This document discusses viral hepatitis, which causes liver inflammation and damage from hepatitis viruses A-E. It provides details on the epidemiology, types, risk factors, pathogenesis, clinical presentation, complications, diagnosis, treatment and drugs used for each viral hepatitis type. Globally over 2 billion people are infected with hepatitis viruses resulting in over 1 million deaths annually. In India, chronic hepatitis B and C infections account for 40-50% and 12-32% of liver cancer cases, respectively. Treatment involves vaccination, antiviral drugs like interferons, immunoglobulins and symptomatic care depending on the viral type and disease stage.

1. D r . V . S . S W A T H I
A S S I S T A N T P R O F E S S O R
Viral Hepatitis

2. Definition
 Viral hepatitis is an inflammation that causes
liver inflammation and damage by hepatitis
virus A, B, C, D and E.

3. Epidemiology
 Globally around 2.3 billion people of the world
are infected with one or more of the hepatitis
virus and results around 1.4 million deaths
In India:
 Chronic HBV infection accounts for 40-50% of
hepatocellular carcinoma
 Chronic HBV infection accounts for 20-30% of
cirrhosis
 Chronic HCV infection accounts for 12-32% of
hepatocellular carcinoma
 Chronic HCV infection accounts for 12-20% of
cirrhosis

4. Types
 Hepatitis A- It is caused by Hepatitis A Virus (HAV), self
limiting, and leads to acute infection and mainly transmitted by
contaminated food and water
 Hepatitis B- It is caused by Hepatitis B Virus (HBV), severe, and
leads to chronic infection and mainly transmitted by injectables
 Hepatitis C- It is caused by Hepatitis C Virus (HCV), severe, and
leads to chronic infection, mainly transmitted by injectables
 Hepatitis D- It is caused by Hepatitis D Virus (HDV), commonly
occurs in patients with Hepatitis B, causes chronic infection and
mainly transmitted by injectables
 Hepatitis E- It is caused by Hepatitis E Virus (HEV), self
limiting, and causes acute infection and mainly transmitted by
contaminated food and water

5. Risk factors
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
 Poor sanitation
 Lack of safe water
 Living in a
household with
an infected
person
 Sex with hepatitis
affected partner
 Use of
recreational
drugs
 Patients
undergoing blood
transfusion and
dialysis
 Infants
 Children
 Injectable
drug users
 Patients
undergoing
blood
transfusion
and dialysis
 Injectable drug
users
 Intranasal drug
users
 Patients
undergoing blood
transfusion and
dialysis
 People live in
closed settings
 Sex with hepatitis
affected partner
 Children born to
mother infected
with HCV
 People who have
tattoos/ piercings
 Injectable
drug users
 Chronic
HBV
carriers
 People
who are
not
immune to
HBV
vaccine
 Sex with
hepatitis
affected
partner
 Poor
sanitation
 Ingestion of
undercooked
meat
 Injectable drug
users
 Patients
undergoing
blood
transfusion
and dialysis
 Children born
to mother
infected with
hepatitis

6. Etiology
 Hepatitis A- It is caused by Hepatitis A Virus
(HAV)
 Hepatitis B- It is caused by Hepatitis B Virus
(HBV)
 Hepatitis C- It is caused by Hepatitis C Virus
(HCV)
 Hepatitis D- It is caused by Hepatitis D Virus
(HDV)
 Hepatitis E- It is caused by Hepatitis E Virus
(HEV)

7. Pathogenesisof
HepatitisAandE

8. Pathogenesisof
HepatitisB,CandD

9. Continue.....

10. Clinical Presentation
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Acute failure
 Anorexia
 Nausea
 Fatigue
 Malaise
 Vomiting
 Fever
 Head ache
 Right upper
quadrant
abdominal
pain
 Dark
urination
 Alcoholic
stools
 Pruritis
Chronic failure
 Fatigue
 Anxiety
 Anorexia
 Malaise
 Ascites
 Jaundice
 Variceal
bleeding
 Hyper
excitability
 Impaired
mentation
 Confusion
 Obtundation
 Coma
Chronic failure
 Fatigue
 Anxiety
 Anorexia
 Malaise
 Ascites
 Jaundice
 Abdominal pain
 Dark urine
Advanced stage
 Spider nevi
 Splenomegalay
 Palmar
erythema
 Testicular
atrophy
 Caput medusae
Chronic failure
 Jaundice
 Abdominal
pain
 Vomiting
 Loss of
appetite
 Dark urine
 Fatigue
Acute failure
 Anorexia
 Mild fever
 Abdominal
pain
 Itching
 Skin rash
 Joint pain
 Jaundice
 Hepatomegaly

11. Spider nevi

12. Caput medusae

13. Complications
 Acute / Sub acute hepatic necrosis
 Chronic hepatitis
 Cirrhosis
 Hepatic failure
 Hepatocellular carcinoma
 Glomerulonephritis
 Cryoglobulinemia
 Hepatic encephalopathy
 Portal hypertension
 Porphyria
 HIV infection

14. Diagnosis
 Physical examination
 Liver function tests
 Anti HAV testing
 HBSAg testing
 Anti HCV testing
 Anti HDV testing
 Anti HEV testing
 Liver biopsy
 Ultrasound of liver

16. Non Pharmacological Treatment
 Hepatitis vaccination for Hepatitis A, B and E
 Immunoglobulin treatment
 Counselling about risk factors and
transmission
 Stopping of alcohol
 Stopping of smoking
 Physical exercise
 Liver transplantation

18. Treatment Algorithm
Hepatitis A
 Vaccination
 Immunoglobulins
 Symptomatic treatment
Hepatitis B
 Interferons
 Pegylated interferons
 Entecavir
 Tenofavir
 Adenovir
 Lamivudine
 Telbivudine

19. Hepatitis C
Type Without Cirrhosis With Cirrhosis
Genotype
1a and 1b
Daclatasavir+ Sofosbuvir for 12
weeks
Daclatasavir+ Sofosbuvir+ Ribavirin for 24
weeks
Simeprevir + Sofosbuvir for 12
weeks
Simeprevir + Sofosbuvir+ Ribavirin for 24
weeks
Genotype
2
Daclatasavir+ Sofosbuvir for 12
weeks
Daclatasavir+ Sofosbuvir+ Ribavirin for 24
weeks
Genotype
3
Daclatasavir+ Sofosbuvir for 12
weeks
Daclatasavir+ Sofosbuvir+ Ribavirin for 24
weeks
Daclatasavir+ Ribavirin+ PEG
interferon for 12 weeks
Daclatasavir+ Ribavirin+ PEG interferon
for 12 weeks

20. Hepatitis D
 PEG INF for 48 weeks
 Liver transplantation in case of fulminant
hepatitis and end stage liver disease
Hepatitis E
 Vaccination
 Symptomatic treatment
 Ribavirin in case of immunosupressed people

21. Drugs used in treatment of viral hepatitis
Drug Category Mode of action Dose Adverse affects
IG Immunoglobulin Produces passive
immunity
0.02ml/kg -IM  Head ache
 Erythema
 Myalgia
 Malaise
 Injection site reactions
Pegylated
interferon
Immunomodulator Enhances
activity of
phagocytic
activity of
macrophages
and cytotoxic
activity of
lymphocytes for
target cells
180mcg-SC-once
weekly for 24-48-
weeks
 Fatigue
 Headache
 Fever
 Myalgia
 Influenza like illness
Entecavir Nucleoside reverse
transcriptase inhibitor
Inhibit viral
replication
0.5-1mg- PO-OD  Fatigue
 Head ache
 Dizziness
 Nausea
 Diarrhoea

22. Tenofavir Nucleoside
reverse
transcriptase
inhibitor
Inhibit viral
replication
300mg-PO-OD  Asthenia
 Diarrhoea
 Nausea
 Pain
 Anorexia
Lamivudine Nucleoside
reverse
transcriptase
inhibitor
Inhibit viral
replication
100mg-PO-OD  Diarrhoea
 Cough
 Fever
 Joint pain
 Pancreatitis
Telbivudine
Nucleoside
reverse
transcriptase
inhibitor
Inhibit viral
replication
600mg-PO-OD  Fatigue
 Headache
 Cough
 Diarrhoea
 Abdominal pain

23. Daclatasavir HCV NS5A
inhibitor
Inhibit viral
replication
60mg-PO-OD  Headache
 Nausea
 Fatigue
 Diarrhoea
 Elevation of lipase
levels
Sofosbuvir HCV NS5B
inhibitor
Inhibit viral
replication
400mg-PO-OD  Fatigue
 Headache
 Nausea
 Fatigue
 Insomnia
Simeprevir HCV protease
inhibitor
Inhibit viral
replication
150mg-PO-OD  Photosensitivity
 Hyperbilirubenemia
 Pruritis
 Dyspnoea
 Myalgia
Ribavirin Synthetic nucleoside
analog of
ribofuranose
Inhibit viral
protein synthesis
800-1000mg/day-BD  Fatigue
 Headache
 Myalgia
 Haemolysis
 Rigors

24. Resources
 https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6418070/
 http://www.ijmm.org/article.asp?issn=0255-
0857;year=2018;volume=36;issue=2;spage=2
17;epage=223;aulast=Sarkar
 https://www.ncbi.nlm.nih.gov/pubmed/2979
8951
 https://doi.org/10.1111/jvh.12870
 https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC5719604/