Актуальная Медицина - Hepatitis (Infectious Hepatitis )

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Viral Hepatitis
(Infectious Hepatitis & Homologous Serum Hepatitis)

Essentials of Diagnosis:
• Anorexia, nausea, vomiting, malaise, symptoms of upper respiratory infection, aversion to smoking;
• Fever; enlarged, tender liver, jaundice.
• Normal to low WBC (white blood count), abnormal hepatocellular liver function tests;
• Liver biopsy characteristics.
Differentiate viral hepatitis from other diseases that cause hepatitis or involve the liver such as Weil’s disease, amebiasis, cirrhosis, infectious mononucleosis, and toxic hepatitis.
The prodromal phase or the nonicteric form of the disease must be distinguished from other infectious diseases such as influenza, upper respiratory infection, and the prodromal stages of the exanthematous diseases. In the obstructive phase of viral hepatitis it is necessary to rule out other obstructive lesions such as choledochlolithiasis, chlorpromazine toxicity, and carcinoma of the head of the pancreas.
Homologous serum hepatitis is clinically indistinguishable from infectious hepatitis.
General Considerations:
Infectious hepatitis is a viral infection of the liver which may occur sporadically or in epidemics.
The liver involvement is a part of a generalized infection, but dominates the clinical picture. This disease is the most common infection of the liver, and often becomes a major health problem in crowded establishments, e.g. military bases, mental hospitals, camps.
Transmission of the virus is by the intestinal-oral route.
The virus is present in the feces and blood during the prodromal and acute phases of the icteric disease, and in the feces and blood in the unicteric form of the disease; occasionally it is present in an asymptomatic carrier state.
The incubation period is 2-6 weeks.
Homologous serum hepatitis is a viral infection of the liver transmitted by the inoculation of infected blood or blood products.
The virus is similar to that which causes infectious hepatitis but is immunologically distinct, and little or no cross-immunity exists between the 2 diseases. The virus is found only in the blood and tissues of an infected person and is never excreted via the intestinal tract.
The incubation period is 6 weeks to 6 months. The pathologic findings are identical with those of infectious hepatitis.
Clinical features are also similar, but there is usually a history of injection, the disease is more common in the older age groups, and the onset is more often insidious than abrupt.
These facts, with the longer incubation period, often allow clinical differentiation, but in many cases the exact type cannot be determined.
Pathologic findings in both diseases are varying degrees of necrosis of the perenchymal cells and cellular mononuclear exudation. The reticulum framework is generally preserved, although it may become condensed.
Healing is by regeneration from surviving cells, usually without distortion of the normal architecture.

Clinical Findings:
The clinical picture is extremely variable, ranging from asymptomatic infection without jaundice to a fulminating disease and death in a few days.

А. Symptoms:
  1. Prodromal phase: (The speed of onset varies from abrupt to insidious with general malaise, myalgia, fatigability, upper respiratory symptoms (coryza, scratchy throat), and severe anorexia out of proportion to the degree of illness).
  - Nausea and vomiting are frequent;
  - diarrhoea or constipation;
  - Fever is generally present but it rarely over 39.4° C. (103° F)
  - Chill or chilliness may mark an acute onset;
  - Abdominal pain is generally mild and constant in the upper right quadrant or right epigastria (often aggravated by jarring or exertion);
- Distaste for smoking may occur early in the illness.
2. Icteric phase:
- Clinical jaundice occurs after 5-10 days but may be present at the onset, although many patients never develop clinical jaundice;
- With the onset of jaundice there is often an intensification of the prodromal symptoms followed by progressive clinical improvement;

3. Convalescent phase: there is an increasing sense of well being, return of appetite, and disappearance of jaundice, abdominal pain, and fatigability.
B. Signs:
- Hepatomegaly, rarely excessive and often variable from day to day, is present in over half of cases;
- Liver tenderness is often present;
- Splenomegaly is present in 15 % of cases;
- Soft lymphadenopathy (especially cervical);
- Sings of general toxemia vary from minimal to severe;
C. Laboratory Findings:
- The WBC (white blood count) is normal to low;
- abnormal lymphocytes (virus lymphocytes);
- mild proteinuria is common;
- bilirubinuria often precedes jaundice;
- Acholic stools are often present during the initial icteric phase;
- Liver function tests tend to reflect hepatocellular damage with abnormal cephalic flocculation;
- BSP (thymol turbidity, SGOT (serum glutamic oxaloacetic transaminase) SGPT (serum glutamic pyruvic transaminase) values;
- Decreased hippuric acid synthesis;
- Depression of cholesterol esters;
- Increased gamma globulin;
- Urobilinogenuria;
- In the cholongiolitic variety the liver function tests may indicate obstruction as well;
- Liver biopsy generally shows the characteristic pathology;
Treatment:
A. General Measures: 
Bed rest is necessary until the initial acute symptoms have subsided and should be maintained judiciously until clinical and laboratory evidence of the acute disease has disappeared.
Absolute bed rest beyond the most acute phase is not warranted.
The return to activity during the convalescent period should be gradual.
- It is essential to keep a close check on the patient’s actual intake and output during the phase;
- If the patient is unable to take or retain food or fluids by mouth, give 10 % glucose solution I.V;
- If the patient shows signs of impending hepatic coma, protein should be restricted to 40 Gm./day and increased as improvement progress;
- Dietary management consists of giving a palatable diet as tolerated;
- Patients with infectious hepatitis should avoid physical exertion, unnecessary transportation, alcohol, all medication whenever possible, especially barbiturates, morphine, and sulfonamides, surgery, especially with general anesthesia.
- Corticotrophin or adrenal glucocorticoids are recommended only in the following circumstances:
a) If the patient’s condition is deteriorating;
b) If serum bilirubin remains high (> 15 mg./100 ml.)
c) If convalescence is prolonged (serum bilirubin>10 mg./100 ml.) for two weeks or longer.
Prevention:
- Isolation of infected individuals (Human immune globulin, 0.02-0.06 ml./ lb., may attenuate the disease if given to exposed persons during the incubation period. The higher doses are usually justified only in special circumstances (e.g. pregnancy, debility, previous liver disease, or complicating illness).
- Avoid unnecessary transfusions, especially of possibly infected blood, serum, or plasma.
Prognosis:
In the majority of cases of infectious hepatitis clinical recovery is complete in 3-16 weeks. Laboratory evidence of disturbed liver function may persist longer.
Overall mortality is less than 1 %, but is higher in older people.
In a few cases the course is prolonged or symptoms are recurrent, with eventual full recovery.
Cirrhosis of the portal or post necrotic types or chronic progressive hepatitis develops infrequently.
Homologous serum hepatitis is a more severe illness than infectious hepatitis since it is more likely to occur in older persons, often as a complication of other diseases treated with blood products.
It occurs as a complication in 0.25 – 3 % of blood transfusions and up to 12 % of pooled plasma transfusions.
The asymptomatic carrier state and persistent viremia after acute disease make control of contamination in donor blood extremely difficult.

Variants of Infectious Hepatitis:
Cholangiolitic Hepatitis:
There is usually a cholestatic phase in the initial icteric phase of infectious hepatitis, but in occasional cases this is the dominant manifestation of the disease.
The course tends to be more prolonged than that of ordinary hepatitis, and biliary cirrhosis may develop.
The symptoms are often extremely mild, but jaundice is deeper and pruritus is often present.
Laboratory tests of liver function indicate obstruction with marked hyperbilirubinuria, elevated alkaline phosphates and cholesterol, and normal flocculation reactions.
Differentiation from extra hepatic obstruction may be difficult even with liver biopsy.
Fulminant Hepatitis:
Hepatitis may take a rapidly progressive course terminating in less than 10 days. Extensive necrosis of large areas of the liver gives the typical pathologic of acute liver atrophy.
Toxemia and gastrointestinal symptoms are more severe, and hemorrhagic phenomena are common. Neurological symptoms of hepatic coma develop.
Jaundice may be absent or minimal, but laboratory tests show extreme hepatocellular damage.
Chronic Hepatitis:
The persistence of symptoms six months or more after an acute episode of hepatitis presents a problem of differentiation of psychoneurosis and hepatitis.
Anorexia, fatigability, vague dyspepsia, and variable tenderness and enlargement of the liver are present.
Laboratory findings: hyperbilirubinuria, positive flocculation tests, bromsulphalein retention, urobilinogenuria, increased gamma globulin.
Liver biopsy gives evidence of hepatitis.
The diagnosis of chronic hepatitis should be based on objective evidence of liver dysfunction and, preferably, liver biopsy in addition to symptoms.
Treatment:
- adequate rest with gradual return to activity as tolerated;
- a well balanced diet;
- vitamin supplementation;
- avoidance of alcohol and all other potentially hepatotoxic agents;
- If jaundice is present despite conservative treatment, corticosteroid therapy may be given until no further improvement is noted;
- Intermediate or advanced chronic hepatitis responds only temporarily to corticosteroids.
Chronic hepatitis may cause mild prolonged disability or it may progress to death.

Vocabulary:

retention [rǐ`ten∫n] – затримка, збереження; viremia [v a ǐ r ǐ`m ǐə] – віремія;
serum [`serəm] – сироватковий; distinct [dǐs`tǐnkt] – виразний;
aversion [ə`və:∫n] – відраза; to be excreted via [bǐ ǐks`kri:tǐd`v a ǐə] – виділятися через;
tenderness [`tendənǐs] – м’якість, ніжність; parenchymal [pǐ`renkǐml] – паренхіматозний;
biopsy [`ba ǐəpsǐ] –біопсія; exudation [ǐgzј`deǐ∫n] – виділення;
viral [`v a ǐ r əl ] – вірусний; reticulum [rǐ`tǐkјυləm] – сітківка;
to involve [ǐn`volv] – ускладнювати, містити; to become condensed [bǐ`kǎm kən`denst] – згуститись;
prodromal phase [prə`drəυməl`f eǐz] – фаза передуюча хворобі; architecture [α:kǐ`tekt∫ə] – будова, структура;
nonicteric form [nonǐk`tə:rǐk`fo:m] – нежовтянична форма хвороби; insidious [ǐn`sǐdǐəs] – підступний;
exanthematous [ǐgzənθǐ`mætəυəs] – висиповий; regeneration [rǐdзǐnǐ`reǐ∫n] – переродження;
obstructive phase [əbs`trǎktǐv`feǐz] –загороджуюча, перешкоджаюча фаза; fulminating [fǎlmǐ`neǐtǐŋ] – гримучий (хім.)
carcinoma [kα:kǐ`nəυmə] – ракове новоутворення; myalgia [ma ǐəl`dзǐə] – міальгія, біль у м’зах;
toxicity [tə`ksǐsǐtǐ] – токсичність; coryza [kə`r a ǐzə] – нежить;
sporadically [spəυ`rædǐkəlǐ] – спорадично; chilliness [`t∫ǐlǐnǐs] – сухість, зяблість;
inoculation [ǐnəυkјυ`leǐ∫n] – прививка, посів; quadrant [`kwo:drənt] – секторний;
to be aggravated [bǐ əgrə`veǐtǐd] – погіршитися, загостритись; epigastrium [epǐ`gα:str ǐəm] – надчеревний район;
jarring [`dзα:rǐŋ] – неприємний звук; jaundice [`dзo:ndǐs] – жовтяниця;
exertion [ǐg`zə:∫n] – напруга; improvement [ǐm`pru:vmǐnt] – покращення;
distаste [dǐs`teǐst] – відраза; excessive [ǐk`sesǐv] – надмірний;
convalescent phase [konvə`lesnt] – фаза одужання; cervical [sə`va ǐkl] – шийний;
acholic [æ`həυlǐk] – ахолічний; hippuric [`hǐpərǐk] – гіпурічний;
hepatocellular damage [hǐpətəυ`selјυlə`dæmədз] – гепатоклітковинне ушкодження; globulin [`globјυlǐn] – глобулін;
flocculation [flokјυ`leǐ∫] – флокуляція; ethers [`i:θəz] – складні ефіри;
turbidity [tə:`bǐdǐtǐ] – затуманенність, неясність; to subside [səb`sa ǐd] – спадати, стихати;
judiciously [dзə`dǐ∫ǐəslǐ] – розсудливо; to be warranted [bǐ`wo:rəntǐd] – гарантуватися;
palatable diet [`pælətəbl`d a ǐət] – прийнятна дієта; impending coma [ǐm`pendǐŋ`kəυmə] – кома, яка загрожує, нависла.
barbiturates [bα:`bǐtјυrəts] – барбітурати; circumstances [`sə:kəmstənsǐs] – обставини;
to attenuate [ə`tenјυeǐt] – пом’якшувати; exposed persons [ǐks`pəυzd`pə:sənz] – незахищені особи; 
debility [dǐ`bǐlǐtǐ] – недомагання, слабкість; portal [`po:təl] – портальний;

Exercises:
Exercise 1: Choose the correct variant.
1. Which of the following tests would most likely be normal in an uncomplicated case of infectious hepatitis?
a) Total proteins and A/G ratio;
b) SGOT;
c) BSP retention;
d) Direct bilirubin;
e) SGPT;
2. Patients with acute hepatitis can be allowed out of bed when:
a) All symptoms have subsided;
b) The liver is not enlarged and tender;
c) The SGOT is less than 40 units;
d) The serum bilirubin is less than 2 mg./100 ml;
e) All of the above;
3. The viral hepatitis is diagnosed by:
a) Direct bilirubin test;
b) Skin test;
c) Hepatocellular liver function test;
d) Felix-Weil reaction test; 
4. Characteristic feature of homologous serum hepatitis is:
a) liver cirrhosis;
b) viral infection;
c) immunodeficiency;
d) low white blood count;
5. Which of the following symptoms and sings is not related to hepatitis:
a) chilliness;
b) liver tenderness;
c) blood clots;
d) abdominal pain;
6. One of the following is not related as the laboratory finding of hepatitis:
a) Acholic stools; 
b) Proteinuria;
c) Abnormal lymphocytes;
d) Decreased gamma globulin;
7. We can prevent spreading of infectious hepatitis by:
a) injections;
b) drugs;
c) transfusions;
d) isolation;

Exercise 2: Complete the following situation:

Doctor: Come in, please. How can I help you?
Patient: Oh, doctor. I’ve got some complaints of my general state.
  I have nausea and jaundice of my skin. Can you examine me thoroughly?
Doctor: …..
Patient: …..Should I have this test made?
Doctor: …..
Patient: Thank you doc. I’ll follow your advice.
Doctor: …..

Exercise 3: Answer the following questions:
1. What are the basic tests used for diagnostics of hepatitis?
2. What is the incubation period in case of hepatitis?
3. Does the viral hepatitis have any pathologic findings?
4. How many phases can be differentiated in the development of hepatitis?
5. What are the main signs in case of the disease?
6. What preparations can be used for the procedure of treatment?
7. Does the disease have any recurrent symptoms?
8. Do you know any complications connected with viral hepatitis?
9. What are the basic variants of infectious hepatitis?
10. How should the chronic hepatitis be treated in case of complications?


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