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Clinical Terms
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
Pathophysiology
Targets 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.
Histologic Findings
Lymphocytic infiltration, moderate degrees of inflammation and necrosis, and
portal or bridging fibrosis are noted. Regenerative nodules are seen in
patients with cirrhosis.
Acute hepatitis: histopathology
Lymphocytes
surround
apoptotic Clustered hepatocytes with ballooning
hepatocytes degeneration (clear vacuolated cytoplasm)
Lab Studies:
•LFT: Elevation of serum transaminases not diagnostic, but useful
a)ALT elevated more than AST
b)Acute Hepatitis: ALT > 1000
c)Chronic HCV: ALT is generally lower than 1000
Parenterally/percutaneous route----IV
Drug Users, needle sticks,
Hemodialysis patients
Sexually
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
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
Histology--Immunoperoxidase staining
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
Serology
Hepatitis D antibody (Anti-HDV)
Indicates HDV superinfection
Ab not always present in acute infection---requires repeat
testing
HEPATITIS D
Risk Factors - Same high risk groups as those for Hip B
Clinical
Coinfection-self limited
Superinfection-acute HBV carriers present with severe acute hepatitis
infection w/ increased risk for HDV infection.
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
3)Step up to Medicine