Viral Hepatitis:A C E

Hepatitis: inflammation of liver; presence of inflammatory cells in organ tissue

Acute Viral Hepatitis: symptoms last less than 6 months Acute Hepatic Failure: Massive hepatic necrosis with

impaired consciousness within 8 wks of onset of illness. Chronic Hepatitis: Inflammation of liver for at least 6

months Cirrhosis: Replacement of liver tissue fibrosis, scar

tissue Fulminant Hepatitis: severe impairment of hepatic

functions or severe necrosis of hepatocytes in the absence of preexisting liver disease

Clinical Terms

PathophysiologyTargets of the Hep viruses are hepatocytes: Hepatocyte uptake involves a receptor on the

plasma membrane of the cell After entry into the cell, viral RNA is uncoated, and

host ribosomes bind to form polysomes. Viral proteins are synthesized, and the viral genome is copied by a viral RNA polymerase

Minimal cellular morphologic changes result from hepatocyte infection

Lymphocytic infiltrate; varying degree of necrosis.

Classic presentation:infectious hepatitis

Phase 1 - Viral replication; Patients are asymptomatic during this phase.

Phase 2 – Prodromal Phase 3 - Icteric phase Phase 4 - Convalescent phase;

symptoms and icterus resolve. Liver enzymes return to normal.

Clinical Evaluation: Acute Viral Hepatitis

1. Prodromal phase: Patients experience anorexia, nausea, vomiting, alterations in taste, arthralgias,

malaise, fatigue, urticaria, and pruritus. Some develop an aversion to cigarette smoke.

When seen by a health care provider during this phase, patients are often diagnosed as having gastroenteritis or a viral syndrome.

2. Icteric Phase Jaundice, Patients may note dark urine, followed by pale-colored stools. In addition to the predominant gastrointestinal symptoms and malaise, patients

become icteric and may develop right upper quadrant pain with hepatomegaly.

Severe cases may result in Fulminant Hepatitis:1.Hepatic Encephalopathy: B/L asterixis, palmar erythema2.Hepatorenal syndrome3.Bleeding diathesis

Clinical Evaluation: Chronic Hepatitis

- Occurs after acute Hepatitis in >80% of people with HCV

- Some are asymptomatic, or have mild symptoms; others may only present with late complications (cirrhosis/HCC)

- Categorized based on grade of inflammation, stage of fibrosis, and etiology of disease

Physical Exam Low-grade fever.

Significant vomiting and anorexia dehydration such as tachycardia, dry mucous membranes, loss of skin turgor, and delayed capillary refill.

Icteric phase: icterus of the sclerae or mucous membranes or discoloration of the tympanic membranes.

The skin may be jaundiced and may reveal urticarial rashes. Liver may be tender and diffusely enlarged with a firm, sharp,

smooth edge.

Imaging Studies No specific imaging studies needed for diagnosis Obtain the appropriate diagnostic imaging studies (eg, ultrasound, CT) if

the differential diagnosis favors gallbladder disease, biliary obstruction, or liver abscess.

Liver biopsy usually in cases of: o The diagnosis is uncertain. o Other coinfections or disease may be present. o The patient is immunocompromised. o Asses severity of chronic hepatitis B or chronic hepatitis C.

Histologic FindingsLymphocytic infiltration, moderate degrees of inflammation and necrosis,

and portal or bridging fibrosis are noted. Regenerative nodules are seen in patients with cirrhosis.

Lymphocytes surround apoptotic hepatocytes

Clustered hepatocytes with ballooning degeneration (clear vacuolated cytoplasm)

•LFT: Elevation of serum transaminases not diagnostic, but usefula)ALT elevated more than ASTb)Acute Hepatitis: ALT > 1000c)Chronic HCV: ALT is generally lower than 1000

* Urine analysis: presence of bilirubin. * Serum bilirubin: Total bilirubin may be elevated in infectious hepatitis. Bilirubin levels higher than 30 mg/dL indicate more severe disease. * Alkaline phosphatase: if elevated significantly, consider abscess or biliary obstruction. * Prothrombin time (PT) if prolonged impaired synthetic function of the liver. * BUN & serum creatinine decreased renal function suggests fulminant hepatic disease. * Serum ammonia in patients with AMS or other evidence of hepatic encephalopathy.* CBC: lymphocytosis

Lab Studies:

Differentials:Abdominal Trauma, Blunt

Obstruction, Small BowelAneurysm, Abdominal

PancreatitisCholangitis

Pediatrics, GastroenteritisCholecystitis and Biliary Colic

Pediatrics, IntussusceptionCholelithiasis

Gastritis and PUDGastroenteritis

Hepatitis A Common cause of acute hepatitis Single-stranded, positive-sense, linear RNA enterovirus

(Picornaviridae) Transmission fecal-oral route; Contaminated water and food The incubation period of hepatitis A virus is 2-7 weeks, AST & ALT levels usually return to reference ranges over 5-20

weeks. High risk Travellers: vaccinations; passive immunoglobins

given to those exposed Mild self-limited disease and confers lifelong immunity to hepatitis

A virus. Chronic infection with hepatitis A virus does not occur. Treatment: supportive

Diagnosis: HAV **Serum Serology: presence of serum

antigens and immunoglobins HAV: IgM anti-HAV: positive at the time of

onset of symptoms; results remain positive for 3-6 months after the primary infection

Anti-HAV IgG appears soon after IgM and generally persists for many years.

Hepatitis C Spherical, enveloped, single-stranded RNA virus

(Flavivirus genus) Incubation period: 7-8 wks 170 million infected worldwide Major cause of chronic hepatitis in U.S. More common in Hispanic, AA population;

females have better outcome Parenteral Transmission: IV drug users Most common indication for liver transplantation

Hepatitis C Usually clinically mild, does not cause significant

acute illness Fluctuating elevations of AST & ALT 20% likelihood of developing cirrhosis 50% likelihood of developing chronic hepatitis Incubation period: 15-150 days, with symptoms

developing anywhere from 5-12 weeks after exposure.

Diagnosis: HCV HCV: Anti-HCV; cannot distinguish acute from chronic

infection EIA: antibodies against core protein and nonstructural

proteins; may appear 3 – 5 months after infection

PCR: used to detect viral RNA HCV

80% of cases: patients are asymptomatic and do not develop icterus.

Treatment: Interferon alpha, Ribavirin; PEG-IFNs (better sustained absorption, a slower rate of clearance, and a longer half-life than those of unmodified IFN)

Hepatitis E Hepatitis E virus (HEV) RNA virus of the

genus Hepevirus Enterically transmitted infection; fecal-oral

route, typically self-limited Most outbreaks occur in developing countries. Symptoms of acute hepatitis Incubation period of hepatitis E virus is 2-9

weeks Case fatality rate is 4%

Hepatitis E: diagnosis Serum, liver, and stool samples can be

tested for HEV RNA Anti-HEV antibodies:

- IgM (acute)

- IgG (chronic)

AST & ALT are elevated several days before the onset of symptoms; return to normal within 1-2 months after the peak severity of disease.

Treatment: supportive

A 61 yo F is brought to the ER, drowsy and disoriented, only able to follow simple commands. On PE, her abdomen is distended and non-tender and she is jaundiced. In her purse, the physician finds prescriptions for peginterferon and ribavirin. When asked to raise her hands, the physician notes a coarse tremor. Lab values show ALT = 93U/L, AST = 89U/L, total bilirubin = 3.1 mg/dL, and ammonia = 124microg/dL. What is the most likely diagnosis?

A. Bleeding esophageal varices

B. Hepatic encephalopathy

C. Hepatocellular carcinoma

D. Hepatorenal syndrome

E. Spontaneous bacterial peritonitis

Hepatitis: B & DRobert Leahy

Hepatitis B(HBV)--EPIDEMIOLOGY HBV is a DNA virus that belongs to the hepadnavirus family.

2 billion people worldwide have past or present infections 400 million people are chronic  HBV carriers. Eight genotypes of HBV identified and re-labeled A through H. HBV is the cause of 60% to 80% of worldwide Hepatocellular

Carcinoma(HCC). 500,000 to 1 million deaths worldwide are attributed to it. 5% to 10% of all liver transplants are attributed to HBV.

 

AT Risk Groups

IV drug users People receiving multiple blood transfusions Sexual promiscuity People in contact with HBV carriers Travelers to endemic areas of South

America, Southern Asia, and Africa Resident and employees of residential care

facilities Health Care Workers

PathophysiologyTransmission 3 main ways:

Parenterally/percutaneous route----IV Drug Users, needle sticks, Hemodialysis patients

Sexually

Vertical/ Perinatal route

SerologyHBsAg Present in acute of chronic infection Detectable 1 to 2 weeks after infection

HBeAg Appears shortly after HBsAg Indicates viral Replication and Infectivity

HBsAB(Anti-HBS) Present after vaccination or clearance of HBsAg(Usually 1 to 3

months) Indicates immunity to HBV

Hb core Antibody  (IgM anti-Hbc or IgG anti-HBc) Only Serological marker of HBV during "Window Period"

Clinical PresentationAcute Hepatitis B - less than 6 months; Based on significant aminotransferase activity

due to necro inflammatory injury  Symptoms are often non-specific symptoms such as myalgia, malaise , nausea,

fatigue , pruritus, abdominal pain, RUQ, jaundice  Fulminant Hepatitis--Acute HBV results in Liver Failure

Chronic Hepatitis B - greater than 6 months; Based  on grade, stage, and etiology. Fibrosis and Necroinflammatory processes; can last for  decades

Immune tolerant--High viral replication, NL liver enzymes, low inflammation and fibrosis. Seen in children or those affected early in life.

Immune active--High Liver enzymes and High HBV DNA and HBeAg, Active Replication

Carrier State with low replication Seroconversion from HBeAg to HBeAB Low HBV levels, NL liver enzymes, Reduced Liver inflammation Low risk for developing of HCC

Clinical Presentation cont.

Chronic HbeAg negative HBV DNA high, Liver enzymes high,

No HbeAg Seen in late phase of HBV

Resolution Viral clearance of HBV DNA

Diagnosis Serology

Liver Chemistry tests AST, ALT, ALP, and total Bilirubin

Histology--Immunoperoxidase staining

HBV Viral DNA--Most accurate marker of viral DNA and detected by PCR

Liver Biopsy--to determine grade(Inflammation) and stage(Fibrosis) in chronic Hepatitis

 

Progression Incubation Period:  30-180 days

Acute HBV Infection:  90% resolve by themselves; less than 1% develop fulminant hepatitic failure

Chronic HBV Infection: 2-10% progress to chronic state 90% in children less than five progress to chronic state Risk of Liver  Cirrhosis:  5 year accumulation risk of 8% to

20% 5% to 10% of people progress to HCC with or without

preceding cirrhosis; less than 5%  achieve  a chronic carrier state

Treatment

1) Interferon therapy – First Line

Method of action is the inhibition of viral replication of cells thus assisting the immune system

Interferon alpha: TX: SUB-Q  5 million units q D or 10 million units 3x weekly Sub-Q

Side effects: "Flulike Symptoms", alopecia, rash, diarrhea pINF-alpha(pegylated interferon-alpha):  180ug q weekly

SUB-Q Better Choice than IFN-Alpha--Greater Bioavailability, 

Longer half life, Better treatment schedule

Treatment cont.2) Nucleoside Analogues -- Lamivudine, Entecavir, Telbivudine

Method of action is the inhibition of viral reverse transcriptase

Lamivudine Dose :  100 mg PO q daily Good for reducing the risk of progression to hepatic decompensation in patients with cirrhosis or

advanced fibrosis Pregnancy category B--Not teratogenic in animal studies and successful use with pregnant women Problem: High rates of resistant mutations Side effect: lactic acidosis

Entecavir – 1st line 0.5 to 1mg PO very effective; low resistance and greater than 90%  HBV DNA clearance rate in HBeAG positive Px's. more effective than lamivudine Side effect: lactic acidosis

Telbivudine Dose: 600mg q daily Worse resistant profile than Entecavir Side effect: lactic acidosis

Treatment cont.3) Nucleotide analogues

Method of action is the inhibition of viral reverse transcriptase Tenovir

Dose: 300mg qd Highly effective with low resistance Well tolerated

Adefovir – 1st line Dose: 10mg daily Resistance less than Tenovir Side effect: nephrotoxicity and lactic acid

Medication Guidelines

Optimal treatment duration not yet defined

Interferon drugs don't have resistance issues unlike the antivirals

When to Treat for Chronic Hepatitis

HBV DNA(copies/ml) ALT Recommendation

<105             Normal No treatment , monitor, considered inactive

>105       Normal No treatment, current tx is limited benefit

>105            Elevated   (greater than 2 x ULN)

Oral Agents, not PEG IFN

+ or - and compensated cirrhosis             

Normal or elevated Oral Agents, not PEG IFN

+ or - and uncompensated cirrhosis    

Normal or elevated Oral agents and refer for treatment

1) HBeAg positive 

When to Treat for Chronic Hepatitis2)HBeAG negative                  

HBV DNA(copies/ml) ALT Recommendation

<104 Normal No tx necessary, inactive carrier

>104 Normal Liver Biopsy , treat if abnormal

>104 Elevated Oral agents or PEG IFN 

+ or -  w/ compensated cirrhosis

Elevated or normal        Oral agents, not PEG IFN

+ or -  w/ uncompensated cirrhosis

Elevated or normal   Oral agents, not PEG IFN

ProphylaxisHBV Vaccine Indicated for everyone and especially those in high risk groups

IM injection at 0,1,6 months in infants and adults Response greater than 90% after 3rd dose

HBV Pregnant Mothers Give 1st dose of Hip B vaccine and Hip B Immunoglobulin(HBIG)  o.5 ml within 12 hours of

birth. 2nd dose at 1 month, 3rd at 6 months Recheck at 12 months for active infection 95% lifetime immunity Not Done---leads to 90% chronic HBV Transmitted through birth canal  during birth or through umbilical cord.

Others i.e. those receiving a needle stick Should receive 0.04 to 0.7 ml/kg  of HBIG and 1st dose vaccine within 48  and no later than a

week.

Transplant

Last resort for  those with advanced Liver Disease and HCC due to infection 

HEPATITIS D

Transmission Only as co-infection with acute HBV or with superinfection in

chronic HBV carrier Requires outer envelope of HBsAG for replication and

transmission Can progress to chronic disease Incubation Period 30to 150 days

Serology Hepatitis D antibody  (Anti-HDV)

Indicates HDV superinfection Ab not always present in acute infection---requires repeat testing

HEPATITIS DRisk Factors - Same high risk groups as those for Hip B

 

Prevention - Avoidance of Hip B and/or Hip B vaccine

 

DX - HDV antigen in serum or finding Ab to HDV antigen

Clinical Coinfection-self limited Superinfection-acute HBV carriers present with severe acute hepatitis infection  w/

increased risk for HDV infection.

                 

Fatality Rate - 2% to 10%

Cirrhosis – None

TX:IFN-alpha

Other Causes of Hepatitis

Alcoholic Hepatitis Drug induced Hepatitis Autoimmune Hepatitis Ischemic Hepatitis

A hepatitis panel is ordered for a 27 year old female as part of a routine workup for abdominal pain. Results of serological testing a negative for HBeAg and HBsAg, but positive for HBsAb and IgG HBcAb. The patient has been exposed to Hep B.

a. Patient has recovered

b. Patient is in acute infective disease state

c. Window period

d. Chronically infected

e. Patient was never infected

Sources

1)The Washington Manual of Medical Therapeutics

2)Harrison's Principles of Internal Medicine

3)Step up to Medicine