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1、Viral HepatitisDept. of Infectious Diseases SunYat-sen University Q.F.XIEIntroduction Viral hepatitis are a group of diseases, Caused by A、B、C、D and E 5 hepatitis virus Hepatitis A and E Transmitted by fecal-oral route, present acute and self-limited course Hepatitis B ,C and D Spread parenterally e

2、asily lead to chronic hepatitis Clinical characters including fatigue, intestinal symptoms tender and enlarged liver abnormal LFTs jaundice in some cases very variable in severitySignificanceHighly endemicWide clinical spectrumHigh fatality rate in severe casesNo specific pathogenic therapy availabl

3、e nowChronic hepatitis B and C very common, some may develop to cirrhosis even HCCSuccessful vaccination for HBV and HAVEtiology-HAVHeparnavirusAppeared in bile and feces, spreaded via fecesNo chronic carrier status observedAnti-HAV antibody to HAVAnti-HAV IgM indicative of current or recent infecti

4、on appeared very early, disappear in about 3months most useful for confirm the diagnosisAnti HAV IgG current or previous infection a protective antibody, conferring immunity persist for life long timeEtiology-HBV Orthohepadnavirus, Dane particle 4 open reading frame: S,C,P,X 8 genotypes A-H, B and C

5、 predominantly in China Strong ability against to environment 3 antigen and antibody system HBsAg found in serum and other body fluid not infectious itself suggesting current infection and infectivity Anti-HBs a protective antibody to HBsAg an indicator of past infection and immunity to HBV reinfect

6、ion suggesting non-infectious HBeAg suggesting HBV replication and high infectivity negative when pre-C mutation but with high level of replication useful for evaluation of anti-HBV therapy Anti-HBe antibody to HBeAg HBe seroconversion HBeAg(+) (-)and anti-HBe(-) (+) HBcAg existing in the core of vi

7、rion a marker of replication and infectivity Anti-HBc IgM a marker of acute primary HBV infection Anti-HBc IgG appeared in almost all HBV present and past infection host body HBVDNA the genome of HBV suggesting active virus replication and infectivity useful for diagnosis and evaluation of anti-HBV

8、therapyHepatitis B VirusEtiology-HCV RNA virus, 6genotypes, mainly 1b in the country Molecular heterogeneity driven by high mutation rate usually proceed to chronic course Anti-HCV IgM and IgG types antibody to HCV suggesting HCV infection HCVRNA the genome of HCV suggesting replication and infectiv

9、ity of HCV useful for the diagnosis and evaluation of antivirus treatmentEtiology-HDV An incomplete RNA virus Causes hepatitis only patients with either acute(coinfection) or chronic (superinfection) hepatitis B HDVAg and anti-HDV both the markers of HDV infection HDVRNA the genome of HDV a marker o

10、f existing HDV infection suggesting virus replication and infectivityEtiology-HEVNonenveloped RNA virusAppeared in bile and feces, spreaded via fecesNo chronic carrier status observedAnti-HEV IgM and IgG both appeared in acute infection useful for the diagnosis of HEV infection HEVRNA the genome of

11、the virus suggesting existing of HEV infection not available for routine clinical diagnosisEpidemiology Source of infection Patients with acute or chronic viral hepatitis Carriers of hepatitis virus, particularly asymptomatic carriers Transmission Hepatitis A and E transmitted by the fecal- oral rou

12、te, water-borne and food-transmitted infection in epidemicsHepatitis B transmitted parenterally mother-to-infant play a key role in China blood ,blood products and body fluid othersHepatitis C and D similar to hepatitis B intravenous drug abusers most common hepatitis C for the time being Prevalence

13、 rate in China 1992 Hepatitis A anti-HAV+ 80.90% Hepatitis B HBsAg + 9.75% (2019) 7.18% Hepatitis C anti-HCV+ 3.20% Hepatitis D anti-HDV+ 1.15% Hepatitis E anti-HEV+ 17.2%Pathogenesis Hepatocellular damage produced by viral replication directly only in hepatitis D Other types of viral hepatitis indu

14、ced mainly by immune-mediated attack on the liverPathology The varying lesion could be seen in entire liver, but variable in severity and in different stages of the disease No specific lesion suggesting etiologic type of hepatitis virusClinical manifestations Wide clinical spectrum from asymptomatic

15、 form to fatal outcome such as liver failure Similar clinical course in different etiological type of viral hepatitis The clinical types viral hepatitisAcute hepatitisChronic hepatitisLiver failure (severe hepatitis)Cholestatic viral hepatitisHepatitis cirrhosisAsymptomatic virus carrier status (usu

16、ally only in HBV)Incubation period Hepatitis A 2-6w 4w Hepatitis E 2-9w 6w Hepatitis B 1-6m 3m Hepatitis C 2w-6m 6w Hepatitis D 4-20wAcute hepatitis 3 phases of the icteric hepatitis Prodromal phase sudden or insidious onset, lasting 3-7d constitutional symptom: malaise, fatigue, mild fever some tim

17、e, dark urine gastrointestinal symptoms: anorexia, nausea, vomiting serum ALT level rise deeplyJaundice phase jaundice appeared and peak level often in 2 weeks after the onset other symptoms subside after jaundice tender liver palpable serum bilirubin elevated lasting for 26 weeksConvalescent phase

18、symptoms and jaundice gradual resolution liver return to normal size serum ALT and bilirubin decreased 1 to 2 months neededAnicteric acute viral hepatitis more common, mild manifastationChronic hepatitis Seen only in hepatitis B,C and D, virus infection over 6 months Severity variable, 3 subtypes: m

19、ild, typical and advanced Common manifestations: malaise, fatigue, poor appetite, nausea, distension of abdomen Jaundice seen in some cases Enlargement of liver and/or spleen Spider naevi, hepatic palms in cases with long history Abnormal LFTs: transaminase, bilirubin A/G Prognosis different: stable

20、, breakthrough or flare, develop to Cir or CaLiver failure (severe hepatitis) Bad prognosis Pathological basis: extensive necrosis of hepatic cells 4 subtypes: acute liver failure, subacute, acute-on-chronic, chronic Clinical syndrome including: jaundice deepen rapidly liver size become smaller blee

21、ding, prolonged prothrombin time, PTA less than 40% cerebral edema, high intracranial pressure complicated infection: SBP hepatic encephalopathy toxic abdominal distension and ascites hepatic-renal syndrome Cholestatic viral hepatitis acute and chronic mild manifestation but deepen jaundiceHepatitis

22、 cirrhosis hepatic fibrosis compensated cirrhosis decompensated cirrhosisAsymptomatic HBV carrier HBV infection more than 6 months have no symptoms and signs normal LFTs 70%-80%have no pathologic change in liver biopsyDiagnosisClinical DataEpidemiological evidencesLaboratory investigationsUltrasound

23、BiopsyDifferential diagnosisJaundice caused by other etiological agentsHepatitis caused by other etiological agentsTreatmentBasic principles of management guideline for daily living, physical activity , food and drink intake of the patients supportive and symptomatic treatment Hepatic function prote

24、ctive agentsAnti-virus therapy most important treatment for chronic hepatitis B、acute and chronic hepatitis C hepatitis B indication: HBVDNA 105copies/ml for HBeAg, HBVDNA 104copies/ml for HBeAg+; ALT 2ULN, or biopsy G2S2 Drugs: interferon-(typical or pegylated) or, nucleotide analogues:3TC,adfovir, ent