臨床表現(xiàn)課件

1、Viral HepatitisDept. of Infectious Diseases SunYat-sen University Q.F.XIE臨床表現(xiàn)課件1Viral HepatitisDept. of InfeIntroductionViral hepatitis are a group of diseases, Caused by A、B、C、D and E 5 hepatitis virusHepatitis A and E Transmitted by fecal-oral route, present acute and self-limited courseHepatitis

2、B ,C and D Spread parenterally easily lead to chronic hepatitis臨床表現(xiàn)課件2IntroductionViral hepatitis arClinical characters including fatigue, intestinal symptoms tender and enlarged liver abnormal LFTs jaundice in some cases very variable in severity臨床表現(xiàn)課件3臨床表現(xiàn)課件3SignificanceHighly endemicWide clinical

3、 spectrumHigh fatality rate in severe casesNo specific pathogenic therapy available nowChronic hepatitis B and C very common, some may develop to cirrhosis even HCCSuccessful vaccination for HBV and HAV臨床表現(xiàn)課件4SignificanceHighly endemic臨床表現(xiàn)Etiology-HAVHeparnavirusAppeared in bile and feces, spreaded

4、via fecesNo chronic carrier status observedAnti-HAV antibody to HAVAnti-HAV IgM indicative of current or recent infection appeared very early, disappear in about 3months most useful for confirm the diagnosis臨床表現(xiàn)課件5Etiology-HAVHeparnavirus臨床表現(xiàn)課件Anti HAV IgG current or previous infection a protective

5、antibody, conferring immunity persist for life long time臨床表現(xiàn)課件6臨床表現(xiàn)課件6Etiology-HBVOrthohepadnavirus, Dane particle4 open reading frame: S,C,P,X8 genotypes A-H, B and C predominantly in ChinaStrong ability against to environment3 antigen and antibody system臨床表現(xiàn)課件7Etiology-HBVOrthohepadnavirus,HBsAg f

6、ound 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 reinfection suggesting non-infectious臨床表現(xiàn)課件8HBsAg臨床表現(xiàn)課件8HBeAg suggesting HBV replication and high infectivi

7、ty negative when pre-C mutation but with high level of replication useful for evaluation of anti-HBV therapyAnti-HBe antibody to HBeAgHBe seroconversion HBeAg(+) (-)and anti-HBe(-) (+)臨床表現(xiàn)課件9HBeAg臨床表現(xiàn)課件9HBcAg existing in the core of virion a marker of replication and infectivityAnti-HBc IgM a marker

8、 of acute primary HBV infectionAnti-HBc IgG appeared in almost all HBV present and past infection host body臨床表現(xiàn)課件10HBcAg臨床表現(xiàn)課件10HBVDNA the genome of HBV suggesting active virus replication and infectivity useful for diagnosis and evaluation of anti-HBV therapy臨床表現(xiàn)課件11HBVDNA臨床表現(xiàn)課件11Hepatitis B Virus臨

9、床表現(xiàn)課件12Hepatitis B Virus臨床表現(xiàn)課件12Etiology-HCVRNA virus, 6genotypes, mainly 1b in the countryMolecular heterogeneity driven by high mutation rate usually proceed to chronic courseAnti-HCV IgM and IgG types antibody to HCV suggesting HCV infection臨床表現(xiàn)課件13Etiology-HCVRNA virus, 6genotyHCVRNA the genome

10、of HCV suggesting replication and infectivity of HCV useful for the diagnosis and evaluation of antivirus treatment臨床表現(xiàn)課件14HCVRNA臨床表現(xiàn)課件14Etiology-HDVAn incomplete RNA virusCauses hepatitis only patients with either acute(coinfection) or chronic (superinfection) hepatitis B HDVAg and anti-HDV both th

11、e markers of HDV infection HDVRNA the genome of HDV a marker of existing HDV infection suggesting virus replication and infectivity臨床表現(xiàn)課件15Etiology-HDVAn incomplete RNA Etiology-HEVNonenveloped RNA virusAppeared in bile and feces, spreaded via fecesNo chronic carrier status observedAnti-HEV IgM and

12、IgG both appeared in acute infection useful for the diagnosis of HEV infection臨床表現(xiàn)課件16Etiology-HEVNonenveloped RNA vHEVRNA the genome of the virus suggesting existing of HEV infection not available for routine clinical diagnosis臨床表現(xiàn)課件17HEVRNA臨床表現(xiàn)課件17EpidemiologySource of infection Patients with acut

13、e or chronic viral hepatitis Carriers of hepatitis virus, particularly asymptomatic carriers臨床表現(xiàn)課件18EpidemiologySource of infectioTransmission Hepatitis A and E transmitted by the fecal- oral route, water-borne and food-transmitted infection in epidemics臨床表現(xiàn)課件19Transmission臨床表現(xiàn)課件19Hepatitis B transm

14、itted 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 臨床表現(xiàn)課件20臨床表現(xiàn)課件20Prevalence rate in China 1992Hepatitis A anti-HAV+ 80.90%Hepatitis B HB

15、sAg + 9.75% (2006) 7.18%Hepatitis C anti-HCV+ 3.20%Hepatitis D anti-HDV+ 1.15%Hepatitis E anti-HEV+ 17.2%臨床表現(xiàn)課件21Prevalence rate in China 1992HPathogenesisHepatocellular damage produced by viral replication directly only in hepatitis DOther types of viral hepatitis induced mainly by immune-mediated

16、attack on the liver臨床表現(xiàn)課件22PathogenesisHepatocellular damPathologyThe varying lesion could be seen in entire liver, but variable in severity and in different stages of the diseaseNo specific lesion suggesting etiologic type of hepatitis virus臨床表現(xiàn)課件23PathologyThe varying lesion coClinical manifestati

17、onsWide clinical spectrum from asymptomatic form to fatal outcome such as liver failureSimilar clinical course in different etiological type of viral hepatitis 臨床表現(xiàn)課件24Clinical manifestationsWide clThe clinical types viral hepatitisAcute hepatitisChronic hepatitisLiver failure (severe hepatitis)Chol

18、estatic viral hepatitisHepatitis cirrhosisAsymptomatic virus carrier status (usually only in HBV)臨床表現(xiàn)課件25The clinical types viral hepatIncubation period Hepatitis A 2-6w 4w Hepatitis E 2-9w 6w Hepatitis B 1-6m 3m Hepatitis C 2w-6m 6w Hepatitis D 4-20w臨床表現(xiàn)課件26Incubation period臨床表現(xiàn)課件26Acute hepatitis

19、3 phases of the icteric hepatitis Prodromal phase sudden or insidious onset, lasting 3-7d constitutional symptom: malaise, fatigue, mild fever some time, dark urine gastrointestinal symptoms: anorexia, nausea, vomiting serum ALT level rise deeply臨床表現(xiàn)課件27Acute hepatitis臨床表現(xiàn)課件27Jaundice phase jaundice

20、 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 weeks臨床表現(xiàn)課件28Jaundice phase臨床表現(xiàn)課件28Convalescent phase symptoms and jaundice gradual resolution liver return to normal size serum ALT and bilir

21、ubin decreased 1 to 2 months neededAnicteric acute viral hepatitis more common, mild manifastation臨床表現(xiàn)課件29Convalescent phase臨床表現(xiàn)課件29Chronic hepatitis Seen only in hepatitis B,C and D, virus infection over 6 months Severity variable, 3 subtypes: mild, typical and advanced Common manifestations: malai

22、se, fatigue, poor appetite, nausea, distension of abdomen 臨床表現(xiàn)課件30Chronic hepatitis臨床表現(xiàn)課件30Jaundice seen in some casesEnlargement of liver and/or spleenSpider naevi, hepatic palms in cases with long historyAbnormal LFTs: transaminase, bilirubin A/GPrognosis different: stable, breakthrough or flare,

23、develop to Cir or Ca臨床表現(xiàn)課件31Jaundice seen in some cases臨床表Liver 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臨床表現(xiàn)課件32Liver fail

24、ure (severe hepatiti liver size become smaller bleeding, 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 臨床表現(xiàn)課件33 liver size become smallCholestati

25、c viral hepatitis acute and chronic mild manifestation but deepen jaundiceHepatitis cirrhosis hepatic fibrosis compensated cirrhosis decompensated cirrhosis臨床表現(xiàn)課件34Cholestatic viral hepatitis臨床表Asymptomatic HBV carrier HBV infection more than 6 months have no symptoms and signs normal LFTs 70%-80%ha

26、ve no pathologic change in liver biopsy臨床表現(xiàn)課件35臨床表現(xiàn)課件35DiagnosisClinical DataEpidemiological evidencesLaboratory investigationsUltrasoundBiopsy臨床表現(xiàn)課件36DiagnosisClinical Data臨床表現(xiàn)課件36Differential diagnosisJaundice caused by other etiological agentsHepatitis caused by other etiological agents臨床表現(xiàn)課件37Di

27、fferential diagnosisJaundiceTreatmentBasic principles of management guideline for daily living, physical activity , food and drink intake of the patients supportive and symptomatic treatment 臨床表現(xiàn)課件38TreatmentBasic principles of mHepatic function protective agentsAnti-virus therapy most important tre

28、atment for chronic hepatitis B、acute and chronic hepatitis C hepatitis B indication: HBVDNA 105copies/ml for HBeAg, 臨床表現(xiàn)課件39Hepatic function protective ag HBVDNA 104copies/ml for HBeAg+; ALT 2ULN, or biopsy G2S2 Drugs: interferon-(typical or pegylated) or, nucleotide analogues:3TC,adfovir, entecavir,Ldt Hepatitis C indication: HCVRNA+ drugs: interferon-(