Hepatitis Viral Akut

Introduction:
Inflammation of Liver
Viral, immune, drugs, toxins & other.
Acute, Chronic & Fulminant - types
Viral Hepatitis
Hepatitis A, B, C, D, E, & other
Specific

Systemic - CMV, EBV, other.

 Hepatitis-3

Hepatitis viruses:(A,B,C,D,E,G & other)

Virus Hep-A Hep-B Hep-C

Agent ssRNA dsDNA ssRNA

Transm. Feco-oral Parenteral Parenteral

Carrier None 0.1-1.0% 0.2-1.0%

state
Chronic None 5-10% >50%
Hepatitis
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 Phases of Hepatitis :
Carrierstate / Asymptomatic phase
Acute hepatitis
Chronic Hepatitis
Chronic Persistent Hepatitis
Chronic Active Hepatitis

Fulminant hepatitis
Cirrhosis
 Acute Hepatitis:
1. Incubation phase.
2. Symptomatic pre-icteric / prodromal phase.
3. Symptomatic icteric phase.
4. Convalescence.
 Hepatitis-6

PRODROMAL :
3-4 HARI S/D 2-3 MGG,LELAH, ANOREKSIA,
MUAL, HIPERPIREKSIA RINGAN,NYERI PERUT
KANAN ATAS, SAKIT KEPALA, NYERI OTOT

IKTERIK :
1-4 MGG URIN GELAP, HEPATOMEGALI,
SPLENOMEGALI.

KONVASELEN :
MULAI MENGHILANGNYA IKTERUS,NAFSU
MAKAN BAIK.
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 Hepatitis-7

Acute Chronic
1. Ballooning deg. Ground glass (B)
2. Cholestasis Apoptosis
3. Apoptosis Periportal Necrosis
4. Periportal Necrosis Macrophages
5. Macrophages Portal Lymphoid
6. Inflammation infiltrate
7. Portal inflammation Bridging fibrosis

8. Fatty change(C) Fatty change(C)

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 Hepatitis-8

HEPATITIS AKUT - A

. 1912 COCKAYNE = HEPATITIS INFEKSIOSA.

. 1923 BLUMMER MENDESKRIPSI SEMPURNA.
. DIGOLONGKAN ENTERO VIRUS TIPE 72
( PICORNAVIRIDAE VIRUS FAMILY ).
. 27-28 nm.
. STABIL PADA 60 0C.
. INAKTIF PADA 85 0C DALAM 1 MENIT.
. HANYA 1 ( SATU ) JENIS SERO TIPE

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 Hepatitis-9

PATOGENESE :

. ORAL FECAL ROUTE INOKULASI

VIRUS HEPATOCYTE REPLIKASI
JUMLAH VIRUS AKAN MENURUN SETELAH
TIMBUL MANIFESTASI KLINIS MUNCUL
IgM ANTI HAV YANG SPESIFIK.

. KERUSAKAN SEL HATI OLEH KARENA VIREMIA

YANG SANGAT PENDEK.

. KERUSAKAN SEL HATI DISEBABKAN OLEH

AKTIFASI SEL T LIMFOSIT.
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 Hepatitis-10

. HISTOLOGIS :
NEKROSIS SEL HATI
DIIKUTI INFILTRASI LIMFOSIT, MAKROFAG,
SEL PLASMA, EOSINOFIL DAN NEUTROFIL.

. IKTERUS AKIBAT GANGGUAN ALIRAN EMPEDU

. KERUSAKAN SEL HATI MENYEBABKAN

PELEPASAN ENZIM TRANSAMINASE (SGPT)

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 Hepatitis-11

GEJALA KLINIS
-ASYMPTOMATIS
-SYMPTOMATIS JAUNDICE SELF LIMITED
SEMBUH DALAM 8 MINGGU
-CHOLESTASIS JAUNDICE DALAM 10 MINGGU
ATAU LEBIH
-RELAPSE
-FULMINANT HEPATITIS (JARANG HIDUP)
-PENINGGIAN TRANSAMINASE > 10-20 KALI
-GEJALA KLINIS KLASIK TDD :
PRODROMAL (FLU LIKE SYNDROME)
FASE IKTERIK
FASE PENYEMBUHAN

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 Hepatitis-12

DIAGNOSTIK :
Gejala klinis, pemeriksaan fisik dan laboratorium.
Berdasarkan ditemuinya Ig M anti HAV

PENATALAKSANAAN :
- Tidak ada yang spesifik, bersifat :
- Suportif
- Simptomatis

Prognosis
- Prognosis baik, angka kematian akibat hepatitis
fulminan 0,1 - 0,2%.
- Dilaporkan terjadi 0,13 - 0,35% kasus hospitalisasi.
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 Hepatitis-13

PENCEGAHAN :
POLA HIDUP YANG BAIK DAN BERSIH.

SECARA UMUM :
HIGIENE PERORANGAN, LINGKUNGAN
SANITASI YANG BAIK,PEMAKAIAN AIR BERSIH,
PEMBUANGAN EKSKRETA, PEMBUATAN
SUMUR YANG MEMENUHI STANDAR.

MENCEGAH KONTAMINASI MAKANAN,

MEMASAK DENGAN BAIK.

VAKSINASI
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 Hepatitis-14

IMUNISASI PASIF :

a. PENCEGAHAN SEGERA SETELAH KONTAK.

(KELUARGA SERUMAH).

b. PENCEGAHAN SEBELUM KONTAK (BERPERGIAN KE

DAERAH ENDEMIS).

HBIG( HUMAN NORMAL IMUNO GLOBULIN ), 0,02 ml / kg

BB, TIDAK LEBIH SATU MINGGU SETELAH KONTAK.

SEBELUM KONTAK 0,02ml/kg BB UNTUK PERJALANAN <

2 BULAN, 0,08ml/kg BB > 4 BULAN.

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 Hepatitis-15

IMUNISASI AKTIF :

VAKSIN LIVE ATTENUATED YANG BERASAL

DARI GINJAL MONYET HIJAU AFRIKA
STRAIN HM -175

1993 DIIJINKAN PENGGUNAANNYA OLEH

REPORT OF COMMITTEE ON INFECTIOUS
DISEASE.

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 Hepatitis-16

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 Hepatitis-17
Hepatitis B - Clinical
Features
Incubation period: Average 60-90 days
Range 45-180 days
Clinical illness (jaundice): <5 yrs, <10%
5 yrs, 30%-50%
Acute case-fatality rate: 0.5%-1%
Chronic infection: <5 yrs, 30%-90%
5 yrs, 2%-10%
Premature mortality from
chronic liver disease: 15%-25%

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 Hepatitis-18

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 Hepatitis-19

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 Hepatitis-20

Typical Serologic HepB Course

Symptoms

HBeAg anti-HBe

Total anti-HBc
Titer

HBsAg IgM anti-HBc anti-HBs

0 4 8 12 16 20 24 28 32 36 52 100
Weeks after Exposure
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 Hepatitis-21
Outcome of Hepatitis B Virus Infection
100 by Age at Infection 100

Symptomatic Infection (%)

Chronic Infection (%)

80 80

60 60
Chronic Infection

40 40

20 20

Symptomatic Infection
0 0
Birth 1-6 months 7-12 months 1-4 years Older Children
and Adults
Age at Infection
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 Hepatitis-22

Hepatitis B Virus
Modes of Transmission

Sexual
Parenteral
Perinatal

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 Hepatitis-23

Risk Factors for Acute Hepatitis B

United States, 1992-1993
Heterosexual*
(41%)

Injecting
Drug Use
(15%)

Homosexual Activity (9%)

Household Contact (2%)
Health Care Employment (1%)

Unknown (31%)
Other (1%)
* Includes sexual contact with acute cases, carriers, and multiple partners.
Source: CDC Sentinel Counties Study of Viral Hepatitis
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 Hepatitis-24
Elimination of Hepatitis B Virus
Transmission United States
Strategy
Prevent perinatal HBV transmission
Routine vaccination of all infants
Vaccination of children in high-risk groups
Vaccination of adolescents
all unvaccinated children at age 11-12
high-risk adolescents at all ages
Vaccination of adults in high-risk groups
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 Hepatitis-25

Concentration of Hep B Virus

in Various Body Fluids

Low/Not
High Moderate Detectable

blood semen urine

serum vaginal fluid feces
wound exudates saliva sweat
tears
breastmilk

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 Hepatitis-26

Fulminant Hepatitis:
Hepatic failure with in 2-3 weeks.
Reactivation of chronic or acute hepatitis
Massive necrosis, shrinkage, wrinkled
Collapsed reticulin network
Only portal tracts visible

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 Hepatitis-27

GAMBARAN KLINIS
IKTERUS PROGRESIF

BILIRUBIN > 20MG%

GANGGUAN KESADARAN PROGRESIF,

MUAL DAN MUNTAH, HATI MENGECIL, MASA
PROTROMBIN MEMANJANG,
TRANSAMINASE NAIK CEPAT DAN SANGAT
MENINGGI SERTA ALBUMIN MENURUN.

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 Hepatitis-28
IMUNOPATOGENESE DARI FULMINAN HEPATITIS

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PATOGENESE
Hepatitis-29 FULMINAN HEPATITIS OLEH VIRUS

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 Hepatitis-30
ETIOLOGI
VIRAL HEMORAGIC FEVER VIRUS
HEPATITIS VIRUS SITOMEGALOVIRUS
HEPATITIS A HERPES SIMPLEX VIRUS
HEPATITIS B EPSTEIN BARR VIRUS
HEPATITIS C PARAMIXOVIRUS
HEPATITS E ADENOVIRUS
HEPATITIS G

DRUG/ TOXIN NEOPLASTIK

DOSE RELATED LIMFOMA
ACETAMINOFEN METASTASE HATI,
CCI 4 MELANOMA , PARU
AMANITA POISONING
YELLOW PHOSPORUS
BACILLUS CEREUS EMETIC TOXIN

PREGNANCY RELATED
ACUTE FATTY LIVER OF PREGNANCY
HELLP SINDROME
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Hepatitis-31
IDIOSINKRINASI METABOLIC
HALOTHANE INBORN METABOLISM ERROR
ISONIAZID GALACTOSEMIA
RIFAMPISIN FRUCTOSE INTOLERANCE
VALPROIC ACID TYROSINEMIA
DISULFIRAM NEONATAL IRON STORAGE
NSAID DISEASE
NORTRIPTYLINE WILSON DISEASE
REYE SYNDROME ALFA 1 ANTITRIPSIN DEFF.
HERBAL MEDICINE
MISC
BUDD CHIARI SYNDROME
VENO OCCLUSIVE DISEASE
AUTOIMUNE HEPATITIS
ISCHEMIC SHOCK LIVER
PRIMARY GRAFT NON FUNCTIONIN LIVER
TRANSPLANTED PATIENT
HEAT STROKE
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ADULT ONSET STILLS DISEASE
 Hepatitis-32

TATALAKSANA
N-ASETIL SISTEIN
PENDEKATAN
FARMAKOLOGI PROSTAGLANDIN

HAEMOPERFUSI ARANG
KOLOUMN HEPATOSIT
PENDEKATAN REGULASI SITOKIN
MOLEKULER
REGULASI KASKADE KOAGULASI

INHIBISI APOPTOSIS
HEPATOSIT GROWTH FACTOR

HEPATOSIT TRANSPLANT
TRANSPLANTASI
LIVER TRANSPLANT

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 Hepatitis-33

Features of Hepatitis C Virus

Infection

Incubation period Average 6-7 weeks

Range 2-26 weeks
Acute illness (jaundice) Mild (<20%)
Chronic infection 60%-85%

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 Hepatitis-34

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 Hepatitis-35

Chronic Hepatitis C
Factors Promoting Progression
or Severity
Increased alcohol intake
Age > 40 years at time of infection
HIV co-infection
Other
Male gender
Chronic HBV co-infection

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 Hepatitis-36

Serologic Pattern of Acute HCV Infection

with Recovery
anti-
HCV
Symptoms +/-

HCV RNA
Titer

ALT

Normal
0 1 2 3 4 5 6 1 2 3 4
Months Years
Time after exposure
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 Hepatitis-37

Estimated Incidence of Acute HCV

Infection
United States, 1960-2001
140
New Infections/100,000

120
100 Decline in injection
80 drug users
60
40 Decline in
transfusion recipients
20
0
1960 1965 1970 1975 1980 1985 1989 1992 1995 1998 2001
Year
Source: Hepatology 2000;31:777-82; Hepatology 1997;26:62S-65S;
CDC, unpublished data
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 Hepatitis-38

Exposures Known to Be Associated With

HCV Infection in the United States

Injectingdrug use
Transfusion, transplant from infected donor
Occupational exposure to blood
Mostly needle sticks
Iatrogenic (unsafe injections)
Birth to HCV-infected mother
Sex with infected partner
Multiple sex partners

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 Hepatitis-39 HCV Prevention and Control

Reduce or Eliminate Risks for

Acquiring HCV Infection
Screen and test donors
Virus inactivation of plasma-derived
products
Risk-reduction counseling and services
Obtain history of high-risk drug & sex behaviors
Provide information on minimizing risky
behavior, including referral to other services
Vaccinate against hepatitis A and/or hepatitis B

Safe injection and infection control practices

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 Hepatitis-40

HCV Testing Routinely

Recommended
Based on increased risk for infection
Ever injected illegal drugs
Received clotting factors made before 1987
Received blood/organs before July 1992
Ever on chronic hemodialysis
Evidence of liver disease
Based on need for exposure management
Healthcare, emergency, public safety workers
after needle stick/mucosal exposures to HCV-
positive blood
Children born to HCV-positive women
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 Hepatitis-41

Postexposure Management for HCV

IG, antivirals not recommended for
prophylaxis
Follow-up after needlesticks, sharps, or
mucosal exposures to HCV-positive blood
Test source for anti-HCV
Test worker if source anti-HCV positive
Anti-HCV and ALT at baseline and 4-6 months later
For earlier diagnosis, HCV RNA at 4-6 weeks

Confirm all anti-HCV

Refer infected worker to specialist for medical
evaluation and management

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 Hepatitis-42 HCV Counseling

Preventing HCV Transmission to Others

Avoid Direct Exposure to Blood
Do not donate blood, body organs,
other tissue or semen
Do not share items that might have
blood on them
personalcare (e.g., razor, toothbrush)
home therapy (e.g., needles)

Cover cuts and sores on the skin

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 Hepatitis-43 HCV Counseling
Mother-to-Infant Transmission of HCV

Postexposure prophylaxis not available

No need to avoid pregnancy or
breastfeeding
Consider bottle feeding if nipple cracked/
bleeding
No need to determine mode of delivery
based on HCV infection status
Test infants born to HCV-positive women
>15-18 months old
Tests any children born since mom infected
Evaluate infected children for CLD

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 Hepatitis-44 HCV Counseling

Other Transmission Issues

HCV not spread by kissing, hugging,

sneezing, coughing, food or water, sharing
eating utensils or drinking glasses, or
casual contact
Do not exclude from work, school, play,
child-care or other settings based on HCV
infection status

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 Hepatitis-45

Diagnostik :
Ditemuinya anti HCV. (minggu 5-6 setelah terpapar)
Peninggian transaminase pada minggu ke-2 s/d 26,
puncaknya minggu ke-5 s/d 12.
Kadar ALT biasanya meninggi pada pasien lebih dari
15 kali dari batas atas normal.
RNA HCV (+) menetap pada yang terinfeksi.

Gejala :
Banyak kasus asimtomatik
Flu-like sindrome, anoreksia, BB menurun, nyeri
abdominal, mialgia, atralgia dan fatigue.
Simptom yang jarang : demam dan rash.
Jaundice < 1/3 pasien.

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 Hepatitis-46

HEPATITIS AKUT - D
Terdeteksi bersamaan dengan virus Hepatitis B.
HDV (+) diseluruh dunia berhubungan dengan
prevalensi infeksi HBV (+).
Lebih dominan didaerah tropikal dan subtropikal.
Infeksi HDV di negara berkembang lebih besar dari
pada di negara maju (Barat).
Manifestasi klinis dari coinfeksi atau super infeksi
bervariasi dari asimptomatis sampai yang berat
80% kasus kronik hepatitis D menjadi sirosis dalam
5-10 tahun.
Gold standard diagnosis : HDV RNA (+) atau HDAg (+)
liver.
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 Hepatitis-47

Transmisisi :
Melalui parenteral, seksual, transfusi, jarum suntik,
haemodialisis.
Infeksi HDV dapat berupa koinfeksi atau superinfeksi
dengan HBV.

Prevalensi Geografis :
+ 5% carier HbsAg terinfeksi dengan HDV

Diagnosa :
HDV (+) di serum dan liver, HDV RNA dan HDAg (+)
Diagnosa dini dengan IgM anti HD

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 Hepatitis-48

Gambaran Klinis :
Biasanya berat dan ikterus
Amino transferase meningkat

Pencegahan :
Dengan cara vaksinasi HBV

Therapi :
Tidak banyak bermanfaat dengan pemberian
antivirus dan immunodulator

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 Hepatitis-49

HEPATITIS AKUT E
Tidak berkapsul, sporadis , bersifat akut.
Terdistribusi di Asia, Timur Tengah, sebagian Afrika, dan
Meksiko.
Transmisi fecal oral route.
Paling sering pada dewasa muda.
Masa inkubasi 2 - 10 minggu.
Mortalitas : 25 %.
Bersifat asimptomatis dan anikterik

Diagnosa :
HEV (+) , anti HEV (+) dan HEV RNA (+)
Tidak ada yang spesifik untuk terapi hepatitis E

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 Hepatitis-50

HEPATITIS AKUT G
Termasuk Flava virus.
Terdistribusi secara luas.
Ditularkan melalui parenteral, seksual
dan perinatal.
HGV RNA dideteksi dengan PCR.
HGV tidak mempengaruhi respon untuk
terapi antiviral.

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