IMMUNE MEDIATED LIVER DISEASES AND VIRAL HEPATITISSpeakers :

• Ammara Farouqi• Anam Hassan

Immune-mediated diseases are conditions which result from abnormal activity of the body's immune system.Autoimmune diseases are a subset of immune-mediated diseases. 

IMMUNE-MEDIATED DISEASES

Autoimmune liver diseases (AILDs) Autoimmune liver diseases (AILDs) are common leading causes for liver cirrhosis and terminal stage of liver disease.

Primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis are the three major immune-mediated liver diseases.

Characterized by continuing hepatocellular inflammation and necrosis, tending to progress to cirrhosis.

AUTOIMMUNE HEPATITIS

The disease often is associated with other autoimmune diseases. It is associated with other autoimmune diseases.

TYPES OF AUTOIMMUNE HEPATITIS:

1. TYPE 1 : most common occur at any age but most often

starts in young adulthood associated with other autoimmune

disorders like type 1 diabetes, proliferative glomerulonephritis, thyroiditis and ulcerative colitis.

2. TYPE 2 : less common typically affecting girls aged 2 to 14

SYMPTOMS OF AUTOIMMUNE HEPATITIS:

1. Fatigue2. an enlarged liver3. jaundice4. itching5. skin rashes6. joint pain7. abdominal discomfort8. spider angiomas, or abnormal

blood vessels, on the skin9. nausea10. vomiting11. loss of appetite12. dark urine13. pale or gray-colored stools

DIAGNOSIS :

1. Blood tests

2. Liver Biopsy

TREATMENT:

3. Corticosteroids

4. Immunosuppressant Therapy

5. Liver transplantation

.

PREDNISOLONE

Corticosteroids have potent anti-inflammatory properties, and are used in inflammatory conditions such as arthritis, asthma, bronchitis, certain skin rashes, hepatitis and allergic or inflammatory conditions of the nose and eyes.

Prednisolone is a synthetic adrenal corticosteroid

SIDE EFFECTS :1. weight gain2. anxiety and confusion3. thinning of the bones, a condition called

osteoporosis4. thinning of the hair and skin5. diabetes6. high blood pressure7. cataracts8. glaucoma

CONTRAINDICATIONS:

1. peptic ulcer2. Lactation3. Osteoporosis4. Diabetes5. hypertension

AZATHIOPRINE

Prodrug (a precursor of a drug) which is converted in the body to its active form called mercaptopurine (Purinethol). It suppresses the proliferation of T and B lymphocytes and defend the body against both infectious diseases & foreign materials.

Azathioprine is found in breast milk.

Azathioprine is an Immunosuppressant.

1. Lowering of the white blood cell count2. cause nausea, vomiting, and loss of appetite3. cause liver toxicity4. fatigue, hair loss, joint pains, and diarrhea

SIDE EFFECTS:

CONTRAINDICATION:

1. Not given to Hypersensitive patients

2. Not given to pregnant women

PRIMARY BILIARY CIRRHOSISIrritation and swelling (inflammation) of the bile ducts of the liver leading to cirrhosis.Characterized by positive antimitochondrial antibody Its cause is still unknown.Commonly affects middle-aged womenIt is associated with autoimmune disorders such as Hypothyroidism and Sicca syndrome (dry eyes or mouth)

SYMPTOMS:

1. Abdominal pain2. Enlarged liver3. Fatigue4. Fatty deposits under

the skin5. Fatty stools6. Itching7. Jaundice8. Soft yellow spots on

the eyelid

DIAGNOSIS:

1. Elevated immunoglobulin M level in the blood

2. Liver biopsy3. Anti-mitochondrial antibodie

s (results are positive in about 95% of cases)

4. ultrasound imaging of the liver,

TREATMENT:

5. Medicines6. Vitamin Replacement

Therapy7. Liver transplant8. AMA Test

CHOLESTRAMINE OR COLISTEPOL

It reduces Cholestrol level.It cures itching which is in some cases is a result of of accumulation of bile acids in the skin. It ease the elimination of bile acids from the body and skin.SIDE EFFECTS:1. constipation2. bloating3. stomach

pain4. gas5. upset

stomach6. vomiting7. diarrhea8. loss of

appetite9. heartburn10. indigestion

CONTRAINDICATION:

•Hypersensitivity can cause complete biliary obstruction.•Renal impairment•Constipation

URSODEOXYCHOLIC ACID:

It is one of the secondary bile acids, which are metabolic byproducts of intestinal bacteria.Ursodiol dissolve gallstones in patients who avoid surgery.Also prevent formation of gallstone by decreasing the production of cholesterol.SIDE EFFECTS:

1. diarrhea2. constipation3. indigestion4. dizziness5. vomiting6. sore throat7. Cough with runny nose8. muscle and joint pain9. hair loss

CONTRAINDICATIONS:acute inflammation of the gall bladderimpaired contract ability of the gall bladderhypersensitivity to bile acidspregnant or breastfeedingchronic liver disease, peptic ulcers or in those with inflammatory diseases of the small intestine and colon.

PRIMARY SCLEROSING CHOLANGITISchronic and progressive disease of the bile ducts. infection in the bile ducts that leads to cirrhosis and liver failure.It can occur alone as well as in association with Crohn's disease (Inflammatory Bowel Disease).

SYMPTOMS:1. Fatigue2. Itching3. Yellowing of the skin and

eyes (jaundice4. Enlarged liver5. Enlarged spleen6. Loss of appetite and

weight loss7. Repeat episodes of

cholangitis.8. Abnormally elevated

blood levels of liver enzymes

9. Abdominal pain

DIAGNOSIS:

1. Blood Tests2. Radiological Tests3. Liver Biopsy4. Colonoscopy

TREATMENT:

1. Medications such as Cholestyramine, Ursodeoxycholic acid, Fat-soluble vitamins (D, E, A, K) and that quiet the immune sys. (prednisone, azathioprine, cyclosporine, methotrexate)

2. Liver transplant

VIRAL HEPATITIS

Speakers:

• Rabia • Sundus

What Is Hepatitis ?

Hepatitis (plural hepatitides ) is a medical condition defined by the inflammation of liver and characterized by the presence of inflammatory cells in the tissues of organ .

Causes Of Hepatitis:

•Drugs•Alcohols•Chemicals•Auto-immune disease•Viruses•Blood transfusions

Symptoms :. For those who do develop symptoms of viral hepatitis, the most common are flu- like symptoms including:• loss of appetite• nausea• vomiting• Fever• weakness• tiredness• aching in the abdomenLess common symptoms include:• dark urine• light-colored stools• fever• jaundice (a yellow appearance to the skin and white portion of the eyes)

Types Of Viral Hepatitis

There are several viral hepatitis caused by specific viruses, they have been named as :

• Hepatitis A virus (HAV)• Hepatitis B virus (HBV)• Hepatitis C virus (HCV)• Hepatitis D virus (HDV)• Hepatitis E• Hepatitis F• Hepatitis G (not confirmed yet).

Hepatitis A (HAV)

At one time, hepatitis A was referred to as "infectious hepatitis" because it could be spread from person to person like other viral infections. Infection with hepatitis A virus can be spread through the ingestion of food or water, especially where unsanitary conditions allow water or food to become contaminated by human waste containing hepatitis 

Hepatitis B (HBV)

Type B hepatitis was at one time referred to as "serum hepatitis," because it was thought that the only way hepatitis B virus (HBV) could spread was through blood or serumAbout 6-10% of patients with hepatitis B develop chronic HBV infection (infection lasting at least six months and often years to decades) and can infect others as long as they remain infected. Patients with chronic hepatitis B infection also are at risk of developing cirrhosis, liver failure and liver cancer.

Type C hepatitis was previously referred to as "non-A, non-B hepatitis,Patients with chronic hepatitis C infection are at risk for developing cirrhosis, liver failure, and liver cancer.The hepatitis C virus (HCV) usually is spread by shared needles among drug abusers, blood transfusion, hemodialysis, and needle sticks. Approximately 90% of transfusion-associated hepatitis is caused by hepatitis C

Hepatitis C (HCV)

Types D, E, F, and G Hepatitis

There also are viral hepatitis types D, E, F (not confirmed yet), and G. The most important of these at present is the hepatitis D virus (HDV), also known as the delta virus or agent. It is a small virus that requires concomitant infection with hepatitis B to survive. HDV cannot survive on its own because it requires a protein that the hepatitis B virus makes (the envelope protein, also called surface antigen) to enable it to infect liver cells.

Who Is At Risk For Viral Hepatitis?People who are most at risk for developing viral hepatitis are:

• Workers in the health care professions• People with multiple sexual partners• Intravenous drug users• Hemophiliacs • Blood transfusion• By piercing body (tattooing).

Tests Used to Diagnose Viral Hepatitis

• Liver enzyme tests

• Test for antibodies

• liver biopsyA number of conditions have the same symptoms as viral hepatitis.

• Mononucleosis • Reaction to medicines, such as birth control pills, certain antibiotics, or acetaminophen (Tylenol®)•Autoimmune hepatitis•Infections caused by certain viruses, such as herpes simplex virus, cytomegalovirus, or coxsackievirus• Congestive heart failure• Wilson's disease• Liver cancer

How is viral hepatitis treated?Treatment of acute viral hepatitis and chronic viral hepatitis are different.

In patients with acute viral hepatitis, the initial treatment consists of relieving the symptoms of nausea, vomiting, and abdominal pain. Careful attention should be given to medications which can have adverse effects in patients with abnormal liver function. Only those medications that are considered necessary should be administered since the impaired liver is not able to eliminate drugs normally, and drugs may accumulate in the blood and reach toxic levels. In addition, sedatives and "tranquilizers" are avoided because they may accentuate the effects of liver failure on the brain and cause lethargy and coma.It occasionally is necessary to provide intravenous fluids to prevent dehydration caused by vomiting. 

Acute Hepatitis:

Chronic Hepatitis:Treatment of chronic infection with hepatitis B and hepatitis C usually involves medication or combinations of medications to eradicate the virus.

Medications for chronic hepatitis C infection include:

Medications for chronic hepatitis C infection include:• Injectable interferon• Oral ribavirinMedications for chronic hepatitis B infection include:• Injectable interferon• Oral lamivudine (epivir)• Oral adefovir (hepsera)• Oral entecavir (baraclude)

RIBAVIRIN :Ribavirin (brand names:, Rebetol, Ribasphere, Vilona and Virazole) is an anti-viral drug indicated for severe , hepatitis C infection . Ribavirin is a prodrug.Mechanism:ribavirin is known to enhance host T-cell-mediated immunity against viral infection through helping to switch the host T-cell phenotype from type 2 to type 1.ContraindicationsWomen who are pregnant or men whose female partners are pregnant; hypersensitivity to ribavirin or any component of the product.

Medications for chronic infection with hepatitis B and hepatitis C are not always effective. Prolonged treatment (6 months to years) often is necessary

Fulminant hepatitis. Treatment of acute fulminant hepatitis should be done in centers that can perform liver transplantation since acute fulminant hepatitis has a high mortality without liver transplantation.

How Is Viral Hepatitis Prevented?

Prevention of hepatitis involves measures to avoid exposure to the viruses, using immunoglobulin in the event of exposure, and vaccines.Hepatitis A. Two hepatitis A vaccines are available, Havrix andVaqta. Both contain inactive (killed) hepatitis A virus.For active vaccination, a harmless hepatitis B antigen is given to stimulate the body's immune system to produce protective antibodies against the surface antigen of Hepatitis B. Vaccines that are currently available are made (synthesized) using recombinant DNA technology(joining DNA segmentsThere is currently no vaccine for Hepatitis C.