Viral hepatitis include a wide range of states, from mild to severe, rapidly progressing forms of the disease; from acute, self-limiting to chronic lesions with the development of cirrhosis and liver cancer.
The greatest threat to public health are viral hepatitis with extraintestinal by transmitting (B, C and D).
When infected with viral hepatitis B adult transition in the chronic form of the disease is observed in 10% of cases, of which 2/3 is formed in a "healthy" carrier of the virus and only in 30% of cases progressing hepatitis.
Infection of hepatitis C, according to most authors, is chronic in 80-90% of cases.
Manifestations of viral hepatitis
Chronic viral hepatitis is generally hidden, and often occur are first detected in step cirrhosis. The most common symptoms of chronic hepatitis are fatigue, malaise, fatigue, decreased appetite, nausea, heaviness in the right upper quadrant. There may be pain in the muscles and joints. Classic "hepatic" symptoms such as jaundice, itchy skin, vascular spiders, redness of the palms and soles are found mostly in the later stages of the disease.
The early stage of chronic hepatitis B are usually completely hidden, reflecting the "indifference" of the immune system to the virus. Chronic hepatitis B is acquired in childhood, occurs decades. The disease can be complicated by superinfection hepatitis C or D, lead to development of cirrhosis and liver cancer.
The high frequency of chronic hepatitis C infection is caused mainly by the characteristics of the virus, and liver disease progression - the characteristics of the host. The development of cirrhosis of the liver occurs in 30% of patients, on average, 30 years after infection. In older men, especially consume significant quantities of alcohol liver cirrhosis is formed faster than in women infected at a young age. Most patients with hepatitis long runs hidden and accidentally revealed by the survey.
Main symptoms caused by liver disease, hepatitis observed in all embodiments.
Diagnostics
Biochemical analysis of blood - the totality of the data on indicators of bilirubin metabolism, serum proteins and Enzymes can detect inflammatory processes occurring in the human body and to assume their localization. These criteria are not specific and do not characterize viral hepatitis, however, essential for the evaluation of liver status.
Qualification bilirubin exchange state based on biochemical analysis of blood, urine and feces. Bilirubin in a healthy person's blood is contained in a concentration of 1,7-17,1 mmol / l and contains the two fractions: insoluble bilirubin is bound to albumin - indirect bilirubin, and soluble glucuronide bilirubin - direct bilirubin. Normally, their ratio is 3: 1. In hepatitis damaged liver cells and thereby reduced production of bile. Furthermore, as a result of damage to the liver bile flows not only in the bile canaliculi, but also in blood. These processes lead to an increase in total blood bilirubin. It should be noted that the bilirubin metabolism to diagnose viral hepatitis play a role only in the development of jaundice. Anicteric form and preicteric phase of viral hepatitis in the majority remain undiagnosed.
Determination of serum aminotransferase activity (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) It is a highly sensitive indicator of the destruction of liver cells that determines its leading role in the diagnosis of hepatitis. To further confirm liver damage can be determined pechenochnospetsificheskih enzyme activity - sorbitol dehydrogenase, fructose-1-fosfataldolazy, urokinase, etc. They localize mainly in the liver cells and their detection in blood is uniquely associated with liver failure.
Install viral nature of hepatitis and to obtain information about its origin is only possible through the identification of serum markers of hepatitis viruses. Such markers include viral proteins (antigens) specific antibodies produced by the body in response to infection, and viral nucleic acids (DNA or RNA) representing its genome.
The basis for the laboratory diagnosis of viral hepatitis B infection is the determination of serum markers of infection with the virus: HBsAg, HBeAg, anti-HBc IgM class and IgGAnti-HBe and anti-HBs, HBV DNA and activity of viral DNA polymerase. Depending on the course of viral hepatitis in the range of changes in serum markers look different.
genodiagnostic methods which include PCR, substantially expanding the laboratory diagnostics of viral hepatitis B, allowing to identify the pathogen directly.
Hepatitis C virus: Screening for HCV using ELISA method, and as a confirmatory test - a method immunnoblota (RIBA).
Detection of serum hepatitis C virus RNA is the "gold standard" for diagnosis. According to WHO recommendations establishing the diagnosis of hepatitis C possible based on triple detection of hepatitis C virus RNA in serum of a patient with no other hepatitis marker. Conducting PCR reveals the hepatitis C virus is not only in the serum, but also in the liver tissue.
Treatment of Viral Hepatitis
Currently, interferon alpha drugs are the most common and best-known antiviral drugs used in the treatment of chronic viral hepatitis. Among more than 20 subtypes of interferon alfa most biologically significant alpha-2 recombinant analogs which are preparations roferonT and intron-AT, as well as domestic reaferonT.
Promising applications of alpha interferon preparations of prolonged action, pharmacokinetics which allows them to be administered one time per week. These are preparations of PEG-intron® and pegasis®.
All of the daily dose of alpha interferon administered subcutaneously or vnutrmyshechno once. The most common early side effect of alpha interferon is flu-like symptoms, especially intense after 1-2 injections. With continued treatment the severity of fever, muscle pain diminishes, but can be saved irritability, anxiety, depressed mood background, slight fever, disorders digestion. For more rare side effects include severe depression, Psychosis, hair loss is reversible after discontinuation of the drug, bacterial infections.
Contraindications to interferon alpha purpose are mental diseases, convulsive disorder, decompensated cirrhosis, severe diseases of the cardiovascular system, decompensated sugar diabetes, Autoimmune diseases, especially thyroiditis.
Prior to treatment is necessary to establish the presence of viral replication, to assess thyroid function, kidneys, cardiovascular system and liver biopsy with features of the activity assessment and fibrosis. Observation during treatment with interferon alpha comprises regular study blood count, platelet count, ALT, AST, GGT levels TSH (On the 6th, 12th month and 6 months after the end of treatment), and in patients with cirrhosis - albumin, bilirubin and prothrombin time (every 2-4 weeks).
Depending on the time of the observed improvement is evaluated early (within 1-3 months after initiation of treatment), direct (on end of treatment), persistent (6 months after treatment) and long (more than 12 months after the end of treatment) response.
Currently, there is a possibility of using nucleoside analogues, the most studied of which is lamivudine (zeffiksT). Lamivudine is taken once daily at a dose of 100 mg orally is due to food intake, and even with long-term use does not cause significant side effects. A combination of lamivudine with interferon alpha increases treatment efficiency and is the most expedient in connection with a fundamentally different mechanism of antiviral action of these drugs.
To overcome the development of viral drug resistance is advantageous to use a combination of lamivudine with other nucleoside analogues (lobucavir, adefovir).
Treatment of chronic hepatitis D is the most difficult. The only effective preparation is interferon alpha administered in doses of 9-10 million IU three times per week for at least 12 months.
Currently, as the "gold standard" treatment of patients with chronic hepatitis C is recommended combination therapy Intron A and ribavirin (rebetolT). Recommended doses - 1000 mg / day. (At a weight <75 kg) and 1200 mg / day. (At a weight> 75 kg). Contraindications to ribavirin therapy are end-stage renal failure, severe anemia and hemoglobinopathies, pregnancy, severe heart disease, uncontrolled arterial hypertension.
The main factors that adversely affect the success of treatment are:
- male gender;
- age over 40 years;
- widespread availability fibrosis and cirrhosis of the liver;
- 1st genotype of the hepatitis C virus;
- the high level of virus in the blood cell count (> 3,5h106 copies / ml).
Patients had no prior treatment with interferon alpha, it is recommended to appoint 3 million IU INTRON-A subcutaneously or intramuscularly 3 times a week or day in combination with Rebetol 1000-1200 mg daily for 6 months, after which you must explore the hepatitis C virus RNA in serum (Twice). If a positive result of continued treatment according to this scheme is not very promising. In the absence of HCV RNA treatment should be continued until 12 months.
