VIRAL HEPATITIS

Types of Viral Hepatitis

• Hepatitis A, caused by hepatitis A virus (HAV)

• Hepatitis B, caused by hepatitis B virus (HBV)

• Delta hepatitis, caused by hepatitis D virus (HOV)

• Hepatitis C, caused by hepatitis C virus (HCV)

• Hepatitis E, caused by hepatitis E virus (HEV)

 

Hepatitis A

Aetiology

• Caused by hepatitis A virus (HAV), a RNA virus belonging to the picomavirus group.

• HAV survives on human hands and fomites, and requires temperatures higher than 185°F (85°C) for inactivation. It is resistant to freezing, detergents and acids, but it is inactivated by formalin and chlorine.

Epidemiology

• Incubation period is 30 days (15-45 days).

• Source of the infection is persons incubating or suffering from the disease.

• HAV is transmitted almost exclusively by the faecal-oral route. Infected persons excrete the viruses in their faeces for 2 weeks before the onset and 5-7 days after the onset of the illness.

• Can rarely be spread by blood transfusions and homosexual activity.

• Children are most commonly affected. Overcrowding and poor sanitation facilitate the spread.

• In outbreaks, water, milk and shell fish are all implicated.

• No carrier state has been identified.

• The single most important predictor of the clinical course of an acute hepatitis A infection is the age. Symptomatic infections are uncommon in young children. In adults 75-90% of the infections are symptomatic, with jaundice in majority of cases.

Prevention

• At community level prevention is attempted by improving social conditions, especially overcrowding and unhygienic situations.

• Immune serum globulin (0.02 mL/kg) can protect from infection for 3 months. It is used in those at particular risk, e.g close contacts, those with other major diseases, pregnant females and in outbreaks, for example, in a school or nursery.

• A vaccine is available for active immunisation. It is approved for use in persons above the age of 2 years. Two doses at 6 months interval are recommended. It seems to provide lifelong immunity.

Hepatitis B

• Caused by hepatitis B virus (HBY), belonging to the group of hepadna viruses.

Epidemiology

• Incubation period is about 90 days (50--150 days).

• Humans are the only source of infection, being individuals incubating or suffering from acute hepatitis, asymptomatic carriers or persons with chronic liver disease.

• Major route of transmission is parenteral but occasionally non-parenteral.

• Commonly follows transfusion of infected blood or blood products, injections with contaminated needles, intravenous drug use with needle sharing, tattooing and acupuncture. Albumin solutions and gamrnaglobulins are free of risk. At present, HBY accounts for only less than 10% cases of post-transfusion hepatitis.

• Non-parenteral means of transmission include spread through body fluids like saliva, urine, semen and vaginal secretions. However, this requires close personal contact, sexual intercourse and male homosexuality.

• Mother-to-child spread (perinatal transmission) is also common. It could be either transplacental transmission or transmission at or soon after birth.

• The groups with high-risk rates of HBY infection include spouses of acutely infected persons, sexually promiscuous males (homosexuals), health-care workers exposed to blood, dentists, haemophiliacs and prisoners.

• Risk of transmission of hepatitis B through needle-stick injury from an HBsAg positive person is about 30%.

• A chronic carrier state is described for HBY infection (1-20%).

• Serum HBsAg is positive in 30% cases of Down's syndrome, lepromatous leprosy, leukaemia, Hodgkin's disease, polyarteritis nodosa, patients on chronic haemodialysis and needle using drug addicts.

• The age at which a person is infected with the virus determines the disease outcome; 90% of those who acquire HBV perinatally or in early childhood will develop chronic hepatitis as their immune system cannot destroy and clear infected hepatocytes. In adults, 90% of infections are acute and only 5-10% develop into chronic hepatitis.

Prevention

• For active immunisation recombinant vaccines (containing HBsAg) are available which provide 95% efficacy against HBV infection. Since non-percutaneous routes of transmission are quite prevalent in India, this vaccine is recommended in all children. It is also recommended in high-risk groups (health workers, haemodialysis patients, injection drug users, haemophiliacs and sexual contacts of HBsAg carriers). Injections are given at 0, 1 and 6 months for full immunity. Dose is 10 µg for children under 10 years and 20 µg in children above 10 years. The duration of immunity provided is not known but protective levels of anti-HBs have been found for 5-10 years. Boosters are not recommended at present except in immunosuppressed. The vaccine is not effective in HBsAg carriers.

• Hyperimmune B immunoglobulin (HBIG) is prepared from blood containing anti-HBs. This can prevent or minimise hepatitis B. This should preferably be given within 24 hours or at most a week of exposure. Dose is 0.06 rnL/kg. Indications are accidental needle puncture, gross personal contamination with infected blood, oral ingestion or contamination of mucous membranes, and exposure to infected blood in the presence of cuts and grazes

 

Delta Hepatitis

• Caused by hepatitis D virus (HDV), which is a defective RNA virus.

• It has no independent existence. It requires HBV for replication and expression.

Hepatitis C

Aetiology

• Previously called blood-borne non-A, non-B hepatitis.

• It is a single-stranded RNA virus belonging to the family Flaviviridae.

• HCV has six genotypes. Chronic HCV 1 infection has poor response to therapy. In India, HCV 3 is most prevalent

Epidemiology

• Incubation period is 50 days (15-160 days).

• Major route of transmission is parenteral.

• More than 90% of cases of post-transfusion hepatitis are caused by HCV. Also common in drug addicts.

• Common sources of infection are blood and blood products capable of transmitting hepatitis B, particularly coagulation factor concentrates. Other modes include perinatal and sexual transmission.

 

• HCV is not transmitted by breastfeeding.

• Nearly 80% develop chronic hepatitis (see chronic hepatitis).

• Prevention by vaccine or immunoglobulin not possible.

 

Hepatitis E

Aetiology

• Previously called epidemic or enterically transmitted non-A, non-B hepatitis.

• It is a single-stranded RNA virus.

Epidemiology

• Incubation period is 40 days (15-60 days).

• Primarily enteric mode of transmission.

• Accounts for epidemic, water-borne hepatitis; common in India.

• Commonly occurs after contamination of water supplies as after monsoon flooding.

Prevention

• Similar to hepatitis A (no vaccine available)

 

Clinical Features of Viral Hepatitis

• Prodromal symptoms usually last for a few days to 2 weeks before the onset of jaundice, characterised by fever, chills, headache, malaise and prominent gastrointestinal symptoms like anorexia and distaste for cigarettes. Nausea, vomiting and diarrhoea follow. Patients with HBV infection have polyarthralgia and occasionally a "serum sickness syndrome" with skin rashes and polyarthritis.

• Steady upper abdominal pain, sometimes severe (due to stretching of liver capsule).

• Urine is dark with yellowish discolouration of sclera.

• With onset of clinical jaundice constitutional symptoms diminish.

• Liver becomes palpable and tender.

• Enlarged cervical lymph nodes and splenomegaly.

 

Investigations

• Urine shows bilirubinuria (in early stages), slight microscopic haematuria and mild proteinuria.

• Total count is low, with neutropenia, relative lymphocytosis and atypical lymphocytes.

• Aminotransferases (AST, ALT) are raised. Maximum levels are seen in the prodromal phase, varying from 400 to 4000 IU/L. They decline progressively during icteric and recovery phase.

• Bilirubin levels are variably raised. Both conjugated and unconjugated bilirubins are equally raised.

• ALP level may be raised but is usually less than two times the normal.

• Serum protein levels are normal.

• Prothrombin time-marked prolongation signifies extensive hepatocellular damage. This is one of the best indices of prognosis.

 

Precautions

• Rest

• During the acute symptomatic period, complete rest and thereafter gradual ambulation.

• In high-risk patients (patients more than 50 years, pregnant and those with other major diseases) rest is continued till symptoms and signs have disappeared, and liver function tests have returned to near normal.

• Diet

• Nutritious general diet of 2000-3000 kcal/day. In the initial stage, when good diet is not tolerated, give a light diet, fruit drinks and glucose. There is no need to avoid fatty diets, but most patients cannot tolerate these diets.

• Encourage good protein intake.       

• If vomiting is severe, intravenous fluids are given.

• Drugs

• Drugs should be avoided if possible.

• Alcohol to be avoided for next 6 months.

 

TREATMENT AT DR. SOHAN LAL CLINIC

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