Hepatitis by dffhrtcv3

VIEWS: 0 PAGES: 49

									                             SCOR




    Hepatitis
Doctor John Evans
Assistant Medical Director
 Fong Looi Foong
    Life Underwriter
       Viral Hepatitis - Overview
                                   Type of Hepatitis
                  A              B             C             D             E
Source of        feces          blood/        blood/        blood/       feces
virus                       blood-derived blood-derived blood-derived
                             body fluids   body fluids   body fluids
Route of       fecal-oral    parenteral    parenteral     parenteral    fecal-oral
transmission                 + sexual     +/- sexual

Chronic           no            yes           yes            yes           no
infection
    Hepatitis A - Clinical Features
          - mainly anicteric
• Incubation period:      Average 30 days
                       Range 15-50 days
• Jaundice by              <6 yrs,    <10%
  age group:                 6-14 yrs, 40%-50%
                          14 yrs, 70%-80%
• Complications:           Fulminant hepatitis
                       Cholestatic hepatitis
                       Relapsing hepatitis
• Chronic sequelae:          None
Age-specific Mortality Due to Hepatitis
                  A
         Fulminant Hepatitis
          Age group    Case-Fatality
           (years)      (per 1000)

             <5            3.0
            5-14           1.6
           15-29           1.6
           30-49           3.8
            >49           17.5
           Total           4.1
            Hepatitis A- Serologic Course
    Titer

                Symptoms                     Total anti-HAV

                   ALT


      Fecal
      HAV
                                    IgM anti-HAV




0           1       2      3    4      5     6       12       24

                           Months after Exposure
     Concentration of Hepatitis A Virus
         in Various Body Fluids
Feces


Serum

Saliva


Urine


     100   102       104       106         108   1010
                 Infectious Doses per ml
           Hepatitis A - Mode of
              Transmission

• Close personal contact
(e.g., household contact, child day care centers)
• Contaminated food, water
(e.g., infected food handlers, raw shellfish)
SCOR
Hepatitis B Virus
 Hepatitis B - Clinical Features

Incubation period                  Average 60-90 days
                                   Range 45-180 days
Clinical illness (jaundice):        <5 yrs, <10%
                                    ³5 yrs, 30%-50%
Acute case-fatality rate:         0.5%-1%
Chronic infection:                   <5 yrs, 30%-90%
                               ³5 yrs, 2%-10%
Premature mortality from
Chronic liver disease:         15%-25%
        Acute Hepatitis B- Serologic Course

                    Symptoms
                HBeAg                        anti-HBe


                                             Total anti-HBc
Titer

        HBsAg                      IgM anti-HBc                    anti-HBs




        0   4   8   12   16   20   24   28    32   36         52       100
                         Weeks after Exposure
   Progression to Chronic Hepatitis B
                   Acute                        Chronic
                (6 months)                      (Years)
                                 HBeAg
                                         HBsAg
                                         Total anti-HBc
Titer



                                IgM anti-HBc




        0   4   8 12 16 20 24 28 32 36     52             Years
            Weeks after Exposure
Possible Reaction After Contact With
          Hepatitis B Virus
                     infection agent
                          HBV

     no reaction     HBsAg in serum
                                           anti HBs

                     acute hepatitis
      no hepatitis
                                          no hepatitis
                     chronic hepatitis



HBsAg carrier        cirrhosis of liver
                                          anti HBs
healthy or ill
                        hepatoma
Natural History Of Chronic Hepatitis B
                Carrier

   e Antigen +      HBeAg / Anti Hbe Variable         Anti - Hbe positive


                                                 HBV DNA

                                                 AST/ALT



                        AST
     AST variable       variable      AST variable

   normal ->            Lobular Hepatitis                  Fibrosis + / -
   Chronic /
   Acute                Chronic + / - fibrosis             cirrhosis
   hepatitis
100                                                       100


80                                                        80


60                                                        60
                                    Chronic Infection

40                                                        40


20                                                        20

              Symptomatic Infection
 0                                                        0
      Birth   1-6 months      7-12 months     1-4 years

                           Age at Infection
           Liver Cancer & Relative Risk In
              Relation To HBsAg Status
                    22,707 Taiwan government servants


3,454 HBsAg (+)                                     19,253 HBsAg ( - )
( 15.2 % )                                          ( 84.8 % )


70 cases of liver
                                                   1 case of liver cancer
cancer


PHC/100,000
                                                        PHC/100,000
2,027
                                                        5.2



     Relative Risk of 390 times !!
  Age-sex specific mortality from liver cancer in
  Taiwan
              140

              120

              100
                             LIVER
Mortality                    CANCER
              80
Per 100,000                                       Male
              60                                  Female

              40

              20

               0
                    0   10 20 30 40 50 60 70 80
                                Age
Geographic Distribution - HBV




            HBsAg Prevalence
                ³8% - High
                2-7% - Intermediate
                <2% - Low
 Concentration of Hepatitis B Virus
     in Various Body Fluids

                                  Low/Not
     High         Moderate       Detectable

    blood          semen            urine
    serum        vaginal fluid     feces
wound exudates      saliva         sweat
                                    tears
                                 breastmilk
Hepatitis B - Mode Of Tansmission

 Sexual Relationship
 Perinatal ( Mother -> Baby )
 IV Drug Abusers
 Blood transfusion
 Unknown
Problem of «healthy» carrier
        of B virus
 HBs   Ag +ve

 Normalhepatic analysis
 (Aminotransferases - GGT)
 Chronic > 6 mois

(   Liver biopsy: Normal)
Hepatitis C - Clinical Features

Incubation period:                  Average 6-7 wks
                                    Range 2-26 wks
Clinical illness (jaundice):        30-40% (20-30%)
Chronic hepatitis:                  60%
Persistent infection:               85-100%
Immunity:                      No protective antibody
                               response identified
        Hepatitis C - Serologic Course
                                                     anti-HCV
                    Symptoms
Titer




                                                     ALT



                               Normal
        0   1   2     3    4   5   6    1   2    3   4
                    Months                   Years
                       Time after Exposure
             Clinical Outcomes of HCV
             Infection
                  HCV Infection


                ACUTE HEPATITIS

                       100%
cure   40%                        chronic hepatitis   60%

                                   chronic active     16%
chronic asymptomatic               hepatitis
carrier
                                    CIRRHOSIS         8%


                                       HCC            1%
            Hepatitis C - Risk Factors

• Transfusion or transplant from infected donor
• Intravenous drug use
• Hemodialysis (years of treatment)
• Accidental injuries with needles/stylets/scalpels
• Sexual/household exposure to anti-HCV-positive
   contact
• Multiple sex partners (< 1%)
• Birth by HCV-infected mother
   Prevention of Hepatitis C


• Screening of blood, organ, tissue donors
• High-risk behavior modification
• Blood and body fluid precautions
   Hepatitis D - Clinical Features


• Coinfection
   – severe acute disease
   – lower risk of chronic infection
• Superinfection
   – usually develop chronic HDV infection
   – higher risk of severe chronic liver diseas
Hepatitis D Virus - Modes of
Transmission

        •Percutaneous exposures
          –injecting drug use
        •Permucosal exposures
          –sex contact
        HBV - HDV Coinfection
        - Serologic Course
               Symptoms

              ALT Elevated




                                      anti-HBs
Titer




              IgM anti-HDV



            HDV RNA

                  HBsAg
                                      Total anti-HDV



                Time after Exposure
            HDV       HBV

                                  HBV - HDV
                                  COINFECTION

            Healthy Individual

     3-4%                        Rare
                   90%

Fulminant   Recovery with        Chronic
Hepatitis   immunity             HBV/HDV
                                 Hepatitis




 Death                            Cirrhosis
   HBV - HDV Superinfection
   - Serological Course
           Jaundice

               Symptoms
                                       Total anti-HDV
                 ALT
Titer




                          HDV RNA
                HBsAg

                                        IgM anti-HDV

                 Time after Exposure
                      HDV
                                  HBV - HDV
                                  SUPER-
                                  INFECTION
                   HBV Carrier

         7-10%                   80%
                        10-15%

Fulminant        Acute, severe   Chronic
Hepatitis        disease         HBV/HDV
                                 Hepatitis




 Death             Recovery       Cirrhosis
      Hepatitis E - Clinical Features


•Incubation period: Average 40 days
                     Range 15-60 days
•Case-fatality rate: Overall, 1%-3%
                     Pregnant women, 15%-25%
•Illness severity:      Increased with age
•Chronic sequelae: None identified
            Hepatitis E - Serologic Course
                                       Symptoms

                                                             IgG anti-HEV
                                            ALT



                                                      IgM anti-HEV
Titer




             Virus in stool




        0     1    2     3     4   5    6    7    8     9   10   11   12    13
                              Weeks after Exposure
    Hepatitis E - Epidemiologic
             Features

• Most outbreaks associated with
  fecally contaminated drinking water

• Minimal person-to-person transmissio
 Geographic Distribution of Hepatitis E
Outbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis
    Medical Selection in Chronic Hepatitis
If possible:
 Date of onset
 Several liver analyses
  (Aminotransferases +++)
 Liver biopsy
 Treatment: ( Interferon - other...)
 Specialised hepatic analysis, PCR...
 Platelets
   Interactions with chronic hepatitis


 Alcoholism     +++
B   +C
B   +D
 drug   abuse
       European ratings for «healthy»
            Hepatitis B Carriers
Extramortality
rating %
  80
  70
  60       75
  50
  40
                     50
  30
  20
  10                                   25
   0
          <40      >40-54             >55
                            Age in years
  Ratings for Asymptomatic HCV positive
    subjects with normal transaminases
Extramortality
in %
      80
      70
      60         75
      50
      40
                         50
      30
      20
      10                                       25
       0
                 <40   >40-54              >55
                                Age in years
Ratings for chronic persistant hepatitis B and C
           KNODELL SCORE    Extramortality Ratings %
   AGE
                             VHC           VHB
                <6            200           100
 <40           6-11           300           300
               >11            AJT           AJT
                <6            150            75
40-50          6-11           200           200
               >11            AJT           AJT
                <6             75            50
51-60          6-11           150           150
               >11            AJT           AJT

                <6             50           25
 >60                                        75
               6-11            75
               >11            AJT          AJT
                       Alcohol
                       B Virus
Aggression
                       C Virus
                       Iron overload
                       Other co-factors ...
         Necrosis



    Fibrous reaction
                           Cirrhosis
     Course of cirrhosis

 Portal   hypertension

 Hepatic    insufficiency

 Gastro-intestinal   Haemorrhage

 Liver    cancer
Portal Hypertension

• Ascites

• Oesophageal Varices

 Thrombocytopaenia     +++
         Underwriting Cirrhosis



          Cirrhosis = DECLINE!!!




* Primary bilary cirrhosis
              Case Study 1
 46 year-old woman with no clinical
  impairment but a previous history of acute
  hepatitis B in 1996
 Current serology:
HBs Ag -ve; HBs Ab +ve; HCV Ab +ve
 ASAT = N; ALAT = 2N; GGT = N x 1.5
 Hb 11g%; WCC 4 500; Platelets 95 000/mm3
              Case Study 2
 42 year-old man with no clinical
  impairment but a history of hepatitis in
  1980
 Current serology :
HBs Ag +ve; HBs Ab -ve; HBc Ab -ve;
HCV Ab -ve; HDV Ab +ve;
 Transaminases
ALAT = N x 4; ASAT = N x 2

								
To top