Acute Viral Hepatitis

Umar Zein
Faculty of Medicine
Universitas Islam Sumatera Utara
2019
 Definition:
Diffuse liver inflammation lasting less than
6 months
 Causes:
Hepatitis A Hepatitis B Hepatitis Hepatitis C Hepatitis E
HAV HBV D HCV HEV
Infective serum HDV Post transfusion Epidemic/
hepatitis hepatitis hepatitis Entral

virus 27 nm RNA 42 nm DNA 35 nm 30 – 60 nm 32 nm RNA

Hepa virus Incomplete RNA flavi firus
RNA+HBsAg
transmission Feco-oral Paraentral and post transfusion Feco-oral
Sexual low risk 1-5 %
Intrauterine low risk <5%
Incubation p. 2 – 6 weeks 2 – 6 months 2 – 6 months 2 – 6 months 2 – 6 weeks

Chronicity no Yes Yes Yes No

&liver cancer
Immunization Non specific Specific Ig IgM Non specific
-passive Ig Ig

-active HAV vaccine Heptavax Heptavax

danger HBV vaccine HBV vaccine
 Pathogenesis
Initial viremia, with inflammation of GIT mucosa.

Intrahepatic localization lead to

A- diffuse centrilobular necrosis, with cellular infiltration around portal
tracts
B- intrahepatic cholestasis due to cellualar edema & inspissation of bile

Other organ: splenomegaly –

lymphoadenopathy
Hypoplasia of BM
 Clinical picture

1. Preicetric stage or prodromal stage:3 – 9 days

Sudden onset of influenza like picture: fever - headache –

malaise – muscular pain
Anorexia is marked with nausea – vomiting – distension
Pain in Rt hypochondrium & epigastrium
Dark urine – pale stool
Transient itching

Examination: fever with relative bradycardia + enlarged

tender liver
 Clinical picture
Icteric stage: 2-4 w

Jaundice with fever & improvement of general

condition
Anorexia nausea & vomiting diminish or disappear
Urine is dark brown & frothy
Stool are clay in color – bulky – offensive – greasy

Examination:
Soft tender enlarged liver Spleen is enlarged in 20 %
L N 10% geralized lymphoadenopathy with LN of
post. Triangle of neck
 Clinical picture
Convalescence stage:

Signs & symptoms gradually disappear

Jaundice may persist for some times due to affinity of
bile pigment to elastic tissue
Complete recovery of liver may take up to 6 months
 Investigation:
LFT:
1. serum bilirubin : total, direct and indirect

2. ALT – AST : from 500 – 2000 IU/L ALT > AST

3. Alkaline phosphatase – 5’nucleotidase – GGT:

Blood :
Leucopenia with relative lymphocytosis, ESR
Urine :
Early bilirubin appearance
Bile salt : granular casts – frothy urine - +ve hay sulfur
test

Stool:
Pale – clay with staetorrhea
Diminished stercobilinogen

Serology
Acute stage Chronic stage others
Hepatitis A Anti HAV IgM Anti HAV IgG Fecal
HAV
Hepatitis D Anti HDV IgM Anti HDV IgG
Hepatitis E Anti HEV IgM Anti HEV IgG
 Hepatitis B marker:
antigen Significance Corresponding significance
Ab

HBsAg Appear after 6 week Anti HBs Appear after 3 m

(surface) Acute infection, remain Reflecting recovery &
for 3 ms immunity
Chronic infection if >6
ms
HBcAg Detected on Liver Anti HBc Appear after 2 m
(core) Biopsy only (not serum) Reflecting sever
acute & chronic form
HBeAg Reflect ongoing viral Anti HBe Appear after 2.5 m
(envolop) replication (chronicity) Non replicating virus

HBV DNA Most sensitive indication for viral replication & chronicity (Dan
particle)
It is detected by PCR
 •Serological gap:
It is a window last several weeks between
disappearing of HBs Ag & appearance of Anti
Hbs. Anti HBc Ab may represent serological
evidence of recent HBV infection

Blood free from Hbs Ag & Anti Hbs (but

containing anti – HBC) is the major cause of
transfusion HBV infection
 Hepatitis C markers:
Marker technique time significance

HCV Ab 2nd & 3rd generation ELISA or RIBA After 3 – 6 ms of Exposure to infection
test infection not immunity

HCV PCR – quantitative PCR is more After 1 – 2 weeks Indicate active virus
RNA accurate & assess interferon ttt
 Course & Complication:
Complete recovary:
Occur in most cases of virus A – E
Less common in virus B – D & in small case of virus C

Relapse:
Characteristic of virus C – less common in B – D
Present by reappearance of CL.p. or
biochemical
Abnormalities ( bilirubin & enzymes )
 Fulminant hepatitis: ( Acute liver failure )
Acute hepatic necrosis – acute yellow atrophy
After typical onset deep jaundice , vomiting ,
encephalopathy & coma
Patient usually dies in 10 days

• Prolonged cholestasis
• Cholestatic jaundice Watson’s syndrom
• After 3 W of jaundice, condition improves but jaundice
deepens & patients starts to itch
• This is due to intra hepatic Biliary obstruction by
inflammation
• Jaundice persist to 6 m then recovery
post hepatitis syndrome:
Common intelligent
Features : anxiety , fatigue , anorexia, Rt upper
abdominal discomfort
Palpable liver raised copula of diaphragm in X Ray
LFT & biopsy are normal

Chronic sequelae:
In C, B, D not in A & E
Chronic active hepatits
Chronic persistent hepatitis
Post hepatic cirrhosis
Hepatocellular carcinoma
 Extrahepatic manifestation of hepatitis

Clinical condition Associated comments

virus
Polyarteitis nodosea HBV 60 % have HBV

Glomeronephritis HCV & HBV Mainly mesengioproliferative –result in CRF

Porphyria cutnea tarda HCV Blistering lesion on back of hands
Cryoglobulinemia HCV Type 2 (mixed – essential)
Sjogren syndrom HCV Virus isolated from salivary tissue
Lichen planus HCV 60 % have HCV
Others associated with HCV Studies involve small number of patients
Erythema nodusm – erythema multiforme Impotance need evaluation
Polymyosistis – hachimoto’s thyroiditis
Diabetes mellitus – bahcet’s syndrome
Down syndrome – Aplastic anemia
 Treatment:
Rest:
Bed rest till LFT normal

Diet:
Protein: gives freely except with Liver failure
CHO: gives freely
Fats: better avoided
Alcohol & hepatotoxic: contraindicated
 Drugs:
Vitamins especially K parental
Cholestyramine: for itching
Corticosteroids are indicated in : fulminant cases –
cholestatic jaundice
Interferon: reduce risk of chronic hepatitis in acute
hepatitis C
Prophylaxis:
Screening: of blood for hepatitis Ag , disposable
syringes, avoid sharing razors or tooth brush
passive prophylaxis:
Hepatitis A : gamma globulin in contact or preicteric phase
patient
Hepatitis B: (HBIG) rich with anti HBs
 Active prophylaxis:
Hepatitis A:
Inactivated HAV 0.5 – 1 ml IM to be repeated after 6 -12m

Hepatitis B:
Recombinant HBV vaccine (Heptavax) IM in 3doses at
0-1-6m

High risk people:

Medical doctors & nurses
Hemophiliacs & hemolytic anemia
Prenatal drug abusers
Babies porn to HBsAg +ve mother
Now for all infant & children
N.P: HBV is prophylactic against hepatitis D viral infection