临床表现课件

1、Viral HepatitisDept. of Infectious Diseases SunYat-sen University Q.F.XIE临床表现课件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临床表现课件2IntroductionViral hepatitis arClinical characters including fatigue, intestinal symptoms tender and enlarged liver abnormal LFTs jaundice in some cases very variable in severity临床表现课件3临床表现课件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临床表现课件4SignificanceHighly endemic临床表现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临床表现课件5Etiology-HAVHeparnavirus临床表现课件Anti HAV IgG current or previous infection a protective

5、antibody, conferring immunity persist for life long time临床表现课件6临床表现课件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临床表现课件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临床表现课件8HBsAg临床表现课件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(-) (+)临床表现课件9HBeAg临床表现课件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临床表现课件10HBcAg临床表现课件10HBVDNA the genome of HBV suggesting active virus replication and infectivity useful for diagnosis and evaluation of anti-HBV therapy临床表现课件11HBVDNA临床表现课件11Hepatitis B Virus临

9、床表现课件12Hepatitis B Virus临床表现课件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临床表现课件13Etiology-HCVRNA virus, 6genotyHCVRNA the genome

10、of HCV suggesting replication and infectivity of HCV useful for the diagnosis and evaluation of antivirus treatment临床表现课件14HCVRNA临床表现课件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临床表现课件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临床表现课件16Etiology-HEVNonenveloped RNA vHEVRNA the genome of the virus suggesting existing of HEV infection not available for routine clinical diagnosis临床表现课件17HEVRNA临床表现课件17EpidemiologySource of infection Patients with acut

13、e or chronic viral hepatitis Carriers of hepatitis virus, particularly asymptomatic carriers临床表现课件18EpidemiologySource of infectioTransmission Hepatitis A and E transmitted by the fecal- oral route, water-borne and food-transmitted infection in epidemics临床表现课件19Transmission临床表现课件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 临床表现课件20临床表现课件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%临床表现课件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临床表现课件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临床表现课件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 临床表现课件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)临床表现课件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临床表现课件26Incubation period临床表现课件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临床表现课件27Acute hepatitis临床表现课件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临床表现课件28Jaundice phase临床表现课件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临床表现课件29Convalescent phase临床表现课件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 临床表现课件30Chronic hepatitis临床表现课件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临床表现课件31Jaundice seen in some cases临床表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临床表现课件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 临床表现课件33 liver size become smallCholestati

25、c viral hepatitis acute and chronic mild manifestation but deepen jaundiceHepatitis cirrhosis hepatic fibrosis compensated cirrhosis decompensated cirrhosis临床表现课件34Cholestatic viral hepatitis临床表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临床表现课件35临床表现课件35DiagnosisClinical DataEpidemiological evidencesLaboratory investigationsUltrasoundBiopsy临床表现课件36DiagnosisClinical Data临床表现课件36Differential diagnosisJaundice caused by other etiological agentsHepatitis caused by other etiological agents临床表现课件37Di

27、fferential diagnosisJaundiceTreatmentBasic principles of management guideline for daily living, physical activity , food and drink intake of the patients supportive and symptomatic treatment 临床表现课件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, 临床表现课件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-(