HEPATITIS

Viral liver infections include six distinct diseases:  Hepatitis A,B,C,D,E and  G   They are similar in many respects but different in their immunological and clinical characteristics.

1. Hepatits A

 Incubation Period:   Between 15 and 50 days, with an average of 30 days before symptoms appear.

Symptoms:  The start of the disease is usually a surprise with fever, malaise, loss of appetite and nausea then after a few days jaundice.

-  Lighter symptoms of the disease may last from one to three weeks.  The              stronger more dangerous symptoms may  last for several months.  In general, the severity of the disease increases with age but the general rule is complete cure without any complications or set-backs.

- The disease usually attacks in  isolated  cases or epidemics which is     higher among children or school age, at camps or in the poorer classes.

 Transmittal of the disease:  The virus is transmitted from contaminated stools to the mouth of the healthy person via food, water, milk, touch or flies.  The affliction becomes more serious as standard rules of personal hygiene are not followed.

Diagnosis:  Hepatitis A is diagnosed via blood by measuring the recently formed antibody HAV Ig M.  It is preferable to measure a few days after jaundice has set in or during increased liver functions in the cases where there is no jaundice.  For information, HAV Ig M may remain positive for a period of six weeks to six months from start of the disease.

2. Hepatitis B (HBV)

Incubation Period:   Incubation period for this virus ranges between 45 and 160 days with an average of 60-90 days
           
Symptoms:  The disease usually starts gradually with loss of appetite,  irregular digestion, nausea, vomiting and sometimes joint pains.  This mostly develops into jaundice.  The severity of the disease ranges between light cases discovered only by the conventional liver functions test, to severely dangerous cases.  In some instances the virus is present in the blood without any clinical manifestations whereas pathological test results of the liver indicate a severe liver infection and in some cases, also  liver fibrosis.

This type of liver infection is more common among adults and is rarely in epidemic proportions.

Transmittal of the Disease:  The disease is usually transmitted by contaminated blood and its derivatives, or through use of contaminated syringes or scalpels, or by means of non sterilized dialysis machines, intercourse, from pregnant mother to fetus or by tattoos.   Moreover, the most exposed group is doctors and nurses, particularly those working in laboratories, surgeons, dentists, drug addicts and promiscuous persons.

Diagnosis:  This type of viral liver disease may be diagnosed by blood tests ( HBs antigen or HBc IgM).

In certain cases, the doctor may resort to use of PCR techniques to measure HBV-DNA in the blood to confirm quick primary results, particularly if these results were negative and do not agree with the clinical symptoms.  Results of these techniques are delivered within one week.

A new method has been used to reveal the presence of the virus inside he liver cells by biopsy and sending the tissue sample to the lab to find out if the liver has been infected by the virus or not (In Situ Hybridisation (ISH) for HBV-DNA).  This test together with histopathology of the liver cells are indispensable to reveal if the liver is suffering from a chronic infection whether active or dormant or if there is fibrosis or malignancy etc.

3-    Hepatitis C  (HCV)

Sources of Infection:

The virus is transmitted through the transfusion of contaminated blood and its derivatives, or contaminated syringes or scalpels, through tattoos, or contaminated medical equipment.  Transmittal of the disease through sexual intercourse or from expectant mother to fetus has so far not been proven 

Incubation Period:

This is the time between a person's infection with the virus and appearance of the symptoms.  This period ranges between two weeks and six months, but is mostly 6-9 weeks.

Symptoms:

These usually are gradual or accompanied by loss of appetite, disturbance of the digestive system, nausea and vomiting then develop to jaundice although not to the same extent as in Hepatitis B.  The severity of the cases range from those discovered by chance upon doing a conventional liver function test to sudden, fatal cases.  Moreover, a percentage of chronic patients suffer from fibrosis of the liver.

Diagnosis:

1. Usually the viral liver infection is discovered by chance when doing a regular check-up.  We find that the liver functions are high.
2. Hepatitis C is usually diagnosed by  measuring  HCV-IgG antibody.  Then a confirmatory test known as LIA is run to reconfirm the results of the positive HCV-IgG.

Note:  If one of the above tests is positive, this only means that the patient has been previously exposed to the virus, and does not indicate that he/she is still infected.  Also, these tests may remain positive for a long time.

 Undoubtedly, the most accurate method for discovery of the virus in the blood is measuring the virus components themselves HCV-RNA by PCR.

Why is PCR testing conducted?

a- To confirm infection after positive LIA
b- For early detection and prior to the formation of any viral   antibodies.
c-  For follow up and post treatment

What does Positive PCR indicate?

It indicates the presence of the virus in the blood.  When the virus is found in the liver cells but not in the blood, the results are negative.  This does not mean the patient has been cured.  If the virus becomes active again and goes to the blood, the test becomes positive one more time and so on.

Why are PCR results contradictory?

Certain labs run PCR without abiding by the conditions and specifications  laid by the International Conference on DNA Engineering held in Australia in 1993, and which prerequisite the following:

a- Laboratories which run these tests must have 3 different rooms assigned only to these tests to prevent contamination.
b- Years of experience of persons working on DNA in medical laboratories.
c- Certain world-known equipment must be available for accuracy of results.
d- The basic substances for running these tests are called primers.  The more of these used, the more accurate and efficient the tests, and consequently the more expensive.  Also, primers must be directed to  generations of the virus found in the Middle East and not just in Europe, USA or Japan.

Follow up response to treatment by:

1- Monthly follow up of liver functions
2-  Transformation of LIA results from positive to negative or from (+++) to (+) in  case of success of the treatment and the patient's response to the drug.
3- Quantitative PCR to determine the extent of the virus in the blood, since the increase or decrease in the virus amount is considered an accurate indicator of response to treatment.
4- A new method for discovering the virus within the liver cells is used by conducting a  liver biopsy and sending the results to the lab to find out if the liver has been infected by the virus or not ( In Situ  Hybridisation (ISH) for HCV-RNA).  This, of course, in addition to examination of the liver cells (Histopathology) are indispensable in knowing if the liver infection is chronically active or dormant.  and, if there is fibrosis or malignancy etc. ….

Does every patient infected with Hepatitis C respond to treatment?

Tests have been introduced to help the treating physician predict the chances of cure, by knowing the type of virus C, since it is recognized that certain types do respond very well to treatment while others do not (HCV genotype & subtype).

· Hepatitis D (Delta Virus):

This disease has an acute onset with symptoms and signs similar to Hepatitis B, and a person must be infected with Hepatitis B to be infected with Hepatitis D.  This infection may terminate on its own or may be transformed into a chronic liver infection.  It may be diagnosed  by measuring Delta antibody in the blood.

· Hepatitis E (HEV):

This virus is transmitted to humans by means of contaminated water, street vendors, those who soil their food with their remains or by means of sanitary  drainage where efficiently operated networks do not exist.

· Incubation period:

Ranges between 15 and 65 days.

Symptoms:

This disease may become an epidemic and the rate of infection  higher particularly among adults and pregnant women in the final three months of their pregnancy.  It  is not common in children or the elderly. Its most important symptoms are nausea, high fever, jaundice and discoloration of the urine.

Diagnosis:

First Step  includes measuring the HEV antibody.
Second Step is confirmatory and includes measuring certain components of the virus itself by (PCR).

Hepatitis G (HGV):

This virus is found  in 12% of the patients infected with Hepatitis C.  Infection is transmitted by contaminated transfusions of blood and its derivatives or by use of contaminated syringes or scalpels.
Diagnosis is made by PCR techniques to measure HGV-RNA..

Prevention of Hepatitis viral infections:

1- Educating the public on the importance of personal hygiene,     particularly washing hands before eating and after going to bathrooms as well as general cleanliness particularly in fighting flies, using correct methods of  collecting and disposing of garbage and waste from hospitals and medical centers.
2- Conducting  periodical physical examinations of street vendors to discover any medical conditions  - it is preferable not to eat any food handled by them.
3- Periodically washing and disinfecting water tanks.
4- Extending sanitary drainage to all residential  areas.
5- Following the same precautions as those against AIDS, since Hepatitis B is transmittable through intercourse.
6- Taking the Hepatitis B vaccine.
7- It is advisable to increase the body's immunity if you are traveling to epidemic areas with preventive doses of Immunoglobulins..
8- It is recommended that a complete laboratory check-up be performed periodically and must include liver functions to discover any early dysfunction, followed by a battery of Hepatitis markers to know the reason for elevated liver enzymes.
Liver function profile
SGPT (ALT), SGOT (AST), Gamma GT, Bilirubin (direct & indirect), Alkaline phospatase, Albumin/Globulin, Prothrombin time