Hepatitis PROPHYLAXIS and Hepatitis TREATMENT and Management

Hepatitis PROPHYLAXIS

• Prevention is through immunization

Hepatitis A prophylaxis

• Passive immunization with IG
• Active immunization with killed vaccines
• 1. Passive immunization is given before exposure or during early incubation period.
• 2. Post exposure prophylaxis – 0.02 ml/kg IgG is given after exposure as soon as possible. It is effective up to 2 weeks after exposure.
• 3. If a person is traveling to developing countries 0.02 ml/kg IgG is given.
• 4. For more than 3 months- 0.6 ml/kg is given ev­ery 4 months.
• 5. Vaccines of HAV are safe and effective and pro­tection lasts about 20 yrs.

Hepatitis B prophylaxis

• 1. Passive immunoprophylaxis with IgG – hepatitis B immune globulin.
• 2. Active immunization with recombinant vaccine
• 3. For pre-exposure prophylaxis 3 intramuscular deltoid injections of hepatitis B vaccine are given at 0, 1 and 6 months. The injection is not given in the gluteal region. All the children up to the age of 18 yrs m ust be vaccinated.
• 4. All the persons at risk of exposure to blood must be vaccinated.
• To recombinant hepatitis B vaccines are:
• 1. Recombivax HB – 10 ~gm of HBsAg
• 2. Engerix B – 20 ~gm of HBsAg
• Protection after vaccination is for approximately 10 years.

Hepatitis D prophylaxis

• Hepatitis D is prevented by vaccination with hepatitis . B vaccine.

Hepatitis C prophylaxis

• IG is ineffective.
• Hepatitis C is prevented by :
• 1. Screening of all blood donors.
• 2. Avoid contact with infected persons’ secretions and blood .
• . 3. Hepatitis C patients should not share tooth­brushes, nail clippers, razors.

Hepatitis E prophylaxis

• Recombinant vaccine is under trial.

PROGNOSIS of Hepatitis

• Hepatitis A patients recovers completely.
• In hepatitis B healthy adults recovery completely. In hepatitis B prognosis is bad if :
• · Patient is aged
• · Patient has ascites
• · Peripheral edema
• · Hepatic encephalopathy
• · Prolonged PT
• · Low serum albumin
• · Hypoglycemia
• · High serum bilirubin
• Such patients must be hospitalized. Hepatitis C is less severe than hepatitis B.
• In patients of hepatitis Band D mortality is higher than other types of hepatitis.

COMPLICATIONS AND SEQUELAE of Hepatitis

• In hepatitis A there may be a relapse after weeks or months.
• In hepatitis A there may be cholestatic hepatitis. But hepatitis A is self-limited.
• In hepatitis B there may be a serum sickness like syndrome with arthralgia high fever, rash, an­gioedema, proteinuria, hematuria. ALT and AST are elevated. Serum HBsAg is positive.
• In hepatitis C there may be porphyria cutanea and lichen planus.
• Most serious complication of viral hepatitis is fulmi­nant hepatitis or massive hepatic necrosis. It is seen in hepatitis B, D and E, Most common in hepatitis B and rarest in hepatitis E.
• Fulminant hepatitis is common in pregnancy.
• In fulminant hepatitis there is encephalopathy, con­fusion, disorientation, somnolence, ascites, edema, cerebral edema, GI bleeding, sepsis, respiratory fail­ure, altered consciousness, small liver, increased PT, increased bilirubin level, (but SGOT, SGPT may fall), cardiovascular collapse, renal failure and death. When patients go into deep coma, mortality is very high.
• Liver transplant may be life saving in fulminant hepa­titis.
• 10% of patients remain positive for HBsAg for more than 6 months after acute hepatitis B. 50% of these become HBsAg negative in some years.
• Acute hepatitis B leads to chronic hepatitis and there is persistent anorexia, weight loss, fatigue, hepatome­galy, bridging hepatic necrosis, high bilirubin and SGPT levels more than 6 months and upto 1 year.
• Rare complications are pancreatitis, myocarditis, aplastic anaemia, transverse myelitis, peripheral neu­ropathy, hepatocellular carcinoma.
• Hepatitis Band C is common in HIV patients.

Hepatitis TREATMENT

Treatment of Acute Attack of Hepatitis

• In hepatitis B, if patient was healthy before acute hepatitis, recovery occurs in 99% persons.
• No antiviral therapy required.
• Some physicians like to give in acute hepatitis B, Lamivudine 100 mg/day oral.
• In hepatitis C recovery usually does not occur and it progresses to chronic hepatitis.
• In such cases antiviral therapy with interferon alpha 5 million units subcutaneous daily for 4 weeks then 3 times a week for another 20 weeks· results in nearly 100% response.
• For chronic hepatitis C long acting pegylated in­terferon plus Ribavirin is given.
• Patients with chronic hepatitis C are rare.
• In health workers who get hepatitis C due to contaminated needles therapy should be started immediately.
• Most patients of acute hepatitis do not require hospital admission. Physical activity should be restricted.
• High calorie diet is given especially in the morn­ing.
• If patient has vomiting, IV fluids are given for severe itching (pruritus), Cholestyramine the bile salt binding resin is given.
• Steroids (glucocorticocoid) should not be given. Isolation of patient is not required except if :
• 1. Patients have fecal incontinence
• 2. Severe bleeding in hepatitis Band
• 3. Hepatitis C patients with bleeding.
• Gloves should be used by all those handling stools of hepatitis patients.
• Gloves should be used for people handling blood and body fluids of hepatitis Band C patients.
• Hands should be washed thoroughly when nurs­ing hepatitis patients.
• Patients’ are discharged from hospital when:
• 1. There is symptomatic relief
• 2. Serum aminotransferase (AST and ALT) falls down ‘
• 3. Serum bilirubin falls down
• 4. Prothrombin time returns to normal.

MANAGEMENT OF FULMINANT HEPATITIS

• 1. Maintain fluid balance
• 2. Support of circulation
• 3. Support of respiration
• 4. Control of bleeding
• 5. Treat hypoglycemia
• 6. Management of comatose patient
• 7. Diet – protein restriction, plenty of carbohydrates
• 8. Oral lactulose or neomycin
• 9. Therapies like sterOid, exchange transfusion,
• plasmapharesis are not effective.
• 10. Liver assist devices are under trial
• 11. Intensive care management
• 12. Liver transplantation gives excellent results.

Complementary & Alternative Hepatitis Therapies

• No medical evidence exists for using herbal or alternative therapy in HCV/cirrhosis/HCC
• Milk thistle (silymarin) generally safe and may reduce ALT but does not eradicate virus nor improve outcomes; avoid while on IFN.
• Rate of HCC tripled in patients on herbal therapy compared to IFN therapy