Hepatitis PROPHYLAXIS and Hepatitis TREATMENT and Management

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.

Hepatitis TREATMENT

Hepatitis PROPHYLAXIS and Hepatitis TREATMENT and Management

 

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.
Hepatitis TREATMENT Contraindications:
  • Mouse IG, egg, or neomycin allergy
  • Pregnancy/breast-feeding
  • Decompensated liver disease
  • Renal failure
  • Untreated psychiatric disease
  • Corticosteroid use
  • Uncontrolled autoimmune disease
  • DDI in HIV patients (substitute comparable agent)
  • •Precautions:
    • Disorders of coagulation
    • Seizures
    • Anemia, myelosuppression
    • Depression/suicidal ideation; psychiatric clearance and monitoring recommended
    • Retinopathy (diabetic/hypertensive). Needs ophthalmology clearance and monitoring

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
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