CHRONIC HEPATITIS

Hepatic inflammation and necrosis continue for at least 6 months

Classification: cause, grade, stage

By Cause

Hepatitis B

Hepatitis B and D

Hepatitis C

Autoimmune Hepatitis

Drug-associated chronic hepatitis

Cryptogenic hepatitis

By Grade

Piecemeal necrosis – periportal necrosis and disruption of the limiting plate

Bridging necrosis –confluent necrosis that forms bridges between portal tracts and central vein

Degree of hepatocyte degeneration

Portal inflammation

Scoring Indices: HAI, METAVIR

Table 300-2

Table 300-2

Chronic Viral Hepatitis

Hepatitis A and E – no chronic forms

Hepatitis B

Hepatitis C

Hepatitis B with superimposed Hepatitis D

Chronic Hepatitis B

Likelihood of chronicity varies with age

Infection at birth: clinically silent but 90% chance of chronic infection

In adults: acute infection associated with clinical symptoms but risk of chronicity is 1%

Liver injury: absent (carriers), mild , moderate, severe

Survival Rates

5 Years

Mild 97%

Moderate-severe 86%

Cirrhosis 55%

15 Years

Mild 77%

Moderate-severe 66%

Cirrhosis 40%

CHB: Clinical features

Broad: asymptomatic debilitating end stage hepatic failure

Fatigue, anorexia

Jaundice (persistent, intermittent)

Ascites, edema

Bleeding varices, encephalopathy, coagulopathy, hypersplenism

CHB: Laboratory Features

Elevated bilirubin levels

Elevated ALT/AST

Alk Phos – marginally elevated

Hypoalbuminemia

Prolongation of Prothrombin time

Lab: hepatitis B markers

HBsAg

Anti HBs

HBeAg: viral replication, infectivity, liver injury

AntiHBe

HBVDNA viral load

Clinical Forms of Hep B

HBeAg + CHB: ALT & HBVDNA elevated

HBeAg – CHB: ALT & HBVDNA elevated (pre-core mutants

Hepatitis B carrier: ALT normal; HBVDNA low or undetectable

Cirrhosis

Past: irreversible

Present: reversible, Chronic Hep C, hemochromatosis

Pathology: hepatic fibrosis architectural distortion with formatiion of regenarative nodules; decrease in hepatocellular mass/function; alteration of blood flow

Survival rate: < 50% in 5 years

Clinical Features

Portal HPN: ascites, variceal bleeding

Loss of hepatocellular: decrease in hepatocellular mass/function, alteration of blood flow

Survival rate: <50 % in 5 years

Alcoholic Cirrhosis

Types: CLD, Fatty Liver, Alcoholic hepatitis, alcoholic cirrhosis

Micronodular type - <3mm

Clinical Features:

Clinical features

RUQ discomfort

Fever

Nausea & vomiting

Anorexia

Malaise

Ascites

Edema

GI bleeding

Hepatomegaly

Splenomegaly

Jaundice

Palmar erythema

Spider nevi

Parotid enlargement

Gynecomastia

Testicular atrophy

Laboratory Investigations

Anemia

Thrombocytopenia

Elevated bilirubin

Prolonged prothrombin time

Elevated AST, ALT

Therapy

Abstinence

Supportive treatment of complications

Steroids

TNF antagonist, Pentoxifylline

Post Necrotic Cirrhosis

Hep B+ CHB 5% Cirrhosis 25%

Hep C+ CHC 80% Cirrhosis 20- 30%

Clinical Features

Labs: Hep B markers, HBVDNA

HCVRNA, genotype

Rx:Interferons, Nucleoside analogues

Interferons, Ribavirin

Clinical features

RUQ discomfort

Fever

Nausea & vomiting

Anorexia

Malaise

Ascites

Edema

GI bleeding

Hepatomegaly

Splenomegaly

Jaundice

Palmar erythema

Spider nevi

Parotid enlargement

Gynecomastia

Testicular atrophy