Hepatitis

Definition:- inflammation of the liver due to various causes of injury.

What is inflammation ? Inflammation (from Latin: inflammatio) is part of the

biological response of body tissues to harmful stimuli, such as pathogens,
damaged cells, or irritants.

The five cardinal signs of inflammation are heat, pain, redness, swelling, and
loss of function
 Causes of Hepatitis:-

• viruses, bacteria, parasitic infections, alcohol, drugs, and immune disorders

• The main viruses of clinical importance are

A, B, C, D, and E,
• A, C, D and E – RNA virus

• B- DNA virus
 Mode of transmission
• HAV and HEV are transmitted through Oro-fecal while HBV, HCV, and HDV
transmitted exposure to infected blood/body fluids

• Effective vaccine is available to prevent HAV, HBV, HDV and HEV but no
vaccine for HCV.

• HEV is a common cause of Hepatitis out break in developing countries

Main Hepatitis Viruses

A. E. B. D C.
Faecal oral route Exposure to blood / body fluids

Acute hepatitis
Chronic infections
 Epidemiology
Global

• An international public health Challenge

• Agenda for Sustainable Development (SDG)– Target 3.3

• Causing 1.4 million deaths a year (47% HBV and 48% from HCV).

• The second major killer infectious disease after tuberculosis

• 9 times more people are infected with hepatitis than HIV.

 Epidemiology
Ethiopia

• According to Global Burden of Disease estimates it is projected that by 2040, Viral Hepatitis
will cause more deaths than AIDS, TB, and Malaria combined.

• Population-based cross sectional study reported that the national HBV prevalence in Ethiopia
is 9.4%. (MoH and EPHI)
• This study showed that there is significant regional variation of HBV prevalence in the
country ranging from 4.9% in Harari to 28.8% in Afar region.
• Higher prevalence in rural areas (9.7% vs 8.35%)
 Signs and symptoms
• Hepatitis has a broad spectrum of presentations that range from a complete lack
of symptoms to severe liver failure

• The acute form of hepatitis, generally caused by viral infection, is characterized

by constitutional symptoms that are typically self-limiting

• Chronic hepatitis presents similarly, but can manifest signs and symptoms
specific to liver dysfunction with long-standing inflammation and damage to the
organ.
 [Link] hepatitis
• Acute viral hepatitis follows three distinct phases:
[Link] initial prodromal phase (preceding symptoms) involves non-specific and
flu-like symptoms common to many acute viral infections.
• These include fatigue, nausea, vomiting, poor appetite, joint pain, and
headaches.
• Fever, when present, is most common in cases of hepatitis A and E.
2. Yellowing of the skin and whites of the eyes follow the prodrome after about
1–2 weeks and can last for up to 4 weeks.
The non-specific symptoms seen in the prodromal typically resolve by this time,
but people will develop an enlarged liver and right upper abdominal pain or
discomfort.
 Acute hepatitis
[Link] recovery phase is characterized by resolution of the clinical symptoms of
hepatitis with persistent elevations in liver lab values and potentially a
persistently enlarged liver.
• All cases of hepatitis A and E are expected to fully resolve after 1–2 months.
• Most hepatitis B cases are also self-limiting and will resolve in 3–4 months.
Few cases of hepatitis C will resolve completely.
 [Link] hepatitis
• Fulminant hepatitis, or massive hepatic cell death, is a rare and life-threatening
complication of acute hepatitis that can occur in cases of hepatitis B, D, and E,
in addition to drug-induced and autoimmune hepatitis.
• The complication more frequently occurs in instances of hepatitis B and D co-
infection at a rate of 2–20% and in pregnant women with hepatitis E at rate of
15–20% of cases.
• In addition to the signs of acute hepatitis, people can also demonstrate signs
of coagulopathy and encephalopathy (confusion, disorientation, and sleepiness
).
• Mortality due to fulminant hepatitis is typically the result of various
complications including cerebral edema, gastrointestinal bleeding, sepsis,
respiratory failure
 [Link] hepatitis
• When hepatitis is continued for more than six months it is termed chronic
hepatitis.
• Chronic hepatitis is often asymptomatic early in its course and is detected only
by liver laboratory studies for screening purposes or to evaluate non-specific
symptoms.
• Jaundice can occur as well, but much later in the disease process and is typically
a sign of advanced disease.
•
 [Link] hepatitis
• When hepatitis is continued for more than six months it is termed chronic hepatitis.
• Chronic hepatitis is often asymptomatic early in its course and is detected only by
liver laboratory studies for screening purposes or to evaluate non-specific symptoms.
• Jaundice can occur as well, but much later in the disease process and is typically a
sign of advanced disease.
• Extensive damage and scarring of the liver over time defines cirrhosis, a condition in
which the liver's ability to function is permanently impeded.
• [This results in jaundice, weight loss, coagulopathy, ascites (abdominal fluid collection),
and peripheral edema (leg swelling).
• Cirrhosis can lead to other life-threatening complications such as
hepatic encephalopathy, esophageal varices, hepatorenal syndrome, and liver cancer
Stages of liver disease
 Diagnosis
• Diagnosis of hepatitis is made on the basis of some or all of the following:
• a person's signs and symptoms,
• medical history including sexual and substance use history,
• blood tests,
• imaging, and liver biopsy.
In general, for viral hepatitis and other acute causes of hepatitis, the person's
blood tests and clinical picture are sufficient for diagnosis
 Diagnosis
• For other causes of hepatitis, especially chronic causes, blood tests may not be
useful.
• In this case, liver biopsy is the gold standard for establishing the diagnosis:
histopathology analysis is able to reveal the precise extent and pattern of
inflammation and fibrosis.
• Biopsy is typically not the initial diagnostic test because it is invasive and is
associated with a small but significant risk of bleeding that is increased in
people with liver injury and cirrhosis.
 Diagnosis
• Generally, AST and ALT are elevated in most cases of hepatitis regardless of
whether the person shows any symptoms.
• The degree of elevation the predominance for AST vs. ALT elevation, and the
ratio between AST and ALT are informative of the diagnosis.
• Aspartate transaminase (AST)
• Alanine transaminase (ALT)

• Ultrasound, CT, and MRI can all identify steatosis (fatty changes) of the liver
tissue and nodularity of the liver surface suggestive of cirrhosis
Histopathology of acute hepatitis with lobular
disarray and associated lymphocytic inflammation
 Diagnosis of Viral hepatitis
• Viral hepatitis is primarily diagnosed through blood tests for levels of viral
antigens (such as the hepatitis B surface or core antigen)
• anti-viral antibodies (such as the anti-hepatitis B surface antibody or anti-
hepatitis A antibody), or viral DNA/RNA
 Virus screening
• The purpose of screening for viral hepatitis is to identify people infected
with the disease as early as possible, even before symptoms and
transaminase elevations may be present.

• This allows for early treatment, which can both prevent disease progression

and decrease the likelihood of transmission to others

 Hepatitis A
• Hepatitis A causes an acute illness that does not progress to chronic liver disease.
• Therefore, the role of screening is to assess immune status in people who are at high risk
of contracting the virus, as well as in people with known liver disease for whom hepatitis
A infection could lead to liver failure.
• People in these groups who are not already immune can receive the hepatitis A vaccine.
Those at high risk and in need of screening include
• People in close contact with someone who has hepatitis A
• People traveling to an area with endemic hepatitis A
• People who do not have access to clean water
• People who use illicit drugs
• People with liver disease
• People with poor sanitary habits
• The presence of anti-hepatitis A IgG in the blood indicates past infection with the virus or
 Hepatitis B
• The CDC, WHO, recommend routine hepatitis B screening for certain high-risk
populations.
• Specifically, these populations include people who are:
• Found to have elevated liver enzymes without a known cause.
• HIV positive
• In close contact with people known to have hepatitis B.
• Intravenous drug users
• On hemodialysis
• Pregnant
• Screening consists of a blood test that detects hepatitis B surface antigen (
HBsAg)
 Hepatitis C
• Blood or organ donors.
• Born to HCV-positive mothers
• HIV-positive
• Incarcerated, or who have been in the past
• Intranasal illicit drug users.
• Intravenous drug users (past or current).
• Men who have sex with men.
• On long-term hemodialysis, or who have been in the past
• Pregnant, and engaging in high-risk behaviors.
• Recipients of blood products or organs prior to 1992 in the United States.
• Recipients of tattoos in an "unregulated setting"
• Sex workers
• Workers in a healthcare setting who have had a needlestick injury
 Hepatitis D
• The CDC, WHO, recommend screening people at high risk for hepatitis D
infection. These populations include people who are.
• Blood or organ donors
• Incarcerated, or who have been in the past.
• Intranasal illicit drug users.
• Intravenous drug users (past or current).
• Sex workers.
• Workers in a healthcare setting who have had a needle stick injury.
• Hepatitis D is extremely rare.
 Prevention of hepatitis
1. Vaccines
Hepatitis A
• The CDC recommends the hepatitis A vaccine for all children beginning at
age one, as well as for those who have not been previously immunized and
are at high risk for contracting the disease
• The dosing is slightly different for adults depending on the type of the
vaccine

Havrix vaccine
 Prevention of hepatitis
1. Vaccines
• Hepatitis B
CDC recommends the routine vaccination of all children under the age of 19
with the hepatitis B
Routine vaccination for hepatitis B starts with the first dose administered as a
shot into the muscle before the newborn is discharged from the hospital.
 Prevention of hepatitis
2.. Behavioral changes

Good hygiene, access to clean water and proper handling of Sewage(HAV&HEV ).

Abstaining from the use of injection drugs, safe needle and sharps practices in healthcare

settings, and safe sex practices(HBV&HCV)

 Prevention of hepatitis

[Link] and metabolic hepatitis

• As excessive alcohol consumption can lead to hepatitis and cirrhosis, the following are

maximal recommendations for alcohol consumption

• Men – ≤ 4 drinks on any given day and ≤ 14 drinks per week

• Women – ≤ 3 drinks on any given day and ≤ 7 drinks per week

 Special populations HIV co-
infection
[Link] co-infection
Persons infected with HIV have a particularly high burden of HIV-HCV co-infection
• 2. Pregnancy:
• Vertical transmission is a significant contributor of new HBV cases each year, with 35–50%
of transmission from mother to neonate in endemic countries.
• Vertical transmission occurs largely via a neonate's exposure to maternal blood and
vaginal secretions during birth.
• Pregnant women who contract HEV are at significant risk of developing fulminant hepatitis
with maternal mortality rates as high as 20–30%, most commonly in the third trimester