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					           Jain: Management of acute hepatitis

ACUTE HEPATITIS
Definition: A systemic infection predominantly affecting liver, with
 clinical, biochemical & histological features of acute / recent
 onset hepatic necroinflammation, and usual resolution (Mostly in
 < 4 months)
Clinical profile
• Typical presentation : well recognized
• Extrahepatic manifestations : up to 25%
• Unusual course / Sequalae :
    Cholestatic hepatitis
    Liver failure : acute & subacute
    Subacute hepatitis (?)
    Chronicity : persistence of viremia
    > 24 wks, with / without necro-inflammation
    Jain: Management of acute hepatitis

Cholestatic viral hepatitis

•    Prolonged Cholestatic phase

•    Criteria Varied - Most Accepted (Schiff 1992)

      Peak S Bil >10mg%,       For > 2 wks

      Bilirubin Elevation usually lasts > 12 wks

      Clinical Cholestasis +/- ,   ALP

• Histologic Cholestasis may be seen without
  clinical cholestasis

•    36% Cholestatic Hepatitis due to HBV     (BHU)
           Jain: Management of acute hepatitis

Hepatic failure: nomenclatures - 1
Several terms proposed, based on temporal progression of
disease to development of encephalopathy
Trey & Davidson 1970:       FHF      < 8wks
King’s College 1986   :     LOHF     9-26 wks
Beaujon 1986* :             Fulminant     < 2 wks
                            Sub Fulminant 2-12wks
O Grady 1993*:              Hyper Acute < 7 day
                            Acute       < 8-28 days
                            Sub Acute    29-72 days
Tandon 1999: Acute          < 4 wks
                            (IASL) Hyper acute < 10 days
                             Fulminant 10-30 days
                             Sub Acute    5-24 wks
Overlap in Prognosis in Different Groups
         Jain: Management of acute hepatitis

Acute hepatic failure
• Absence H/O pre-existing liver Disease
• Rapid development of hepatic dysfunction
 (Jaundice, Coagulopathy), often reversible, &
• Encephalopathy within 4 wks* (8 wks**) of onset
  * Tandon et al (IASL) 1999: 4 wks
  **Trey and Davidson 1970 : 8 wks (Fulminant)
Subacute hepatic failure (Tandon IASL 1999)
Persistence of acute hepatitis with:
• Progressive Liver Dysfunction
• Ascites / Encephalopathy at 5th to 24th wks
• Absence of pre-existing liver disease
• Exclusion Criterias : IHBRD ( on US), Varices > Gr.I/CLD on
  histology, ALD, CRF, KF Ring/ Ceruloplasmin
Jain: Management of acute hepatitis


Subacute hepatitis
• Boyer in early 70s for Severe Viral Hepatitis
  (often with Ascites & BHN)

• With Introduction of SAHF : SAH Sparingly
  used

• Recent reports from Japan & India redescribed
  it for Acute Hepatitis cases with
   – Persistent elevation of bilirubin, or
   – Progressive rise of bilirubin after 6 weeks
      Jain: Management of acute hepatitis


Investigations
Haemogram
Biochemical – LFT, Transaminases, Prothrombin time
BUN, Glucose, S.Creatinine (when indicated)
Virologic – HBs Ag, IgM Anti HBc
                 IgM Anti HDV, if deterioration – optional
Jain: Management of acute hepatitis

Management of AVH-B

• SUPPORTIVE

• Hepatoprotectives - No Role / Debatable

• Antiviral Therapy   - No Role

• Spontaneous Recovery in Adults     95-99%

• Lamivudine in Ac Hep B Needs Evaluation

• Risk involved & Benefit obtained

• Family counseling
    Jain: Management of acute hepatitis


Follow up

Biochemical Tests (ALT,Bil, ALP, PT, etc)
   – Every 2 weeks
   – Earlier if Clinical Deterioration / Severe Forms

AVH with Clinical & Biochemical Resolution
      - HBs Ag at 6mNegative : No Action
      - Positive : FU, HBe Ag, Liver Biopsy
Features of Necro inflammation at 26 wks
       - HBs Ag, HBe Ag, HBVDNA
       - Liver Biopsy

				
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posted:4/14/2011
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