Date post: | 22-Aug-2014 |
Category: |
Health & Medicine |
Upload: | mkghoda |
View: | 38 times |
Download: | 14 times |
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