Viral Hepatitis

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Viral Hepatitis:

Viral Hepatitis

Viral Hepatitis:

Viral Hepatitis A  E (B – DNA) CMV / EBV / Herpes Simplex

Clinical Features:

Clinical Features Prodromal Few days to 2 weeks Fever, Headache, Myalgia, Arthralgia, Photophobia, Vomiting, Diarrhoea, Distaste for cigarretes Serum sickness like syndrome – Hepatitis B

Clinical Features:

Clinical Features Abdominal pain Jaundice Dark urine Hepatomegaly Splenomegaly Cervical Lymphadenopathy

Clinical Features:

Clinical Features Cholestatic phase  dark urine, paler stools,  jaundice, pruritis Recovery – prolonged in hepatitis B & C Relapse in Hepatitis A Chronic Liver Disease Chronic Hepatitis / Cirrhosis / HCC in Hepatitis B & C

Investigations:

Investigations WBC – Neutropenia, Lymphopenia, Relative lymphocytosis, atypical lymphocytes Urine – Bilirubinuria LFT Total Bilirubin (Conjugated + Unconjugated) AST, ALT (400 to 4000) ALP (< 2 times elevation) Prothrombin time (elevated) Serology

Complications:

Complications Fulminant Hepatic Failure Relapsing hepatitis, Cholestatic Hepatitis Chronic Hepatitis Cirrhosis HCC Aplastic Anemia Renal Failure HSP PAN

Management:

Management Supportive Care Avoid sedatives, narcotics Avoid alcohol No specific dietary modifications Elective surgery should be avoided – risk of post operative liver failure

Hepatitis A:

Hepatitis A RNA virus Highly infectious Source – Patients who are Incubating Suffering from the disease Route Faeco – oral route

Hepatitis A:

Hepatitis A Serology Anti HAV IgM- Acute infection Anti HAV IgG Presence indicates immunity to HAV Past infection

Hepatitis A:

Hepatitis A Specific Features Acute Liver Failure 0.1 % Cholestatic phase with increased ALP (Adults) Relapsing hepatitis Serious / life threatening in patients with Chronic Liver Disease No carrier state / chronic infection

Hepatitis A:

Hepatitis A Prevention Boiling water – 10 minutes Immunization Active Inactivated vaccine, IM, 2 doses – 0 & 6 months ( ~ 20 years) Indication – Chronic Hepatitis B & C infection Travel to endemic area Passive Immune serum globulin , immediate protection

Hepatitis B:

Hepatitis B

Hepatitis B:

Hepatitis B Source – Humans are the only source Saliva, (Urine) Semen, Vaginal secretion Route Mother – Child Blood Sexual Injections / Tattoos / Acupuncture needles

Hepatitis B:

Hepatitis B Acute – 90% Chronic – 10% (90% with vertical transmission) Acute Failure - < 1%

Hepatitis B - Serology:

Hepatitis B - Serology HBsAg Active infection Chronic infection (> 6 months) HBeAg – Viral replication Anti HBeAg – Decreased viral replication HBV DNA – viral load (10 5 ) Anti HBsAg (3 to 6 months) Anti HBcAg – IgM, IgG

Hepatitis B:

Hepatitis B Chronic Hepatitis HBsAg > 6 months Anti HBC IgG HBeAg or Anti HBeAg

Prevention of Hepatitis B:

Prevention of Hepatitis B Most infectious HBeAg HBV DNA Least infectious Anti HBeAg Low level of virus Hepatitis B > Hepatitis C > HIV (10 times)

Prevention of Hepatitis B:

Prevention of Hepatitis B Active – 0, 1, 6, IM, deltoid Booster dose not routinely recommended Pregnancy is not a contraindication Passive Hepatitis B immunoglobulin (HBIg) Reduces frequency of clinical illness and not in preventing infection Within 24 hours / week

Prevention of Hepatitis B:

Prevention of Hepatitis B Vaccine and immunoglobulin given together in neonates born to Hepatitis B infected mothers

Management of Hepatitis B:

Management of Hepatitis B Acute Hepatitis – Supportive Management Chronic Hepatitis - Not possible to eradicate hepatitis B Alpha Interferon Lamivudine Adefovir Liver Transplantation

Indications for Alpha Interferon:

Indications for Alpha Interferon Low viral load and serum transaminase 33% lose eAg after 4 to 6 Response rates lower in HBeAg negative patients Contraindicated in Cirrhosis Rise in transaminase levels Precipitates Liver Failure

Lamivudine:

Lamivudine Nucleoside analogue Inhibits DNA polymerase and suppresses HBV – DNA levels Useful in improving liver function in decompensated cirrhosis and may prevent transplantation Complications Development of HBV – DNA polymerase mutants

Adefovir:

Adefovir Nucleotide analogue Inhibits DNA polymerase Contraindicated in Renal Failure  less risk of mutants Treatment of Lamivudine induced mutants

Slide 25:

Liver Transplantation Combination drugs HIV + HBV

Hepatitis B course:

Hepatitis B course Acute liver failure – 1% Infection 90 to 95% recover 5 to 10% develop (6 months) chronic infection (recovery) Vertical Transmission, Downs, HIV Cirrhosis 15 to 20% over 5 to 20 years HBeAg + ve --- HCC HBV + HDV  Aggressive disease

Hepatitis D:

Hepatitis D Incomplete RNA virus IV drug abuse / sexual / Vertical Co-infection Superinfection Antidelta IgM Prevention – Prevent Hepatitis B

Hepatitis C:

Hepatitis C RNA Blood transfusion - commonest Other routes - rare Acute symptomatic infection – rare 80% develop chronic infection Chronic Liver Disease Males Immunosuppression (HIV coinfection) C 2 H 5 OH

Prevention:

Prevention Serology HCV RNA – 2 to 4 weeks after infection Anti HCV – 6 to 12 weeks No immunization available Genotypes – 6 No effect on progression Affects response to treatment

Management of Hepatitis C:

Management of Hepatitis C Aim – to eradicate infection Pegylated  - interferon (SC) + oral Ribovarin   Flu like symptoms Hemolytic Anemia Irritability Depression Cure – loss of virus from blood – 6 months after completing therapy Liver Transplantation

Hepatitis E:

Hepatitis E RNA virus Faecal – oral route Self limiting Acute Hepatitis Infection during pregnancy – Acute liver failure with high mortality No carrier / Chronic Liver Disease Anti HEV IgM No active / passive immunization

Drugs and the Liver:

Drugs and the Liver Acute and self limiting Chronic Liver Disease - rare

Patterns:

Patterns Cholestasis Chlorpromazine High dose eostrogens Cholestatic hepatitis NSAIDs Co-amoxiclav Statins Acute hepatitis INH, Rifampicin Non-alcoholic steatohepatitis Amiodarone Tetracycline, Sodium Valproate Venous outflow obstruction Busulfan / Azathioprine Fibrosis Methotrexate

Recovery:

Recovery Hepatic – LFTs – 2 months Cholestatic / Mixed – 6 months

Drugs to be avoided in Cirrhosis:

Drugs to be avoided in Cirrhosis NSAIDs ACE inhibitors Codeine Narcotics Anxiolytics

Slide 36:

Thank You

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