HEPATITIS

Rizki Yaruntradhani Pradwipa, MD, B. Med. Sc

Ilmu Penyakit Dalam
FKUI/ RSUPN Cipto Mangunkusumo
 Chronic Hepatitis
Chronic hepatitis is arbitrarily defined as any
acute inflammatory process of the liver
persisting for more than 6 months.
Clinical manifestation of liver cirrhosis
 Twenty five % clear
 Fifty % dubious
 Twenty five %
asymptomatic
 cirrhosis complication
coma
jaundice
spider naevi bone marrow change
pectoral alopecia
esophageal varices
gynecomastie
splenomegaly
liver damage
caput medusae
altered hair-distribution ascites
ascites

palmar erythema

testicular atrophy

anemia
anemia
leukopenia
thrombocytopenia

hemorrhagic tendency

odema odema
Increasing of
SGOT/SGPT/GGT,bilirubin
LFT alteration: CHE,
Phosphatase alkaline,
albumine, globuline
Viral persistency : HBs Ag,
HBV DNA, HBeAg, anti-
HCV, HCV RNA
Autoimmune
 Diagnostic test
USG
Liver biopsy
Peritoneoscopy
CT scan
Endoscopy (esophagoscopy)
MRI
Two tests that are very important

For liver cirhosis :

1. Enzyme Ratio de Ritis > 1,
2. USG.
For LCC : 1. AFP
2. USG
Acute Hepatitis : Enzyme Ratio de Ritis < 1
Specific Sero marker :
IgM anti-HAV, IgM anti-HBc
Hepatitis B

Acute hepatitis B

Icteric Non-icteric ‘Healthy’ carrier

Cure Fulminant Chronic hepatitis

‘e’ Ag +ve
Reactivation
e Ag -ve

Cirrhosis
(inactive)

Hepato-cellular
carcinoma
 Hepatitis C Akut

Ikterik Non-ikterik Pengidap sehat?

Sembuh Hepatitis C Hepatitis C kronik

Kronik

HCVRNA +
Reaktivasi
HCVRNA - Koinfeksi

Sirosis
A B HIV
Inaktif

Karsinoma Progresif ?
hati
 Hepatitis C: Natural History

• Mostly asymptomatic (~ 90%)

• Chronicity up to 80%, no correlation with genotype

• Progresivity to chronic hepatitis was vary

 Type of Hepatitis and Its Therapy

Hepatitis
A Anti viral -
B
C Therapy Anti Viral
D
E Anti Viral -
G
TT Anti Viral ?

Modified Hoofnagle 1994; Linnen et al. 1996

 The goal of HBV treatment
Short term

 Seroconversion HBe Ag(+)  Anti HBe(+)

 Seroconversion HBVDNA(+)  HBVDNA(-)
 Normalization SGPT/SGOT
 Seroconversion HBsAg (+)  HBsAg (-)
 Therapy of
Chronic Hepatitis B
 Immunomodulator : - Interferon alpha
- Peg-IFN
- Thymosin a 1
- Vaksin terapeutik
 Viral Supressor : Analog Nucleosida
- Lamivudine
- Adefovir
- Entecavir
 Therapy of hepatitis B
 Lamivudine 100 mg/ day for 1 year
 Interferon alpha 3 mu sc for 6 months
 Combination of lamivudine and interrferon
alpha
 Pegylated interferon
 The Goal of Hepatitis C
Treatment

Short term
• HCV RNA (-)
• To diminish liver inflammation: SGOT,
SGPT become normal
• To prevent fibrosis
 Long term goal of treatment

• To clearance the virus

• To diminish liver inflammation

• To prevent fibrosis

• To prevent liver cancer and

other complication
, (Caferon® )
 Hepatitis C treatment

Standard: Interferon alpha 3 m unit, 3 times weekly

+ Ribavirin 800 - 1200 mg/day for 6 months or
0ne year

Induction : Interferon alpha 3 m unit daily for 4 weeks

followed by 3 times weekly for 20 weeks
+ Ribavirin 800 - 1000 mg daily

Sulaiman A dkk, 2000

 Virologic Response After
6 Mo of Treatment With Interferon
a a
Patients (%)

US International Combined
Complementary and Alternative Medicine
(CAM)
 Naturopathy
 Homeopathy
 Acupuncture
 Chiropractic
JAMU JAWA
 Healing or therapeutic touch
 Massage
 Traditional or Chinese Medicine
 Ayurveda
 Special diets: Gerson therapy diet, dll
 Dietery supplement

Rock CL. AGA Postgraduate Course May 19-20,2011

Herbal or its derivative in
Indonesia
 Temulawak
 Silimarin
 Glisirizin
 Schisandrin C
 Imreg
 BRM
E B Keeffe and others. A Treatment Algorithm for the Management of Chronic Hepatitis B Virus
Infection in the United States. Clinical Gastroenterology and Hepatology 2: 87-106. 2004.
E B Keeffe and others. A Treatment Algorithm for the Management of Chronic Hepatitis
B Virus Infection in the United States. Clinical Gastroenterology and Hepatology 2: 87-
106. 2004.
B Keeffe and others. A Treatment Algorithm for the Management of Chronic Hepatitis B Virus Infection in
the United States. Clinical Gastroenterology and Hepatology 2: 87-106. 2004.
B Keeffe and others. A Treatment Algorithm for the Management of Chronic
Hepatitis B Virus Infection in the United States. Clinical Gastroenterology and
Hepatology 2: 87-106. 2004.
Clinical Signs of Hepatic Encephalopathy

Mental status disorders

Clinical Signs of Hepatic Encephalopathy
E.E.G. change

Flapping tremor
Davidson’s Classification of H. E.
STAGE MENTAL STATE FLAPPING BRAIN
TREMOR WAVES

I Euphoria, occasional depression, Tendency for

(Prodrome) slow mentation , arrhythmic sleep (±) - (+) slow wave
II Euphoria, disorientation, (++) Slow wave,
(Impending dyscalculia, mental confusion, rhythmic high
Coma) able to follow physician’s instruct- voltage & wave,
ions triphasic wave
III Delirium, excitement , drowsiness (++) Disappearance
(Stupor) (arousable) , unable or refuses of dominant rhythm;
to follow physician’s instructions rhythmic high
voltage & wave,
triphasic wave
IV Unconsciousness ,
(Semicoma (+) / (-) reaction to noxious stimuli (-) Flattening
or Coma)
 Presipitating Factors
• Infection .
• GIT bleeding : oesophageal and gastric
varices , gastro -duodenal erosions .
• Electrolyte imbalance : large
paracenteses , diuretic .
• Constipation .
• Large protein meal .
• Drugs : sedative
,acetaminophen,alcoholism.
Ref.:Sheila Sherlock , James Dooley : Hepatic Encephalopathy, 1993,9 th ed, 86-101
 PATHOGENESIS OF HEPATIC
ENCEPHALOPATHY

Hypothesis :

- Hyperammonemia

- False Neurotransmitter

- GABA (Gamma Amino Butyric Acid)

1. Fischer, J.E, Bernardini P, Amino Acid Imbalance and Hepatic
Encephalopathy : Ann.Rev.Nutr. 1982,2;419- 454
2. Steven Schenker,MD,Charles E.Brady,III,MD,Pathogenesis of Hepatic
Encephalopathy ; 43- 61