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Viral Hepatitis & Liver Cirrhosis

Rasha Al-Shboul & Rawan Shatnawi

22/4/13

 Viral hepatitis
Today we will talk about viral hepatitis which is very important for us as future dentists. we will know why, and how we can make the risk of viral hepatitis toward the patients and toward ourselves somehow less. The Educational objectives for this lecture, Outline the epidemiology of viral hepatitis, to see how this disease is important, is it common or rare, we will see later. List causative agents for viral hepatitis. They are A,B,C,D,E but not only those viruses that can cause hepatitis, these are the viruses with some heptotropism; means predilection to effect selectively the liver, but cytomegalovirus, adenovirus, any virus virtually can affect the liver but we will limit our talk to those hepatotropic viruses A ,B,C,D,E . Recognize the clinical features of acute and chronic viral hepatitis and their complications. In general chronic hepatitis whether it's acute and even less chronic hepatitis does not produce florid symptom, there is nothing like acute myocardial infarction where the patient has chest pain, sweating, shortness of breath..etc Viral hepatitis generally can be asymptomatic or can give some symptoms like jaundice, abdominal pain and diarrhea, this is why in order to diagnose accurately viral hepatitis you need serology Interpret serologic tests to accurately diagnose the specific cause of viral hepatitis, it's important to diagnose acute or chronic hepatitis. Identify appropriate candidates for vaccination against HAV and HBV.
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 Why Bother For Viral Hepatitis For A Dentist? "As dentists you must take this vaccine early, as you know its three doses and after the third dose you will be fully protected" .For instance, hepatitis B is a virus that abundantly present in the saliva not only in the blood or the urine or the semen. -God forbid any abrasion you can get the infection!- , So it is important to get vaccinated for you and important for the patients you are taking care of because dentists can involuntary transmit the infection to the patient (improper sterilization techniques of tools). Dental patients with chronic hepatitis complicated by coagulopathy can have uncontrollable bleeding, this is a problem when you get a patient for treatment (extraction) inadvertently you don't know that his coagulation profile is altered; the INR is 5 or the platelets because of portal hypertension of chronic liver disease they are 10000 instead of 400000, he will bleed like crazy in your clinic and you will be in a deep trouble so be aware of that! So patients with suspected acute or chronic liver disease do not operate on them. Types Of Hepatitis A
Source of Virus Feces

B
Blood/ BloodDerived body Fluids Percutaneous permucosal Yes

C
Blood/ BloodDerived body Fluids percutaneous permucosal Yes

D
Blood/ BloodDerived body Fluids percutaneous permucosal Yes

E
Feces

Rout of transmission Chronic infection Prevention

Fecal-oral No pre/postExposure Immunization

Fecaloral No Ensure safe drinking water

pre/postBlood donor pre/postExposure screening; risk Exposure Immunization behavior Immunization; modification risk behavior modification

It's important to note that A and E never become chronic; get the infection and clear it or death but you will never develop chronic infection. It's up to 80% in hepatitis C,5% in hepatitis B to become chronic, D is very much like B

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 Clinical Manifestations of Acute Hepatitis, Acute hepatitis A virus is the most symptomatic especially in adults followed by B which is less likely to produce symptoms and C is the least symptomatic (rarely symptomatic) , so A, B then C. Acute hepatitis E virus is most symptomatic and severe in pregnant women for unknown reasons. Acute HBV can present with a serum sickness-like picture (fever, arthritis, urticaria, angioedema). Symptoms are non specific-the viral syndrome (fever, malaise, anorexia, RUQ pain, diarrhea, pruritis). Jaundice is not very common in acute hepatitis and in chronic hepatitis it's extremely rare. HAV only 60 % of patients with jaundice. Generally, symptoms improve after jaundice appears. Acute Hepatitis-LAB If you are in your clinic and suspect that the patient is affected by acute hepatitis you order some labs and you will get what we call acute hepatocellular injury; the liver enzymes ALT and AST are high with or without jaundice, or elevation in other liver functions such as alkaline phosphates. So markedly elevated levels of AST/ALT (more than 500 U/L) typically occurs in acute hepatocellular injury (viral, druginduced, ischemic), generally hepatocellular injury is similar to what drugs do, or even herbs, mushroom or hypotension, hypoperfusion to the liver. Modest elevations (less than 300 U/L) may be seen in a variety of conditions like chronic hepatitis, infiltrative diseases(cancers) , biliary obstruction and acute alcoholic hepatitis( the only which is acute with modest elevation ). Bilirubin and AP may or may not be elevated. WBC count may show leucopenia( they are decreased), viral infections show leucopenia unlike bacterial infections which associated with leucocytosis (elevation in WBC),Except for alcoholic hepatitis which is generally associated with leucocytosis.
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 Stigmata of Chronic Liver Disease,

Some of the patients not all of them will have one or more of these abnormalities: Spider Agiomatas (small dilated blood vessels on upper chest arms and neck anteriorly and posteriorly, if you press on it it will become white means it is not vasculitis). Palmar erythema Clubbing of fingers Dupuytren contractures( flexion deformity; patients can't extend their hands) Gynecomastia (male) or breast atrophy (female),in liver disease females get masculinized and males get feminized this is why we have this problem. Testicular atrophy

Spider Agiomatas

Palmar erythema

Clubbing of fingers
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Now, we will talk about each virus,

Hepatitis A
Clinical features:
Just remember that the incubation period in general for all viral hepatitis is between 2 weeks to 6-8 weeks, C has the highest incubation period, A is the least and B in between. The younger the patient is the less likely that he will have symptoms because with age the immune system is more mature because what kills the hepatocytes is not the virus but it's your immune system( your natural killer cells recognize the viral infected cells). Complications are rarely and never become chronic. ** The incubation period is the time between the entry of the bug in your body and the beginning of the symptoms. * * Numbers in the slides are not for memorizing.

Typical Serological Course for HAV:

To diagnose HAV you order IgM anti-HAV. IgM is a primary immunologic response; your body when it first comes to contact any foreign body he will produce first IgM and then IgG so acute infection make sense that IgM is the way to go.

Geographical distribution of HAV:

HAV is Much less in the Western countries where there higher hygiene standards, actually in Jordan We don't have it much.

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Hepatitis A Vaccination Strategies, Epidemiologic Consideration

Many cases occur in community-wide outbreaks No risk factor identified for most cases Highest attack rates in 5-14 year olds Children serve as reservoir of infection Persons at increased risk of infection: Travelers Homosexual men Injecting drug users ** Vaccination is a good thing especially for those at risk.

Hepatitis B
** Hepatitis B is more important because of the chronicity rate.

Clinical Features:
Just remember that the younger the patient is the more likely to become chronic, If you are less than 5 years old 90% you will become chronic. This is important because those who born to surface antigen positive mothers 90% will become chronic and that's why at birth( first 2 days ) we give them vaccine and immunoglobulin . **All mothers are screened obligatory.

Extra hepatic Manifestations of Hepatitis B

Sometimes viral hepatitis especially chronic viral hepatitis they manifest with symptoms outside the gastrointestinal system and liver.

Acute infection:
Arthralgias Papular acrodrmatitis (Gianotti-Crosti syndrome) this is rare.

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Chronic infection:
Glomerulonephritis Arthrlalgias Polyarteritis nodosa (PAN) is inflammation of the medium sized vessels. Caused by immune complexes they deposit in the joints cause arthritis, glomerulonephritis in kidney, vasculitis in vessels.

Acute Hepatitis B Virus Infection with Recovery

Typical Serological Course:

In recovery the surface antigen will disappear and anti hepatitis B surface antigen will appear so you are protected.(This is very important).

The other way if you are unlucky (among the 5% who will become chronic) the surface antigen will stay in your blood. So to diagnose hepatitis B acute infection we order IgM antiHBc (c stands for core).

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So Remember to diagnose the acute infection for hepatitis A order IgM anti-HA and for hepatitis B igM anti-HBc this is very important

The older you are the more likely to have more symptoms, the older you are the less likely to have chronic infection ;It's 90% to develop chronicity at birth , and at 5 years or older its ~ 10% .

Geographic distribution Of chronic HBV infection:

It is almost the same as HAV. In some countries like Saudi Arabia, it is almost 15% Of the population surface antigen positive. In Jordan between 4-8% depending on the studies. In western countries HCV is higher than in Jordan because it's mostly due to IV drug use.

Concentration of Hepatitis B Virus in Various Body Fluids:

High Blood Serum Wound exudates Moderate semen vaginal fluids saliva low/not detectable urine feces sweat tears Breast milk
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** Saliva has abundant viruses ; If you are operating on a patient who is HBVsAG positive his saliva is full of virus so be aware when you are operating on them wear goggles, gloves to protect yourself.

Hepatitis B Virus Modes of Transmission:

Sexual promiscous heterosexuals and homosexuals are particular at risk. Parenteral - IVDA, Health Workers are at increased risk. Perinatal - Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Perinatal transmission is the main means of transmission in high prevalence populations.

Hepatitis B Serological Scenarios

HBsAG + HBcAb (IgG) HBsAb Interpretation Acute infection (+ HBc IgM Ab) 3 possibilities: 1.Acute infection 2.Chronic infection (high ALT) 3.Carrier (normal ALT) 2 possibilities: 1.Remote infection 2.Immunized 2 possibilities: 1. Window disease 2. Remote infection Acute on chronic infection

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Prevention of HBV:
1-Vaccination - Vaccine can be given to those who are at increased risk of HBV infection such as: - Health care workers. - Neonates as universal vaccination in many countries. 3 doses are given (at 0,1,and 6 months). 2- Hepatitis B Immunoglobulin - efficacious within 48 hours of the incident. It may also be given to neonates who are at increased risk of contracting hepatitis B i.e. whose mothers are HBsAg and HBeAg positive. 3- Other measures - screening of blood donors, blood and body fluid precautions.

Hepatitis C Virus
**450 Million people who have HBVsAG this make hepatitis B the most chronic infection world wide and 170 million with HCV surface antigen. **No vaccine for hepatitis C because it changes itself all the time (hypervariable region) HCV has 6 different genotypes:

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Clinical Features
Chronicity 75-85% The main mode of transmission is blood. Immunity: No protective antibody response identified, no vaccine so protect yourself.

Extrahepatic Manifestations of Hepatitis C

Mixed cryoglobulinemia Vasculitis non-deforming arthritis membranous glomerulonepgritis Porphyria cutanea tarda (blistering painful blisters) Sjogren-like syndrome this should interest you because the patient may has xerostomia (Oral environment should stay alkaline otherwise your teeth will destroyed).

The doctor didn't talk about the typical serologic course for HCV.

Risk Factors Associated with Transmission of HCV

o Transfusion or transplant from infected donor. o Injecting drug use. o Hemodialysis (yrs on treatment). o Accidental injuries with needles/sharps.
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o Sexual/household exposure to anti-HCV-positive contact. o Multiple sex partners. o Birth to HCV-infected mother.

Geografical distribution of HCV:

Egypt has the highest rate of hepatitis C. it's believe to be 20%,In Jordan 0.8-0.9% which is low, South east Asia and north Africa have high rate.

Laboratory Diagnosis
HCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase as it takes at least 4 weeks after infection before antibody appears. HCV antibody is not enough because not everybody infected with HCV will become chronic so if HCV antibody is positive you can't conclude that he is chronically infected. HCV-RNA which is the total virus in the blood. Various techniques are available e.g. PCR and branched DNA. May be used to diagnose HCV infection in the acute phase. However, its main use is in monitoring the response to antiviral therapy. HCV-antigen - an EIA for HCV antigen is available. It is used in the same capacity as HCV-RNA tests but is much easier to carry out.

Prevention of Hepatitis C
Screening of blood, organ, tissue donors High-risk behavior modification Blood and body fluid precautions "The only way is to protect yourself because no vaccine available "

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 Hepatitis D (Delta) Virus

D comes only with B because It is incomplete virus.

Hepatitis E
Clinical features:
It's similar to A; the same symptoms. If the infected person is a pregnant woman there is a very high mortality. Illness severity: Increased with age. Chronic sequelae: None identified. Regions in South America and few cases in Jordan Note: the serologic course for hepatitis E is not important

-South East Asia, Saudi Arabia North Africa Soudan, Mexico

Hepatitis E Epidemiologic Features

Most outbreaks associated with faecally contaminated drinking water Several other large epidemics have occurred since in the Indian subcontinent and the USSR, China, Africa and Mexico Minimal person-to-person transmission

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 As in summary
Viral Hepatitis Serological Diagnosis: Organism HAV Acute
Anti-HAV IgM
-Anti-HBc IgM - HBeAG - HBV DNA

Chronic
NA

Recovered/latent
Anti-HAV IgG

Vaccinated
Anti-HAV IgG Anti-HBs

HBV

- Anti-HBc IgG - HBsAg

- HBeAg or HBeAb

- Anti-HBc IgG - Anti-HBs

HCV

- All tests possibly negative - Anti-HCV Ab - HCV RNA

-Anti-HDV IgM

-Anti-HCV Ab - HCV RNA

Anti-HCV Ab

NA

- Anti-HDV

HDV

- HD Ag

- HDV Ag - HBsAg

Anti-HDV

NA

** It is important to know something about viral hepatitis for you and your patients and GET VACCINATED.

Good Luck Done by: Rawan Shatnawi & Rasha Al-Shboul

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