SEMINAR- GIT MODULE

ACUTE AND CHRONIC HEPATITIS

Saroj Jayasinghe
Professor in the Department of Clinical Medicine
ACUTE AND CHRONIC HEPATITIS

Aetiology and clinical classification

Clinical presentations
Acute hepatitis
Infections (Hepatitis A virus, HBV , Hepatitis E)
Toxins and drugs (alcohol, paracetamol overdose,
INAH)
Autoimmune
Other disorders (Wilsons)

Chronic hepatitis
Infections (HBV and HCV)
Autoimmune
Toxins and drugs (alcohol, INAH)
NASH (non-alcoholic steatohepatitis)
Other disorders (Wilsons)
Acute hepatitis
Infections (Hepatitis A virus, HBV , Hepatitis E)
Toxins and drugs (alcohol, paracetamol overdose,
INAH)
Autoimmune
Other disorders (Wilsons)
 Acute virus hepatitis

Paracetamol toxicity:

Alcoholic steatohepatitis

Zonal necrosis is present around

central veins (V)

hepatocytes near portal areas (P)

remain viable
FEATURES COMMON TO AN ACUTE HEPATITIS
 FEATURES COMMON TO AN ACUTE HEPATITIS

Acute onset and short duration of symptoms

Fever (virus, alcohol, autoimmune)
Malaise, anorexia
Discomfort or pain over RHC
Dark urine
Jaundice
Pruritus , pale stools
 ACUTE HEPATITIS
VIRUSES
Virus hepatitis (A, E, B): anorexia, vomiting, nausea, few
cervical LN, tender soft hepatomegaly

TOXINS
ALCOHOL
..............

PARACETAMOL OVERDONE
History, jaundice, RHC discomfort, bleeding manifestations,
encephalopathy

AUTOIMMUNE
Autoimmune hepatitis: acne, hair pattern, other features of
autoimmune disease
DIAGNOSIS
Clinical features, history (paracetamol, alcohol)
Elevated enzymes
Serological tests in the case of virus hepatitis (HBsAg, Anti-HAV IgM)

Liver biopsy rarely done

PROGNOSIS
Acute liver failure
Development of cirrhosis in alcohol, cirrhosis

MANAGEMENT
Corticosteroids in severe acute alcohol hepatitis
N-acetylcysteine (NAC) infusions or methionine in paracetamol overdoes
Symptomatic treatment (avoid NSAIDs)
Supportive care
Follow-up for evidence of chronicity in alcohol and HBV
CHRONIC HEPATITIS
 CHRONIC HEPATITIS
Chronic hepatitis
Infections (HBV and HCV)
Autoimmune
NASH (non-alcoholic steatohepatitis)
Toxins and drugs (alcohol, INAH)
Other disorders (Wilsons)
Chronic HCV
Small lymphocytes admixed with
plasma cells (arrowheads).
In contrast to primary biliary cirrhosis
(PBC) bile ducts are intact (arrow). The
type and amount of chronic
inflammation does not differentiate AIH
from a chronic virus hepatitis

NASH
FEATURES COMMON TO A CHRONIC HEPATITIS

Incidental finding (asymptomatic)

Insidious (may follow an acute episode, e.g. Hep B)
Prolonged elevation of liver enzymes
waxing and waning in Hepatitis C
Hyper-gammaglobulinamia (AIH)
Longer duration of illness
Features of chronic liver disease
Decompensated liver disease, portal hypertension
Oedema, ascites, jaundice, spider naevi, palmar erythema..
Encephalopathy
Varices, haematemesis, malaena
 HEPATITIS B or C virus infection
Maybe a past history of transfusions,
promiscuity, tattooing, IVDU
Systemic symptoms of long duration
Symptoms of liver disease of long duration
Prolonged jaundice
Features of liver failure, portal hypertension
Features of encephalopathy
Features of liver disease manifesting during an
acute illness such as pneumonia
 AUTOIMMUNE HEPATITIS

Females and Cushings like features (rare)

Other autoimmune diseases:
skin rashes as in SLE, arthritis, RTA, kerato-conjunctivitis,
thyroiditis
Systemic symptoms of long duration
Symptoms of liver disease of long duration
Prolonged jaundice
Features of liver failure, portal hypertension
Features of encephalopathy
Features of liver disease manifesting during an
acute illness such as pneumonia
 AUTOIMMUNE HEPATITIS
Previously known as Chronic Active Hepatitis

Hyper-gammaglobulinamia (AIH)
Three main types based on auto-antibodies
ANA, Anti Smooth Muscle Antibodies
Anti liver/kidney microsomal antibodies
Antibodies against soluble liver antigen

All can progress to cirrhosis

DIAGNOSIS
Clinical features
Elevated enzymes
Low albumin and high globulin
Auto-antibodies in the case of autoimmune hepatitis
Serological tests in the case of virus hepatitis (HBsAg, Anti-HCV)
DNA levels in Hepatitis B

Liver biopsy

PROGNOSIS
Development of cirrhosis

TREATMENT
Corticosteroids or Azathioprine in autoimmune hepatitis
Interferon-alpha, Lamivudine for Hepatitis B
Pegylated interferon, Ribavarin for Hepatitis C
Follow up biopsy
Liver transplant
 NASH
A type of Nonalcoholic fatty liver disease (NAFLD)
Macrovascular steatosis with neutrophilic inflitration, Mallory
bodies (almost indistinguishable from alcoholic liver disease)
Asymptomatic
Metabolic syndrome, diabetes, obese
Hepatomegaly
Elevated enzymes
Progresses to cirrhosis
Weight loss, exercise, restriction of dietary fat and sugar
Vitamin E, metformin, pentoxyfylline, ursodeoxycholic acid
 SUMMARY
Overview of acute and chronic hepatitis
Several causes of acute and chronic hepatitis
Aetiology and clinical presentation varies
Individual diseases: subsequent lectures