Acute Viral Hepatitis.ppt 1sh10

Acute Viral Hepatitis Dr.Hasibi

Etiology  Major

 HAV  HBV  HCV  HDV  HEV

agents:  HGV  TTV  HFV

?

Etiology  Minor

agents:

 EBV,CMV  HSV,VZV  Rubella,Measles

 Coxsackie

B  Adenovirus

Transmission HAV

HBV

HCV

HDV

HEV

Fecal-oral

+

-

-

-

+

Percutan.

+

+

+

+

-

Perinatal

-

+

+

+

-

Sexual

+

+

+

+

-

Epidemiology HAV:fecal-oral HEV:fecal-oral Rarely bloodborne  HBV:percutaneous Mucous membrane Sexual Perinatal:third trimester and 2 months postpartum HDV : like HBV 

Epidemiology 

HCV: Percutaneous transmission Transfusion(0.1 %),needle stick(1.8 %) Mucousal transmission (rare) Sexual transmission is rare(monogamy) Perinatal transmission is uncommon (HIV coinfection,less than 5 % )

Sexual transmission of HCV  Multiple

sexual partner  HIV and STD  Anal sex  Open sore  Sex during menstruation

Pathology  Infiltration

of mononuclear cells  Hepatic cells necrosis  Kupfer cells hyperplasia  Variable degrees of cholestasis  In more severe cases; Bridging necrosis

Clinical Stages  Incubation

period  Prodromal (preicteric) phase  Icteric phase  convalescence

Variation in staging Asymptomatic Anicteric

Fulminant Chronic

Incubation Period  HAV:15-45

days(30)  HBV: 30-180 days(60-90)  HCV: 15-160 days(50)  HDV: 30180 days(60-90)  HEV: 14-60 days(40)

Incubation Period Considerable

overlap Asymptomatic period Viral replication& Shedding

Preicteric Phase Systemic &nonspecific symptoms  Flue like &Dyspepsia:  Fever,sore throat,cough,headache  Fever,anorexia,malaise,nausea Vomiting,abdominal pain Duration : 1-2 weeks 

Icteric Phase  Clinical

jaundice  Dark urine:1-5 days before jaundice  Patient may feel better  Resolution of fever  pruritus

Icter

Icter

Icter

Icteric Phase  Liver

is enlarged,tender  Cervical adenopathy(10-20%)  Splenomegaly(10-20%)  Fever is absent  Venopuncture site  Encephalopathy :Irritability Letargy,confusion

Convalescence  Resolution

of symptoms  Liver is enlarged  Pruritus  Complete recovery: 1-2 months A,E 3-4 months B,C (3/4)

Laboratory Findings  CBC:leukopenia,lymphocytosis  Atypical

lymphocyte,  Normal Hb;except hemorrage  Normal platelet;except DIC  ESR is normal

Laboratory Findings  Serum

bilirubin:5-20 mg/dl  Direct bil =indirect bil  SGOT,SGPT=400-4000 iu  Alk.phosphatase :mild elevation  PT is usually normal:in severe hepatitis,PT is prolonged  Hypoglycemia

Serologic Diagnosis  Ig

M anti-HAV  HBs Ag and Ig M anti-HBc  HCV Ab,HCV RNA PCR  anti-HDV  anti-HEV

Complications  Hepatitis

A:Relapsing hepatitis  Cholestatic hepatitis  Hepatitis B:serum sickness  Chronicity:HBV,HCV,HDV  fulminancy:HAV,HBV,HDV, HEV

Progression of Acute to chronic Hepatitis Lack of resolution of symptoms (WL,fatigue,anorexia,hepatomegaly)  Failure of Bil. ,LFT,Glu to normal (Within 6-12m)  Persistence HBs Ag beyond 6 m or HBe Ag beyond 3 m  Presence of bridging or multilobular necrosis 

Diferential Diagnosis  Viral

hepatitis by minor agent  Gram negative Sepsis  Cholangitis,cholecystitis  Flare up chronic hepatitis  Drug-related hepatitis  Ischemic hepatitis

Management  Indication

of ission: Bilirubin>20 mg/dl Hypoglycemia Abnormal PT Hypoalbuminemia

Management  Indication

of ission : Poor oral intake Mental change,letargy Low compliance Other chronic disease

Management  CBR

isnot mandatory  Restriction activity  No special diet &Therapy(HCV ? )  Drug &Alcohol avoidance  Isolation isnot necessary except special cases

Monitoring  Regular

physical exam  Liver size,mental state,icter  Check of LFT,BS,PT,BIL  Serial check of HBs Ag and HCV Ab

Prevention  Hand

washing,hygiene  Universal percaution  No

sharing of personal items (razor,toothbrush,nail clipper)  Sexual barrier

prevention  HAV:  Pre-exposure

prophylaxis: Vaccine ,SIG:0.02 cc/kg  Post-exposure prophylaxis: SIG:0.02 cc/kg ;For day care centers,family Vaccine ?

Prevention  HBV:  Pre-exposure

prophylaxis: Vaccine :months 0,1,6 Booster isnot recommended  Post-exposure prophylaxis: HBIG:0.06 cc/kg and complete course of vaccine

Prevention  Post-exposure

prophylaxis in vaccinated person :

Responder:No treatment Nonresponder:HBIG+Vaccine(3) OR HBIG (2) in one month  Response:anti-HBs>10miu/ml

Prevention  Ab

response unknown:  Check anti-HBs; If adequate:no treatment If inadequate:HBIG(1) + vaccine(1)

Post exposure prophylaxis  HCV

:no treatment  HEV: no treatment