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Viral Hepatitis & Liver Cirrhosis

Rasha Al-Shboul & Rawan Shatnawi

22/4/13

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Viral hepatitisToday we will talk about viral hepatitis which is very important for

us as future dentists. we will know why, and how we can make the

risk of viral hepatitis toward the patients and toward ourselves

somehow less.

The Educational objectives for this lecture,

Outline the epidemiology of viral hepatitis, to see how this disease

is important, is it common or rare, we will see later.

List causative agents for viral hepatitis.

They are A,B,C,D,E but not only those viruses that can cause

hepatitis, these are the viruses with some heptotropism; means

predilection to effect selectively the liver, but cytomegalovirus,

adenovirus, any virus virtually can affect the liver but we will limit

our talk to those hepatotropic viruses A ,B,C,D,E .

Recognize the clinical features of acute and chronic viral hepatitis

and their complications.

In general chronic hepatitis whether it's acute and even less

chronic hepatitis does not produce floridsymptom, there is nothing

like acute myocardial infarction where the patient has chest pain,

sweating, shortness of breath..etc

Viral hepatitis generally can be asymptomatic or can give some

symptoms like jaundice, abdominal pain and diarrhea, this is why in

order to diagnose accurately viral hepatitis you need serology

Interpret serologic tests to accurately diagnose the specific cause

of viral hepatitis, it's important to diagnose acute or chronic

hepatitis. Identify appropriate candidates for vaccination against HAV and

HBV.


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Why Bother For Viral Hepatitis For A Dentist?

"As dentists you must take this vaccine early, as you know its three

doses and after the third dose you will be fully protected" .For

instance, hepatitis B is a virus that abundantly present in the saliva notonly in the blood or the urine or the semen. -God forbid any abrasion

you can get the infection!- , So it is important to get vaccinated for you

and important for the patients you are taking care of because dentists

can involuntary transmit the infection to the patient (improper

sterilization techniques of tools).

Dental patients with chronic hepatitis complicated by coagulopathy

can have uncontrollable bleeding, this is a problem when you get apatient for treatment (extraction) inadvertently you don't know that his

coagulation profile is altered; the INR is 5 or the platelets because of

portal hypertension of chronic liver disease they are 10000 instead of

400000, he will bleed like crazy in your clinic and you will be in a deep

trouble so be aware of that! So patients with suspected acute or

chronic liver disease do not operate on them.

Types Of Hepatitis

A B C D ESource of

Virus FecesBlood/Blood-

Derived bodyFluids

Blood/Blood-

Derived bodyFluids

Blood/Blood-

Derived bodyFluids

Feces

Rout oftransmission Fecal-oral

Percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal Fecal-

oral

Chronic

infection

No Yes Yes Yes No

Preventionpre/post-Exposure

Immunization

pre/post-Exposure

Immunization

Blood donorscreening; risk

behaviormodification

pre/post-Exposure

Immunization;risk behaviormodification

Ensuresafe

drinkingwater

It's important to note that A and E never become chronic; get theinfection and clear it or death but you will never develop chronicinfection. It's up to 80% in hepatitis C,5% in hepatitis B to becomechronic, D is very much like B


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Clinical Manifestations of Acute Hepatitis,

Acute hepatitis A virus is the most symptomatic especially in adultsfollowed by B which is less likely to produce symptoms and C is the

least symptomatic (rarely symptomatic) , so A, B then C. Acute hepatitis E virus is most symptomatic and severe in

pregnant women for unknown reasons.

Acute HBV can present with a serum sickness-like picture (fever,arthritis, urticaria, angioedema).

Symptoms are non specific-the viral syndrome (fever, malaise,anorexia, RUQ pain, diarrhea, pruritis).

Jaundice is not very common in acute hepatitis and in chronichepatitis it's extremely rare. HAV only 60 % of patients with

jaundice.Generally, symptoms improve after jaundice appears.

Acute Hepatitis-LAB

If you are in your clinic and suspect that the patient is affected by

acute hepatitis you order some labs and you will get what we call

acute hepatocellular injury; the liver enzymes ALT and AST are

high with or without jaundice, or elevation in other liver functions

such as alkaline phosphates.

So markedly elevated levels of AST/ALT (more than 500 U/L)typically occurs in acute hepatocellular injury (viral, drug-induced, ischemic), generally hepatocellular injury is similar towhat drugs do, or even herbs, mushroom or hypotension,hypoperfusion to the liver.

Modest elevations (less than 300 U/L) may be seen in a variety

of conditions like chronic hepatitis, infiltrative diseases(cancers), biliary obstruction and acute alcoholic hepatitis( the only whichis acute with modest elevation ).

Bilirubin and AP may or may not be elevated.

WBC count may show leucopenia( they are decreased), viralinfections show leucopenia unlike bacterial infections whichassociated with leucocytosis (elevation in WBC),Except foralcoholic hepatitis which is generally associated withleucocytosis.


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Stigmata of Chronic Liver Disease,Some of the patients not all of them will have one or more of these

abnormalities:

Spider Agiomatas (small dilated blood vessels on upper chest arms

and neck anteriorly and posteriorly, if you press on it it will become

white means it is not vasculitis).

Palmar erythema

Clubbing of fingers Dupuytren contractures( flexion deformity; patients can't extend

their hands)

Gynecomastia (male) or breast atrophy (female),in liver disease

females get masculinized and males get feminized this is why we

have this problem.

Testicular atrophy

Spider Agiomatas Palmar erythema

Clubbing of fingers


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Now, we will talk about each virus,

Hepatitis AClinical features:

Just remember that the incubation period in general for all viralhepatitis is between 2 weeks to 6-8 weeks, C has the highestincubation period, A is the least and B in between.

The younger the patient is the less likely that he will havesymptoms because with age the immune system is moremature because what kills the hepatocytes is not the virus butit's your immune system( your natural killer cells recognize theviral infected cells).

Complications are rarely and never become chronic.** The incubation period is the time between the entry of thebug in your body and the beginning of the symptoms.* * Numbers in the slides are not for memorizing.

Typical Serological Course for HAV:

To diagnose HAV you order IgM anti-HAV.IgM is a primary immunologic response; your body when it firstcomes to contact any foreign body he will produce first IgM andthen IgG so acute infection make sense that IgM is the way to go.

Geographical distribution of HAV:HAV is Much less in the Western countries where there higherhygiene standards, actually in Jordan We don't have it much.


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Hepatitis A Vaccination Strategies,Epidemiologic Consideration

Many cases occur in community-wide outbreaks

No risk factor identified for most cases

Highest attack rates in 5-14 year olds Children serve as reservoir of infection

Persons at increased risk of infection: Travelers Homosexual men Injecting drug users

** Vaccination is a good thing especially for those at risk.

Hepatitis B** Hepatitis B is more important because of the chronicity rate.

Clinical Features:

Just remember that the younger the patient is the more likely to

become chronic, If you are less than 5 years old 90% you will

become chronic.

This is important because those who born to surface antigen

positive mothers 90% will become chronic and that's why at birth(

first 2 days ) we give them vaccine and immunoglobulin .

**All mothers are screened obligatory.

Extra hepatic Manifestations of Hepatitis BSometimes viral hepatitis especially chronic viral hepatitis theymanifest with symptoms outside the gastrointestinal system andliver.

Acute infection: Arthralgias Papular acrodrmatitis (Gianotti-Crosti syndrome) this is rare.


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Chronic infection: Glomerulonephritis Arthrlalgias Polyarteritis nodosa (PAN)

is inflammation of the medium sized vessels.Caused by immune complexes they deposit in the jointscause arthritis, glomerulonephritis in kidney, vasculitis in

vessels.

Acute Hepatitis B Virus Infection with Recovery

Typical Serological Course:

In recovery the surface

antigen will disappear and

anti hepatitis B surfaceantigen will appear so you

are protected.(This is very

important).

The other way if you are

unlucky (among the 5%

who will become chronic)

the surface antigen will

stay in your blood. So to

diagnose hepatitis B acute

infection we order IgM anti-

HBc (c stands for core).


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So Remember to diagnose the acute infection for hepatitis A order

IgM anti-HA and for hepatitis B igM anti-HBc this is very important

The older you are the

more likely to have

more symptoms, the

older you are the less

likely to have chronic

infection ;It's 90% to

develop chronicity at

birth , and at 5 years or

older its ~ 10% .

Geographicdistribution Of chronic HBV infection:It is almost the same as HAV. In some countries like Saudi Arabia,

it is almost 15% Of the population surface antigen positive. In

Jordan between 4-8% depending on the studies. In western

countries HCV is higher than in Jordan because it's mostly due to

IV drug use.

Concentration of Hepatitis B Virus in Various Body Fluids:High Moderate low/not detectable

Blood semen urineSerum vaginal fluids fecesWound exudates saliva sweat

tearsBreast milk


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** Saliva has abundant viruses ; If you are operating on a patient

who is HBVsAG positive his saliva is full of virus so be aware when

you are operating on them wear goggles, gloves to protect

yourself.

Hepatitis B Virus Modes of Transmission: Sexual promiscous heterosexuals 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. Perinataltransmission is the main means of transmission in high prevalence

populations.

Hepatitis B Serological Scenarios

HBsAG HBcAb (IgG) HBsAb Interpretation

+ - - Acute infection (+ HBc

IgM Ab)

+ + - 3 possibilities:1.Acute infection2.Chronic infection(high ALT)

3.Carrier (normal ALT)

- - + 2 possibilities:1.Remote infection

2.Immunized- + - 2 possibilities:

1. Window disease2. Remote infection

+ + + Acute on chronicinfection


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Prevention of HBV:

1-Vaccination - Vaccine can be given to those who are at increasedrisk of HBV infection such as:

- Health care workers.- Neonates as universal vaccination in many countries. 3 doses aregiven (at 0,1,and 6 months).

2- Hepatitis B Immunoglobulin - 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.3- Other measures - screening of blood donors, blood and body

fluid precautions.

Hepatitis C Virus

**450 Million people who have HBVsAG this make hepatitis B the

most chronic infection world wide and 170 million with HCV surface

antigen.

**No vaccine for hepatitis C because it changes itself all the time

(hypervariable region)

HCV has 6 different genotypes:


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Clinical Features

Chronicity 75-85% The main mode of transmission is blood.

Immunity: No protective antibody response identified, novaccine so protect yourself.

Extrahepatic Manifestations ofHepatitis C

Mixed cryoglobulinemia Vasculitis

non-deforming arthritis

membranous glomerulonepgritis

Porphyria cutanea tarda (blisteringpainful blisters)

Sjogren-like syndrome this should interest you because the patientmay has xerostomia (Oral environment should stay alkalineotherwise your teeth will destroyed).

The doctor didn't talkabout the typicalserologic course forHCV.

Risk Factors Associated with Transmission of HCV

o Transfusion or transplant from infected donor.

o Injecting drug use.o Hemodialysis (yrs on treatment).o Accidental injuries with needles/sharps.


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Hepatitis D (Delta) Virus

D comes only with B because It is

incomplete virus.

Hepatitis EClinical features:

It's similar to A; the same symptoms. If the infected person is a pregnant

woman there is a very high mortality.

Illness severity: Increased with age.

Chronic sequelae: None identified. Regions in South America and few cases in Jordan

Note: the serologic course for hepatitis E is not important-South East Asia, Saudi Arabia

North Africa Soudan, Mexico

Hepatitis E Epidemiologic Features Most outbreaks associated with faecally contaminated drinking

water

Several other large epidemics have occurred since in the Indian

subcontinent and the USSR, China, Africa and Mexico Minimal person-to-person transmission


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As in summaryViral Hepatitis Serological Diagnosis:

Organism Acute Chronic Recovered/latent Vaccinated

HAV Anti-HAV IgM NA Anti-HAV IgG Anti-HAVIgG

HBV

-Anti-HBc IgM- HBeAG- HBV DNA

- Anti-HBc IgG- HBsAg- HBeAg orHBeAb

- Anti-HBc IgG- Anti-HBs Anti-HBs

HCV

- All testspossibly

negative- Anti-HCV Ab- HCV RNA

-Anti-HCV Ab

- HCV RNAAnti-HCV Ab NA

HDV

-Anti-HDV IgM

- HD Ag - Anti-HDV- HDV Ag- HBsAg

Anti-HDV NA

** It is important to know something about viral hepatitis for youand your patients and GET VACCINATED.

Good Luck

Done by: Rawan Shatnawi & Rasha Al-Shboul

9 viral hepatitis

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