Viral Viral HepatitisHepatitis

Clinics, Clinics, diagnostics, diagnostics,

treatment and treatment and prophylaxisprophylaxis

Asymptomatic formAsymptomatic form:: the specific the specific markers of infectious agent and markers of infectious agent and proper immunological changes are proper immunological changes are exposed onlyexposed onlySub-clinical formSub-clinical form:: immunologic, immunologic, biochemical and histological changesbiochemical and histological changes, , however exposed clinical signs of illness however exposed clinical signs of illness are absentare absentNon-jaundice formNon-jaundice form:: appears different appears different clinical symptoms of illness except clinical symptoms of illness except jaundicejaundiceJaundice formJaundice form:: appears jaundice, which appears jaundice, which is the main sign of hepatitisis the main sign of hepatitisFulminant (malignant) formFulminant (malignant) form:: extremely severeextremely severe

Duration of hepatitisDuration of hepatitis::

AcuteAcute – – till 3 monthstill 3 months;;

ProlongedProlonged – – from 3 to 6 monthsfrom 3 to 6 months;;

ChronicChronic – – more than 6 monthsmore than 6 months..

Periods of viral hepatitis, with Periods of viral hepatitis, with jaundicejaundice::

1.1. Pre jaundice (initial , prodromal)Pre jaundice (initial , prodromal);;

2.2. Jaundice or climax of diseaseJaundice or climax of disease;;

3.3. Period of recoveryPeriod of recovery..

Pathologic syndromes of liver Pathologic syndromes of liver affectionaffection

Cytolytic – Cytolytic – ↑ ↑ ALT, LDG, Cu; ALT, LDG, Cu;

↓ ↓ albumins, protrombinalbumins, protrombin Mesenchimal-inflammation – Mesenchimal-inflammation – ↑↑ αα-, -,

γγ -globulins, tymol-test -globulins, tymol-test Cholestasis – Cholestasis – ↑↑ bilirubin, bile acids, bilirubin, bile acids,

cholesterine, GGTP, alkaline cholesterine, GGTP, alkaline phosphatasephosphatase

Variants of initial periodVariants of initial period::1.1. Asteno-vegetativeAsteno-vegetative:: general weakness, general weakness,

fatigue, headache, insomnia, and change fatigue, headache, insomnia, and change in behaviorin behavior;;

2.2. Dyspeptic:Dyspeptic: anorexia, nausea, vomiting, anorexia, nausea, vomiting, abdominal pain, diarrheaabdominal pain, diarrhea;;

3.3. CatarrhalCatarrhal:: influenza, feeling of influenza, feeling of scratching in throat, hyperemia of scratching in throat, hyperemia of conjunctiva and mucus of soft palate, dry conjunctiva and mucus of soft palate, dry cough, increase of body temperaturecough, increase of body temperature;;

4.4. ArtharalgicArtharalgic:: characterized by pain in characterized by pain in joints without local inflammatory changes;joints without local inflammatory changes;

5.5. MixedMixed

Criteria for severity of viral Criteria for severity of viral hepatitishepatitis::

1.1. Stage of intoxicationStage of intoxication;;

2.2. Intensity of jaundiceIntensity of jaundice;;

3.3. Liver sizesLiver sizes ( (mildmild – – enlarged from 1 to 2 enlarged from 1 to 2 cm on right mid-clavicle linecm on right mid-clavicle line, , moderatemoderate – – from 3 to 5 cm, severefrom 3 to 5 cm, severe – – 6 and more or 6 and more or vice versa decreasesvice versa decreases););

4.4. Level of bilirubinLevel of bilirubin ( (respectively respectively 85 85 micmol/lmicmol/l, 86 – 170 , 86 – 170 micmol/l and >micmol/l and >170 170 micmol/lmicmol/l););

5.5. ComplicationsComplications;;

6.6. Index of albumin transport function.Index of albumin transport function.

Clinical peculiarities of viral hepatitis Clinical peculiarities of viral hepatitis AA::

1.1. Short incubation periodShort incubation period (3 – 6 (3 – 6 weeksweeks););2.2. Acute beginningAcute beginning;;3.3. Mostly catarrhal syndrome in prodromal Mostly catarrhal syndrome in prodromal

periodperiod;;4.4. Short prodromal periodShort prodromal period (5 – 7 (5 – 7 daysdays););5.5. Quick appearance of jaundiceQuick appearance of jaundice ( (within some within some

daysdays););6.6. Improvement of self feelings with Improvement of self feelings with

appearance of jaundiceappearance of jaundice;;7.7. Mild forms are predominant, severe forms Mild forms are predominant, severe forms

occurs rarelyoccurs rarely;;8.8. Jaundice period persist not more than 1-2 Jaundice period persist not more than 1-2

weeksweeks..

Clinical peculiarities if viral hepatitis Clinical peculiarities if viral hepatitis BB::

1.1.Long incubation periodLong incubation period ( (more than 4more than 45 5 daysdays, , maximum maximum – 6 – 6 monthsmonths););

2.2.Progressive beginning of diseaseProgressive beginning of disease;;3.3.Often arthralgic syndrome in prodromal Often arthralgic syndrome in prodromal

periodperiod (20 – 30 %); (20 – 30 %);4.4.Prurience of skin and urticaria in prodromal Prurience of skin and urticaria in prodromal

periodperiod;;5.5.Prodromal period often persist more than 2 Prodromal period often persist more than 2

weeksweeks;;6.6.Progressive appearance of jaundiceProgressive appearance of jaundice, ,

sometimes 2 weeks and moresometimes 2 weeks and more;;7.7.Self feelings do not improve with Self feelings do not improve with

appearance of jaundiceappearance of jaundice;;

8.8. Prolonged and severe jaundice periodProlonged and severe jaundice period, , less less than during hepatitis Athan during hepatitis A; ;

9.9. Often exacerbationsOften exacerbations, , remissions and remissions and complications complications ((reason may be hepatitis D reason may be hepatitis D infectioninfection););

10.10.Presence of expressed asthenic syndrome Presence of expressed asthenic syndrome during all clinical periods of diseaseduring all clinical periods of disease, , prolonged post hepatic asthenia, sometime prolonged post hepatic asthenia, sometime years and moreyears and more;;

11.11.Possible transformation into chronic Possible transformation into chronic hepatitis hepatitis ((inin 5 – 15% 5 – 15% casescases) ) and then into and then into liver cirrhosisliver cirrhosis ( (inin 15 – 30% 15 – 30% patients of patients of chronic hepatitischronic hepatitis););

12.12.Hepatitis B often run on background of Hepatitis B often run on background of concomitant diseasesconcomitant diseases..

Rashes Rashes in case in case of viral of viral hepatitihepatitis s

Icteric Icteric sclerasclera

Skin Skin jaundicejaundice

Skin jaundiceSkin jaundice

Criteria for without jaundice form Criteria for without jaundice form of viral hepatitis :of viral hepatitis :

1.1. Concrete epidemiological data (contact Concrete epidemiological data (contact with patient or parenteral manipulations, with patient or parenteral manipulations, which according to time are similar to which according to time are similar to maximum incubation periodmaximum incubation period););

2.2.Typical prodromal periodTypical prodromal period;;3.3.Presence of hepatic splenomegaly Presence of hepatic splenomegaly

syndromesyndrome;;4.4.Brick color of urine Brick color of urine ((lot of urobilinlot of urobilin););5.5.High activity of serum ALTHigh activity of serum ALT;;6.6.Positive data of specific investigation Positive data of specific investigation

((presence of infectious agent’s markerspresence of infectious agent’s markers).).

Signs of cholestatic form of viral Signs of cholestatic form of viral hepatitishepatitis::

1.1. Developed pruritis of skinDeveloped pruritis of skin;;2.2. Mild intoxication or absentMild intoxication or absent;;3.3. Green or grey-green shade of jaundiceGreen or grey-green shade of jaundice;;4.4. Liver has normal sizes or little enlargedLiver has normal sizes or little enlarged;;5.5. Activity of secretary enzymes is elevated Activity of secretary enzymes is elevated

in blood in blood ((alkaline phosphates, alkaline phosphates, gammaglutamiltranspeptidase), quantity gammaglutamiltranspeptidase), quantity of of ββ--lipoproteins, cholesterol and salts of lipoproteins, cholesterol and salts of bile acidsbile acids;;

6.6. Don’t present urobilin in urine and Don’t present urobilin in urine and stercobilin in stoolsstercobilin in stools;;

7.7. Little elevation or normal activity of liver Little elevation or normal activity of liver cell’s enzymescell’s enzymes;;

8.8. Prolonged durationProlonged duration – 3-5 – 3-5 months and months and moremore..

Precursors of liver comaPrecursors of liver coma::1.1. Quick increase of jaundice and Quick increase of jaundice and

intoxicationintoxication;;2.2. Memory disturbancesMemory disturbances;;3.3. Inversion of sleepInversion of sleep;;4.4. Complaints about pain in liver regionComplaints about pain in liver region;;5.5. Liver smell from mouthLiver smell from mouth;;6.6. Elevation in body temperatureElevation in body temperature;;7.7. TremorsTremors;;8.8. Appearance of hemorrhagic syndromeAppearance of hemorrhagic syndrome; ; 9.9. TachycardiaTachycardia;;10.10. Decreasing of liver sizesDecreasing of liver sizes;;11.11. Bilirubin-enzymes Bilirubin-enzymes dissociation;dissociation;12.12. Elevation of nitrogen products Elevation of nitrogen products

concentration in bloodconcentration in blood;;13.13. Decreasing of prothrombin index <Decreasing of prothrombin index <50%;50%;14.14. Appearance of tyrosine and lucien in Appearance of tyrosine and lucien in

urineurine;;

Periods of acute hepatic Periods of acute hepatic encephalopathyencephalopathy: :

Pre-comaPre-coma 1, 2. 1, 2.

1.1. Initial period of precomaInitial period of precoma ( (period of period of precursorsprecursors););

2.2. Finishing period of precomaFinishing period of precoma ( (partial partial disorders of consciousnessdisorders of consciousness); );

ComaComa 1, 2. 1, 2.

3.3. Superficial comaSuperficial coma ( (loss of verbal contact loss of verbal contact with kept reactions on painful with kept reactions on painful irritationsirritations););

4.4. Deep comaDeep coma ( (disappear pain reactiondisappear pain reaction).).

DiagnosticDiagnostic

Preliminary diagnosis of viral hepatitis is Preliminary diagnosis of viral hepatitis is based on epidemiological anamnesisbased on epidemiological anamnesis

finding of the development of the finding of the development of the disease, clinical picture, duration of disease, clinical picture, duration of incubation periodincubation period

character of prejaundice periodcharacter of prejaundice period presence of typical subjective and presence of typical subjective and

objective signs with account of the objective signs with account of the patients agepatients age

DiagnosticDiagnostic

Routine blood test – lymphocytosis, Routine blood test – lymphocytosis, anemia and leucopenia, ESR is anemia and leucopenia, ESR is slightly decreasedslightly decreased

In urine - urobilin and bile pigments In urine - urobilin and bile pigments In blood serum - bilirubinemia In blood serum - bilirubinemia

(direct fraction) increasing activity (direct fraction) increasing activity of ALT, ACT, testifying about the of ALT, ACT, testifying about the presence of cytolytic processes in presence of cytolytic processes in the liver the liver

DiagnosticDiagnostic

Revealing of specific antigens and Revealing of specific antigens and antibodies to antigens in the blood antibodies to antigens in the blood

Discovery of antibodies of class Discovery of antibodies of class IgM testifies about acute diseaseIgM testifies about acute disease

Discovery antibodies of other Discovery antibodies of other classes of immunoglobulins classes of immunoglobulins testifies about chronic course of testifies about chronic course of viral hepatitisviral hepatitis

Differential diagnosisDifferential diagnosis1.1. Influenza Influenza 2.2. Food born toxic infectionsFood born toxic infections3.3. Acute appendicitisAcute appendicitis4.4. LeptospirosisLeptospirosis5.5. Infection mononucleosisInfection mononucleosis6.6. Pseudo-tuberculosisPseudo-tuberculosis7.7. Malaria Malaria 8.8. Toxic hepatitisToxic hepatitis9.9. Pregnancy toxicosisPregnancy toxicosis10.10.Hemolytic jaundiceHemolytic jaundice11.11.Sub-hepatic mechanical jaundiceSub-hepatic mechanical jaundice12.12.Pigmented hepatosisPigmented hepatosis ( ( syndrome syndrome

Zhielber-MailengrkhtZhielber-Mailengrkht, , Krigler-NayarKrigler-Nayar, , Dabin-Jhonsen and RotorDabin-Jhonsen and Rotor))

TreatmentTreatment

Bed regimeBed regime Diet № 5Diet № 5 Polyvitamines (A, B, E)Polyvitamines (A, B, E) Desensitizing drugs: calcium Desensitizing drugs: calcium

gluconate, Diazolin, Diprazin or gluconate, Diazolin, Diprazin or Tavegil Tavegil

Ferment drugs: Festal, Digestal, Ferment drugs: Festal, Digestal, Enzystal, Panzinorm, Pancurmen, Enzystal, Panzinorm, Pancurmen, Allochol, Cholenzym.Allochol, Cholenzym.

TreatmentTreatment Plentiful drinkPlentiful drink In Vein - 5 % solution of glucose, In Vein - 5 % solution of glucose,

saline solutions, Ringer’s solution, saline solutions, Ringer’s solution, Trisault, Quartasault, 20 % solution of Trisault, Quartasault, 20 % solution of Sorbit (or. Sorbitoli), donor AlbuminSorbit (or. Sorbitoli), donor Albumin

Enterosorbents of different brands: Enterosorbents of different brands: Carbaphosfer, Carbosilan, Sillard P, Carbaphosfer, Carbosilan, Sillard P, Enterosgel, Polyphepan Enterosgel, Polyphepan

Drugs for improving of metabolism in Drugs for improving of metabolism in hepatocytes: ascorbinic acid, Thiamin hepatocytes: ascorbinic acid, Thiamin chlorid, pyridoxine hydrochloride, chlorid, pyridoxine hydrochloride, cocarboxylase, potassy Orotat, cocarboxylase, potassy Orotat, Riboxin, Citochrom C, Lipamid, Calcy Riboxin, Citochrom C, Lipamid, Calcy Pangamat Pangamat

TreatmentTreatment::

EtiotropicEtiotropic:: antiviral preparations antiviral preparations (lamivudin)(lamivudin); ; natural interferonnatural interferon ((velferonvelferon, , human leukocytes human leukocytes interferoninterferon,, leukinferon leukinferon); ); recombinant recombinant interferoninterferon ( (intron A, roferon, reaferon, intron A, roferon, reaferon, laferonlaferon); ); inductors of endogenous inductors of endogenous interferon stimulatorsinterferon stimulators ( (cycloferon, cycloferon, amikainamikain).).PathogeneticPathogenetic:: disintoxication disintoxication therapytherapy; ; entero-sorbents, entero-sorbents, immunomodulators methodsimmunomodulators methods; ; glucocorticoidsglucocorticoids; ; hepato-protectorshepato-protectors ((bioflavonoids, analogue of amino bioflavonoids, analogue of amino acids, essential phospholipidsacids, essential phospholipids); ); Symptomatic:Symptomatic: regulators of motor regulators of motor function;function; enzymes preparationsenzymes preparations; ; cholekineticscholekinetics; ; cholereticscholeretics; ; herbal herbal therapytherapy; ; vitamin therapyvitamin therapy..

ProphylaxisProphylaxis Hepatitis А и ЕHepatitis А и ЕMedical observation in epidemic spot during 35 days; laboratory Medical observation in epidemic spot during 35 days; laboratory

examination of contact persons (blood analyses of bilirubin examination of contact persons (blood analyses of bilirubin level, alaninaminotrasferase activity, bile pigments in urine) level, alaninaminotrasferase activity, bile pigments in urine)

Children under 10 and pregnant women - injection of human Children under 10 and pregnant women - injection of human immunoglobuline, for others - amizon, mephenamine acid;immunoglobuline, for others - amizon, mephenamine acid;

Current and final desinfection;Current and final desinfection;Sanitary control measures;Sanitary control measures;Active immunization – HAV-Vax;Active immunization – HAV-Vax;

Parenteral hepatitis (В, С, D)Parenteral hepatitis (В, С, D)Use of disposable medical instruments, thorough sterilisation of Use of disposable medical instruments, thorough sterilisation of

non-expendable non-expendable instrumentsinstrumentsClinical and laboratory examination of blood and organ donors; Clinical and laboratory examination of blood and organ donors; Specific prophylaxis - vaccination against B hepatitis Specific prophylaxis - vaccination against B hepatitis HB-Vax, HB-Vax,

Ingerix-BIngerix-B