Pemicu 3 Hepato

Pemicu 3
Hepatobilier
Lidya Octalia Ligita
405150047
Learning Issues
1. Menjelaskan klasifikasi hepatitis
2. Menjelaskan hepatitis A
3. Menjelaskan hepatitis B
4. Menjelaskan hepatitis C
5. Menjelaskan hepatitis D
6. Menjelaskan hepatitis E
7. Menjelaskan hepatitis G
LI 1 : Klasifikasi Hepatitis
Hepatitis
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G

LI 2 : Hepatitis A
Definition and Etiology
• Hepatitis A is a liver disease caused by the hepatitis A virus.
• The virus is primarily spread when an uninfected (and unvaccinated)
person ingests food or water that is contaminated with the faeces of
an infected person.
• The disease is closely associated with unsafe water or food,
inadequate sanitation and poor personal hygiene.
• Unlike hepatitis B and C, hepatitis A infection does not cause chronic
liver disease and is rarely fatal, but it can cause debilitating symptoms
and fulminant hepatitis (acute liver failure), which is often fatal.
http://www.who.int/mediacentre/factsheets/fs328/en/
Epidemiology
• Hepatitis A occurs sporadically and in epidemics worldwide, with a
tendency for cyclic recurrences.
• Epidemics related to contaminated food or water can erupt
explosively, such as the epidemic in Shanghai in 1988 that affected
about 300 000 people.
• In developing countries with poor sanitary conditions and hygienic
practices, most children (90%) have been infected with the hepatitis A
virus before the age of 10 years.
• In developed countries with good sanitary and hygienic conditions,
infection rates are low.
Transmission
• By the faecal-oral route  is when an uninfected person ingests food
or water that has been contaminated with the faeces of an infected
person.
• In families, this may happen though dirty hands when an infected
person prepares food for family members.
• Waterborne outbreaks, though infrequent, are usually associated with
sewage-contaminated or inadequately treated water.
• The virus can also be transmitted through close physical contact with
an infectious person, although casual contact among people does not
spread the virus.
Symtomps
• The incubation period of hepatitis A is usually 14–28 days.
• Symptoms of hepatitis A range from mild to severe, and can include fever, malaise, loss of
appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a
yellowing of the skin and whites of the eyes).
• Not everyone who is infected will have all of the symptoms.
• Adults have signs and symptoms of illness more often than children.
• The severity of disease and fatal outcomes are higher in older age groups.
• Infected children under 6 years of age do not usually experience noticeable symptoms, and
only 10% develop jaundice.
• Among older children and adults, infection usually causes more severe symptoms, with
jaundice occurring in more than 70% of cases.
• Hepatitis A sometimes relapses.
• The person who just recovered falls sick again with another acute episode.
Risk Factor
• poor sanitation;
• lack of safe water;
• use of recreational drugs;
• living in a household with an infected person;
• being a sexual partner of someone with acute hepatitis A infection;
• travelling to areas of high endemicity without being immunized.
Diagnosis
• Cases of hepatitis A are not clinically distinguishable from other types
of acute viral hepatitis.
• Specific diagnosis is made by the detection of HAV-specific
Immunoglobulin G (IgM) antibodies in the blood.
• Additional tests include reverse transcriptase polymerase chain
reaction (RT-PCR) to detect the hepatitis A virus RNA
Treatment
• There is no specific treatment for hepatitis A.
• Recovery from symptoms following infection may be slow and may take
several weeks or months.
• Most important is the avoidance of unnecessary medications.
• Acetaminophen / Paracetamol and medication against vomiting should
not be given.
• Hospitalization is unnecessary in the absence of acute liver failure.
• Therapy is aimed at maintaining comfort and adequate nutritional
balance, including replacement of fluids that are lost from vomiting and
diarrhoea.
Prevention
• adequate supplies of safe drinking water;
• proper disposal of sewage within communities; and
• personal hygiene practices such as regular hand-washing
with safe water
LI 3 : Hepatitis B
Definition and Epidemiology
• Hepatitis B is a potentially life-threatening liver infection caused by the
hepatitis B virus (HBV).
• It can cause chronic infection and puts people at high risk of death from
cirrhosis and liver cancer.
• Hepatitis B prevalence is highest in the WHO Western Pacific Region and the
WHO African Region, where 6.2% and 6.1% respectively of the adult
population is infected.
• In the WHO Eastern Mediterranean Region, the WHO South-East Asia Region
and the WHO European Region, an estimated 3.3%, 2.0% and 1.6%% of the
general population is infected, respectively. 0.7% of the population of the
WHO Region of the Americas is infected.
Transmission
• The hepatitis B virus can survive outside the body for at least 7 days.
• During this time, the virus can still cause infection if it enters the body of a person who is not
protected by the vaccine.
• The incubation period of the hepatitis B virus is 75 days on average, but can vary from 30 to
180 days.
• The virus may be detected within 30 to 60 days after infection and can persist and develop
into chronic hepatitis B.
• In highly endemic areas, hepatitis B is most commonly spread from mother to child at birth
(perinatal transmission), or through horizontal transmission (exposure to infected blood),
especially from an infected child to an uninfected child during the first 5 years of life.
• The development of chronic infection is very common in infants infected from their mothers
or before the age of 5 years.
Transmission
• Hepatitis B is also spread by percutaneous or mucosal exposure to infected blood
and various body fluids, as well as through saliva, menstrual, vaginal, and seminal
fluids.
• Sexual transmission of hepatitis B may occur, particularly in unvaccinated men who
have sex with men and heterosexual persons with multiple sex partners or contact
with sex workers.
• Infection in adulthood leads to chronic hepatitis in less than 5% of cases.
• Transmission of the virus may also occur through the reuse of needles and syringes
either in health-care settings or among persons who inject drugs.
• In addition, infection can occur during medical, surgical and dental procedures,
through tattooing, or through the use of razors and similar objects that are
contaminated with infected blood.
Symptoms
• Most people do not experience any symptoms during the acute
infection phase.
• However, some people have acute illness with symptoms that last
several weeks, including yellowing of the skin and eyes (jaundice),
dark urine, extreme fatigue, nausea, vomiting and abdominal pain.
• A small subset of persons with acute hepatitis can develop acute liver
failure, which can lead to death.
• In some people, the hepatitis B virus can also cause a chronic liver
infection that can later develop into cirrhosis (a scarring of the liver)
or liver cancer.
Risk Factor for Chronic Disease
• The likelihood that infection becomes chronic depends upon the age at which a
person becomes infected.
• Children less than 6 years of age who become infected with the hepatitis B virus
are the most likely to develop chronic infections.
• In infants and children:
• 80–90% of infants infected during the first year of life develop chronic infections;
• 30–50% of children infected before the age of 6 years develop chronic infections.
• In adults:
• less than 5% of otherwise healthy persons who are infected as adults will develop chronic
infection
• 20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer.
HBV-HIV coinfection
• About 1% of persons living with HBV infection (2.7 million people) are
also infected with HIV.
• Conversely, the global prevalence of HBV infection in HIV-infected
persons is 7.4%.
• Since 2015, WHO has recommended treatment for everyone
diagnosed with HIV infection, regardless of the stage of disease.
• Tenofovir, which is included in the treatment combinations
recommended in first intention against HIV infection, is also active
against HBV.
Diagnosis
• Laboratory diagnosis of hepatitis B infection focuses on the detection of the hepatitis
B surface antigen HBsAg.
• WHO recommends that all blood donations be tested for hepatitis B to ensure blood
safety and avoid accidental transmission to people who receive blood products.
• Acute HBV infection is characterized by the presence of HBsAg and immunoglobulin
M (IgM) antibody to the core antigen, HBcAg.
• During the initial phase of infection, patients are also seropositive for hepatitis B e
antigen (HBeAg).
• HBeAg is usually a marker of high levels of replication of the virus.
• The presence of HBeAg indicates that the blood and body fluids of the infected
individual are highly infectious.
Diagnosis
• Chronic infection is characterized by the persistence of HBsAg for at
least 6 months (with or without concurrent HBeAg).
• Persistence of HBsAg is the principal marker of risk for developing
chronic liver disease and liver cancer (hepatocellular carcinoma) later
in life.
Treatment
• There is no specific treatment for acute hepatitis B.
• Therefore, care is aimed at maintaining comfort and adequate
nutritional balance, including replacement of fluids lost from vomiting
and diarrhoea.
• Chronic hepatitis B infection can be treated with medicines, including
oral antiviral agents.
• Treatment can slow the progression of cirrhosis, reduce incidence of
liver cancer and improve long term survival.
Treatment
• WHO recommends the use of oral treatments - tenofovir or entecavir,
because these are the most potent drugs to suppress hepatitis B virus.
• They rarely lead to drug resistance as compared with other drugs, are
simple to take (1 pill a day), and have few side effects so require only
limited monitoring.
• Entecavir is off-patent, but availability and costs vary widely.
• In most people, however, the treatment does not cure hepatitis B
infection, but only suppresses the replication of the virus.
• Therefore, most people who start hepatitis B treatment must continue it
for life.
Complication
• Among the long-term complications of HBV infections, cirrhosis and
hepatocellular carcinoma cause a large disease burden.
• Liver cancer progresses rapidly, and since treatment options are
limited, the outcome is in general poor.
• In low-income settings, most people with liver cancer die within
months of diagnosis.
• In high-income countries, surgery and chemotherapy can prolong life
for up to a few years.
• Liver transplantation is sometimes used in people with cirrhosis in high
income countries, with varying success.
Prevention
• WHO recommends that all infants receive the hepatitis B vaccine as

soon as possible after birth, preferably within 24 hours.
• In most cases, 1 of the following 2 options is considered appropriate:
• a 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent)
being given at birth and the second and third (monovalent or combined
vaccine) given at the same time as the first and third doses of diphtheria,
pertussis (whooping cough), and tetanus – (DTP) vaccine
• a 4-dose schedule, where a monovalent birth dose is followed by three
monovalent or combined vaccine doses, usually given with other routine
infant vaccines.
Pencegahan
• WHO merekomendasikan semua bayi menerima vaksin hepatitis B
segera setelah lahir, lebih baik dilakukan dalam 24 jam.
• Pemilihan vaksin
• 3 dosis pemberian : dosis pertama (monovalen diberikan saat lahir), dosis
kedua danketiga (monovalen atau kombinasi) diberikan bersamaan dengan
jadwal kedua dan ketiga diberikannya vaksin DTP (difteri, pertussis, tetanus)
• 4 dosis pemberian : smuanya dierikan scara monovalen.
Pencegahan
• Vaksin yang diberikan secara lengkap akan meningkatkan level
antibodi pada 95% bayi, anak dan dewasa
• Proteksi bertahan sekitar 20 tahun.
• WHO tidak merekomendasikan vaksin booster pada orang yang telah
melengkapi 3 dosis vaksinasi
Pencegahan
• Orang yang berisiko dan harus dilakukan vaksinasi
• Orang yang menerima donor secara rutin, pasien dialisis, penerima
transplantasi organ
• Tahanan penjara
• Pengguna narkoba suntik
• Kontak seksual dengan orang dengan infeksi HBV kronik
• Orang dengan banyak pasangan seksual
• Pekerja di bidang kesehatan
• Orang yang suka berpergian
Prevention
• The complete vaccine series induces protective antibody levels in
more than 95% of infants, children and young adults.
• Protection lasts at least 20 years and is probably lifelong.
• Thus, WHO does not recommend booster vaccination for persons
who have completed the 3 dose vaccination schedule
Prevention
• In those settings it is possible that more people in high-risk groups may
acquire the infection and they should also be vaccinated. They include:
• people who frequently require blood or blood products, dialysis patients, recipients
of solid organ transplantations;
• people interned in prisons;
• persons who inject drugs;
• household and sexual contacts of people with chronic HBV infection;
• people with multiple sexual partners;
• healthcare workers and others who may be exposed to blood and blood products
through their work; and
• travellers who have not completed their hepatitis B vaccination series, who should
be offered the vaccine before leaving for endemic areas.
GUIDELINES FOR THE PREVENTION, CARE AND TREATMENT OF
PERSONS WITH CHRONIC HEPATITIS B INFECTION, WHO
LI 3 : Hepatitis C
• Hepatitis C is a liver disease caused by the hepatitis C virus
• Hepatitis C virus (HCV) causes both acute and chronic infection.
• Acute HCV infection is usually asymptomatic, and is only very rarely (if
ever) associated with life-threatening disease.
• About 15–45% of infected persons spontaneously clear the virus within 6
months of infection without any treatment.
• The remaining 55–85% of persons will develop chronic HCV infection. Of
those with chronic HCV infection, the risk of cirrhosis of the liver is
between 15–30% within 20 years.
• Globally, an estimated 71 million people have chronic hepatitis C infection.
Transmission
• The hepatitis C virus is a bloodborne virus. It is most commonly
transmitted through:
• Injecting drug use through the sharing of injection equipment;
• the reuse or inadequate sterilization of medical equipment, especially syringes
and needles in healthcare settings; and
• the transfusion of unscreened blood and blood products.
• HCV can also be transmitted sexually and can be passed from an infected
mother to her baby
• Hepatitis C is not spread through breast milk, food, water or by casual
contact such as hugging, kissing and sharing food or drinks with an
infected person.
Symptoms
• The incubation period for hepatitis C is 2 weeks to 6 months.
• Following initial infection, approximately 80% of people do not exhibit
any symptoms.
• Those who are acutely symptomatic may exhibit fever, fatigue,
decreased appetite, nausea, vomiting, abdominal pain, dark urine,
grey-coloured faeces, joint pain and jaundice
Screening and Diagnosed
• HCV infection is diagnosed in 2 steps:
• Screening for anti-HCV antibodies with a serological test identifies
people who have been infected with the virus.
• If the test is positive for anti-HCV antibodies, a nucleic acid test for
HCV ribonucleic acid (RNA) is needed to confirm chronic infection
because about 15–45% of people infected with HCV spontaneously
clear the infection by a strong immune response without the need
for treatment.
• Although no longer infected, they will still test positive for anti-HCV
antibodies.
Screening and Diagnosed
• After a person has been diagnosed with chronic hepatitis C infection, they
should have an assessment of the degree of liver damage (fibrosis and
cirrhosis).
• This can be done by liver biopsy or through a variety of non-invasive tests.
• In addition, these people should have a laboratory test to identify the
genotype of the hepatitis C strain.
• There are 6 genotypes of the HCV and they respond differently to treatment.
Furthermore, it is possible for a person to be infected with more than 1
genotype.
• The degree of liver damage and virus genotype are used to guide treatment
decisions and management of the disease.
Screening
• Populations at increased risk of HCV infection include:
• people who inject drugs;
• people who use intranasal drugs;
• recipients of infected blood products or invasive procedures in health-care
facilities with inadequate infection control practices ;
• children born to mothers infected with HCV ;
• people with sexual partners who are HCV-infected;
• people with HIV infection;
• prisoners or previously incarcerated persons; and
• people who have had tattoos or piercings.
Treatment
• Hepatitis C does not always require treatment as the immune
response in some people will clear the infection, and some people
with chronic infection do not develop liver damage.
• When treatment is necessary, the goal of hepatitis C treatment is
cure.
• The cure rate depends on several factors including the strain of the
virus and the type of treatment given.
• Sofosbuvir, daclatasvir and the sofosbuvir/ledipasvir combination are
part of the preferred regimens in the WHO guidelines, and can
achieve cure rates above 95%.
Prevention
•hand hygiene: including surgical hand preparation, hand washing and use of gloves;
•safe and appropriate use of health care injections;
•safe handling and disposal of sharps and waste;
•provision of comprehensive harm-reduction services to people who inject drugs
including sterile injecting equipment;
•testing of donated blood for hepatitis B and C (as well as HIV and syphilis);
•promotion of correct and consistent use of condoms
• education and counselling on options for care and treatment;
• immunization with the hepatitis A and B vaccines to prevent coinfection from these
hepatitis viruses and to protect their liver;
• early and appropriate medical management including antiviral therapy if
appropriate; and
• regular monitoring for early diagnosis of chronic liver disease.
LI 4: Hepatitis D
• Hepatitis D is a liver disease in both acute and chronic forms caused by the hepatitis D
virus (HDV) that requires HBV for its replication.
• Hepatitis D infection cannot occur in the absence of hepatitis B virus.
• The coinfection or super infection of HDV with HBV causes a more severe disease than
HBV monoinfection.
• It is estimated that globally, 5% of HBsAg positive people are coinfected with HDV and
the distribution is worldwide.
• High-prevalence areas include the Mediterranean, Middle East, Pakistan, Central and
Northern Asia, Japan, Taiwan, Greenland and parts of Africa (mainly the horn of Africa
and West Africa), the Amazon Basin and certain areas of the Pacific.
• Prevalence is low in North America and Northern Europe, South Africa, and Eastern
Asia.
http://www.who.int/mediacentre/factsheets/hepatitis-d/en/
Transmission
• The routes of HDV transmission are the same as for HBV:
percutaneously or sexually through contact with infected blood or
blood products.
• However, in some settings, the increase of hepatitis D prevalence has
been observed in people who inject drugs, or as a result of migration
from areas where HDV is endemic.
Symptoms
• Acute hepatitis: simultaneous infection with HBV and HDV can lead to a mild-
to-severe or even fulminant hepatitis, but recovery is usually complete and
development of chronic hepatitis D is rare (less than 5% of acute hepatitis).
• Superinfection: HDV can infect a person already chronically infected with HBV.
• The superinfection of HDV on chronic hepatitis B accelerates progression to a
more severe disease in all ages and in 70‒90% of persons.
• HDV superinfection accelerates progression to cirrhosis almost a decade
earlier than HBV monoinfected persons, although HDV suppresses HBV
replication.
• The mechanism in which HDV causes more severe hepatitis and a faster
progression of fibrosis than HBV alone remains unclear.
Risk Factor, Screening and Diagnosed
• Chronic HBV carriers are at risk for infection with HDV.
• People who are not immune to HBV (either by natural disease or
immunization with the hepatitis B vaccine) are at risk of infection with
HBV which puts them at risk of HDV infection.
• HDV infection is diagnosed by high titres of Immunoglobulin G (IgG)
and Immunoglobulin M (IgM) anti-HDV, and confirmed by detection
of HDV RNA in serum.
• However, HDV diagnostics are not widely available and there is no
standardization for HDV RNA assays, which are used for monitoring
response to antiviral therapy.
Treatment
• There is no specific treatment for acute or chronic HDV infection.
• Pegylated interferon alpha is the only drug effective against HDV;
• antiviral nucleotide analogues for HBV have no or limited effect on
HDV replication.
• The optimal duration of therapy is not well defined, nor how long
patients need to be HDV RNA negative after the end of therapy to
achieve a sustained virological response.
• More than 1 year of therapy may be necessary.
Prevention
• Prevention and control of HDV infection requires prevention of HBV
transmission through hepatitis B immunization, blood safety, injection
safety, and harm reduction services.
• Hepatitis B immunization does not provide protection against HDV for
those already HBV infected
LI 5: Hepatitis E
Definition
• Hepatitis E is a liver disease caused by the hepatitis E virus (HEV): a small
virus, with a positive-sense, single-stranded ribonucleic acid (RNA) genome.
• The virus has at least 4 different types: genotypes 1, 2, 3 and 4. Genotypes 1
and 2 have been found only in humans.
• Genotype 3 and 4 viruses circulate in several animals (including pigs, wild
boars, and deer) without causing any disease, and occasionally infect humans.
• The virus is shed in the stools of infected persons, and enters the human body
through the intestine.
• It is transmitted mainly through contaminated drinking water.
• Usually the infection is self-limiting and resolves within 2–6 weeks.
Epidemiology
• Every year, there are an estimated 20 million HEV infections worldwide,
leading to an estimated 3.3 million symptomatic cases of hepatitis E (1).
• WHO estimates that hepatitis E caused approximately 44 000 deaths in
2015 (accounting for 3.3% of the mortality due to viral hepatitis).
• Hepatitis E is found worldwide, but the prevalence is highest in East and
South Asia.
Transmission
• The hepatitis E virus is transmitted mainly through the faecal-oral route due to
faecal contamination of drinking water.
• This route accounts for a very large proportion of clinical cases with this disease.
• The risk factors for hepatitis E are related to poor sanitation, allowing virus
excreted in the faeces of infected people to reach drinking water supplies.
• Other routes of transmission have been identified, but appear to account for a
much smaller number of clinical cases.
• These routes of transmission include:
• ingestion of undercooked meat or meat products derived from infected animals;
• transfusion of infected blood products; and
• vertical transmission from a pregnant woman to her fetus.
Symptoms
• The incubation period following exposure to the hepatitis E virus
ranges from 2 to 10 weeks, with an average of 5–6 weeks.
• The infected persons are believed to excrete the virus beginning a few
days before to around 3-4 weeks after the onset of disease.
• In areas with high disease endemicity, symptomatic infection is most
common in young adults aged 15–40 years.
• In these areas, although infection does occur in children, they often
have either no symptoms or only a mild illness without jaundice that
goes undiagnosed.
Symptoms
• Typical signs and symptoms of hepatitis include:
• an initial phase of mild fever, reduced appetite (anorexia), nausea and
vomiting, lasting for a few days; some persons may also have abdominal pain,
itching (without skin lesions), skin rash, or joint pain.
• jaundice (yellow discolouration of the skin and sclera of the eyes), with dark
urine and pale stools; and
• a slightly enlarged, tender liver (hepatomegaly).
• These symptoms are often indistinguishable from those experienced
during other liver illnesses and typically last between 1–6 weeks.
Diagnosed
• Definitive diagnosis of hepatitis E infection is usually based on the
detection of specific IgM antibodies to the virus in a person’s blood;
this is usually adequate in areas where disease is common.
• Additional tests include reverse transcriptase polymerase chain
reaction (RT-PCR) to detect the hepatitis E virus RNA in blood and/or
stool; this assay requires specialised laboratory facilities.
• This test is particularly needed in areas where hepatitis E is
infrequent, and in cases with chronic HEV infection.
Prevention
• Prevention is the most effective approach against the disease. At the
population level, transmission of HEV and hepatitis E disease can be
reduced by:
• maintaining quality standards for public water supplies;
• establishing proper disposal systems for human feces.
• On an individual level, infection risk can be reduced by:
• maintaining hygienic practices such as hand-washing with safe water,
particularly before handling food;
• avoiding consumption of water and/or ice of unknown purity;
LI 6: Hepatitis G
Virus HGV
• NonA-NonB virus
• Flaviviridae
• Ss RNA
• Mirip HCV namun tdk ada gen core
•  paparan pd populasi risiko tinggi: multi-transfused indv, hemodialisis, transplantasi, pecandu obat, seksual
• Blood-blood products, sexually, vertically
• ✗ ada bukti situs replikasi utama virus pd hati, dideteksi pd MN blood cells perifer
• ✗ gejala patologis jelas
• Mgkn virus komensal
• Ab thd protein envelope 2
Liver: A complete book on hepato-pancreato-biliary diseases. Saunders Elsevier: 2009

Pemicu 3 Hepato

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Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G

• WHO recommends that all infants receive the hepatitis B vaccine as

Liver: A complete book on hepato-pancreato-biliary diseases. Saunders Elsevier: 2009

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