An overview of Hep A-E .

1. VIRAL HEPATITIS
An overview
PRESENTATION BY: DR. UROOJ ARSHAD

2. • Around 12 million people are suffering from hepatitis B or C in Pakistan.
Each year brings about 150 000 new cases.
• The Department of Health also states that among children who are infected
with Hepatitis-B, more than 90% will most likely suffer from life-long
infection.

3. What isViral Hepatitis?
• Viral hepatitis is a systemic disease with primary inflammation of the liver
by any one of a heterogeneous group of hepatotropic viruses.
• The most common causes of viral hepatitis are the five unrelated
hepatotropic viruses Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and
Hepatitis E.

4. Hepatitis A
• Hepatitis A is an inflammation of the liver that can cause mild to severe illness.
• The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or
through direct contact with an infectious person.
• Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small
proportion of people infected with hepatitis A could die from fulminant hepatitis.
• The risk of hepatitis A infection is associated with a lack of safe water and poor sanitation and
hygiene (such as contaminated and dirty hands).
• A safe and effective vaccine is available to prevent hepatitis A.
• There is no specific treatment for hepatitis A. Recovery from symptoms following infection may
be slow and can take several weeks or months.

5. Hepatitis B
• Hepatitis B is an infection of the liver caused by the hepatitis B virus.The infection
can be acute (short and severe) or chronic (long term).
• If the virus remains in the blood for more than six months, then it is considered a
chronic infection. Hepatitis B can cause a chronic infection and puts people at high
risk of death from cirrhosis and liver cancer. While most adults do not develop
chronic hepatitis B, infants and young children are less able to rid their bodies of
the virus and may develop chronic hepatitis B as a result.

6. Mode ofTransmission
Hepatitis B virus can be transmitted through:
• Blood transfusions
• Sexual contact
• IV needle sharing
• From mother to child during pregnancy and birth

7. CLINICAL MANIFESTATIONS
Incubation period is 30-180 days.
There are three phases of acute hepatitis B infection, and symptoms may differ depending on the stage. Early in the disease, called the prodromal phase, symptoms may
include:
• Fever
• Joint pain or arthritis
• Rash
• Edema (swelling)
Symptoms of the next phase, the preicteric phase, include:
• Fatigue
• Myalgia (muscle pain)
• Anorexia
• Nausea and/or vomiting
• Fever
• Cough
• Abdominal pain and/or diarrhea
• Dark urine and light stool color
During the icteric phase:
• Jaundice (yellowing of the skin and whites of the eyes) develops
• Anorexia, nausea and vomiting may worsen
• Irritated skin lesions may develop
• Other symptoms may subside

8. DIAGNOSIS
• BloodTests:
1. Liver FunctionTest
2. Hepatitis B surface antigen (HBsAg)
3. Antibody to hepatitis B surface antigen (anti-HBs)
4. Total antibody to hepatitis B core antigen (total anti-HBc).
• Liver Biopsy

9. INTERPRETATION
OFTEST RESULTS

10. MANAGEMENT APPROACH
• For Acute Hepatitis B infection:
More than 95% of immunocompetent individuals with acute infection will achieve
seroconversion with appearance of antibody to hepatitis B surface antigen in the
absence of treatment.Therefore, supportive care is usually all that is needed in most
patients.
However, Initiate antiviral therapy in patients with acute liver failure or in those who
have a severe, protracted course (i.e., total bilirubin level (>3 mg/dL), INR >1.5,
encephalopathy, or ascites). Entecavir, tenofovir alafenamide, and tenofovir
disoproxil are the drugs of choice.
Simultaneously, assess the patient for the need for liver transplantation, as there is a
high risk of mortality in patients with liver failure who do not undergo a transplant.

11. • For Chronic hepatitis B infection without complications (cirrhosis):
Initiate antiviral therapy in patients with immune-active chronic hepatitis B
virus (HBV) infection (i.e., elevated alanine aminotransferase [ALT] levels ≥2
the upper limit of normal [ULN] or evidence of histological disease with
elevated HBV DNA levels >2000 IU/mL if hepatitis B e antigen [HBeAg]
negative, or >20,000 IU/mL if HBeAg positive)
Entecavir, tenofovir disoproxil or tenofovir alafenamide, or peginterferon alfa
2a are the recommended first-line drugs.

12. • For Chronic Hepatitis B infection with cirrhosis:
(a) With compensated Cirrhosis:
Initiate anti-virals in such patients. Monitor patients (at least every 3 months
for 1 year) after stopping therapy to check for viral rebound that could lead to
decompensation.
(b) With decompensated Cirrhosis:
Initiate antiviral therapy as soon as possible. In patients with chronic HBV and
decompensated cirrhosis, referral to a liver transplantation centre is
necessary.

13. COMPLICATIONS
• Fulminant hepatic failure: Heightened immune response to hepatitis B
virus (HBV) resulting in massive immune-mediated lysis of infected
hepatocytes is thought to be the cause of fulminant hepatitis associated
with acute hepatitis B infection.
• Cirrhosis: It occurs in about 20% of patients with chronic hepatitis B virus
(HBV) and is thought to be due to ongoing immune attack of infected cells
in the liver, resulting in development of fibrosis and regenerative nodules.
• Hepatocellular Carcinoma

15. Hepatitis C
• Hepatitis C is an inflammation of the liver caused by the hepatitis C virus.
• The virus can cause both acute and chronic hepatitis, ranging in severity
from a mild illness to a serious, lifelong illness including liver cirrhosis and
cancer.

16. Mode ofTransmission
• Hepatitis C virus can be transmitted through:
• Blood transfusions
• Sexual contact
• IV needle sharing
• From mother to child during pregnancy and birth

17. CLINICAL MANIFESTATIONS
For people who develop symptoms, they usually happen 2–12 weeks after exposure to the
hepatitis C virus and can include:
• yellow skin or eyes (icterus)
• Anorexia upset stomach
• nausea and vomiting
• Abdominal pain
• fever
• dark urine
• light-colored stool
• joint pain (arthralgia)
• fatigue

18. DIAGNOSIS

19. MANAGEMENT APPROACH
• Treatment should be initiated in all patients with acute hepatitis C virus (HCV)
infection with viremia without awaiting spontaneous resolution.The same
regimens that are used for chronic infection are recommended for acute infection
• Direct-acting oral agents are recommended by the American Association for the
Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America
(IDSA).The specific regimen depends on the genotype and the presence or
absence of cirrhosis.
• Ribavirin and alpha pegylated interferon is also used in combination for the
treatment of patients 5 years of age and older with chronic hepatitis C (CHCV) virus
infection who have compensated liver disease and have not been previously
treated with interferon alpha.Treatment duration is of 24 – 48 weeks.
• Liver transplantation is the definite treatment of decompensated Liver Cirrhosis.

20. Direct Acting Oral Antiviral Agents

21. Hepatitis D
• Hepatitis D, also known as “delta hepatitis,” is a liver infection caused by the hepatitis D virus (HDV).
• Hepatitis D only occurs in people who are also infected with the hepatitis B virus.
• Hepatitis D is spread when blood or other body fluids from a person infected with the virus enters the body
of someone who is not infected.
• Hepatitis D can be an acute, short-term infection or become a long-term, chronic infection. Hepatitis D can
cause severe symptoms and serious illness that can lead to life-long liver damage and even death.
• People can become infected with both hepatitis B and hepatitis D viruses at the same time (known as
“coinfection”) or get hepatitis D after first being infected with the hepatitis B virus (known as
“superinfection”).There is no vaccine to prevent hepatitis D.
• However, prevention of hepatitis B with hepatitis B vaccine also protects against future hepatitis D
infection.

22. Hepatitis E
• Hepatitis E is a liver infection caused by the hepatitis E virus (HEV).
• HEV is found in the stool of an infected person. It is spread when someone unknowingly ingests
the virus – even in microscopic amounts.
• People most often get hepatitis E from drinking water contaminated by feces from people who
are infected with the virus. In the past, most cases in developed countries involved people who
have recently traveled to countries where hepatitis E is common.
• Symptoms of hepatitis E can include fatigue, poor appetite, stomach pain, nausea, and jaundice.
However, many people with hepatitis E, especially young children, have no symptoms. Except
for the rare occurrence of chronic hepatitis E in people with compromised immune systems,
most people recover fully from the disease without any complications.