CHRONIC HEPATITIS

DEFINITION
Chronic hepatitis is defined as a chronic inflammatory reaction in the liver continuing without improvement for at least 6 months.

CAUSES OF CHRONIC HEPATITIS

Viral
Hepatitis B &/or D Hepatitis C Hepatitis G CMV

Autoimmune
type 1 (lupoid) type 2 (LKM1) Type 3

Drugs/toxins
Drugs -- methyldopa, isoniazid, ketoconazole, nitrofurantoin Alcoholic

CAUSES OF CHRONIC HEPATITIS

NAFLD Wilson Haemochromatosis Alpha 1 antitrypsin deficiency Biliary Cirrhosis Cryptogenic

PRESENTATIONS
Fatigue : generally unwell Positive hepatitis B or C markers at routine check up Failure of recovery from acute hepatitis whether clinical or biochemical Abnormal liver function tests Hepatomegaly, Splenomegaly, Jaundice Blood transfusion or drug abuse in the past

LIVER FUNCTION TESTS

Bilirubin Aspartate transaminase (AST) Alanine transaminase (ALT) Gamma globulin Albumin Alkaline phosphatase Alpha feto protein

Serum bilirubin, albumin & phosphatase are normal except in severe disease. Serum transaminase levels do not always reflect the severity of the underlying liver disease as shown by liver biopsy, but can be used for an approximate grading: Mild..less than100 iu Moderatefrom 100 to 400 iu Severe.more than 400 iu

HAEMATOLOGY
CBC Prothrombin time Hepatitis B surface antigen HBeAg HBeAb HBV DNA HBcAb(IgG &IgM) Hepatitis C antibody HCV RNA (PCR)

SPECIAL TESTS
Antinuclear antibody Aantismooth muscle antibody Anti Liver/kidney microsomal antibody (LKM) Anti soluble liver antigen Serum iron & transferrin Antimitochondrial antibody Serum copper & ceruloplasmin Alpha 1 antitrypsin level

OTHER TESTS
Needle liver biopsy Fibrotest & Actitest

IMAGING
A T Fi r i l ltr (N )

ROLE OF LIVER BIOPSY

Confirm the diagnosis Indicate the possible etiology Grading & staging of the disease Establish the presence of cirrhosis Evaluation of treatment

CLASSIFICATION OF CHRONIC HEPATITIS

The old classification
chronic persistent hepatitis chronic active hepatitis chronic lobular hepatitis

has been replaced by a new one based on etiology, clinical grade, histological severity & the extent of fibrosis

Knodell Histological Activity Index (HAI)

Periportal necrosis....0---10 Intralobular degeneration & focal necrosis..0---4 Portal inflamation .0---4

CORRELATION OF HAI SCORE & DIAGNOSIS

1---3Minimal 4---8Mild 9---12.Moderate 1318Severe

STAGING OF CHRONIC HEPATITIS ON THE BASIS OF FIBROSIS

SCORE 0 1 2 3 4 5 6
None Portal fibrosissome Portal fibrosismost Bridging fibrosisfew Bridging fibrosismany Incomplete cirrhosis Cirrhosis

DESCRIPTION

Treatment of viral hepatitis

HBV :
interferon . alfa-2b pegylated interferon alfa-2a Antiviral drugs
adefovir dipivoxil, entecavir, and lamivudine.

HCV :
Pegylated interferon (alfa 2a or alfa 2b) plus ribavirin is the preferred

Autoimmune Hepatitis
Steroids Immuno-suppressive

COMPLICATION OF CHRONIC HEPATITIS

Li r irr i Port l rt ion,A it ri H ti Encephalopathy Hepatocell lar carcinoma