Acute hepatitis

Presented by Dr Dhyey J PandyaModerator : Aabha Nagral

Jaslok Hospital & Research Centre

History

A 12 year old boy, 2nd by birth order admitted with c/o Yellowish discolouration of eyes –20 days Dark yellow urine --20 days Abdominal pain 15 days back which lasted for 3 days Nausea and anorexia

• No h/o fever, bleeding, pruritus.• No family history of jaundice .• No h/o blood transfusion.• Pt had not taken Hep A or B vaccine

• Past history: similar complaints 5 years ago, recovered completely in few days

History

Examination

On Examination Vitals stable Icterus ++ No pallorNo lymphadenopathyNo peripheral stigmata of Chronic liver disease

P/A – no distension /dilated veins umbilicus inverted, soft , non tender.Liver – 3 cm below costal margin, sharp margins, smooth surface, firm in consistency, with left lobe palpable. Liver span 9 cmsSpleen -2 cm, soft.• Rest systemic examination was normal

Examination

Diagnosis

ACUTE VIRAL HEPATITIS

D/D -- Wilson’s disease -- Autoimmune Hepatitis -- Hepatitis B

Chronic liver disease with acute exacerbation

Investigations CBC LIVER FUNCTION SYNTHETIC

FUNCTIONHB 12 ALT 469 TOTAL P 7 GM%

TC 8500 AST 499 ALB 3.8 , GLB 3.2

DC 54/45/1/0 TOTAL BIL 9.5 PT 19/14

APC 3.8 L DIRECT 3.9 APTT 34/30

ALP04 231 INR 1.12

Investigations

• USG Abdomen Hepatomegaly liver 10 cm with normal echo texture. Mild splenomegaly 12 cm PV 8 mmGall bladder wall thickened

Serology

• Anti-HAV IgM –positive • HBsAg - positive • Anti-HCV- negative• Anti-HEV IgM - negative

Diagnosis

• Acute hepatitis A with• Underlying Inactive carrier of hepatitis B or

chronic hepatitis B

Management of acute viral hepatitis

– DIET– HOSPITALISATION– LIVER PROTECTIVE AGENTS

FOLLOW UP INVESTGATIONS13/11 19/11 30/11

T.PROT 7.2 7.0 7.0

ALB 3.6 3.5 3.5

T.BILIRUBIN 5.4 4.2 2.4

D.BILIRUBIN 3.9 1.7 0.8

SGPT/ALT 503 573 102

SGOT/AST 497 443 68

Follow-up

• After 6 months, LFTs normalized completely

• HBsAg remained positive

What next?

Approach of HBsAg +ve patient

Disease activity: ALT/ASTSynthetic function: S.Albumin, Prothrombin time Replicating status: HBeAg, anti HBe, HBV DNA (quantitative)USG Abdomen: Cirrhosis/ Portal Hypertension

How to classify chronic HBV infection?

Chronic hepatitis B

Immune tolerant

(IT)

Immune clearance

(IC)

Lowreplicating

(LR)

e - negative hepatitis

(ENH)

HBeAg+Anti HBe-DNA> 20,000 IU/mlALT< 2 times ULN

HBeAg+Anti HBe-DNA>20,000 IU/mlALT> 2 times ULN

HBeAg-Anti HBe+DNA: <2,000 IU/mlALT< 2 times ULN

HBeAg-Anti HBe+DNA>2,000 IU/mlALT> 2 times ULN

PATIENT ON FOLLOW-UP AFTER 6 MONTHS

• HBeAg – NEGATIVE, anti HBe positive• HBV DNA –1,200 IU/ml• LFT- ALT 34 INR 1.1 USG Normal AST 23 S Alb 3.9

What is the diagnosis and what to do next?

Low replicating or inactive carrierALT monitoring: 6-12 monthly

Treatment of chronic HBV in children

Approved drugs:Interferon, lamivudine, adefovir (children >12 year)Indications:HBsAg > 6monthsALT> 2 times ULNHBeAg+, anti HBe-, HBV-DNA > 20, 000 IU/mlHBeAg- anti HBe+,HBV-DNA>2000IU/mlHistological activity: Liver biopsy active hepatitisAge: > 2 yrs

AASLD 2009. J Pediatr Gastroenterol Nutr 1999: 29; 163-170

How to interpret HBV serology?

• Acute hepatitis B (HBsAg +ve, anti HBcIgM positive)• Chronic hepatitis B (HBsAg+ve > 6m, anti HBcIgG +ve)

• Chronic hepatitis B with reactivation (HBsAg+ve > 6m, anti HBcIgG +ve, anti HBcIgM+ve/-ve)

• Past Hepatitis B and recovered(HBsAg –ve, anti HBcIgG +ve, anti HBs +ve)

• Vaccinated for Hepatitis B(HBsAg –ve, anti HBcIgG -ve, anti HBs +ve)

THANK YOU