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Transcript of Chronic hepatitis
Chronic hepatitisChronic hepatitisin childrenin children
BYBYDr. Tai Al AkawyDr. Tai Al Akawy
Senior pediatrician at Alexandria Senior pediatrician at Alexandria University Children’s HospitalUniversity Children’s Hospital
الرحمن الله الرحمن بسم الله بسمالرحيمالرحيم
Chronic hepatitisChronic hepatitisBased on Nelson text book of pediatrics Based on Nelson text book of pediatrics
and many online articles that will be and many online articles that will be mentioned mentioned
on the slideson the slides
LiverLiver Diseases Diseases
DEFINITIONDEFINITION
The term chronic hepatitis means The term chronic hepatitis means ongoing inflammation of the liver ongoing inflammation of the liver
persisting for persisting for more than six more than six monthsmonths that is detectable by that is detectable by biochemical and histologic biochemical and histologic
means. means.
Clinical featuresClinical features
-Depend on pathology & aetiology -Depend on pathology & aetiology --Mild illness Mild illness with dyspepsia & with dyspepsia &
variablevariable increase in liver enzymes without increase in liver enzymes without
evidenceevidence of chronic liver disease of chronic liver disease --Florid progressive Florid progressive illness with illness with evidence of chronic liver disease.evidence of chronic liver disease.
DiagnosisDiagnosis
Elevated transaminasesElevated transaminases
Minimal elevation of alk. Phos.Minimal elevation of alk. Phos.
Hepatic dysfunctionHepatic dysfunction - serum bilirubin- serum bilirubin - serum albumin- serum albumin - P.T.- P.T. Liver biopsyLiver biopsy
Chronic hepatitisChronic hepatitis OLD CLASSIFICATIONOLD CLASSIFICATION
Chronic persistant hepatitisChronic persistant hepatitis
Chronic active hepatitisChronic active hepatitis
Based on histopathological Based on histopathological distinctiondistinction
1-Chronic persistent 1-Chronic persistent hepatitis (CPH)hepatitis (CPH)
-Chronic inflammatory infiltrate-Chronic inflammatory infiltrate confined to portal tractconfined to portal tract-Spotty necrosis-Spotty necrosis-Normal liver architecture -Normal liver architecture -Cirrhosis is rare -Cirrhosis is rare
2- Chronic active 2- Chronic active hepatitis (aggressive)hepatitis (aggressive)
-Inflammatory infiltrate in portal tract & -Inflammatory infiltrate in portal tract & parenchyma (piece meal necrosis)parenchyma (piece meal necrosis)-Distorted lobular architecture -Distorted lobular architecture -Septa linking portal tract -Septa linking portal tract & C.V& C.V-Subsequent Cirrhosis can -Subsequent Cirrhosis can follow.follow.
PRESENT PRESENT CLASSIFICATION of CLASSIFICATION of
chronic hepatirischronic hepatiris CAUSECAUSE
GRADEGRADE
SEVERITYSEVERITY
CAUSECAUSE Chronic viral hepatitisChronic viral hepatitis
Autoimmune hepatitisAutoimmune hepatitis
Drug induced hepatitisDrug induced hepatitis
Metabolic disorders associated Metabolic disorders associated with CLDwith CLD
GRADEGRADE -Histological -Histological assessment of assessment of
necroinflammatory activitynecroinflammatory activity Portal inflammationPortal inflammation
Periportal Periportal necrosis necrosis
Piecemeal Piecemeal necrosis or necrosis or interface interface hepatitishepatitis
Bridging necrosisBridging necrosis
SeveritySeverity
Level of progression of the Level of progression of the disease based on the degree of disease based on the degree of fibrosis orfibrosis or cirrhosiscirrhosis
CAUSESCAUSES Hepatitis B ,C , DHepatitis B ,C , D Autoimmune hepatitisAutoimmune hepatitis Drug-induced hepatitisDrug-induced hepatitis Metabolic :Wilson's disease ,A 1-Metabolic :Wilson's disease ,A 1-
antitrypsin antitrypsin deficiency ,haemochromatosis, deficiency ,haemochromatosis, glycogen storage disease type IVglycogen storage disease type IV
Hepatitis B Virus
Hepatitis B (HBV) Hepadnaviridae (1970)
Hepatitis B Virus (HBV)Hepatitis B Virus (HBV)
1. Keeffe EB, et al. Clin Gastroenterol Hepatol. 2006;4:936–962.2. Lok AS, McMahon BJ. Hepatology. 2007;45:507–539.
19
HBVHBV : Structure: Structure
20
Hepatitis B VirusHepatitis B Virus
21
Replication of HBV
Epidemiology of Hepatitis BEpidemiology of Hepatitis B
Prevalent in Asia, Africa, Prevalent in Asia, Africa, Southern Europe and South Southern Europe and South America (2-20%)America (2-20%)
Age of infection Age of infection is important in is important in determining the outcome of the determining the outcome of the disease.disease.
Lok AS, et al. Hepatology. 2007;45:507-539.
Chronic Hepatitis B Chronic Hepatitis B InfectionInfection
Infections acquired perinatally and in early childhood usually becomes chronic
Symptomatic Infection
Chronic Infection
Age at Infection
Chronic Infection (%)
Symptom
atic Infection (%)
Birth 1-6 months 7-12 months 1-4 years Older Childrenand Adults
0
20
40
60
80
100100
80
60
40
20
0
Outcome of Hepatitis B Virus Infection
by Age at Infection
Chr
onic
Infe
ctio
n (%
)
Sexual - sex workers and homosexuals are particular at risk.
Parenteral - IVDA, Health Workers are at increased risk.
Perinatal - Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Perinatal transmission is the main means of transmission in high prevalence populations.
Hepatitis B Virus Modes of Transmission
Keeffe EB, et al. Clin Gastroenterol Hepatol. 2006;4:936–962.
Diagnostic Interpretations of Diagnostic Interpretations of Hepatitis B markersHepatitis B markers
HBsAgHBsAg Non infectious component of viral coat
Indicator of disease. If > 6 months: chronic HBV
Anti-HBsAnti-HBs Antibody response to HBsAg
Indicates recovery and/or immunity
HBeAgHBeAg Antigen that correlates with replication and infectivity
High level of infectivity and replication
Anti-HBeAnti-HBe Antibody response to HBeAg
Decreasing level of replicationRemission/resolution
Anti-HBc Anti-HBc IgMIgM
Non protective antibody to the HBcAg
Recent HBV infection
Anti-HBc IgGAnti-HBc IgG As above Remote exposure to HBV
HBV DNAHBV DNA Replictative genetic material of HBV; infectious agent
Viral replication and continues infection
Diagnostic Interpretations of Diagnostic Interpretations of Hepatitis B markersHepatitis B markers
HBsAgHBsAg Non infectious component of viral coat
Indicator of disease. If > 6 months: chronic HBV
Anti-HBsAnti-HBs Antibody response to HBsAg
Indicates recovery and/or immunity
HBeAgHBeAg Antigen that correlates with replication and infectivity
High level of infectivity and replication
Anti-HBeAnti-HBe Antibody response to HBeAg
Decreasing level of replicationRemission/resolution
Anti-HBc Anti-HBc IgMIgM
Non protective antibody to the HBcAg
Recent HBV infection
Anti-HBc IgGAnti-HBc IgG As above Acute or remote exposure to HBV
HBV DNAHBV DNA Replictative genetic material of HBV; infectious agent
Viral replication and continues infection
Symptoms
HBeAg anti-HBe
Total anti-HBc
IgM anti-HBc anti-HBsHBsAg
0 4 8 12 16 20 24 28 32 36 52 100
Acute Hepatitis B Virus Infection with Recovery Typical
SerologicCourse
Weeks after Exposure
Titre
IgM anti-HBc
Total anti-HBc
HBsAg
Acute(6 months)
HBeAg
Chronic(Years)
anti-HBe
0 4 8 12 16 20 24 28 32 36 52 Years
Weeks after Exposure
Titre
Progression to Chronic Hepatitis B Virus Infection Typical Serologic
Course
HBV ScenariosHBV ScenariosHBsAgHBsAg anti-HBsanti-HBs anti-HBcanti-HBc
IgMIgManti-HBcanti-HBcIgGIgG
HBeAgHBeAg DXDX
++ -- ++ ++ ++
++ -- -- ++ ++
-- ++ -- -- --
-- ++ -- ++ --
-- -- ++ -- --
-- -- -- ++ --
Acute infection
Carrier
Vaccinated
ExposedImmune
AcuteWindow
ExposedAb lost
32
Possible Outcomes of HBV InfectionPossible Outcomes of HBV Infection
Acute hepatitis B infection
Chronic HBV infection
3-5% of adult-acquired infections
95% of infant-acquired infections
Cirrhosis
Chronic hepatitis
12-25% in 5 years
Liver failure Hepatocellular carcinoma
Liver transplant
6-15% in 5 years 20-23% in 5 years
DeathDeath
Chronic Hepatitis B Chronic Hepatitis B Infection in PediatricsInfection in Pediatrics
•Mostly asymptomaticMostly asymptomatic
•Normal growthNormal growth
•Liver damage is mild during childhoodLiver damage is mild during childhood
•Cirrhosis, hepatocellular carcinoma at any age Cirrhosis, hepatocellular carcinoma at any age (rare)(rare)
Zacharakis G. J Pediat Gastr Nutr; 44:84-91.2006
Natural History of Chronic HBV Natural History of Chronic HBV (in children)(in children)
•HBeAb seroconversion rate 55% HBeAb seroconversion rate 55% in 12 yearsin 12 years
•Lower seroconversion in vertical Lower seroconversion in vertical transmision (38.5%) Vs. transmision (38.5%) Vs. horizontal (74%)horizontal (74%)
•Loss of HBsAg seen in 5%Loss of HBsAg seen in 5%
Courtesy of Jerrold R. Turner, M.D., Ph.D.
Hepatitis B Liver BiopsyHepatitis B Liver Biopsy
This patient has cirrhosis due to hepatitis B virus (HBV)
Courtesy of Jerrold R. Turner, M.D., Ph.D.
Hepatitis B Liver BiopsyHepatitis B Liver Biopsy
The portal area is expanded, and the regenerative nodule is encircled by collagen
Courtesy of Jerrold R. Turner, M.D., Ph.D.
Hepatitis B Liver BiopsyHepatitis B Liver Biopsy
Ground-glass hepatocytes represent cells with cytoplasm swollen by viral particles.
Courtesy of Jerrold R. Turner, M.D., Ph.D.
Hepatitis B Liver BiopsyHepatitis B Liver Biopsy
Immunoreactive HBsAg(stained red) is deposited in the cytoplasm
Who to treat?Who to treat?
High ALTHigh ALT Inflammation in biopsyInflammation in biopsy Low HBV DNALow HBV DNA Late acquisition of Late acquisition of
infectioninfection
Better Better Response Response
to to treatmentreatmen
ttMei-Hwei Chang. Pediatric Gastroint Dis. 2004
Children with chronic HBV (HBsAg > 6 months)Children with chronic HBV (HBsAg > 6 months)
Goals of treatment in Pediatric Goals of treatment in Pediatric populationpopulation
Reducing the risk of HBV related Reducing the risk of HBV related cirrhosiscirrhosis and and HCCHCC
Elimination of Elimination of HBeAg HBeAg may may
considerably improve prognosisconsiderably improve prognosis
How to treat?How to treat?
PediatricsPediatrics
IFN-IFN-αα LamivudinLamivudinee
How to treat?How to treat?
PediatricsPediatrics
IFN-IFN-αα LamivudinLamivudinee
AdefovirAdefovirEntecavirEntecavir
Successful response to treatment will result in the disappearance of HBsAg,
HBV-DNA, and seroconversion of HBeAg.
INF-INF-αα Approx 58% of patient show Approx 58% of patient show
responseresponse Advantage:Advantage:
More durable responseMore durable response Lack of resistant mutantsLack of resistant mutants
Disadvantage:Disadvantage: Weekly SC administrationWeekly SC administration Very expensiveVery expensive Adverse reactions:Adverse reactions: Flu-like symptoms, Flu-like symptoms,
depression, anorexia, bone marrow suppressiondepression, anorexia, bone marrow suppression
LamivudineLamivudine
Virologic response in children, 23% Virologic response in children, 23% compared to 13% in placebocompared to 13% in placebo
Ad:Ad: OralOral Well toleratedWell tolerated CheapCheap
Dis:Dis: Less durability of responseLess durability of response Increased risk of drug resistant , 70% by 5 yearsIncreased risk of drug resistant , 70% by 5 years
HEPATITISHEPATITIS - C - C
Courtesy of the C. Everett Koop Institute at Dartmouth
Hepatitis C Virus Hepatitis C Virus (HCV)(HCV)
hypervariableregion
capsid envelopeprotein
protease/helicase
RNA-dependent
RNA polymerase
c22
5’core E1 E2 NS
2NS3
33c
NS4
c-100
NS5
3’
Hepatitis C Virus
Hepatitis C (HCV) Flaviviridae (1988)Structural genes at the 5' end, the non-structural genes at the 3' end
50
HCV replicates exclusively in the cytoplasmvia an RNA intermediate
Nucleus
Viral entry & uncoating
Translation & processing(+)
(+)
(-)
(+)
HCV RNAreplicationVirus particle
assembly Replicativeintermediate
El-Kamary SS. J Pediatr. 143:54-9, 2003.Jonas MM. J Pediatr. 131:314-6, 1997.
Yeung LT. Hepatology. 34:223-9, 2001.
Aletr MJ. N Engl J Med. 341; 556-62. 1999
Prevalence of Hepatitis Prevalence of Hepatitis CC
•1.8% prevalence in US 1.8% prevalence in US
•10,000-60,000 newborn will be 10,000-60,000 newborn will be infected worldwide yearlyinfected worldwide yearly
Prevalence of Hepatitis Prevalence of Hepatitis CC
Genotype Distribution Genotype Distribution of Hepatitis Cof Hepatitis C
Gower E, Estes C, Blach S, et al. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol 2014.
Mode of Mode of Transmission of Transmission of
Hepatitis CHepatitis C•Transfusion of blood or contaminated Transfusion of blood or contaminated products (prior to 1992)products (prior to 1992)
•Use of intravenous drugsUse of intravenous drugs
•SexualSexual
•VerticalVertical (most important among (most important among children)children)
Mast EE. J Infect Dis. 192:1880-1889, 2005
Perinatal Perinatal Transmission of Transmission of
Hepatitis CHepatitis C•3.7% of the infants(born to HCV infected 3.7% of the infants(born to HCV infected mothers) acquired HCV.mothers) acquired HCV.
•Infection rate in HIV positive mothers, Infection rate in HIV positive mothers, 25%25%
Breast feeding and Breast feeding and transmission of Hepatitis transmission of Hepatitis
CC• HCV detected in breast milk and colostrumHCV detected in breast milk and colostrum
• Rate of transmission is identical to bottle-Rate of transmission is identical to bottle-fed infantsfed infants
• Safety based on the absence of traumatized, Safety based on the absence of traumatized, cracked or bleeding nipplescracked or bleeding nipples
Yeung LT. Hepatology.34:223-9, 2001.
Risk Factors for Vertical Risk Factors for Vertical Transmission of Hepatitis CTransmission of Hepatitis C
Breast feedingBreast feeding Vaginal deliveryVaginal deliverydoes not increasedoes not increase vertical vertical
transmissiontransmission
Mast EE. J Infect Dis. 192:1880-1889, 2005
Risk Factors for Vertical Risk Factors for Vertical Transmission of Hepatitis CTransmission of Hepatitis C
Does increaseDoes increase vertical transmission: vertical transmission: Use of internal fetal monitoring Use of internal fetal monitoring
devicesdevices High viral loadsHigh viral loads Prolonged rupture of membranes Prolonged rupture of membranes
(>6 h)(>6 h) HIV co-infectionHIV co-infection
Mast EE. J Infect Dis. 192:1880-1889, 2005
Natural History of Natural History of Hepatitis CHepatitis C
ExposureExposure
No No infectioninfection
AcuteAcuteChronicChronic
SpontaneoSpontaneous us
clearance clearance (early)(early)
•CirrhosiCirrhosis s (20-40%)(20-40%)
•HCC HCC (1-4%/year)(1-4%/year)
<75%<75%
>20%>20%
England K. J Pediatr. 147:227-32, 2005.
Clinical Features of Clinical Features of Hepatitis C in Hepatitis C in
PediatricsPediatrics•Normal growthNormal growth
•Mostly are asymptomaticMostly are asymptomatic
•HepatomegalyHepatomegaly
•Elevated liver enzymesElevated liver enzymes
Diagnosis of Diagnosis of Hepatitis CHepatitis C
HCV HCV antibodies antibodies (IgG)(IgG)
HCV RNA PCR HCV RNA PCR (quantitative/qualitativ(quantitative/qualitative)e)
Initial Initial screeningscreeningDiagnosisDiagnosis
Confirmation of DiagnosisConfirmation of Diagnosis (qualitative)(qualitative)
Pretreatment Pretreatment evaluationevaluationPost treatment Post treatment monitormonitor
Fried MW, et al. N Eng J Med. 2002;347:975-982.
Manns MP, et al. Lancet 2001;358:958-965.
Kelly DA. Hepatology; 34:680A. 2001Wirth S. Hepatology; 36:1280-4. 2002
Davis GL. N Engl J Med; 339:1493-9.1998
McHutchinson JG. N Engl J Med; 339:1485-92.1998
Antiviral Therapy for Antiviral Therapy for Hepatitis CHepatitis C
•Combined PEGCombined PEG Interferon and Interferon and RibavarinRibavarin
•45-62% sustained virological response45-62% sustained virological response•Better responseBetter response
•Ribavirin Side effectsRibavirin Side effects•Anemia/ThrombocytopeniaAnemia/Thrombocytopenia•Fetal malformationsFetal malformations(teratogenic)(teratogenic)
Genotype 2, Genotype 2, 33Low pretreatment viral Low pretreatment viral loadloadYounger ageYounger ageAbsence of cirrhosisAbsence of cirrhosis
Hepatitis C VirusHepatitis C VirusFate of Acute InfectionFate of Acute Infection
15%
Chronic
85%
Spontaneousresolution
Alter MJ, et al. N Eng J Med. 1999;341:556-562.
64
Symptoms
anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
Hepatitis C Virus InfectionTypical Serologic Course
Titre
Months YearsTime after Exposure
Hepatitis C Virus Hepatitis C Virus InfectionInfection
Natural HistoryNatural History
Stable80% (68%)
HCCLiver failure25% (4%)
Slowlyprogressive75% (13%)
Resolved15% (15%)
Acute HCV
Cirrhosis20% (17%)
Chronic HCV85% (85%)
Liver cancer and liver failure occur in 4% of patients who are exposed to HCV over a 20- to 25-year period.
Chronic Viral Hepatitis in Chronic Viral Hepatitis in PediatricsPediatrics
PreventionPrevention
The Good News: Hepatitis BThe Good News: Hepatitis B
(HBV)(HBV)VaccineVaccineHBsAg recombinant DNA technology HBsAg recombinant DNA technology
90%-95% efficacy (anti-HBs titers 90%-95% efficacy (anti-HBs titers >> 10mIU/ml) 10mIU/ml)Long-term protection Long-term protection
Post Exposure Prophylaxis(PEP)Post Exposure Prophylaxis(PEP)Hep B Immunoglobulin(HBIG),passively acquired anti-HBs Hep B Immunoglobulin(HBIG),passively acquired anti-HBs
Infants born to HBsAg+ mothers Infants born to HBsAg+ mothers (HBIG & vaccine, efficacy 95% )(HBIG & vaccine, efficacy 95% )
HBV: ACIP 2005 RecommendationsHBV: ACIP 2005 Recommendations Birth Dose Birth Dose
““For all medically stable infants weighing ≥2,000 grams For all medically stable infants weighing ≥2,000 grams at birth and born to HBsAg at birth and born to HBsAg negative negative mothers, the first mothers, the first dose of HB vaccine should be administered before dose of HB vaccine should be administered before hospital discharge.” hospital discharge.”
ACIP= Advisory committee of immunization practice
HepatitisHepatitis C C Prevention Prevention The Less Good News:The Less Good News:
There is NO effective vaccineThere is NO effective vaccineBUT;BUT;
Spontaneous clearance of HCV can occur in Spontaneous clearance of HCV can occur in 20-30% of acute infections20-30% of acute infections
Immunity against persistent HCV can be acquiredImmunity against persistent HCV can be acquired
England K. J Pediatr. 147:227-32, 2005.
Prevention HCVPrevention HCVImmune Correlates of Viral ClearanceImmune Correlates of Viral Clearance
Humoral Immunity Humoral Immunity Neutralizing antibodies, in vitro, are not necessary for Neutralizing antibodies, in vitro, are not necessary for
resolution of HCV infection.resolution of HCV infection.
Cellular ImmunityCellular Immunity Vigorous polyclonal CD4+ and CD8+ T-cell responses Vigorous polyclonal CD4+ and CD8+ T-cell responses Weak and narrow in chronically infectedWeak and narrow in chronically infected
HCVHCV Cellular Immune Response in Acute Cellular Immune Response in Acute
InfectionInfection
Bowen and Walker, Nature 2005
HCV Prevention StrategyHCV Prevention Strategy
Increased screening and knowledge of HCV status Increased screening and knowledge of HCV status reduces HCV transmissionreduces HCV transmission
2/3 of people with chronic HCV are not 2/3 of people with chronic HCV are not diagnoseddiagnosed
10% of people with HCV infection have 10% of people with HCV infection have no recognized source for their infection no recognized source for their infection
Hagan 2001 Am J Pub HealthHagan 2001 Am J Pub Health
73
HBsAg
RNA
antigenHepatitis D (Delta) Virus
Hepatitis D (HDV) ? (1977)
Hepatitis DHepatitis D Requires coexistent Hep BRequires coexistent Hep B CoinfectionCoinfection: does not worsen acute : does not worsen acute
Hep B or Hep B or risk for chronic state risk for chronic state SuperinfectionSuperinfection::
– usually develop chronic HDV usually develop chronic HDV infection.infection.
– high risk of severe chronic liver high risk of severe chronic liver disease.disease.
Diagnosis: Anti-HDV IgMDiagnosis: Anti-HDV IgM
75
JaundiceSymptoms
ALT Total anti-HDV
IgM anti-HDV
HDV RNAHBsAg
HBV – HDV SuperinfectionTypical Serologic
Course
Time after Exposure
Titre
76
HBV-HDV CoinfectionPre or post exposure prophylaxis to prevent HBV infection.
HBV-HDV SuperinfectionEducation to reduce risk behaviors among persons with chronic HBV infection.
Hepatitis D - Prevention
Immune disordersImmune disordersAutoimmune disease can affect the Autoimmune disease can affect the hepatocyte or bile duct hepatocyte or bile duct And, is characterized by And, is characterized by The presence of The presence of autoantibodies autoantibodies Increased Increased Ig Ig levels.levels.
DefinitionDefinitionAutoimmune HepatitisAutoimmune Hepatitis
Unresolving inflammation of the liver of unknown Unresolving inflammation of the liver of unknown cause.cause.
Reflect a complex interaction between Reflect a complex interaction between Triggering factorsTriggering factors :Infections, medications, :Infections, medications,
toxins,toxins, molecular mimicry? molecular mimicry? AutoantigensAutoantigens Genetic predisposition:Genetic predisposition:Antigen Antigen
presentation/immunocyte activation, DRB1,presentation/immunocyte activation, DRB1, TNF*2A,TNF*2A, HLA B14, HLA DR3,DR4 HLA B14, HLA DR3,DR4
Immunoregulatory mechanismsImmunoregulatory mechanismsKrawitt. N Engl J Med 2006;354:54
Autoimmune HepatitisAutoimmune Hepatitis Characterized by the presence of interface Characterized by the presence of interface
hepatitis & portal plasma cell infiltration in hepatitis & portal plasma cell infiltration in histological examinationhistological examination
hypergammaglobulinaemia hypergammaglobulinaemia auto antibodiesauto antibodies
Manns et al. Hepatology 2006;43:S132
epidemiologyepidemiology In northern EuropeansIn northern Europeans Annual incidence 1.9/100,000Annual incidence 1.9/100,000 Prevalence 16.9/100,000Prevalence 16.9/100,000 2.6% of liver transplant2.6% of liver transplant Female affected more than males Female affected more than males gender ratio 3.6:1gender ratio 3.6:1
classificationclassification 3 main subtypes3 main subtypes
Based on difference in their Based on difference in their immunological immunological markersmarkers
Czaja et al. Hepatology 2002;36:479
Type 1 AIHType 1 AIH The most common The most common
form of the disease form of the disease worldwideworldwide
Associated with Associated with ANAANA and/or and/or SMASMA
HLA DR3 & DR4HLA DR3 & DR4 Over 70% are female Over 70% are female
and over 40%and over 40% younger age groupyounger age group..
Czaja et al. Hepatology 2002;36:479
Type 2 AIHType 2 AIH More common in More common in
Europe and south Europe and south America.America.
Associated with Associated with anti-anti-LKMLKM
Described in Described in paediatrics patient paediatrics patient but but in Europe 20% are in Europe 20% are adultsadults
Krawitt. N Engl J Med 2006;354:54Czaja et al. Am J Gastroenterol 1995;90:1206
Type 3 AIHType 3 AIH
Is the least Is the least established form of established form of the disease.the disease.
Associated with Associated with anti-SLA/LPanti-SLA/LP
ReclassificationReclassification: Variant type 1 : Variant type 1 AIHAIH
(soluble liver antigen/ liver-pancreas antigen)
Diagnostic criteriaDiagnostic criteria Diagnosis require presence of Diagnosis require presence of characteristics characteristics
features features & & exclusion of other condition that exclusion of other condition that resemble AIHresemble AIH
All patients must be evaluated for All patients must be evaluated for hereditaryhereditary, , infectiousinfectious and and drugdrug induced liver injury. induced liver injury.
Interface hepatitis Interface hepatitis is the histologic hall mark is the histologic hall mark of the syndrome & of the syndrome & portal plasma portal plasma infiltration infiltration typifies the disorder, but typifies the disorder, but neither are specific.neither are specific.
Autoimmune HepatitisClinical Manifestations
Fatigue Fever Jaundice(+/-) RUQ pain Myalgia/arthralgia Anorexia Hepatosplenomegaly Spider angiomata Cushingoid features
Hirsuitism Acne Portal hypertension
– Ascites– Varices– Encephalopathy
FHF HCC Asymptomatic
Desmet et al. Hepatology 1994;19:1513
Autoimmune HepatitisExtrahepatic Autoimmune Diseases
Autoimmune thyroiditis
Grave’s disease Connective tissue
diseases Inflammatory bowel
disease Celiac disease Adrenal insufficiency
Autoimmune hematologic disorders
Type 1 DM Sjogren’s syndrome Fibrosing alveolitis Vitiligo Vasculitis Nephritis
Krawitt. N Engl J Med 2006;354:54Czaja et al. Hepatology 2002;36:479
Interface hepatitis and bridging necrosis in severe type 1 autoimmune hepatitisInterface hepatitis and bridging necrosis in severe type 1 autoimmune hepatitis
Autoimmune HepatitisHistology
Lymphoplasmacytic infiltrate
Interface hepatitis
Portal inflammation and invasion of limiting plate
Plasma cell infiltration of the portal tracts in type 1 autoimmune hepatitisPlasma cell infiltration of the portal tracts in type 1 autoimmune hepatitis
Autoimmune HepatitisCirrhosis to Hepatocellular Carcinoma
Netter’s Gastroenterology, 2nd ed., Elsevier Inc., 2010, all rights reservedHCC
The diagnosis of AIH requires The diagnosis of AIH requires Determination of Determination of elevated aminotransferase elevated aminotransferase
and and gamma globulins gamma globulins Detection of Detection of ANAANA and/or and/or SMASMA or in their or in their
absence, absence, anti-LKManti-LKM liver tissue examinationliver tissue examination
Indications for treatmentIndications for treatment
Czaja et al. Hepatology 2002;36:479
Treatment regimensTreatment regimens
Two regimens comparable with each other Two regimens comparable with each other Prednisone alone orPrednisone alone orlower dose of prednisone in conjunction with lower dose of prednisone in conjunction with azathioprineazathioprineAll patients should be monitored for the All patients should be monitored for the development of drug side effectdevelopment of drug side effect
Czaja et al. Hepatology 2002;36:479Krawitt. N Engl J Med 2006;354:54
Czaja et al. Hepatology 2002;36:479
Autoimmune HepatitisAutoimmune HepatitisDisease RemissionDisease Remission
Disappearance of symptomsDisappearance of symptoms Normalization or near Normalization or near
normalization of AST to < 2 x ULNnormalization of AST to < 2 x ULN GG and bilirubin: normalGG and bilirubin: normal Minimal or no hepatic inflammationMinimal or no hepatic inflammation
10 year survival: 90%10 year survival: 90%Czaja et al. Hepatology 2002;36:479Krawitt. N Engl J Med 2006;354:54
relapserelapse
Relapse is common after drug withdrawalRelapse is common after drug withdrawal Patients Patients should be monitored should be monitored by serum by serum
aminotransferase ,bilirubin and gamma aminotransferase ,bilirubin and gamma globulin levelglobulin level
IBD AS A CAUSE OF IBD AS A CAUSE OF CHRONIC LIVER CHRONIC LIVER
DISEASESDISEASES
Primary sclerosing cholangitis
• PSC is an idiopathic inflammatory disease resulting in intra and extra hepatic biliary strictures and cholestasis
cirrhosis;often assoc.with ulcerative cholitis
• It can occur in infancy and childhood
•This is a cholestatic disease whose etiology is unknown
• This disease differs from primary biliary cirrhosis in that the large bile ducts, the extra hepatic biliary tree ,are affected
Symptoms:FatiguePruritisJaundiceFeverWeight loss
Diagnosis: Liver function tests CT scan Ultrasound ERCP is the diagnostic tool of choice. (Endoscopic retrograde cholangiopancreatography) Liver biopsy
Immunosuppressants and steroids
Ursodeoxycholic acid Endoscopic dilation of dominant strictures, with or without stenting
Treatment
Drug induced Chr. Drug induced Chr. hepatitishepatitis
(Medication-induced liver (Medication-induced liver diseases)diseases)
History of medicines , herbals History of medicines , herbals and alternate medicinesand alternate medicines
Mild to very severe hepatic Mild to very severe hepatic dysfunctiondysfunction
Drug induced chr. Liver DiseaseDrug induced chr. Liver Disease
Idiosyncratic reactionsIdiosyncratic reactions- - Isoniazid, Isoniazid, sodium sodium
valproate, phenytoinvalproate, phenytoin
Cholestatic reactionsCholestatic reactions- - Erythromycin, Erythromycin, phenothiazinesphenothiazines
Acute and chronic hepatitisAcute and chronic hepatitis – – Amiodarone, HIV drugs, Amiodarone, HIV drugs, àà methyl dopa methyl dopa
Discontinuation of the offending drug is the main line of therapy
Metabolic and genetic disorders:Metabolic and genetic disorders: (a) Haemochromatosis(a) Haemochromatosis (b) Wilson’s disease(b) Wilson’s disease (c) (c) αα- antitrypsin deficiency- antitrypsin deficiency (d) Glycogen storage disease type IV(d) Glycogen storage disease type IV
Thank youThank you