL
HBe Ag & ANTI HBe Ag
HBV DNA BY PCR
 HCV RNA BY PCR
 HDV DNA BY PCR

17. IMMUNISATION
ANTI HBs Ag
PAST INFECTION/CONVALESCENCE
ANTI HBc TOTAL & ANTI HBs Ag
INCUBATION/ACUTE
HBsAg & ANTI HBc IgM
INFECTIVITY
HBe Ag & HBV
SEROCONVERSION
ANTI HBe Ag or ANTI HBs Ag
HEPATITIS B INTERPRETATION OF SEROLOGY

18. IMAGING
 ULTRASONOGRAPHY
 DOPPLER US OF HEPATIC VEINS
 CT SCAN
 MRI
 MRCP
 ERCP
 PTC
 EUS
 SLIT-LAMP EYE EXAMINATION

19. CLINICAL AND EPIDEMIOLOGICAL
FEATURES OF VIRAL HEPATITIS

20. FEATURE HAV HBV HCV HDV HEV
INCUBATION
DAYS IN MEAN
30 75 50 75 40
ONSET ACUTE INSIDIOUS OR
ACUTE
INSIDIOUS INSIDIOUS OR
ACUTE
ACUTE
AGE
PREFERENCE
CHILDREN YOUNG ADULTS ADULTS YOUNG ADULTS YOUNG ADULTS
TRANSMISSION FAECAL-ORAL PERCUTANEOUS
PERINATAL
SEXUAL
PERCUTANEOUS PERCUTANEOUS
PERINATAL
SEXUAL
FAECAL-ORAL
CARRIER STATE NONE UPTO 30% 3% VARIABLE NONE
SEVERITY MILD OCC SEVERE MODERATE OCC SEVERE MILD
FULMINANT 0.1% 0.1-1% 0.1% 5-20% 1-2%
CANCER NONE YES YES VARIABLE NONE
PROGNOSIS EXCELLENT WORSE WITH
AGE
MODERATE ACUTE GOOD
CHRONIC POOR
GOOD

21. PREVENTION
VACCINES ARE AVAILABLE FOR
HEPATITIS A
HEPATITIS B
HEPATITIS E

22. TREATMENT OF ACUTE VIRAL HEPATITIS
 REST OR MOBILITY AS TOLERATED
 HIGH-CALORIE DIET
 GLUCOSE JUICE
 IV FLUID FOR VOMITING
 CHOLESTYRAMINE FOR PRURITUS
 AVOID DRUGS
 NO ROLE FOR STEROIDS

23. TREATMENT OF CHRONIC HEPATITIS B
PEGYLATED INTERFERON
LAMIVUDINE
ADEFOVIR
ENTECAVIR
TENOFOVIR
TELBIVUDINE

24. TREATMENT OF CHRONIC HEPATITIS C
 PEGYLATED INTERFERON
 RIBAVIRIN
 SOFOSBUVIR
 DACLATASVIR
 LEDIPASVIR
 SIMEPRAVIR

25. TREATMENT OF AUTOIMMUNE HEPATITIS
PREDNISOLONE
AZATHIOPRINE

26. TREATMENT OF ALCOHOLIC LIVER DISEASE
 ABSTINENCE
 HIGHLY NUTRICIOUS DIET
 MULTIVITAMINS
 PREDNISOLONE
 PENTOXIFYLINE

27. TREATMENT OF NONALCOHOLIC FATTY LIVER DISEASE
 LIFESTYLE CHANGES
 VITAMIN E
 PIOGLITAZONE OR GLUCOPHAGE
 STATINS

28. TREATMENT OF HAEMOCHROMATOSIS
AVOID IRON OR IRON CONTAINING
FOOD
WEEKLY PHLOBOTOMIES/VENESECTION
DEFEROXAMINE
DEFERASIROX
DEFERIPRONE

29. TREATMENT OF WILSON’S DISEASE
 AVOID COPPER CONTAINING FOOD
 PENICILLAMINE
 PYRIDOXINE
 TRIENTINE
 ZINC
 AMMONIUM TETRATHIOMOLYBDATE

30. THANKS