As the patient is 30 years female with normal USG and although significantly raised HBASG- 4557 But there are other factors which need to be considered before starting anti - viral therapy 1.If ALT is 2 times more than normal 2.A significant histological disease 3.HBe Ag negative ( HBV more than 2000 IU / ml 4 HBe Ag positive ( HBV DNA more than 20000 IU/ ml Aim is to prevent progression of disease to cirrhosis, liver failure and HCC In this case - Patient needs a follow up after investigations for LFT , HBeAg testing and if required a liver biopsy for histopathology
Atleast a LFT and CBC is required. But taking the HBV DNA report into consideration that is also likely to be normal. If they are normal, follow up the patient with LFT 6-12 monthly and HBV DNA every 2-3 years. Ask for family screening and vaccination of negative members.
I think Liver biopsy / ALT study /CT Scan study impressions must be reviewd before proceeding further.
High HBSAg titres Long history Chronic active hepatitis . Abdominal ultrasound normal Need to check viral load , antibodies to hepatitis E antigen , core antigen Need hepatologist consultation Antivirals should be started Alcohol history should be asked for.
If viral load is below 40000 SGOT SGPT NOT DOUBL OF NORMAL NO ANTIVIRSL DRUG NEEDED FIBRO SCAN SLSO INDICATED GASTRENTERLOGIST5 OP YOBE CONTINUE
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Case Challenge of the day: A previously healthy 50 y/o male presented with a 2-week history of malaise, anorexia and worsening abdominal pain, which progressed to nausea, vomiting and scleral icterus. He initially attributed his symptoms to an influenza-like syndrome; however, he became alarmed when he developed dark urine and generalized jaundice. The patient had no known personal or family history of liver disease. No history of any medications. He denied any changes in his diet or use of alcohol, tobacco or illicit drugs, but endorsed drinking 4–5 energy drinks daily for 3 weeks prior to presentation. . He did get a tattoo in his 20s, but denied any transfusions of blood products or high-risk sexual behavior. On physical examination, the patient had normal vital signs, scleral icterus and jaundice. Abdominal examination was remarkable for right upper quadrant (RUQ) tenderness, but there was no ascites, asterixis, spider angiomata or other signs of chronic liver disease. Laboratory studies revealed normal renal function. Rest you can see in the image. What do you think is the diagnosis and management of this case? Reference: www.ncbi.nlm.nih.govDr. Shekhar Verma4 Likes32 Answers
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Hepatitis *Hepatitis* refers to an inflammatory condition of the liver. It’s commonly caused by a viral infection, but there are other possible causes of hepatitis. These include autoimmune hepatitis and hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol. Autoimmune hepatitis is a disease that occurs when your body makes antibodies against your liver tissue. ￼ Timeline 8th Century: Infectious Nature of HBV suggested 17th-19th Centuries: Outbreaks of epidemics of jaundice in military and civilian populations during wars 1883: Lurman reports outbreaks of serum hepatitis follwing vaccination of dockers 1908: McDonald postulates that the infectious jaundice is caused by a virus 1939-1945: WWII-A series of outbreaks after vaccination for measles and yellow fever 1947: MacCallum classifies viral hepatitis into two types- Viral hepatitis A—> Infectious hepatitisViral hepatitis B—> Serum hepatitis 1965: Blumberg discovers Australia antigen (HBsAg) in aborigines and shows presence of antigen at high frequency in patients with leukemia and children with Down’s syndrome 1970: Dane discovers the Dane particle (complete HBV particle) 1972: Discovers HBeAg 1973: Feinstone and Purcell identifies HAV 1977: Rizzetto describes delta antigen HDV 1983: Recovery of HEV 1988: Chiron group (Choo, Kuo, Houghton) closes and identifies HCV. 1995: Abbot group reports GB Virus-C (GBV-C) and Genelabs group reports in 1996 hepatitis G virus (HGV)—GBV-C=HGV 1996: Chang’s group at NTUH reports in JAMA the successful prevention of HBV infection by nation-wide vaccination on newborn babies launched in 1984 in Taiwan. 1997: Chang’s group at NTUH reports in NEJM a decrease in annual incidence rate of hepatocellular carcinoma in children ascribed to nation-wide vaccination against HBV on newborn babies launched in 1984 in Taiwan. Epidemiology Globally, viral It was the seventh leading cause of death in 2013, up from the 10th leading cause in 1990. Worldwide, HAV is responsible for an estimated 1.4 million infections annually. About 2 billion people in the world have evidence of past or current HBV infection, with 240 million chronic carriers of HBsAg. HBV, along with the associated infection by the hepatitis D virus, is one of the most common pathogens afflicting humans. HBV leads to 650,000 deaths annually as a result of viral hepatitis–induced liver disease. The worldwide annual incidence of acute HCV infection is not easily estimated, because patients are often asymptomatic. An estimated 71 million people are chronically infected with HCV worldwide. About 55-85% of these people infected progress to chronic HCV infection, with a 15-30% risk of developing liver cirrhosis within two decades. China, the United States, and Russia have the largest populations of anti-HCV positive injection drug users (IDUs). It is estimated that 6.4 million IDUs worldwide are positive for antibody to hepatitis B core antigen (HBcAg) (anti-HBc), and 1.2 million are HBsAg-positive. Types and causes Viral infections of the liver that are classified as hepatitis include hepatitis A, B, C, D, and E. A different virus is responsible for each type of virally transmitted hepatitis. Hepatitis A is always an acute, short-term disease, while hepatitis B, C, and D are most likely to become ongoing and chronic. Hepatitis E is usually acute but can be particularly dangerous in pregnant women. Hepatitis A Hepatitis A is caused by an infection with the hepatitis A virus (HAV). This type of hepatitis is most commonly transmitted by consuming food or water contaminated by feces from a person infected with hepatitis A. Hepatitis B Hepatitis B is transmitted through contact with infectious body fluids, such as blood, vaginal secretions, or semen, containing the hepatitis B virus (HBV). Injection drug use, having sex with an infected partner, or sharing razors with an infected person increase your risk of getting hepatitis B. It’s estimated by the CDC that 1.2 million people in the United States and 350 million people worldwide live with this chronic disease. Hepatitis C Hepatitis C comes from the hepatitis C virus (HCV). Hepatitis C is transmitted through direct contact with infected body fluids, typically through injection drug use and sexual contact. HCV is among the most common bloodborne viral infections in the United States. Approximately 2.7 to 3.9 million Americans are currently living with a chronic form of this infection. Hepatitis D Also called delta hepatitis, hepatitis D is a serious liver disease caused by the hepatitis D virus (HDV). HDV is contracted through direct contact with infected blood. Hepatitis D is a rare form of hepatitis that only occurs in conjunction with hepatitis B infection. The hepatitis D virus can’t multiply without the presence of hepatitis B. It’s very uncommon in the United States. Hepatitis E Hepatitis E is a waterborne disease caused by the hepatitis E virus (HEV). Hepatitis E is mainly found in areas with poor sanitation and typically results from ingesting fecal matter that contaminates the water supply. This disease is uncommon in the United States. However, cases of hepatitis E have been reported in the Middle East, Asia, Central America, and Africa, according to the CDC. Autoimmune Hepatitis Autoimmune hepatitis is a rare form of chronic hepatitis. Like other autoimmune disorders, its exact cause is unknown. Autoimmune hepatitis may develop on its own or it may be associated with other autoimmune disorders, such as systemic lupus erythematosus. In autoimmune disorders, a misdirected immune system attacks the body’s own cells and organs (in this case the liver). Symptoms When symptoms occur, they can include: Jaundice (a yellowing of the skin and eyes)Abdominal painLoss of appetiteNausea and vomitingDiarrheaFeverClay-colored bowel movementsPainful joints ￼ Yellowing of skin and eye ￼ Complications of hepatitis Chronic hepatitis B or C can often lead to more serious health problems. Because the virus affects the liver, people with chronic hepatitis B or C are at risk for: Chronic liver diseaseCirrhosisLiver cancer When your liver stops functioning normally, liver failure can occur. Complications of liver failure include: Bleeding disordersA buildup of fluid in your abdomen, known as ascitesIncreased blood pressure in portal veins that enter your liver, known as portal hypertensionKidney failureHepatic encephalopathy , which can involve fatigue, memory loss, and diminished mental abilities due to the buildup of toxins, like ammonia, that affect brain functionHepatocellular carcinoma, which is a form of liver cancerDeath People with chronic hepatitis B and C are encouraged to avoid alcohol because it can accelerate liver disease and failure. Certain supplements and medications can also affect liver function. If you have chronic hepatitis B or C, check with your doctor before taking any new medications. Diagnosis and test History and physical exam To diagnose hepatitis, first your doctor will take your history to determine any risk factors you may have for infectious or noninfectious hepatitis. During a physical examination, your doctor may press down gently on your abdomen to see if there’s pain or tenderness. Your doctor may also feel to see if your liver is enlarged. If your skin or eyes are yellow, your doctor will note this during the exam. Liver function tests Liver function tests use blood samples to determine how efficiently your liver works. Abnormal results of these tests may be the first indication that there is a problem, especially if you don’t show any signs on a physical exam of liver disease. High liver enzyme levels may indicate that your liver is stressed, damaged, or not functioning properly. Other blood tests If your liver function tests are abnormal, your doctor will likely order other blood tests to detect the source of the problem. These tests can check for the viruses that cause hepatitis. They can also be used to check for antibodies that are common in conditions like autoimmune hepatitis. Ultrasound An abdominal ultrasound uses ultrasound waves to create an image of the organs within your abdomen. This test allows your doctor to take a close at your liver and nearby organs. It can reveal: Fluid in your abdomenLiver damage or enlargementLiver tumoursAbnormalities of your gallbladder Sometimes the pancreas shows up on ultrasound images as well. This can be a useful test in determining the cause of your abnormal liver function. Liver biopsy A liver biopsy is an invasive procedure that involves your doctor taking a sample of tissue from your liver. It can be done through your skin with a needle and doesn’t require surgery. Typically, an ultrasound is used to guide your doctor when taking the biopsy sample. This test allows your doctor to determine how infection or inflammation has affected your liver. It can also be used to sample any areas in your liver that appear abnormal. Treatment and medications Treatment options are determined by which type of hepatitis you have and whether the infection is acute or chronic. Hepatitis A Hepatitis A usually doesn’t require treatment because it’s a short-term illness. Bed rest may be recommended if symptoms cause a great deal of discomfort. If you experience vomiting or diarrhea , follow your doctor’s orders for hydration and nutrition. The hepatitis A vaccine is available to prevent this infection. Most children begin vaccination between ages 12 and 18 months. It’s a series of two vaccines. Vaccination for hepatitis A is also available for adults and can be combined with the hepatitis B vaccine. Hepatitis B Acute hepatitis B doesn’t require specific treatment. Chronic hepatitis B is treated with antiviral medications. This form of treatment can be costly because it must be continued for several months or years. Treatment for chronic hepatitis B also requires regular medical evaluations and monitoring to determine if the virus is responding to treatment. Hepatitis B can be prevented with vaccination. The CDC recommends hepatitis B vaccinations for all newborns. The series of three vaccines is typically completed over the first six months of childhood. The vaccine is also recommended for all healthcare and medical personnel. Hepatitis C Antiviral medications are used to treat both acute and chronic forms of hepatitis C. People who develop chronic hepatitis C are typically treated with a combination of antiviral drug therapies. They may also need further testing to determine the best form of treatment. People who develop cirrhosis (scarring of the liver) or liver disease as a result of chronic hepatitis C may be candidates for a liver transplant . Currently, there is no vaccination for hepatitis C. Hepatitis D No antiviral medications exist for the treatment of hepatitis D at this time. According to a 2013 study , a drug called alpha interferon can be used to treat hepatitis D, but it only shows improvement in about 25 to 30 percent of people. Hepatitis D can be prevented by getting the vaccination for hepatitis B, as infection with hepatitis B is necessary for hepatitis D to develop. Hepatitis E Currently, no specific medical therapies are available to treat hepatitis E. Because the infection is often acute, it typically resolves on its own. People with this type of infection are often advised to get adequate rest, drink plenty of fluids, get enough nutrients, and avoid alcohol. However, pregnant women who develop this infection require close monitoring and care. Autoimmune hepatitis Corticosteroids, like prednisone or budesonide, are extremely important in the early treatment of autoimmune hepatitis. They’re effective in about 80 percent of people with this condition.Azothioprine ( Imuran ), a drug that suppresses the immune system, is often included in treatment. It can be used with or without steroids.Other immune suppressing drugs like mycophenolate (CellCept), tacrolimus (Prograf) and cyclosporine (Neoral) can also be used as alternatives to azathioprine for treatment. Prevention There are many steps you can take to reduce the risk of viral hepatitis: Consider getting vaccinated against hepatitis A and B if you weren’t vaccinated as a child. This is the number one way to prevent these illnesses.Wash your hands with soap and water after using the bathroom or changing a baby’s diaper and before handling food.When traveling in developing countries, avoid unpeeled or raw foods. Drink only bottled, boiled or chemically treated water.Practice safe sex. Hepatitis B is about 50–100 times more transmissible during sex than HIV. Condoms and other barrier methods greatly reduce the risk.Never share syringes, shaving razors, toothbrushes or tattooing or piercing supplies.Wear gloves when performing first aid.Disinfect blood spills (including dried ones) with diluted bleach and wear gloves during clean-up.Follow all occupational safety precautions in your workplace.If you are pregnant, seek early and regular prenatal care. To reduce the risk of non-viral hepatitis, avoid excessive alcohol consumption and consult with a healthcare professional about medications and supplements.Dr. Shailendra Kawtikwar7 Likes25 Answers
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A 22 year old female married for 2.5 months presented to ER with fever since 8 days low to moderate grade, intermittent.and yellowish discolouration of sclera and skin since 3/4 days and altered sensorium since 1 day. On examination: Vitals normal Pallor + Icterus +++ Rest GPE wnl Patient deeply comatosed E1V1M1 No neck rigidity no kernigs. Planter b\l flexor Liver just palpable ( span 11.5 cm) On enquiring her husband and mother, there is history of ayurvedic medicine intake for a month bt that too 2 months back for lump in left breast which seems to be a lipomatous 0.5*0.5 cm swelling. Lmp was 1.5 mnth back. History if rats in house is there. No major prev illness Husband told that she developed rashes on day 1 and 2 and as per description were maculopapular but no scars are seen now. LMP 1.5 month back UPT negative. Leptospira igM sent, hbsag hcv awaited. Reat reports attached. Started ceftriaxone , doxycycline, ppi, emset, ivf, lactulose, rt feed. Kindly give your valuable opinion for further plan.Dr. Rishabh Dixit3 Likes19 Answers
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Friends today I am discussing about Hepatitis. Hepatitis Hepatitis is the inflammation of the liver. The most common cause for hepatitis is viruses. Other causes may include excessive alcohol use, certain medications, toxins, other infections, and autoimmune diseases. Types of Hepatitis Hepatitis is mainly of five types that are caused by a virus, A, B, C, D, and E. These can be commonly determined by a laboratory test. Hepatitis types A, C, D, and E is caused by viruses that have a core of ribonucleic acid (RNA). While virus responsible for hepatitis B has a DNA core. Causes of Hepatitis • Hepatitis A and E are mainly spread by contaminated food and water. Hepatitis A is also called infectious hepatitis as it is very highly contagious disease, but it is rarely fatal. • Hepatitis B spreads through sexually transmission, but may also be passed from mother to baby during pregnancy or childbirth. Hepatitis B is also called as viral hepatitis. It can be severe and often leads to liver cirrhosis. Hepatitis B may commonly transmit through transfusions of contaminated blood. • Both hepatitis B and hepatitis C are commonly spread through infected blood like during sharing of the needle by intravenous drug users. Complications of Hepatitis C can lead to chronic hepatitis, cirrhosis, or liver failure. • Hepatitis D can only infect people already infected with hepatitis B. Hepatitis D is the most serious and also the rarest form of viral hepatitis. Many cases of hepatitis D are fatal, and most chronic cases lead to cirrhosis. • Hepatitis E often occurs in epidemics that can be linked to poor hygiene and contaminated water. Pregnant women can be at risk due to infection by Hepatitis E. The disease has been reported almost exclusively in developing countries. Symptoms of hepatitis Many people with hepatitis experience either mild symptoms or none at all. Symptoms may not occur until liver damage occurs. Acute hepatitis - The initial phase of hepatitis is called the acute phase. The symptoms may include: • Diarrhea • Fatigue • Loss of appetite • Mild fever and flu-like symptoms • Muscle or joint aches • Nausea & Vomiting • Pain in abdominal • Unexplained Weight loss. Chronic hepatitis-- The acute phase is not usually dangerous, but it may develop into the fulminant type of hepatitis which is a very serious stage and can lead to death. As the patient gets worse, these symptoms may follow: • Portal Circulation problems • Dark urine • Dizziness & Drowsiness (only toxic/drug-induced hepatitis) • Enlarged spleen (only alcoholic hepatitis) • Headache • Hives with or without Itching of skin • Clay-colored stool, which may contain pus • Yellow skin, whites of eyes, tongue (jaundice). Complications of Hepatitis Fibrosis - One of the most common complications of chronic hepatitis is fibrosis, which is a type of scarring of the liver. Due to constant inflammation, the liver is damaged and creates the scar tissue to repair itself. Cirrhosis of the liver - Extensive fibrosis is called cirrhosis. There are many causes for Liver cirrhosis, but alcoholic hepatitis and Hepatitis C is the common. Cancer of the Liver - One of the complications of cirrhosis is liver cancer, which are usually two types. First is hepatocellular carcinoma, where liver cells are affected. The other type is cholangiolar carcinoma, which affects the bile ducts. Liver Failure - Liver failure is a serious, but uncommon, complication of hepatitis. In this condition, function of the liver stopped and this leads to the body shutting down, and eventually, death. Glomerulonephritis - Glomerulonephritis is a kidney disorder caused by inflammation of nephrons and is seen in chronic hepatitis B and hepatitis C infections. Cryoglobulinemia - Seen in chronic hepatitis B and hepatitis C infection, cryoglobulinemia is an uncommon disease caused by an abnormal cluster of a kind of protein that blocks small blood vessels leading to circulation problems. Hepatic Encephalopathy - Severe loss of liver function, such as liver failure, can lead to inflammation in the brain called encephalopathy. This causes mental problems, like confusion, and can lead to coma. Portal Hypertension - One of the liver's important jobs is to filter blood. When this portal system is blocked due to liver cirrhosis and other problems, blood can't return to the liver from the digestive system and pressure increases. This is called portal hypertension and it is a serious complication and can be fatal. Porphyria - Porphyria is a group of diseases caused by problems processing important chemicals in the body called porphyrins. One type, called porphyria cutanea tara, leads to blistering of the hands and face and is a rare complication of chronic hepatitis C infection. Viral Co-Infection - A challenging complication of hepatitis is the possibility of having two viral infections at the same time. A common with co-infection with hepatitis is the human immunodeficiency virus (HIV). Other common co-infections are with the hepatotropic viruses, named A through E. This type of Co-infections can be fatal. Diagnosis • Complete blood count • Liver function Test • Laboratory test to identify virus in blood • Bleeding time • Clotting time • Imaging- Ultrasonography, CT- scan, MRI • Liver biopsy Homoeopathy in the treatment of Hepatitis and other liver problem Homeopathy provides a very effective and safe treatment for Hepatitis and other liver disorders. It relieves the discoloration of the skin, mucous membrane, and sclera. These medicines strengthen the liver and metabolic system. The aim of homeopathy is not only to treat Hepatitis infection but It works by treating the underlying cause and not just the symptoms. The treatment is gentle and the relief obtained is usually long term. There are many homoeopathic medicines that have the potential to cure Jaundice. Out of them, few are – Andrographis Paniculata - Useful in resistant jaundice. Useful in Hepatitis B and C. It is found useful when Chelidonium Majus does not help. Arsenic Album - Where hepatitis results from bad food or food poisoning, Arsenic Album is the best Homeopathic medicine. There is burning pain in the liver which gets better with warm drinks. Aurum Metallicum - Very effective for jaundice during pregnancy. Distension of epigastrium with increased thirst and appetite, followed by burning sensation and hot eructations. Carduuas Marianus - Carduus Marianus is a very effective remedy for liver cirrhosis with general edema. There is engorged and laterally swollen liver, which gets worse from pressure. Jaundice. Carica Papaya - Hepatomegaly and splenomegaly associated with fever, dyspepsia and indigestion. Constipation is marked feature of this remedy. Intolerance to milk even small amount may lead to pain. Chelidonium - Chelidonium is very effective in treating an enlarged liver with tenderness. Hepatomegaly with bilious complications. Dull, throbbing pain in the region of the liver is also best treated with Chelidonium. Jaundice due to hepatic and gallbladder obstruction. Pain aggravation on eating. Marked desire for hot food and drinks Chionanthus - Chionanthus is very effective in chronic cases of jaundice, which recur every summer. The symptoms include an enlarged liver, constipation, clay-coloured stools and very yellow skin. Crotalus Horridus - Crotalus Horridus is used to treat jaundice cases where the entire body has gone yellow. Pain in the liver, coldness, Constant nausea and vomiting. Jaundice with haemorrhagic manifestations. Atonic dyspepsia. Complications arise from a blood transfusion. Lachesis - Lachesis is very effective for liver complaints largely among alcoholics. In cases where the liver region is very sensitive and a person can’t bear anything around the waist, Lachesis is one of the most effective Homeopathic medicines for fatty liver. Sensitiveness of right hypochondrium, hazards of blood transfusion. Lycopodium - Hepatitis, the atrophic form of nutmeg liver. Shooting pain across lower abdomen from right to left. Excessive flatulence. Bread aggravates. The desire for sweet and warm things. Natrum Sulpuricum - Natrum Sulphuricum is one of the great Homeopathic medicines for liver problems like jaundice where the symptoms include a liver region that is sensitive, tender and sore to the touch. Vomiting bile is another indicator. Nux Vomica - Hepatitis associated with constipation. Liver enlarged with stitches and soreness. Alcoholic liver. Phosphorus - Acute hepatitis. Fatty degeneration of liver, cirrhosis, and jaundice associated with the pancreatic disease. Suppuration with hectic night sweats, enlargement, and marked soreness. Podophyllum - Chronic relapsing hepatitis. History of repeated jaundice. Pain in right hypochondrium. Not well since the first attack of hepatitis. Irritable temperament with suicidal tendency.Dr. Rajesh Gupta4 Likes14 Answers
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Male/60 yr , c/o - swelling b/L L/L , abdominal fullness , decrease appetite , Usg - ascitis , fatty liverDr. Vishwajeet Kumar2 Likes8 Answers