Hepatitis Hepatitis * Definition: Hepatitis is necro-inflammatory liver disease characterized by the presence of inflammatory cells in in the portal tracts then spillover to neighboring parynchmatous liver cells. Normal liver Hepatitis * Causes of hepatitis: 1. Viral: 1. Viral: hepatotropic (A, B, C, D, E.) and non-hepatotropic (cytomegalovirus and Epstein Barr virus). 2. Alcoholic. 3. immune mediated: 3. immune mediated: autoimmune hepatitis. 4. Drug induced. 5. Metabolic disorders: 5. Metabolic disorders: Hemochromatosis (due to iron accumulation) and Wilsons disease (copper accumulation. * Patterns of hepatitis: Acute hepatitis: Acute hepatitis: hepatitis is considered acute if its manifestation persist for period less than six months. Chronic hepatitis: Chronic hepatitis: hepatitis is considered chronic if there is clinical or serological evidence of liver pathology persistent for more than six consequent months. Fulminant hepatitis: Fulminant hepatitis: hepatitis is considered fulminant if massive hepatic cell necrosis happened within few weeks leading to acute hepatic failure and hepatic encephalopathy. Carrier state: Carrier state: is an individual who harbor and can transmit the virus but has no manifest symptoms. Hepatotropic viruses Acute Viral Hepatitis * Etiology: * Etiology: HAV, HBV, HCV, HDV, HEV. * Pathogenesis: Liver cell injury is caused by: Direct cytopathic effect of the virus. Cell mediated immune response (by cytotoxic T lymphocytes). * Clinical course: * Clinical course: 4 stages; a. I.P incubation period. b. Pre-icteric phase: non-specific flu-like constitutional symptoms. c. Icteric phase: jaundice, dark urine, light colored stool & pruritis. d. Convalescence stage: for few weeks. Jaundice * Histopathology of AVH: The normal liver architecture is usually preserved. Inflammatory cellular infiltrate (plasma cells, lymphocytes and neutrophils) inside portal tracts and around foci of necrosis. The hepatocytes show: Apoptosis: the cells appear acidophilic (Councilman bodies). Hydropic degeneration. The cytoplasm is swollen due to increased water content. Steatosis: in hepatitis C. Cholestasis: accumulation of bile inside liver cells and inside canaliculi (bile plugs). Councilman bodies: Councilman bodies: Eosinophilic dead apoptotic liver cells Cholestasis: accumulation of bile inside hepatocytes * Laboratory investigations of AVH: 1. Ultrasound examination to detect any biliary stones, hepatomegaly. 2. Serologic examination to detect : a. Elevated hepatic enzymes as - aspartate aminotransferase (AST) - alanine aminotransferase (ALT). b. Viral markers as HBVs Ag, HCV Antigen and Antibody. c. Autoantibodies as in case of autoimmune hepatitis. d. Polymerase chain reaction (PCR) to identify the virus. Chronic hepatitis * Clinical picture of Chronic hepatitis: Often asymptomatic and is commonly diagnosed on blood tests performed either for screening or to evaluate nonspecific symptoms. Non-specific symptoms such as malaise, tiredness and weakness and jaundice. On abdominal examination: enlargement of the liver * Histopathology for chronic hepatitis: I. Portal tracts show: a. Piece meal necrosis: necrosis of the hepatocytes at the limiting plate. b. Portal tract inflammation: Inflammatory cells; lymphocytes, macrophages with occasional plasma cells. Lymphoid follicle formation (with HCV). Bile duct inflammation (with HCV). Hepatitis C II. The hepatocytes show: Fatty change (with HCV). Focal necrosis surrounded by inflammatory cells. Bridging necrosis: with progressive hepatitis. Dysplasia (precancerous). Ground glass appearance of hepatocytes (with HBV). represent accumulations of viral antigen in the endoplasmic reticulum. III. Fibrosis & Cirrhosis. * Grading of chronic hepatitis: * Grading of chronic hepatitis: assessment of the degree of activity of the virus; may be minimal, mild, moderate or severe. * Staging of chronic hepatitis: * Staging of chronic hepatitis: by assessment of the degree of fibrosis; ranges for 0 to 6. the 6 th stage means cirrhosis. Histopathology show lymphoid aggregates and fatty change of the hepatocytes, which are characteristically seen in chronic hepatitis C infections Histopathology show ground glass hepatocytes, which are seen in chronic hepatitis B infections represent accumulations of viral antigen in the endoplasmic reticulum. Fibrosis and cirrhosis Thanks