Acute viral hepatitis (AVH): diagnosis and medical treatment

2021-07-22 10:47 PM

Acute viral hepatitis, a common infectious disease, especially in developing countries, is caused by hepatitis viruses, causing inflammation and necrosis of liver cells

Acute viral hepatitis is a systemic infection that mainly affects the liver. It is usually caused by a virus known as liver disease (hepatitis A, B, C, D, and E). Other viral infections can also sometimes affect the liver, such as cytomegalovirus (CMV), herpes simplex, coxsackievirus, and adenovirus. Whereas hepatitis A and E are self-limiting, infection with hepatitis C and, to a lesser extent, hepatitis B often becomes chronic.

Acute viral hepatitis is a common infectious disease, especially in developing countries, caused by hepatitis viruses that cause inflammation and necrosis of liver cells. Currently, 5 different hepatitis viruses have been identified, namely A, B, C, D, E. In which, hepatitis A, B, and E viruses often cause acute hepatitis, especially hepatitis B virus or when hepatitis B virus is present. Viral coinfection can cause severe manifestations such as fulminant hepatitis.

Virological features of hepatitis viruses

Board. Virological characteristics of hepatitis viruses

 

Virus partials

Shape

Gene

Classification

Antigen

antibody

Note

HAV

27nm

no shell

ARN

Picornavirus

HAV

Anti-HAV

HAV sheds feces prematurely. AHV A class IgM anti-HAV(+). Pre-existing HAV infection IgG anti-GAV(+)

HBV

42mm

has two shells

ADN

Hepadnavirus

HBcAg

HBcAg

HBeAg

Anti-HBs

AVH B acute: IgM anti-HBc(+)

HBV proliferation:HBeAg(+), ADN-HBV high

HBcAg detected only on liver biopsy

HBsAg(+) > 95% in AVH acute

HCV

40-60pmm

has shell

ARN

Flavivirus

HCV

C100-3

C33c

C22-3

NS5

Anti-HCV

AVH C acute: Anti HCV (C33c,C22-3,NSS), ARN-HCV

AVH C acute: anti-HCV(C100-3.C33c,C22-3,NSS) and ARN-HCV

HDV

35-37nm

Shell is HBsAg

ARN

Viroid/ Satellite

HBsAg

HDV Ag

Anti HBs

Anti-HDV

 

HEV

32-37nm

No shell

ARN

Calicivirus

HEV Ag

Anti-HEV

AVH acute:IgM anti-HEV(+)

* (HAV: Hepatitis A virus, HBV: Hepatitis B virus, HCV: Hepatitis c virus, HDV: Hepatitis D virus, HEV: Hepatitis E virus)

Board. Clinical and epidemiological characteristics of different types of viral hepatitis

 

Characteristics

HAV

HBV

HCV

HDV

HEV

Incubation(day)

15-45 avg.30

30-180,avg.60-90

15-160,avg.50

30-180 avg.60-90

10-60,avg.40

Onset

Acute

smoldering or acute

smoldering

smoldering or acute

acute

Age

children and young people

youth, infants, children

all age, almost aldult

similar HBV

youth

(20-40)

Spread way

Digest

+++

No

No

No

+++

Blood

No

+++

+++

+++

No

Mother-Child

No

++++

+/-

+

No

Sex

No

++

+/-

++

No

 

Characteristics

HAV

HBV

HCV

HDV

HEV

Clinical

Acute

Minor disease

sometimes serious

average

rarely serious

Minor disease

Acute

0,1%

0,1-1%

0,1%

5-20%

1-2%

Chronic

No

1-10%

Infant 90%

85%

commonly seen

No

chronic disease carrier

No

0,1-30%

1,5-3,2%

Change

No

Cancer

No

+

+

+

No

Prognosis

Good

 Bad by ages

Average

Acute, good, chronic, bad

Good

Prevent

IG

Vaccine

HBIG

Vaccine

No

Vaccine HBV

No

In acute viral hepatitis, the clinical presentation is very variable, may be asymptomatic with elevated transaminases, may be symptomatic with yellowing of the skin and eyes, or the most dangerous manifestation is the fulminant form. Depending on the clinical form, there are symptoms:

Clinical

Typical body

Incubation period:

Lasts from a few weeks to a few months depending on the virus.

Period of onset (pre-jaundice):

Patients present with mild fever, fatigue, loss of appetite, nausea, vomiting, right upper quadrant pain, then dark yellow urine and yellow eyes. Symptoms of fever will disappear when the patient appears yellow eyes.

Full-blown period (also called jaundice):

Yellow skin, yellow sclera, yellow sublingual mucosa. Dark urine, small amount.

The liver is big and light, soft, pressing.

Usually, this stage lasts for 1 month, then the symptoms subside and the patient appears to have a lot of urine, the disease is stable.

Recovery period:

Jaundice reduced appetite, clear urine, a large amount.

Clinical forms

Acute or subacute atrophy of the liver: occurs mainly in HBV, HDV, and HEV infections, very rarely due to HAV if present, usually in people with pre-existing chronic liver disease. In pregnant women infected with HEV, about 20% have fulminant hepatitis.

The disease occurs when the prothrombin ratio falls < 60% with neurological disorders.

Based on the time of appearance of neurological signs, people are divided into 3 types:

Fulminant: from the onset of illness to the appearance of neurological signs in one week.

Acute: neurological signs appear in the first month.

Subacute: neurological signs appear after 1 month.

Symptom

Jaundice is very dark, breath smells of the liver, liver turbidity is small. Neurological signs are divided into 3 degrees:

Grade I: the patient may change personality, difficult to recognize clinically if the doctor does not pay attention.

Grade II: the patient is forgetful, lethargic, and loses memory.

Grade III: showing coma, agitation, struggling, increased muscle tone.

Laboratory tests: AST (aspartate aminotransferase), ALT (alanine aminotransferase) is elevated, bilirubin is elevated mainly directly. Coagulation factors are severely reduced, the prothrombin ratio is sometimes less than 10%.

Patients may present with bleeding on the skin or internal bleeding.

Subclinical

Blood tests

Blood count: white blood cells and platelets normal.

Liver function tests:

AST, ALT increased 5 times higher than normal values, sometimes up to thousands of u/l/37°C.

Hyperbilirubinemia > 17 mmol/l, mainly direct bilirubin.

Serum albumin is normal, decreased in severe cases.

Coagulation: the prothrombin ratio is normal or decreased, in severe cases, it is less than 60%, possibly <10%.

Serum test:

During the acute phase of hepatitis, serological markers appear corresponding to the antigen type.

Acute HBV infection: the appearance of anti-HBc IgM (+).

Infect HAV: anti HAV IgM (+).

Infect HCV: anti HCV (+).

HDV infection: anti HDV (+).

Infect HEV: anti-HEV IgM (+).

Liver ultrasound

There is no localized lesion.

Differential diagnosis

It must be distinguished from all other cases of jaundice:

Sepsis

Infectious state: high fever, chills, sweating, lethargy.

Enlarged liver and spleen.

Laboratory tests: elevated white blood cells, especially polymorphonuclear neutrophils.

Blood culture identifies bacteria.

Severe malaria complications

Epidemiological factors: living or visiting malaria-endemic areas.

Continuous high fever, anemia.

Blood test for malaria parasites.

Gallbladder infection due to stones

Fever, infection.

The white blood cells are increased, and ultrasound shows gallstones or in the liver.

Acute hepatitis is caused by other viruses

Like Dengue virus, Cytomegalovirus, Epstein-Barr virus: in addition to the symptoms of acute hepatitis, there are also symptoms of infection with those viruses.

Treatment

Common acute viral hepatitis

Acute viral hepatitis caused by hepatitis viruses A, B, D and E has no specific indications for drug treatment, mainly symptomatic treatment and rest. Acute hepatitis caused by the hepatitis C virus has specific indications for treatment (see also guidelines for the diagnosis and treatment of hepatitis C).

Drugs that should be avoided in the acute phase: corticosteroids, alcohol, estrogen.

Non-specific therapies:

Infusion: using isotonic solutions: glucose 5%, ringer lactate, sodium chloride 0.9%, ...

B vitamins such as B1, B6 and B12 orally or intramuscularly.

Liver tonic: leverteen, legalon, ...

Infusion of drugs: L-ornithin-L-aspartate 2 - 4g/day.

Diuretics: chophytol, sorbitol, MgS04.

Protein solution for patients with liver disease (without aromatic amino acids):

Morihepamine intravenous infusion.

In severe cases, hypoalbuminemia: Human albumin 20% infusion 50ml x 1-2 vials/day depending on the degree of albumin reduction.

Rest and nutrition regimen:

Plays a very important role in acute viral hepatitis.

Drink glucose.

Eat foods rich in nutrients, protein, and sugar.

Drink the ceiling, eat the fruit.

Rest, avoid labor or strenuous work.

Follow:

Patients infected with acute hepatitis virus, with the following signs need to be hospitalized urgently for monitoring and treatment to avoid turning into severe hepatitis (hepatic coma).

Intense fatigue.

Can't eat, vomit a lot.

Hemorrhagic manifestations.

Consciousness disorder.

Respiratory disorder.

Cardiovascular collapse...

Severe hepatitis (acute and fulminant liver atrophy)

Non-specific therapy: same as usual.

Respiratory resuscitation:

Breathe oxygen, suction sputum, and a safe side position.

Ensure circulation: replenish water and electrolytes.

Neutralize NH3 in the blood:

Infusion of solutions containing arginine or ornithine converts toxic NH3 into a neutral non-toxic salt.

L-ornithine-L-aspartate 3 - 6g/day intravenous infusion.

When prothrombin ratio < 60%:

Fresh frozen plasma infusion: 250 - 500ml/day until prothrombin ratio > 60%.

Vitamin K 10mg X 2 ampoules/day IM or IV, stop when prothrombin ratio > 60%.

Anti-constipation:

Sorbitol 2g X 2-4 sachets/day or duphalac 15ml X 2-4 packs/day orally.

Antibiotic:

Amoxicillin 2g/day, neomycin 3g/day, ciprofloxacin 1g/day in 2 divided doses for 10-14 days or other antibiotics depending on indications such as cefoperazone, ceftazidime,...

Diet:

Protein abstinence, nasogastric tube feeding through the tube.

Absolute bed rest.

Liver transplantation is the best measure to increase survival for patients with fulminant hepatitis.

Prevention

HAV and HEV

Food hygiene is the most necessary measure.

Use vaccines with HAV.

HBV and HDV

HBV vaccination: all cases if possible. However, it should be noted:

Children born to mothers with HBsAg (+), especially with HBeAg (+), need to receive Y immunoglobulin and hepatitis B virus vaccine.

Medical staff.

People who are in frequent contact with someone infected with HBV.

Patients with kidney failure are at risk of requiring hemodialysis.

Teenager.

Prostitutes.

Test blood and blood products before use.

Use a disposable syringe.

Use a condom when having sex with an HBsAg carrier.

HCV

There is currently no vaccine.

Use preventive measures:

Test blood and blood products before use.

Use a disposable syringe.

Do not inject drugs.