VIRAL HEPATITIS

BY
DR ENAS M. FODA
Amal shawky Bakir
professor of internal medicine,
gastroentrology &hepatology
Ain Shams university
 Liver
• Functions
– Stores sugar needed for energy
– Breaks down poisons (toxins) and drugs
– Makes important proteins that help build new
tissue and repair broken tissue
– Produces bile, which helps in digestion of fats
– synthesizes blood coagulation factors V, VII, IX,
and X, prothrombin, and fibrinogen
 Hepatitis
Definition

Hepatitis means inflammation of the liver

Types:
Acute hepatitis
Chronic hepatitis

6
 Hepatitis
• Acute Hepatitis: Short-term hepatitis.
– Body’s immune system clears the virus from the body
within 6 months
• Chronic Hepatitis: Long-term hepatitis.
– Infection lasts longer than 6 months because the
body’s immune system cannot clear the virus from
the body. The term chronic relates to the duration of
infection and not to the severity of the disease.
 Causes of acute hepatitis

▪ Viral :Hepatotropic : (A,B,C,D,E and G)

Non hepatotropic(CMV,EBV, herpes and
HIV).
▪ Drug: Paracetamol, alcohol and halothane.

9
 Viral Hepatitis - Historical Perspectives

A Enterically
E
transmitted

Viral hepatitis

Parenterally
B D C transmitted
F, G, TTV
? other
 VIRAL HEPATITIS
VIRUS Nucleic Acid IP TRANSMIT CHRONIC VACCINE

Hep A RNA 2-6 w Fecal-oral No Yes

Hep B DNA 2-6m Blood Yes Yes

Hep C RNA 2-6m Blood Yes No

Hep D RNA 2-6m Blood Yes (HepB)

Hep E RNA 2-6 w Fecal-oral No No

 Clinical Stages of acute viral
hepatitis

• Incubation period (acc to type of virus)

• Prodromal (preicteric) phase
• Icteric phase
• convalescence

12
 Prodromal
Preicteric Phase
• Systemic &nonspecific symptoms
• Flue like symptoms,fever
• sore hroat,cough,headache
anorexia,malaise,nausea, Vomiting,
abdominal pain.
Duration :
1-2 weeks
13
 Prodromal
Preicteric Phase
• Systemic &nonspecific symptoms
• Flue like symptoms,fever
• sore hroat,cough,headache
anorexia,malaise,nausea, Vomiting,
abdominal pain.
Duration :
1-2 weeks
14
 Icteric Phase
• Clinical jaundice a yellowing of the
skin, eyes and mucous membranes
• Resolution of fever,Patient may feel
better
• Pruritus
• Liver is enlarged,tender
• Splenomegaly(10-20%)
15
Symptoms and Signs:
jaundice

17
• The various human hepatitis viruses cause
very similar illnesses.
• Therefore, neither the individual nor the
healthcare provider can tell by symptoms or
signs if a given individual is suffering from
certain type of viral hepatitis unless
laboratory tests are performed.
▪ Serum bilirubin:increased
▪ ALT,AST (liver enz)=marked
elevation
▪ Alk.phosphatase :mild elevation
▪ ProthrombinTime(PT) is usually
normal:
in severe hepatitis,PT is prolonged

19
 Convalescence
• Resolution of symptoms
• Complete recovery:
1-2 months A,E
3-4 months B,C

20
Transmission:Fecal-oral
• Peak excretion in stool (Infectious
period) occurs during the two weeks
before onset of jaundice.ie.in the
prodromal phase.
 Risk of transmission
• Close personal contact
(e.g., household contact, child day care
centers)
• Intake of Contaminated food, water
(e.g., infected food handlers, raw shellfish)
• Travelers endemic countries
 HAV can survive for several hours on fingertips
and hands
▪ and up to two months on dry surfaces.
HAV can beinactivated by
▪ heating to 185°F (85°C) or higher for one
minute, or
▪ disinfecting surfaces with a 1:100 dilution of
sodium hypochlorite .
 Laboratory Diagnosis
• Acute infection is diagnosed by the
detection of HAV-IgM
• Past Infection i.e. immunity is determined
by the detection of HAV-IgG.
 HEPATITIS A

Prophylaxis:
Improve Hygiene

Passive immunity

Vaccine
 Passive immunity
• After Exposure to HAV
• but not more than 2 weeks after the last
exposure.

28
 Hepatitis A VACCINE
• Pre-exposure
– travelers to HAV-endemic regions
Routine household and intimate
contacts
Selected situations
– institutions (e.g., day care centers)
– common source exposure (e.g., food
handler)
• Post-exposure (within 14 days)
• HAV has no known chronic
carrier state and does not
cause chronic hepatitis or
cirrhosis.
•
 Mode of transmission
HBV
• through blood and infected
bodily fluids ( semen,vaginal or
another body fluid).
• sexual intercourse.
• infected woman transfers the
disease to her baby during
childbirth. Mothers with HBeAg
positive are much more likely to
transmit to their offspring
HCV
• percutaneous exposures to
infected blood.
• Sexual contact, has been
shown to be an inefficient
route of exposure,
• mother-to-child in childbirth
an inefficient route of
exposure,
 Presentation of the disease
HBV
• Around 30-50% of adults
develop clinical illness.
• 90-95 % complete recovery.
HCV
• In most of the cases, the
onset of hepatitis C
infection is unrecognized
because the clinical
symptoms are often mild
and clinically not apparent
• About 20–30%complete
recovery.

• 5-10 % chronic • 70–80% of persons will

hepatitis ends in liver develop chronic HCV
cirrhosis and infection. ends in liver
hepatocellular carcinoma cirrhosis and
hepatocellular carcinoma
 Risk factors
• Blood transfusion before 1992(HCV)
• Hemophilia
• i.v drug abuse
• Body piercing(tattoos)
• Needle stick injury(Health Workers are at increased
risk.)
• Hemodialysis
• Vertical trasmission (HBV) Mothers who are HBeAg
positive are much more likely to transmit to their
offspring than those who are not.
• Sexual (HBV)
Ways to prevent HBV Transmission
• HBV is a DNA virus
• The outer surface of the virus
contains hepatits B surface
antigen (HbsAg).
• HBeAg is a protein from the
hepatitis B virus that
circulates in infected blood
when the virus is actively
replicating.
• It encloses an inner
nucleocapsid (core), which
contains hepatitis B core
antigen (HBc Ag not present
in blood)HBc Ab.

• Inside the core, there is a

circular double-stranded DNA
and a DNA polymerase
 Diagnosis
• HBsAg - used as a general marker of infection.
• HBsAb - used to document recovery and/or immunity to
HBV infection.
• HBc Ab ( IgM )- marker of acute infection.
• HBc Ab (IgG) - past or chronic infection.
• HBeAg - indicates active replication of virus and
therefore infectiveness.
• HBV-DNA - Used mainly for monitoring response to
therapy.
• How long does it take for blood to test
HBsAg-positive after exposure to HBV?
• HBsAg will be detected in an infected
person’s blood an average of 4 weeks (range:
1–9 weeks) after exposure to the virus.
 Prevention
• Passive immunity
• Hepatitis B Immunoglobulin – may be used to
protect persons who are exposed to hepatitis B
(within 48 hours).
• It may also be given to neonates who are at
increased risk of contracting hepatitis B i.e. whose
mothers are HBeAg positive.

40
 Prevention
• Vaccination -high risk adults:
– Healthcare workers
– IV drug users
– Household contacts of people w/ Hep B
– Pts w/ multiple sexual partners
– Hemodialysis patients
– Pts who require repeated transfusions of
blood products
– Pts w/ chronic liver disease
– routinely to neonates as universal vaccination
in many countries.
 Can Hepatitis B vaccine be given after
exposure to HBV?

• Yes., given as soon as possible but

preferably within 24 hours,
 Laboratory Diagnosis
• HCV antibody - generally used to diagnose hepatitis C
infection. Not useful in the acute phase as .In most
individuals, anti-HCV antibodies appear 7 to 8 weeks
after exposure
• HCV-RNA - PCR. used to diagnose HCV infection in the
acute phase (2-4 weeks) .
Is there a vaccine for the prevention of
HCV infection?

NO
In case there is an accidental exposure, to HBV or
HCV follow these steps:
Carefully wash the wound without rubbing for
several minutes with soap and water,
or using a disinfectant of established efficacy
against the virus (iodine solutions or chlorine
formulations).
A complete detailed medical and clinical history of
the patient must be recorded to rule out
possible risks.
 What to do after needle prick from
HCV patient?
• ALT and HCV ab at base line and 1 -3 -6
months later
• HCV PCR within 2-4 weeks to detect
infection
ALT HCV ab comment

At base line +ve +ve Old infection

• 1-3 months +ve (was -ve at +ve (was -ve at Acute infection
base line) base line)

6 months -ve (was -ve at -ve (was -ve at No infection

1-3mon) 1-3mon)
48
• HAV: HAV IgM+ve acute hepatitis A.
• HBV: HBsAg ,eAg and HB DNA by PCR
• HCV: HCV ab and HCV RNA by PCR
• HDV: HDV- antibody
• HEV: Anti body to HEV
• If all tests for viral hepatitis are negative a,
other viruses should be expected as CMV or
EBVor others.
49
 Treatment of Acute Viral Hepatitis

Symptomatic treatment
• Bed rest
• Light palatable meals
• Patient isolation or hospitalization is rarely
necessary.

50
• Oral manifestations of hepatitis C infection

Manifestations in the oral cavity include

lichen planus, Sjögrens syndrome, xerostomia
and sialadenitis, some forms of oral cancers
may also be seen.
• Lichen planus is a mucocutaneous disease of
uncertain cause that affects the oral mucosa.
• It represents a cell-mediated immune
response.
• It is classified as reticular, plaque, atrophic,
erosive, or bullous according to the clinical
presentation.
• There is a relationship between OLP and
hepatitis C notably in the erosive type and
asymmetric lesions on the buccal mucosa
• Xerostomia increases patient vulnerability to
caries and oral soft tissue disorders, which, in
combination with deficient hygiene, in turn
facilitate the development of candidiasis.
56
 • Patient with HAV is infectious:
A. When he becomes jaundiced.
B. After disappearance of jaundice.
C. Before appearance of jaundice.
D. Non of the above .
• After recent exposure to HCV , acute infection
can be diagnosed within 4 ws by :
• A)HCV Ab
• B)HCV RNA
• C) ALT
• D) ALT &HCV Ab
• After accidental exposure to blood from HBV +ve
patient.,if you are not vaccinated you must take:
• HBV vaccine.
• HBIG
• HBV vaccine and HBIG.
• Non of the above.
 • All these viruses can cause chronic hepatitis
except:
A. HAV
B. HBV
C. HCV
D. HDV
• Increase risk of HBV transmission from
mother to her infant detected by presence of :
• A) HBeAg
• B) HBsAg
• C) HBcAb
• D) HBsAb
• give short account on oral manifestation of
hepatitis c infection ?