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HEPATITIS Diah Puspita Rini, dr., SpPK. Hepatitis is inflammation of the liver which can be caused by viruses, medications, or toxic agents. Non viral.

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Presentation on theme: "HEPATITIS Diah Puspita Rini, dr., SpPK. Hepatitis is inflammation of the liver which can be caused by viruses, medications, or toxic agents. Non viral."— Presentation transcript:

1 HEPATITIS Diah Puspita Rini, dr., SpPK

2 Hepatitis is inflammation of the liver which can be caused by viruses, medications, or toxic agents. Non viral : miliary TB, staphylococcal bacteriemia, salmonelloses, amebiasis, drugs, etc. Viral hepatitis :, Hepatitis A,B,C,D,E CMV, Herpes, Epstein Barr virus, Rubella

3 Viral Hepatitis 3 Click to add Title Hepatitis A 1 2 3 4 Hepatitis E 5 Hepatitis G 6 Hepatitis TT 7 Hepatitis Sen 8 Hepatitis B Hepatitis D Hepatitis C

4 VIRAL HEPATITIS 4 LiverCirrhosis A Major Public Health Problems Cause Morbidity & Mortality Chronic Hepatitis B & C HCC

5  a short, mild, flu-like illness  nausea, vomiting and diarrhoea  loss of appetite  weight loss  jaundice (yellow skin and white of eyes, darker yellow urine and pale faeces)  itchy skin  abdominal pain SYMPTOMS

6 Source of virus fecesblood/ blood-derived body fluids blood/ blood-derived body fluids blood/ blood-derived body fluids feces Route of transmission fecal-oralpercutaneous permucosal percutaneous permucosal percutaneous permucosal fecal-oral Chronic infection noyes no Preventionpre/post- exposure immunization pre/post- exposure immunization blood donor screening; risk behavior modification pre/post- exposure immunization; risk behavior modification ensure safe drinking water Type of Hepatitis ABCDE

7 Hepatitis A (HAV) Due to non enveloped, single stranded RNA picornavirus Serum AST and ALT increased to hundreds for 1 to 3 weeks Relative lymphocytosis is frequent

8 Serologic test for HAV Ig M anti HAV : –appears at the same time as syptoms in > 99% of cases – peaks within first month, becomes nondetectable in 12 (usually 6) –Presence confirms diagnosis of recent acute infection Anti HAV total: –Predominantly IgG –Almost always positive at onset of acute hepatitis and is usually detectable for life –Found in ± 50% of population, indicaes previous exposure to HAV

9 Fecal HAV Symptoms 0123 4561224 Hepatitis A Infection Total anti- HAV TitreALT IgM anti-HAV Months after exposure Typical Serological Course

10 Hepatitis B (HBV) Due to enveloped, double stranded DNA hepadna virus Divided into 3 stages: 1.Acute hepatitis: lasts 1-6 months, mild/ no symptoms  AST & ALT increased > tenfolds  Serum bilirubin is usually normal or slightly increased  HBsAg gradually arises to high titer and persist, HBeAg also appears

11 2. Chronic hepatitis: transaminase increased > 50% for > 6 months, most cases resolve but some develop cirrhosis and liver failure  AST & ALT fall to 2-10x normal range  HBsAg usually remains high and HBeAg remains present 3. Chronic carrier: are usually but not always healthy and asymptomatic  AST and ALT fall to normal or < 2x normal  HBsAg positive > 6 months, HBc IgM negative, but anti HBc positive

12  Sexual - sex workers and homosexuals are particular at risk.  Parenteral - IVDA, Health Workers are at increased risk.  Perinatal - Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Perinatal transmission is the main means of transmission in high prevalence populations. Hepatitis B Virus Modes of Transmission

13 HighModerate Low/Not Detectable bloodsemenurine serumvaginal fluidfeces wound exudatessalivasweat tears breastmilk Concentration of Hepatitis B Virus in Various Body Fluids

14 HBV: Structure HBV : Structure

15 SEROLOGICAL TEST OF HBV A battery of serological tests are used for the diagnosis of acute and chronic hepatitis B infection. HBsAg - used as a general marker of infection. HBsAb - used to document recovery and/or immunity to HBV infection. anti-HBc IgM - marker of acute infection. anti-HBcIgG - past or chronic infection. HBeAg - indicates active replication of virus and therefore infectiveness. Anti-Hbe - virus no longer replicating. However, the patient can still be positive for HBsAg which is made by integrated HBV. HBV-DNA - indicates active replication of virus, more accurate than HBeAg especially in cases of escape mutants. Used mainly for monitoring response to therapy.


17 IgM anti-HBc Total anti-HBc HBsAg Acute (6 months) HBeAg Chronic (Years) anti-HBe 048 12 16202428 32 36 52 Years Weeks after Exposure Titre Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course

18 18 Serologic diagnosis of viral hepatitis SignificanceHBsAgHBeAg Anti-HBc IgG Anti-HBc IgM Anti-HBs IgG Acute HBV ++ - + - Chronic HBV, Active replication +++ -- Chronic HBV, quiescent + - + -- Resolved HBV-- ++ - Postvaccine Immune HBV ---- + Quiescent = inactive = quiet

19 Possible Outcomes of HBV Infection Acute hepatitis B infection Chronic HBV infection 3-5% of adult- acquired infections 95% of infant- acquired infections Cirrhosis Chronic hepatitis 12-25% in 5 years Liver failure Hepatocellular carcinoma Liver transplant 6-15% in 5 years 20-23% in 5 years Death

20 Prevention Vaccination - highly effective recombinant vaccines are now available. Vaccine can be given to those who are at increased risk of HBV infection such as health care workers. It is also given routinely to neonates as universal vaccination in many countries. Hepatitis B Immunoglobulin - HBIG may be used to protect persons who are exposed to hepatitis B. It is particular efficacious within 48 hours of the incident. It may also be given to neonates who are at increased risk of contracting hepatitis B i.e. whose mothers are HBsAg and HBeAg positive. Other measures - screening of blood donors, blood and body fluid precautions.


22 22

23  Transfusion or transplant from infected donor  Injecting drug use  Hemodialysis (yrs on treatment)  Accidental injuries with needles/sharps  Sexual/household exposure to anti-HCV- positive contact  Multiple sex partners  Birth to HCV-infected mother Risk Factors Associated with Transmission of HCV


25 Symptoms anti-HCV ALT Normal 012345 61234 Hepatitis C Virus Infection Typical Serologic Course Titre Months Years Time after Exposure

26 PROGRESSION ACUTE HEPATITIS C –15-40% will spontaneously resolve, generally within the first 6-18 months after acute onset. –60-85% will progress to chronic infection CHRONIC –85-90% stable –10-15% progress to cirrhosis

27 PROGRESSION CIRRHOSIS –75% slowly progressive –25% progress to HCC –2-4% liver failure HCC –Risk increases for every year for a patient with chronic hepatitis C. –Patients without signs of cirrhosis can develop HCC Factors of poor prognosis: -Age >40 years -Alcohol > 50g/Hour -Male gender -Duration of infection -Co-infection HBV/HIV -Tobacco consumption

28 28 Indirect tests: detect antibody against HCV 1.Anti HCV 2.RIBA (recombinant immunoblot assay) Diagnosis of HCV Infection Direct tests : components of the HCV particle 1.HCV RNA(PCR) Qualitative Quantitative 2. HCV Core antigen Usefull in detecting window peroid

29  Screening of blood, organ, tissue donors  High-risk behavior modification  Blood and body fluid precautions Prevention of Hepatitis C

30 HEPATITIS D Double stranded enveloped RNA virus Depends upon HBV for expression and replication Often severe with relatively high mortality in acute disease and frequent development of cirrhosis in chronic disease Chronic HDV inf. Is more severe and higher mortality rate than other types of viral hepatitis Serologic test : Anti HDV in px with HBsAg positive hepatitis

31 HEPATITIS E Unveloped, single stranded enveloped RNA virus Endemic area: Mexico, India, Africa, Burma, Russia Serologic test: -Antibody to hepatitis E establish dx. -IgM antibodies indicate recent infection -Serologic markers for HVA, HBV, HCV and other cause of acute hepatiti are absent

32 Soal Kasus Laki2 datang dengan keluhan demam 14 hari, sklera tampak ikterus, nyeri tekan abdomen kanan atas Pemeriksaan Lab apa yg anda usulkan? –HBsAg (-) –HBsAb (+) –IgM anti HAV (+) – anti HBc (-) Apa diagnosis pasien ini?


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