The document discusses acute and chronic hepatitis, including their pathophysiology, causes, clinical features, investigations, and management strategies. It outlines the differences between mild and severe acute hepatitis, explains various viral and non-viral causes, and details complications such as acute liver failure. Management includes general measures like bed rest and dietary adjustments, alongside monitoring and treatment to address complications.

1. ACUTE HEPATITIS
(vs. Chronic
Hepatitis)
Dr. A. B. M. Adnan
Associate Professor, Hepatology

2. Pathophysiology:
Acute Hepatitis (mild)
 Acute inflammation of the liver parenchyma.
 Acute inflammatory cell infiltration
 Inflammatory exudates and oedema
 Swelling of cells, balloon degeneration
→ All result in organomegaly

3. Pathophysiology:
Acute Hepatitis (severe)
In severe organ inflammation:
 Widespread cell damage and cell death
 Organ shrinkage
 Features of organ failure (hepatic failure)
• disorientation, confusion, coma
• deepening jaundice
• bleeding manifestation

4. Pathophysiology:
Chronic Hepatitis
• Persistant hepatocyte injury
– Alcohol, virus, drugs, toxins, genetic etc.
• Chronic inflammation – chronic hepatitis
– Cell necrosis + Fibrosis
• Bridging fibrosis.
• Regeneration of remaining hepatocytes
forming nodules.
• Loss of vascular arrangement results in
regenerating hepatocytes ineffective.

5. Acute - Hepatitis - Chronic

6. Normal Liver - Microscopy

7. Liver Biopsy – CPH:

8. Causes of Acute Hepatitis
A.Viral causes
B.Non-viral causes

9. Viral Causes
of Acute Hepatitis
Hepatotrophic viruses: Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)
Hepatitis D virus (HDV)
Hepatitis E virus (HEV)
Other viruses: Cytomegalovirus (CMV)
Epstein-Barr virus (EBV)
Yellow fever virus
Dengue virus
Herpes simplex

10. Non-viral Causes
of Acute Hepatitis
1. Drugs:
– Pyrazinamide, INH
– Paracetamol
– NSAIDs
– Clavaulanic acid
– Valproic acid
– Alcohol
– Helothene
2. Trauma
3. Disseminated intravascular coagulation (DIC)
4. Infarction

11. Chronic
Acute
Causes: Acute vs. Chronic
• Virus: HAV, HBV, HCV, HDV,
HEV, CMV, EMV, Flabivirus
• Drug: paracetamol, INH,
pyrazinamide, NSAIDs, valproic
acid etc.
• Alcohol
• Infarction/Trauma
• DIC
• Rare: Wilson’s disease,
autoimmune
• Virus: HBV, HCV, HDV
• Drug: methotrexate
• Alcohol
• Fatty liver (NAFLD)
• Biliary stasis: PBC, PSC, cystic
fibrosis
• Genetic: Wilson’s disease,
haemochromatosis, α-1ATD
• Autoimmune
• Venous stasis: Budd-Chiary
syndrome, CHF

12. Virus Characteristics
Virus Hepatitis
A
Hepatitis B Hepatitis
C
Hepatitis D Hepatitis
E
Nucleic
acid
RNA DNA RNA RNA RNA
Incubation 2-4 weeks 4-20 weeks 2-26 weeks 6-9 weeks 3-8 weeks
Spread Fecal-oral Blood Blood Blood Fecal-oral
Chronicity No Yes Yes Yes
(ē HBV)
No
Vaccine Yes Yes No HBV
vaccine
No

13. Viruses: Photomicrographs
HAV HBV HEV

14. HBsAg
RNA
 antigen
Hepatitis D (Delta)
Virus

15. Clinical Features:
Symptoms
• Asymptomatic
• Prodromal symptoms: weakness, myalgia,
arthralgia, headache
• GI symptoms: anorexia, nausea, vomiting,
lose stool, constipation, abdominal
discomfort/pain
• Yellow urine, yellow eyes (jaundice)
• Features of cholestasis: pruritus, pale stool,
deep jaundice

16. Clinical Features: Signs
• Jaundice
• Tender hepatomegaly
• Ill looking
• Scratch marks for pruritus
• Splenomegaly
• Features of complications: Hepatic
failure, bleeding, infection

17. Pruritus

18. Clinical Features
SGPT/SGOT precedes jaundice

19. Acute Hepatitis:
Gross Appearance of Liver
Haemorrhage
Nacrosis with
furrows

20. Histology
Liver section
under light
microscope

21. Histology
Ballon
degeneration:
Rt. arrow
Councilman
body:
Lt. arrow

22. Outline
• Pathophysiology of acute hepatitis
• Difference with chronic liver disease
• Causes of acute (vs. chronic) hepatitis
• Characteristics of hepatotrophic viruses
• Clinical features
• Complications
• Investigations
• Management
• Fulminant hepatic failure

23. Complications
• Acute liver failure/Fulminant HF (esp. AVH
in pregnancy)
• Hepato-renal syndrome
• Hypoglycaemia
• Cholestatic hepatitis (hepatitis A)
• Aplastic anaemia
• Chronic liver disease and cirrhosis
(hepatitis B and C)
• Relapsing hepatitis

24. Investigations
• Liver function tests:
– SGPT, SGOT
– Serum bilirubin
– Prothrombin time
• Viral markers:
- HBsAg, Anti-HEV IgM, Anti-HAV IgM, Anti-HCV
• USG of liver:
- Hypoechoic liver parenchyma
• Others:
- CBC, Blood sugar, RFT, electrolytes etc.

25. Management
A. General measures:
1. Complete bed rest
2. Nutrition: normal diet
3. Remove offending cause, if any.
B. Medications:
1. Mostly symptomatic
PPI, anti-emetics, laxatives, UDCA, antibiotics
2. Avoid sedatives, narcotics, NSAIDs, diuretics,
alcohol,
elective surgery/trauma
3. Management of complications.

26. Acute Liver Failure

27. Acute Liver Failure
• Synonym: Fulminant hepatic failure.
• Liver failure occurring in the setting of acute
hepatitis.
• Feature of liver failure: encephalopathy,
bleeding manifestation, hypoalbuminaemia.
• Definition: the syndrome occurring within 8
weeks of onset of the precipitating illness, in the
absence of evidence of preexisting liver disease.

28. Classification
Type Time: jaundice
to
encephalopathy
Cerebral
oedema
Common
causes
Hyperacut
e
<7 days Common Viral,
paracetamol
Acute 8-28 days Common Cryptogenic,
drugs
Subacute 29 days-12
months
Uncommo
n
Cryptogenic,
drugs

29. Causes
• Acute viral hepatitis (most common)
• Paracetamol toxicity
• Anti-TB
• Mushroom poisoning (Amanita phalloides)
• Pregnancy,
• Unknown (‘non-A–E viral hepatitis’)

30. Encephalopathy Grade
Clinical
grades
Clinical signs
Grade I Poor concentration, slurred speech, slow
mentation, disordered sleep rhythm.
Grade II Drowsy but easily rousable, occasional
aggressive behaviour, lethargic, asterixis.
Grade III Marked confusion, drowsy, sleepy but
responds to pain and voice, gross
disorientation.
Grade IV Unresponsive to voice, may or may not
respond to painful stimuli, unconscious.

31. Complications
• Encephalopathy and cerebral oedema
• Hypoglycaemia
• Metabolic acidosis
• Infection (bacterial, fungal)
• Renal failure
• Multi-organ failure (hypotension and respiratory
failure).

32. Monitoring
Cardiorespiratory
• Pulse
• Blood pressure
• Central venous pressure
• Respiratory rate
Neurological
• Intracranial pressure monitoring (specialist units)
• Conscious level
Fluid balance
• Hourly output (urine, vomiting, diarrhoea)
• Input: oral, intravenous

33. Investigations
• To determine cause:
Anti-HEV IgM, anti-HBc IgM, anti-HAV IgM,
CMV, HCV, EBV.
S. caeruloplasmin & copper, u. copper, slit-lamp exam.
Autoantibodies: ANA, ASMA, LKM, SLA.
• LFTs: Prothrombin time (2 hourly), ALT, s. bilirubin.
• To assess complication:
RBS (2-hourly), creatinine, electrolytes, ABG, CBC,
platelet
• USG, Doppler study

34. Management
• Admission in HDU/ICU
• Surveillance of complications
• Maintenance of nutrition
• Treatment of complications
• Transplantation.