Ivan Yeoh

Differential Diagnosis of Viral Hepatitis!

Hepatitis A
Virus Characteristics

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis E

Piconaviridae!
Hepadnaviridae !
Flaviridae!
Single-stranded RNA! Double-stranded
Single-stranded RNA
DNA!
Replication:!
*HbS Ag (hepatocyte
Cytoplasm
receptor)!
*HbC Ag (hepatocyte
nucleus)!
*HbE Ag
(nucleus&blood)!
*HbX Ag

Deltaviridae!
Caliciviridae!
Single-stranded RNA! (+) & (-) RNA!

Route of transmission

Fecal-Oral

Childbirth, needles,
sex, transfusion

Childbirth, needles,
sex, transfusion

Childbirth, needles,
sex, transfusion

Fecal-Oral

Incubation period

15-30 days!
1 month

75 days!
1-6 months

1-6 months!
insidious onset

35 days-1 month!

40-65 days!
(minimum 30 days)

Course of infection

Acute only (due to

adequate immune
response )

95% Acute
5%Chronic

5% Acute!
95% Chronic

Acute (co-infection of
HBV)!
Chronic
(superinfection of
HBV)!

Acute & Self-limiting!

(2-3 weeks)!

Mild-Moderate !
Mortality (0.2%)

Moderate-Severe

Mild-Moderate-Severe!
Genotype 3- severe/
fulminant acute HD!
Mortality (2-20%)!

Mild-Moderate!
*pregnant women
leads to abundant
uterine bleeding ->
death

Severity

Replication:!
Membrane and
Endoplasmic
reticulum

!
!

Envelops: NONE!
EPIDEMIC

Ivan Yeoh
Main Signs/Syndromes

Jaundice!
Flu-like syndrome!
Dyspeptic syndrome!
Asthenic syndrome!
Pale colour of stool!
Hepatomegaly!
Itching (cholestasis)

Intoxication signs
increase after icteric
period (unlike HAV)!
Icteric:!
Flu-like syndrome!
Dyspeptic syndrome!
Asthenic syndrome!
Arthral syndrome!

20-30% Jaundice!
10-30% Non specific
symptoms!
Arthralgia!

6 months- Chronic!
10-20 years- Cirrhosis!
25-30 years- HCC

Intoxication!
Jaundice!
LIver dysfunction!
Flu-like syndrome!
Dyspeptic syndrome!
Asthenic syndrome

Jaundice!
Flu-like syndrome!
Dyspeptic syndrome!
Asthenic syndrome!
Pale colour of stool!
Hepatomegaly!
Itching (cholestasis)!

Severe:!
Fever!
Hemorrhagic
syndrome!
Diagnostic Criteria

1st objective sign:

onset of dark urine!

I: ALT and AST!

(marked cytolysis
during pre-icteric and
icteric phase)!

Hepato&
Splenomegaly!
(normalisation after
3-4 weeks)!

Lympho-monocytosis!

!
!

Dark urine!
(Increased bilirubin)!
Albumin !
(decrease) lead to
cirrhosis

I: ALT!

Chronicity follows
I: Bilirubin!
1-3% co infection!
I: ALT!
Chronicity follows 70%
of superinfection!

Superfinfection- IgM
decreases in a few
weeks, but IgG
persists for 1-2 weeks.!

Ivan Yeoh
Biological Markers

ALT>AST (preictric/
prodromal)!
AST>ALT (toxic
hepatitis)!
*may persist for 2-3
weeks but <4 weeks)!

First incidence!
*IgM AB!
*IgM anti-HAV!
*IgG anti-HAV!

PAST infection!
*IgG anti-HAV

I: ALT!
I: AST!
I: AP!
I: Gamma transferase!
I: Liver enzymes!

HBV DNA
(quantitative marker of
viral replication)!
CORE ANTIGEN!
HbC Ag!
cytotoxic lymphocytes
expressed on
hepatocyte surface
with HLA-A2
molecules!

HbC antibody!
IgM acute!
IgG chronic!
EARLY ANTIGEN!
HbE Ag!
*early appearance
during infective and
replicative period!

HbE antibody!
*decrease by the end
of replication period!
SURFACE ANTIGEN!
HbS Ag!
>6 months!
(chronic infection)!
marker of infectivity!

HbS antibody!
vaccination or
passively acquired Ab!

Anti HCV!
(4-10 WEEKS)!
Detect HCV RNA!
(PCR)

Co-infection:!
HbS Ag!
HbE Ag!
Anti HbC IgM!
Anti HbC IgG!
Anti HDV IgM!
Anti HDV IgG!

Superinfection!
HbS Ag!
Anti HbC IgG!
Anti HbE!
Anti HDV IgM!
Anti HDV IgG!

DO PCR! Because
Anti HDV develops
very slowly

Anti-HEV IgM!
(41st day infection till
2 years)!
HEV RNA !
(22 days)!

FALSE DIAGNOSIS!
Anti-HAV IgM

Ivan Yeoh
Prognosis/Complications

Prolonged jaundice
leads to fever and
pruritus (cholestatic
hepatitis)!

Fulminant HAV (rare)!

*in elderly patient!
severe jaundice!
deterioration of liver
function!
encephalopathy!
Prevention

Passive immunization
of human Ig !
Vaccine

Acute encephalopathy 20% Acute Hepatitis!

70% Chronic Hepatitis!
40% Liver Cirrhosis!
60% HCC!
30% Liver
transplantation

Acute hepatic
encephalopathy!

Vaccine!
Anti-HbS Ag (6
months)!

Vaccination to HBV

3 dose

Absent!
(Mutation is high)!

Fulminant HEV (2-3%)

Endotoxin theory!
Ammonia theory!

Absent

Tx: Detoxification
+Symptomatic
treatment!

!
!

Chronic HCV: Antiviral

drugs and interferon

TREATMENT:!
1. Detoxification therapy:!
Crystalloid- Colloids (3:1)!
Enterogel!
2. Osmotic Diarrhea!
Lactulose!
Duphalac!
3. Low absorption antibiotics!
Aminoglycosides!

!
!
!

*if present of liver encephalopathy, give chilled plasma and amino acid to correct hemorrhagic syndrome, osmotic diarrhea drugs to eliminate
ammonia.