VIRAL HEPATITIS ARTICLE - QUIZ INSTRUCTIONS Participants who complete the Quiz found on the last two pages of this Lecture will receive a certificate of credit for one CME hour.

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Instructions:

Read this article Go to the Quiz at the end of the article and print off the Quiz. Answer the required number of questions correctly Fax to (876)946-0954 with this page and indicate your method of payment

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CHECK ONE:

c Cash c Credit Card: Card number _______________________Exp. date: ______ Name as it appears on card:______________________________________ c Certified Cheque - Deposit to: (NCB -Jamaica Ltd. Brown's Town Branch a/c# 716409325

Viral Hepatitis A to G

M. G. Lee MB,BS;DM;FRCPC;FACP;FACG

Viral Hepatitis Virus primarily affects liver

1. HAV 2. HBV 3. HCV (nonA nonB) 4. HDV (delta) 5. HEV 6 - 7. HGV

Viral Hepatitis

Incubation Period HAV -- 15 – 50 d HBV -- 50 -150 HCV -- 42 - 56 HDV -- occurs with HBV HEV -- 40 d

Viral Hepatitis

Clinical Features 1. Incubation Period 2 Prodromal Preicteric 3. Icteric 4. Convalescent

Viral Hepatitis

Prodromal Phase ( 3d – 3 wks) Acute non-specific symptoms Anorexia Nausea Vomiting Fever Headache Malaise Myalgia Photophobia R upper abdo pain

Jaundice Phase (1 – 4 weeks)

Prodromal symptoms diminish Jaundice Pale stools. Dark urine Hepatomegaly (80%) Splenomegaly (20%)

Convalescent Phase Well – being improve progressively Weakness, easy fatiguability may persist Clinical, biochemical recovery – 6 months

Viral Hepatitis

Many have sub-clinical infection -- asymptomatic -- non-specific illness Jaundice occurs in minority

Viral Hepatitis Diagnosis

Preicteric Leucopenia, Lymphopenia Atypical lymphocytes Liver Function Tests -- bilirubin variable -- alkaline phosphatase mildly ↑ --- transaminases elevated

Treatment Symptomatic, supportive measures Bed rest Normal diet No Alcohol – 6 months Majority recover

Viral Hepatitis A Transmission : fecal - oral

Viral Hepatitis A

Clinical Features 1. Incubation Period (15 – 50d) 2 Prodromal Preicteric 3. Icteric (10%) 4. Convalescent (complete recovery

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Viral Hepatitis A Diagnosis

Stool Culture

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late incubation

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early prodromal Anti – HAV - IgM

Hepatitis B DNA virus

Hepatitis B - Transmission • • • •

Vertical Close contact – family members Sexual Blood – transfusion - needlestick - contaminated instruments - IV drug abuse

Hepatitis B High Risk Individuals

Promiscuous heterosexuals Homosexuals IV drug abusers Partners of HB patient

High Risk Individuals

Health care personnel - contact blood Dentists Patients -- neonates HB+ mother -- hemodialysis -- frequent transfusions -- immunosuppressed patients -- mental institution

Hepatitis B infection

Clinical Features 1. Incubation Period (50 – 150d) 2 Prodromal Preicteric 3. Icteric (50%) 4. Convalescent (90% recover)

Serological Events

1. HBsAg -- 2 – 8 weeks before illness 2. HBeAg -- transient DNA polymerase 3. Anti HBc -- persist 4. Anti HBsAg

Fulminant Hepatitis

Massive hepatocellular necrosis Related to enhanced immune response Hepatic encephalopathy Coma Liver shrinks rapidly High mortality

Cholestatic Hepatitis Prolonged course jaundice (6 months) Pale stools Dark urine Pruritus Good prognosis

Hepatitis B infection Chronic Carrier

HBsAg positive after 6 months 10% will not clear virus Impaired immunity Male:Female – 6:1 0.1% - NA. UK 3% Greece 10% Africa 15% Far East

Hepatitis B infection Chronic Sequelae

1. Chronic carrier 2. Chronic persistent hepatitis 3. Chronic active hepatitis 4. Cirrhosis 5. Hepatocellular carcinoma

Hepatitis B infection Prevention

1. Passive immunization - HB immune globulin -- needle stick, neonates, 2. Active immunization - HB vaccine

Hepatitis C

Hepatitis C

Most common, important etiology --- chronic liver disease

Hepatitis C Transmission

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Blood transfusion IV drug use Tatooing Acupuncture Dialysis

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Health care workers Sexual Vertical Household

Hepatitis C Acute Incubation - - 50d Most asymptomatic Symptoms mild, non-specific -- fatigue, fever, arthralgia -- 25% jaundice

Hepatitis C Diagnosis

Elevated ALT -- May fluctuate in chronic HC infection Hepatitis C antibody -- Positive 1 – 3 months after acute HC -- 2 nd generation anti-HCV pos in acute hepatitis Hepatitis C RNA

Hepatitis C Sequelae

Chronic Hepatitis -- 75% after acute HC Cirrhosis -- 20 – 30% (20 years) Hepatoma (30 years) -- ↑ HBV, alcohol

Hepatitis D Delta hepatitis

Hepatitis D Delta virus

Defective RNA virus Requires HBV - - protein cover HBV patient 1. Co-infect 2. Super-infect

Hepatitis D Clinical Features

1. Acute Delta Hepatitis - acute HBV infection 2. Acute Delta Hepatitis - chronic HBV infection 3. Chronic Delta Hepatitis - chronic HBV infection

Hepatitis D Clinical Features

More severe illness More rapid progress

Hepatitis E Single stranded RNA virus Incubation : 40 days

Hepatitis E Transmission - Faecal – oral Infection highest - 15 – 40 years

Hepatitis E

Disease mild, self-limiting - No chronic sequelae Mortality Pregnant Women -- 20%

Hepatitis E Diagnosis Prodromal: serum HEV – RNA Jaundice : stool HEV – RNA HEV – IGM HEV - IgG

Hepatitis G

Hepatitis G

Flavivirus Transmission Blood transfusion IV drug abuse Sexual Vertical Dialysis Sporodic

Hepatitis G

Mild acute illness -complete clinical, biochemical resolution 75% persistent HGV infection - no chronic liver disease

Post- Lecture Quiz

*Participants who complete the Quiz for this Lecture will receive a certificate and credit for one CME hour.*

Directions: Print and complete the Quiz found on the following pages of this lecture.

When complete, fax the Quiz to the attention of Miss Maureen Phillips, Secretary-CCFP at 946-0954

3.

(a) (b) (c) (d) (e) 1.

(a) (b) (c) (d) (e) 2.

(a) (b) (c) (d) (e) Name: Address: Contact Tel #: Post- Lecture Quiz ______________________________ ______________________________ ______________________________ Please answer the following 5 questions. Each question has a main statement and five stems each of which is either True or False.

Viral Hepatitis A h as an incubation period of 5 to 10 days leads to most cases becoming icteric usually has complete recovery can be detected by stool cultures in the late incubation phase is transmitted by the fecal-oral route High risk individuals for Hepatitis B include partners of Hep B patients homosexuals individuals undergoing hemodialysis patients on cholesterol lowering drugs promiscuous heterosexuals Cholestatic hepatitis in Hepatitis B infection presents with a transient (5 -10 days) of jaundice symptoms include pale stools produces pruritus has a worse prognosis only occurs if the liver was previously damaged Continued on next page….

Post- Lecture Quiz

(cont’d)

4.

(a) (b) (c) (d) (e) 5.

(a) (b) (c) (d) (e) Hepatitis C infection is mostly asymptomatic can present with fatigue and fever can produce an acute arthritis increases subsequent risk of hepatoma produces elevated ALT Hepatitis E infection is transmitted in a similar way to Hepatitis B usually produces a mild self limiting disease can have up to a 20% mortality in pregnant women is also caused by a DNA virus like Hepatitis B infection is highest in the 15 to 40 year age group You have come to the end of the Quiz. Please print off the Quiz and fax to the attention of Miss Maureen Phillips, Secretary-CCFP at 946-0954 along with a processing payment of US$10. Your certificate for one CME hour credit will be sent to you as soon as possible.