General characteristics of hepatitis a. Viral hepatitis B and C: symptoms, causes, treatment Consequences and prognosis

Viral hepatitis A(Botkin's disease) is an acute infectious lesion of the liver, characterized by a benign course, accompanied by necrosis of hepatocytes. Viral hepatitis A is included in the group of intestinal infections, since it has a fecal-oral infection mechanism. In the clinical course of viral hepatitis A, there are pre-icteric and icteric periods, as well as convalescence. Diagnosis is carried out according to the data of a biochemical blood test, the results of RIA and ELISA. Hospitalization of patients with viral hepatitis A is necessary only in severe cases. Outpatient treatment includes diet and symptomatic therapy.

General information

Viral hepatitis A(Botkin's disease) is an acute infectious lesion of the liver, characterized by a benign course, accompanied by necrosis of hepatocytes. Botkin's disease refers to viral hepatitis, transmitted by the fecal-oral mechanism, and is one of the most common intestinal infections.

Exciter characteristic

The hepatitis A virus belongs to the genus Hepatovirus, its genome is represented by RNA. The virus is quite stable in the environment, persisting for several months at 4 °C and for years at -20 °C. At room temperature, it remains viable for several weeks, dies when boiled after 5 minutes. Ultraviolet rays inactivate the virus after one minute. The pathogen may survive for some time in chlorinated tap water.

Hepatitis A is transmitted by the fecal-oral mechanism, predominantly by water and alimentary routes. In some cases, it is possible to become infected by household contact when using household items, utensils. Outbreaks of viral hepatitis A in the implementation of the water route of infection usually occur when the virus enters public water tanks, the food route of infection is possible both when eating contaminated vegetables and fruits, and raw shellfish that live in infected water bodies. The implementation of the contact-household path is typical for children's groups, where insufficient attention is paid to the sanitary and hygienic regime.

The natural susceptibility to the hepatitis A virus in people is high, the greatest is in children of prepubertal age, post-infection immunity is tense (slightly less tension is characteristic after a subclinical infection) and long. Infection with viral hepatitis A most often occurs in children's groups. Among adults, the risk group includes employees of catering departments of preschool and school nurseries, as well as medical and preventive and sanatorium-resort institutions, food processing plants. Currently, collective outbreaks of infection among drug addicts and homosexuals are increasingly noted.

Symptoms of viral hepatitis A

The incubation period of viral hepatitis A is 3-4 weeks, the onset of the disease is usually acute, the course is characterized by a successive change of periods: pre-icteric, icteric and convalescence. The preicteric (prodromal) period proceeds in various clinical variants: febrile, dyspeptic, asthenovegetative.

The feverish (flu-like) variant of the course is characterized by a sharply developed fever and intoxication symptoms (the severity of the general intoxication syndrome depends on the severity of the course). Patients complain of general weakness, myalgia, headache, dry cough, sore throat, rhinitis. Catarrhal signs are moderately expressed, reddening of the pharynx is usually not observed, their combination with dyspepsia (nausea, loss of appetite, belching) is possible.

The dyspeptic variant of the course is not accompanied by catarrhal symptoms, intoxication is not very pronounced. Patients complain mainly of digestive disorders, nausea, vomiting, bitterness in the mouth, belching. Often there is a dull moderate pain in the right hypochondrium, epigastrium. Perhaps a defecation disorder (diarrhea, constipation, their alternation).

The preicteric period proceeding according to the asthenovegetative variant is not very specific. Patients are lethargic, apathetic, complain of general weakness, suffer from sleep disorders. In some cases, prodromal signs are not observed (latent variant of the preicteric period), the disease begins immediately with jaundice. If there are signs of several clinical syndromes, they speak of a mixed variant of the course of the preicteric period. The duration of this phase of infection can be from two to ten days, on average, the prodromal period usually takes a week, gradually moving into the next phase - jaundice.

In the icteric period of viral hepatitis A, the signs of intoxication disappear, the fever subsides, and the general condition of patients improves. However, dyspeptic symptoms, as a rule, persist and worsen. Jaundice develops gradually. First, darkening of the urine is noted, the sclera, mucous membranes of the frenulum of the tongue and soft palate acquire a yellowish tint. In the future, the skin turns yellow, acquiring an intense saffron shade (hepatic jaundice). The severity of the disease may correlate with the intensity of skin staining, but it is preferable to focus on dyspeptic and intoxication symptoms.

In severe hepatitis, there may be signs of hemorrhagic syndrome (petechiae, hemorrhages on the mucous membranes and skin, nosebleeds). On physical examination, a yellowish coating on the tongue and teeth is noted. The liver is enlarged, moderately painful on palpation, in a third of cases there is an increase in the spleen. The pulse is somewhat slowed down (bradycardia), blood pressure is lowered. Feces brighten up to complete discoloration at the height of the disease. In addition to dyspeptic disorders, patients may complain of asthenovegetative symptoms.

The duration of the icteric period usually does not exceed a month, averaging 2 weeks, after which a period of convalescence begins: there is a gradual regression of clinical and laboratory signs of jaundice, intoxication, and the size of the liver normalizes. This phase can be quite long, the duration of the convalescence period usually reaches 3-6 months. The course of viral hepatitis A is predominantly mild or moderate, but in rare cases, severe forms of the disease are noted. Chronization of the process and virus carrying for this infection are not typical.

Complications of viral hepatitis A

Viral hepatitis A is usually not prone to exacerbations. In rare cases, the infection can provoke inflammatory processes in the biliary system (cholangitis, cholecystitis, biliary tract and gallbladder dyskinesia). Sometimes hepatitis A is complicated by the addition of a secondary infection. Severe liver complications (acute hepatic encephalopathy) are extremely rare.

Diagnosis of viral hepatitis A

In the general analysis of blood, a reduced concentration of leukocytes, lymphocytosis, ESR is increased. Biochemical analysis shows a sharp increase in the activity of aminotransferases, bilirubinemia (mainly due to conjugated bilirubin), a low content of albumin, a low prothrombin index, an increase in sublimate and a decrease in thymol samples.

Specific diagnosis is carried out on the basis of serological methods (antibodies are detected using ELISA and RIA). In the icteric period, an increase in Ig M is noted, and in the convalescent period, IgG. The most accurate and specific diagnosis is the detection of virus RNA in the blood using PCR. Isolation of the pathogen and virological examination is possible, but due to the complexity of general clinical practice, it is impractical.

Treatment of viral hepatitis A

Botkin's disease can be treated on an outpatient basis, hospitalization is carried out in severe forms, and also according to epidemiological indications. During the period of severe intoxication, patients were prescribed bed rest, diet No. 5 (in the version for the acute course of hepatitis), and vitamin therapy. Nutrition is fractional, fatty foods are excluded, products that stimulate the production of bile are encouraged, dairy and vegetable components of the diet are encouraged.

A complete exclusion of alcohol is necessary. Etiotropic therapy for this disease has not been developed, a set of therapeutic measures is aimed at alleviating symptoms and pathogenetic correction. For the purpose of detoxification, a plentiful drink is prescribed, if necessary, infusion of crystalloid solutions. In order to normalize digestion and maintain intestinal normobiocenosis, lactulose preparations are prescribed. Antispasmodics are used to prevent cholestasis. If necessary, prescribe drugs UDCA (ursodeoxycholic acid). After clinical recovery, patients are under dispensary observation by a gastroenterologist for another 3-6 months.

In the vast majority of cases, the prognosis is favorable. With complications from the biliary tract, the cure is delayed, but with false therapy, the prognosis is not aggravated.

Prevention of viral hepatitis A

General preventive measures are aimed at ensuring high-quality purification of drinking water sources, control over wastewater discharge, sanitary and hygienic requirements for the regime at public catering establishments, in the food units of children's and medical institutions. Epidemiological control is carried out over the production, storage, transportation of food products, in case of outbreaks of viral hepatitis A in organized groups (both children and adults), appropriate quarantine measures are taken. Patients are isolated for 2 weeks, their infectivity after the first week of the icteric period comes to naught. Admission to study and work is carried out upon the onset of clinical recovery. Contacts are monitored for 35 days from the date of contact. In children's groups, quarantine is assigned for this time. In the focus of infection, the necessary disinfection measures are taken.

Acute infectious disease, with fever, liver damage. Anthroponosis.

The causative agent of hepatitis A is a virus (HAV, Hepatitis A virus, HAV), first identified by Finestone et al. in 1973; is hepatotropic, has a weak cytopathogenic effect on liver cells. HAV is one of the most resistant human viruses to environmental factors; it can persist for a long time in water, food products, wastewater, and on various environmental objects.

Taxonomy, morphology, antigenic structure: Family Picornaviridae genus hepatovirus. The type species has one serotype. It is an RNA-containing virus, simply organized, has one virus-specific antigen. Currently, it is preferred to classify the hepatitis A virus as a so-called heparnovirus. Hepatitis A virus is small, diameter 27-32 nm, RNA. The virus is simple, has a cubic type of symmetry (icosahedron), RNA (+) stranded, single-stranded. The capsid contains 4 proteins. The hepatitis A virus has only 1 serotype, which makes it easier to diagnose and makes it possible to create a vaccine. The virus is stable in the external environment - it can persist in food, in water, in soil - 1 year, resistant to solvents, to pH from 3 to 9, so it passes through the stomach and duodenum without damage. The virus dies under the action of standard sterilizing agents and factors (autoclaving, air sterilization) and in addition, disinfection by boiling for 30 minutes kills the virus.

Cultivation: The virus is grown in cell cultures. The reproduction cycle is longer than that of enteroviruses, the cytopathic effect is not pronounced. The hepatitis A virus is hardly cultivated in cell cultures of primary trypsinized cells without CPE (cytopathic action), therefore, the method of culturing the virus in cell cultures is not used for diagnosis due to the complexity of cultivation.

Resistance: Heat resistant; inactivated by boiling for 5 min. Relatively stable in the environment (water).

Epidemiology

Viral hepatitis A is widespread in all countries. The transmission mechanism is fecal-oral. The source of infection is the patient, the virus is excreted in the stool. Most of the virus is released at the end of the incubation period (before the onset of clinical symptoms). Large outbreaks have been observed by waterborne transmission (“war jaundice”) and by ingestion of various shellfish that filter organic matter in the water. Hepatitis is the most common infection after acute respiratory infections, occurs in Russia in 90-100 cases per 100,000 population.

Source - patients. The mechanism of infection is fecal-oral. Viruses are shed in the faeces at the onset of clinical manifestations. With the appearance of jaundice, the intensity of virus isolation decreases. Viruses are transmitted through water, food, hands. Mostly children aged 4 to 15 years are ill.

Pathogenesis

Possesses hepatotropism. After infection, the replication of viruses occurs in the intestine, and from there through the portal vein they enter the liver and replicate in the cytoplasm of hepatocytes. Damage to hepatocytes occurs as a result of immunopathological mechanisms. The incubation period is long 15-45 days, begins acutely, with symptoms of acute respiratory infections. Then hepatocytes are destroyed by immunocompetent cells (T-killers, NK-cells). Immunity - persistent humoral type-specific.

Clinic

The incubation period is from 15 to 50 days. The onset is acute, with fever and nausea, vomiting). Perhaps the appearance of jaundice on the 5th day. The clinical course of the disease is mild, without any complications. The duration of the disease is 2 weeks. Chronic forms do not develop.

Immunity

After infection - persistent lifelong immunity associated with IgG. At the onset of the disease in the blood IgM, which remain in the body for 4 months and have diagnostic value. In addition to humoral, local immunity develops in the intestine.

Microbiological diagnostics

Diagnosis includes serodiagnosis - determination of class M immunoglobulins in ELISA, search for viral antigens in the blood using ELISA, using DNA probes, immuno-electron microscopy (IEM) - you can see the virus (expensive methods). If hepatitis A is suspected, biochemical tests are performed, determining the activity of ALT, AST enzymes, and the amount of bilirubin.

The material for the study is serum and feces. Diagnosis is based mainly on the determination of IgM in the blood using ELISA, RIA and immune electron microscopy. The same methods can detect viral antigen in feces. Virological testing is not carried out.

Prevention

nonspecific prophylaxis. For specific passive prophylaxis, immunoglobulin is used. Immunity lasts about 3 months. For specific active prophylaxis - inactivated culture concentrated vaccine. Recombinant genetically engineered vaccine.

The content of the article

Hepatitis A(synonyms of the disease: Botkin's disease, infectious, or epidemic, hepatitis) - an acute infectious disease caused by the hepatitis A virus, mainly with a fecal-oral mechanism of infection; characterized by the presence of an initial period with fever, dyspeptic, flu-like symptoms, predominant liver damage, symptoms of hepatitis, metabolic disorders, often jaundice.

Historical data on hepatitis A

For a long time, the disease was mistakenly considered catarrhal jaundice, caused by blockage of the common bile duct with mucus and swelling of its mucous membrane (R. Virkhov, 1849). For the first time, the position that the so-called catarrhal jaundice is an infectious disease was scientifically substantiated, expressed by S. P. Botkin (1883). The causative agent of the disease - hepatitis A virus (HAV) was discovered in 1973 p. S. Feinstone.

Etiology of hepatitis A

The causative agent of hepatitis A belongs to the Picornaviridae family.(Italian picollo - small, small; English RNA - ribonucleic acid), a genus of enteroviruses (type 72). Unlike other enteroviruses, HAV replication in the gut has not been conclusively proven. HAV is a particle size of 27 - 32 nm, which does not contain lipids and carbohydrates. The virus can reproduce in some primary and continuous cultures of human and monkey cells. The virus is resistant to environmental factors, can survive for several months at room temperature, is sensitive to formalin, concentrated solutions of chloramine and bleach, is resistant to freezing, and remains viable for two years at a temperature of -20 ° C.
Sterilization with flowing steam at a temperature of 120 ° C for 20 minutes completely inactivates the infectious material.

Epidemiology of hepatitis A

The only source of infection is a sick person. Isolation of the pathogen into the environment with faeces begins even in the incubation period, 1-3 weeks before the onset of clinical symptoms of the disease. The greatest contagiousness is observed in the first 1-2 days of the disease and stops after the 10-14th day of the disease. The causative agent is found in urine, menstrual blood, semen, which has less epidemiological significance.
There is no pathogen in breast milk. Often the source of infection are patients with anicteric and inapparent forms of viral hepatitis A, the number of which can significantly exceed the number of patients with the manifest form. Virus carrying is not observed.
The main mechanism of infection is fecal-oral, realized by water, food and contact household routes. A large number of cases of food and water outbreaks of infection are known. Often group outbreaks of viral hepatitis A occur in preschool institutions and schools. There is the possibility of parenteral infection with hepatitis A during medical procedures, but the short duration of the period of viremia makes this route of infection secondary. Sexual transmission is possible.
Human susceptibility to infection with hepatitis A is 100%. Due to the intensive spread of the disease, most people have time to recover from an icteric or anicteric form of the infection before the age of 14. According to the age structure of the incidence of hepatitis A, it approaches childhood infectious diseases (measles, scarlet fever). Adults account for approximately 10-20% of all cases of hepatitis A.
Seasonality is autumn-winter, observed only among children. Characterized by the periodicity of the growth of the incidence with an interval of C-5 years.
Hepatitis A is a very common infection, the incidence rate depends on the state of sanitary culture and communal amenities. Immunity is stable, lifelong.

Pathogenesis and pathomorphology of hepatitis A

The pathogenesis is not well understood. To a large extent, this is due to the lack of an adequate model of the disease and the lack of data on the replication of the pathogen. According to the scheme developed by A. F. Blyuger and I. GI. Novitsky (1988) distinguish seven main phases of pathogenesis.
I. Epidemiological phase, or penetration of the pathogen into the human body.
II. enteral phase. The virus enters the intestines, but it is not possible to detect it in the cells of the intestinal mucosa. The hypothesis that the virus multiplies in the intestine is confirmed experimentally in tamarin monkeys. According to electronic morphological studies, at the beginning of the disease, signs of cytolysis of varying degrees are found in enterocytes, similar to those observed in various viral infections.
III. Regional lymphadenitis.
IV. The primary generalization of the infection is the penetration of the pathogen through the blood into the parenchymal organs.
V. Hepatogenic phase, which begins with the penetration of the virus into the liver. There are two forms of liver damage. With one - changes cover the mesenchyme, hepatocytes are not damaged, the process breaks off in the phase of parenchymal dissemination. In the second form, moderate damage to hepatocytes is observed. It was believed that cell damage was due only to the cytopathic effect of the virus (CPE). However, the development of pathological changes in the liver coincides with the appearance of antibodies against the virus, and the most significant changes develop after the cessation of viral replication. It has been proven that the virus can cause a strong and rapid immune response, antibodies appear even before the onset of clinical symptoms, and immunocyte sensitization occurs early. All this gives reason to believe that the destruction of hepatocytes is largely associated with immunological processes.
VI. The phase of secondary viremia associated with the release of the virus from damaged liver cells.
VII. phase of convalescence.
Secondary viremia ends with an increase in immunity, the release of the body from the virus, and the predominance of reparative processes.
Morphological changes in the case of hepatitis A are somewhat different from those observed in patients with viral hepatitis B. A characteristic morphological type of liver damage in hepatitis A is portal or periportal hepatitis. Inflammatory and alternative changes in the central zone of the hepatic lobule around the hepatic vein, as a rule, are not observed. An electron microscopic examination of the hepatitis A virus in the liver tissues is not detected.

Hepatitis A Clinic

The following clinical forms of hepatitis A are distinguished: icteric (with cytolysis syndrome; with cholestasis syndrome), anicteric, subclinical.
The disease often occurs in an acute cyclic form, although exacerbations, relapses, a protracted course and a transition to a chronic form are possible (0.3-0.5% of patients).
There are the following periods of illness: incubation; initial, or dozhovtyanichny; icteric; convalescence. The incubation period lasts 10-50 days, with an average of 15-30 days.

icteric form

Initial period. In most cases, the onset is acute. An increase in temperature (not more than 38.5 ° C) is observed within 2-3 days. Patients complain of general weakness, loss of appetite, nausea, sometimes vomiting, pain or a feeling of heaviness in the right hypochondrium and epigastric region. Examination reveals a moderately enlarged liver, sometimes the spleen. This onset of the disease is observed in dyspeptic variant. The flu-like variant of the initial period is characterized by a short fever (2-3 days), short-term body aches, and feasting in the throat.
At the end of the initial period, urine acquires a dark color (strong tea or beer), which is due to the presence of bile pigments and precedes jaundice by 2-3 days.
The patient may complain of itchy skin. In the initial period of the disease, an important laboratory sign of viral hepatitis is an increase in the activity of serum enzymes, primarily alanine aminotransferase (ALAT). The duration of the initial period averages 3-7 days.

icteric period

Subicteric sclera indicates the end of the initial period and the transition to icteric. Jaundice reaches its maximum development within 2-3 days, after which it lasts an average of 5-7 days. First, it appears on the sclera, the mucous membrane of the soft palate, the frenulum of the tongue, then on the skin of the face and trunk. With the development of jaundice, a significant part of the clinical manifestations of the disease, characteristic of the initial period, disappears, the general condition of patients improves, in most of them appetite normalizes, nausea and signs of intoxication disappear.
In most cases, the disease has a mild course, only in 3-5% of patients - moderate. Severe hepatitis A is rare (1-2%). When examining the patient (palpation), further enlargement of the liver, which can be compacted, sensitive, even painful, attracts attention. More often than in the initial period, an increase in the spleen is detected.
In the period of increasing jaundice, the main laboratory indicator is the level of bilirubin in the blood serum. The concentration of bilirubin in the blood of patients with hepatitis A can vary considerably, reaching 300-500 µmol/l in severe forms of the disease, although such high rates are rarely found. Hyperbilirubinemia is characterized by the predominant accumulation in the blood of the bound (direct, soluble) fraction of the pigment, which makes up 70-80% of its total amount. A relatively low level of the free fraction of bilirubin (20-30%) indicates that the function of hepatocytes regarding the binding of bilirubin by glucuronic acid is the least vulnerable, excretory function is more impaired. Violations of the excretion of bilirubin in the intestine leads to discoloration of the feces. Thus, clinically, pigment metabolism disorders are manifested by jaundice, darkening of urine and discoloration of feces. Urobilinuria at this time stops, because due to acholia, urobilinogen is not produced and does not enter the bloodstream. Jaundice gradually decreases. The first sign of renewal of the excretory function of hepatocytes is the color of feces. Since that time, the level of bilirubin in the blood serum and the intensity of jaundice have been decreasing.
During the height of the disease, increased activity of ALT remains. Among other laboratory indicators, it should be noted an increase (sometimes significant) in the thymol test, an increase in the proportion of gamma globulins in the blood serum. In patients with severe forms of hepatitis, hemorrhagic manifestations may appear on the skin. In these cases, violations of the blood coagulation system are detected (decrease in the prothrombin index, as well as plasma concentrations of V, II, VI, X coagulation factors).
In the study of blood - leukopenia with relative lymphocytosis or a normal number of lymphocytes, ESR, as a rule, does not change.
cholestasis syndrome is not typical for hepatitis A. It is characterized by the presence of cholestasis without pronounced signs of hepatocellular insufficiency. The duration of the cholestatic form can be C-4 months. In addition to jaundice, acholic feces, in the clinical signs of cholestasis belongs to skin itching. A blood test reveals moderate leukocytosis, an increase in ESR, an increase in the activity of alkaline phosphatase, cholesterol, and beta-lipoproteins.
The anicteric form of hepatitis A includes cases of the disease without jaundice syndrome, when the level of bilirubin in the blood does not exceed 25-30 µmol / l. Other main clinical manifestations of icteric and anicteric forms of hepatitis A coincide, but with the latter they are weaker, the duration of the disease is shorter. Changes in the blood are insignificant, except for the level of ALT activity, which increases in all clinical forms of hepatitis A.
Chronic forms of the disease are possible (0.5-1% of cases).

Complications of hepatitis A

Exacerbation and relapses are observed in 2-5% of patients. Often they are associated with violations of the diet and regimen, the irrational use of glycocorticosteroids, the addition of intercurrent diseases, and the like. In some patients, exacerbations are manifested by a deterioration in laboratory parameters (biochemical exacerbations). In the event of distant relapses, the possibility of infection with viral hepatitis B should be taken into account. In such cases, a study for markers of the hepatitis B virus (HBsAg, anti-HBc) is required.
The prognosis for patients with hepatitis A is favorable.

Hepatitis A Diagnosis

The main symptoms of the clinical diagnosis of hepatitis A in all variants of the initial (pre-hot) period are pain or a feeling of heaviness in the right hypochondrium, sometimes itching of the skin, enlargement and sensitivity of the liver, darkening of the urine. These signs indicate damage to the liver. It is important to increase the activity of ALT in the blood serum. In the icteric period, the above symptoms are accompanied by jaundice, acholia (white feces), the content of bilirubin in the blood serum increases with the predominance of the bound (direct) fraction, and the activity of ALT increases significantly. Epidemiological data, communication with patients and a certain duration of the incubation period are taken into account. On account of the fact that hepatitis A affects mainly children.

Specific diagnosis of hepatitis A

Specific diagnosis is based mainly on the detection of antibodies to the hepatitis A virus, which belong to class M immunoglobulins, the so-called early antibodies (anti-HAV IgM). Detection of the virus in the feces in the presence of clinical signs of the disease almost stops, therefore, a scatological study is informative when examining persons who have had contact with patients in the outbreaks, especially during outbreaks in children's institutions.

Differential diagnosis of hepatitis A

In the initial (pre-hot) period of the disease, hepatitis A most often needs to be differentiated from influenza and other respiratory diseases, acute gastritis, and food poisoning. Hepatomegaly, pain or a feeling of heaviness in the right hypochondrium, liver sensitivity on palpation, a feeling of bitterness in the mouth, sometimes itching of the skin, dark urine, splenomegaly are not observed in these diseases. Sometimes a rapid increase in the liver with stretching of its fibrous capsule, an increase in lymph nodes in the gates of the liver cause pain, which resembles the clinic of acute appendicitis. A carefully collected history of the disease in most cases allows us to establish that the patient had a decrease in appetite, nausea, dark urine a few days before the onset of signs of an acute abdomen. A careful examination of the patient reveals an enlarged liver, sometimes the spleen.
Instead of the expected leukocytosis, there is a normal leukocyte count or leukopenia with relative lymphocytosis. Of great importance are the data of the epidemiological anamnesis.
To establish the diagnosis of hepatitis A in the initial period of the disease or in the case of an anicteric form, determining the level of activity of serum alanine aminotransferase helps.
During the icteric period of viral hepatitis, it is necessary to find out the origin of jaundice.
Prehepatic jaundice is caused by increased hemolysis of erythrocytes (hemolytic jaundice) and accumulation of unbound (indirect, insoluble) fraction of bilirubin in the blood, which indicates against viral hepatitis. In such persons, unlike patients with viral hepatitis, the level of ALT does not increase, the color of the urine does not change, there is no acholia - the feces are intensely colored.
Differentiation of subhepatic (obstructive) jaundice with a cholestatic form of viral hepatitis can cause significant difficulties. In such cases, a thorough analysis of the characteristics of the pre-ovarian period helps to clarify the diagnosis; with hepatitis, it has quite pronounced signs, and in the case of subhepatic (obstructive) jaundice, they are absent. Clinically, the possibility of subhepatic jaundice is indicated by an earthy-gray skin tone, intense itching, and a sharp pain in the abdomen.
Often the development of jaundice is preceded by bouts of biliary colic or acute pancreatitis. Of great importance is the examination of the patient - the presence of Courvoisier's symptom, local muscle tension, Ortner's symptom, etc. If jaundice is caused by cholelithiasis, fever, chills, leukocytosis, and an increase in ESR are often observed.
Quite difficult is the differential diagnosis of viral hepatitis with cancer of the major duodenal papilla. In these cases, jaundice is often preceded by prolonged itching of the skin, while the mouths of the common bile duct and pancreatic duct are still only partially blocked. In such patients, the manifestation of pancreatitis and cholangitis is possible, jaundice has an alternate character (an important sign of this pathology).
In all forms of obstructive jaundice, the study of bilirubin has no differential diagnostic value. More attention should be paid to determining the activity of ALT in the blood serum, which is normal or slightly elevated in this form of jaundice, while it is significantly increased in viral hepatitis. Of secondary importance is the ratio of transaminases - AsAT / AlAT. In patients with viral hepatitis, ALT activity mainly increases, therefore this coefficient is less than one, with obstructive jaundice - more than one. The activity of alkaline phosphatase in viral hepatitis is normal or moderately increased, with obstructive jaundice it is significantly increased. However, in the cholestatic form of viral hepatitis, the activity of the enzyme in the blood serum increases markedly, and therefore its differential diagnostic value decreases. In difficult cases, special instrumental (including endoscopic), ultrasound, duodenography, and, if necessary, laparoscopy are used.
With chronic hepatitis and cirrhosis of the liver, viral hepatitis is differentiated on the basis of the clinical features of the disease and laboratory parameters - the duration of the course, signs of portal hypertension, profound disorders of protein metabolism, a decrease in albumin synthesis, an increase in the amount of gamma globulins more than 30%, the presence of liver signs similar. In difficult cases, a liver scan is diagnostic.
Jaundice can develop in infectious diseases such as infectious mononucleosis, leptospirosis, cytomegalovirus disease, toxoplasmosis, pseudotuberculosis, etc. Leptospirosis, for example, is characterized by an acute onset, fever, pain in the calf muscles, kidney damage, hemorrhagic syndrome, scleritis, leukocytosis and a significant increase in ESR, for infectious mononucleosis - tonsillitis, polyadenitis, leukocytosis, the presence of atypical mononuclear cells in the blood. Pseudotuberculosis is characterized by an acute onset, pain in the vermiform appendix, a clinical picture of mesadenitis, symptoms of socks, gloves, lapels, various rashes, including scarlet fever.
Differential diagnosis of hepatitis A with other types of viral hepatitis (B, C, E) is carried out using specific research methods. Take into account epidemiological data.

Hepatitis A treatment

Treatment of patients with mild and moderate forms of hepatitis A does not require the use of drugs. The basis of treatment is sufficient basic therapy, sparing regimen in the acute period - bed and diet No. 5, which provides for the exclusion from the patient's diet of fatty, smoked, pickled foods, fried foods, canned food, meat broths, sour cream, etc. containing refractory fats (for example, lard), strong tea, coffee, cocoa and all types of alcohol. Low-fat cheese, vegetarian and milk soups, oatmeal, semolina, buckwheat, rice porridge, kefir, yogurt, pasta, meat and low-fat fish are recommended. It is allowed to use vegetable fats, butter within the limits of physiological needs. To enrich the diet with vitamins, berries, fruits, vegetables (beets, carrots, cabbage) are recommended in grated form, as well as compotes, jelly, mousses and jelly from juices. meat (in the form of minced meat) is steamed. The amount of liquid should exceed the physiological need by 30-40%. Of the choleretic agents in the acute period, it is advisable to prescribe only sorbitol and magnesium sulfate, which, without increasing bile production, contribute to its outflow due to osmotic action and the release of the hormone - cholecystokinin. It is necessary to ensure that defecation is daily.
If necessary, apply detoxification and infusion therapy. In case of significant intoxication, a 5-10% glucose solution is administered with the addition of ascorbic acid.
Patients are discharged from the hospital according to clinical indications, after the complete normalization of pigment metabolism.

Clinical examination

A month after discharge, the patient is examined in the infectious diseases hospital, where he was treated. If the biochemical parameters are normal, the patient further requires observation by a KIZ doctor or a gastroenterologist, or a local doctor at the place of residence with a second examination after 3 and 6 months.
With residual effects of viral hepatitis, the patient is subject to monthly outpatient supervision by a doctor of an infectious diseases hospital, and if indicated, hospitalization.

Prevention of hepatitis A

Patients are hospitalized, sometimes isolated at home under the supervision of an epidemiologist. The main sanitary and epidemiological measures to prevent the fecal-oral spread of infection.
Surveillance of persons who have been in contact with patients in outbreaks is carried out for 35 days. Children's institutions establish quarantine for 35 days; within two months after the last case of hepatitis A, routine vaccinations are not carried out. Prevention of viral hepatitis A involves the introduction of immunoglobulin according to epidemiological indications (intensity of incidence) in the most susceptible age groups of the population: children from 1 to 6 years old - 0.75 ml, 7-10 years old - 1.5 ml, over 10 years old and adults - 3 ml.

Almost everyone is familiar with hepatitis A (Botkin's disease). The patient's outpatient card is marked with special symbols, and after that, for many years, the person is re-examined for the presence of the virus in the body. Although the latter is not necessary, because after the infection there are no people with a chronic course. Nevertheless, you need to know about the disease because of some features of the course.

Hepatitis A - what is it and how is it transmitted? What is the difference between this type of viral liver damage? What you need to know about the disease and its treatment?

What is Hepatitis A

Scientists have calculated that among all cases of liver damage by viruses, hepatitis A is about 40%. Almost every second case! The infection is not included in the category of particularly dangerous, it proceeds relatively favorably and almost always ends in complete recovery.

Why is hepatitis A dangerous?

The disease does not manifest itself for a long time, sometimes after 4-6 weeks only its first signs will appear.
A person infects others in the last days of the incubation period, when even the patient himself does not know about the disease. During this time, you can manage to infect hundreds of people.
The causative agent of hepatitis A is a virus that is stable in the external environment; on surfaces at a temperature of only 4 ° C, it persists for several years.
The microorganism tolerates exposure to ultraviolet radiation, detergents, formalin.
Boiling alone kills the virus within 5 minutes.
It affects equally all children and adults, susceptibility to the virus is universal.
A large number of latent or anicteric forms of the disease.

So what is this disease - hepatitis A? This is an infectious disease of the liver, the cause of which is a type A virus. A simple transmission route, a high susceptibility of the population and many unusual forms of the disease are characteristic of it. Even the best modern methods of prevention will not save people from this infection. Hepatitis A circulates throughout the world and infects the population at regular intervals. Therefore, you need to remember about it.

Reasons for the spread of hepatitis A virus

In nature, the virus is found only among humans. It is transmitted from person to person, it does not infect or infect animals. This is a severe anthroponotic infection (circulating only between people).

Ways of infection with viral hepatitis A are as follows.

Contact-household way, through infected objects in the environment around people. The danger is a sick person at the stage of isolation of the hepatitis A virus.
Alimentary route - in case of ingestion of a microorganism through contaminated food.
One of the leading ways of infection is water. Infection with hepatitis A occurs most often due to the ingress of the virus into sewers, natural reservoirs and other sources.
A controversial, but quite possible route of transmission is parenteral, which is less common than others, but doctors have recorded isolated cases of hepatitis A virus entering the body through injections, droppers.

All this is explained only by the ability of the virus to survive in any conditions and the inability to neutralize it in ways available to everyone.

How is hepatitis A transmitted from person to person? The mechanism of transmission is fecal-oral, which is realized if the pathogenic microorganism is located and multiplies in the intestine. With urine, vomit or feces, the virus enters the environment, if hygiene standards are not observed or violated, it remains on surrounding objects. People become infected when they are touched, causing the microorganism to infect the next person.

Countries with a low level of development are considered the most unfavorable in terms of epidemics, where they become infected as a result of the widespread spread of the virus and due to the low level of development of sanitary and epidemic standards.

Stages of development of viral hepatitis A

There are several variants of the course of hepatitis A. The disease can occur with a typical clinical picture and asymptomatically.

In the case of manifest (flowing with vivid symptoms) forms, several stages are distinguished in the development of the disease.

The incubation period of viral hepatitis A begins from the moment the pathogen enters the human body and up to the moment of initial manifestations. It can last from 1 to 7 weeks, but on average it is 21-28 days.
The prodromal period lasts about 7 days, sometimes three weeks. It resembles the onset of a viral disease of the upper respiratory tract.
The peak of the disease or the period of familiar typical clinical manifestations lasts about two or three weeks, but in special cases it reaches two months.
Reconvalescence or recovery.

After the transfer of the infection, a stable lifelong immunity is formed. Can you get hepatitis A again? This is excluded, after the transfer of the disease, the body produces cells that protect against re-infection.

The first signs of the disease

The incubation period does not give itself away. This, from the point of view of epidemiology, is the most dangerous period, since at the end of it a person is already contagious to others, but he still does not know about it. Therefore, hepatitis A is considered dangerous.

The next stage in the development of the disease is prodromal. A person is contagious throughout.

Manifestations of the prodromal period of hepatitis A are as follows:

the disease begins acutely with an increase in body temperature to 38-40 ° C, which is observed for at least three days;
the first signs of hepatitis A include redness of the throat, headaches, mild nasal congestion;
nausea, loss of appetite, vomiting is possible, but in rare cases;
perhaps the appearance of pain in the stomach or a feeling of discomfort;
after about two days, the urine becomes dark in color, many draw an analogy with the color of dark beer or strong tea, the stool becomes discolored and becomes liquid;
it is during this period of hepatitis A that the liver and spleen enlarge and become painful on palpation.

At the very beginning, the prodrome period resembles a respiratory infection, and only at the end, before the peak, its symptoms become more understandable.

Symptoms of Hepatitis A

This stage takes up to two months, and with a typical course, the diagnosis almost never raises questions. Moderate course of the disease is approximately as follows.

Jaundice, liver enlargement and dyspeptic symptoms are typical hallmarks of Botkin's disease.

Features of the course of hepatitis A in children and adults

In adults and children, sometimes the disease occurs with some features that depend on the immune system and on the body itself.

How is hepatitis A different in children?

Most often, children aged 3 to 12 get sick, especially those who are in organized children's groups: in kindergartens, schools, boarding schools.
In babies up to a year, in most cases, mother's or passive immunity is preserved.
Symptoms of hepatitis A in children: severe intoxication, an increase in the size of the liver, noticeable not only on palpation, but also visually, as a rule, of moderate severity.
A protracted course of the disease is observed only in 3% of cases.
What are the signs of hepatitis A in a young child? - the child becomes nervous, whiny, refuses to eat, sleeps badly, vomiting occurs after eating, does not allow himself to be examined, because the stomach is painful on palpation, chronic infections become aggravated against the background of the underlying disease and new ones often join.

How does hepatitis A progress in adults? The average severity of the disease is fully consistent with the above clinical picture. Easy or protracted flow is slightly different.

Most adults develop active immunity by the age of 35 or 40, sometimes due to the transfer of a latent form of infection.
Mixed infections proceed aggressively and for a long time, for example, if a person becomes infected with hepatitis A and B at the same time.
Symptoms of hepatitis A in adults are varied - the temperature at the onset of the disease may increase or rise sharply; dyspeptic phenomena are expressed: discomfort in the stomach, nausea, repeated vomiting, and jaundice can manifest itself in a mild form.
With age, the likelihood of deaths due to hepatitis A increases; in patients older than 50 years, the number of such complications is 4 times higher than mortality in childhood.

Hepatitis A at the very beginning, during active manifestations, resembles more of a respiratory disease, therefore, during protracted infections, it is necessary to be fully examined for a correct diagnosis.

Diagnosis of hepatitis A

The diagnosis of hepatitis A is based on several tests.

Complications of hepatitis A

A favorable course of the disease does not mean that there are no consequences. The only thing that pleases after the transfer of hepatitis A is that there is no chronic course of the disease, that is, having been ill once, a person will no longer become infected.

What changes does the hepatitis A virus cause after an acute illness?

In 90% of cases, the disease ends with an absolute complete recovery without any residual effects. The remaining 10% were less fortunate.
A prolonged course and resumption of symptoms during the period of extinction of the infection sometimes indicates additional infection with other types of hepatitis or weak immunity.
After the disease, signs of damage to the biliary tract are found: inflammation, dyskinesia.
Sometimes the disease is complicated by extrahepatic manifestations: pneumonia, inflammation of the heart muscle, impaired production of blood cells.
Mortality is no more than 0.04% of cases.

Hepatitis A treatment

Therapy for infectious liver disease primarily includes adherence to the regimen. Full sleep, walks in the fresh air and daytime sleep are the norm for patients with hepatitis A.

How long should patients and their contacts be monitored? The patient is isolated for 30 days, and quarantine for hepatitis A for contact persons is at least 35 days.

Diet for hepatitis A

The basis of the treatment of all diseases of the digestive system is a balanced diet.

The hepatitis A diet begins during the development of the disease and continues after recovery for several more months.

How do patients eat?

You can not reduce the caloric content of food, calories must correspond to the physiological norm.
You can not reduce the amount of proteins, fats and carbohydrates, their ratio must be correct. Only some indigestible animal fats are limited: beef, pork and mutton.
You need to drink the optimal amount of fluid - 2-3 liters of water per day.
Five small meals a day are recommended for patients with hepatitis A.

This dietary regimen must be followed for another six months after recovery. We must not forget that all harmful and spicy foods are prohibited so as not to create a burden on the liver.

Prevention of hepatitis A

Protection against the development of the disease or prevention of hepatitis A is carried out in the focus of detection of infection. The patient is isolated, and in the place of his residence, surfaces are treated with chlorine-containing agents. The patient's belongings are subject to special treatment - chamber disinfection.

In addition to the above measures, after a year, children are vaccinated against hepatitis A. Some vaccines can be administered only three years after the birth of a child.

Who should be vaccinated against hepatitis A?

Since the year, the hepatitis A vaccine has been administered to children living in countries with a high incidence rate.
According to epidemic indications, all contacts in the foci of infection are vaccinated.
Immunization is also carried out for people from risk groups.

The drug is administered twice intramuscularly into the deltoid muscle. Revaccination is carried out no earlier than one month after the first injection of the vaccine. This scheme provides full protection against the disease for at least 20 years.

Vaccination against hepatitis A is carried out with the following drugs:

The peculiarity of hepatitis A vaccinations is that all of them are well tolerated, provide early protection, and after their introduction, there are practically no complications.

How dangerous is hepatitis A? It belongs to the category of mild infections, which anyone can get infected, and almost 100% of the sick are cured. But these are all positives. The disease proceeds for a long time, is complicated by damage to neighboring organs, and even deaths are possible. You cannot hide from hepatitis A, but timely prevention saves even small children.

Viral hepatitis is a dangerous infectious disease that affects the liver. They are classified in Latin letters A, B, C, D, E and G. The causative agent of hepatitis B is a DNA-containing virus from the hepadnavirus family, A is from the picornavirus family, a genus of enteroviruses. They are grouped together because, regardless of the causative agent of the disease, the symptoms of diseases are similar, as well as the fact that their action is aimed at damaging liver cells, which leads to a similar change in the biochemical blood test.

You should immediately consult a doctor, the disease is contagious. Moreover, the carrier of the virus most often does not know about the disease and can infect others.

Types of hepatitis and transmission mechanism

Group A and E

The source of viral hepatitis in this form is dirty hands, poorly washed vegetables and fruits, water containing viruses. With viral hepatitis A and E, during the incubation period, carrier individuals who are sick or have contact with patients are contagious, so the disease can become epidemic.

Group B, C, D and G

You can get infected through blood. So, for example, the main ways of transmission of hepatitis C are hematogenous, parenteral (through the blood). Infection occurs when medical instruments are reused (if the previous user was infected), when sharing razors, manicure supplies and even toothbrushes, when bitten.

causative agents of the disease

The causative agents of viral hepatitis are dangerous because they affect liver cells. Viral hepatitis A is an infectious disease that belongs to enteroviruses. This virus actively multiplies in liver cells. The structure of the hepatitis B virus makes it possible to attribute it to the group of DNA-containing viruses. For effective reproduction of this virus, it is necessary to infiltrate the liver cells and change the synthesis of normal proteins. The hepatitis C virus also belongs to the group of DNA-containing viruses. Getting into the liver cells, it blocks the synthesis of normal proteins, causing inflammation of hepatocytes.

Incubation period and symptoms of the disease

The duration of the incubation period depends on the type of virus. For example, in hepatitis A - from 14 to 28 days. Carriage of hepatitis B, namely the latent period, is from 2 to 6 months, during this period the patient is very contagious. The incubation period for hepatitis C can be from 4 days to 6 months. Each species has its own characteristics that you need to know.

Signs of Hepatitis A

The initial stage proceeds rapidly: temperature fluctuations, nausea, vomiting, malaise, abdominal pain, lack of appetite, loose stools, vomiting. Further, yellowness of the skin and eye proteins appears, the urine darkens and the feces become discolored. In some patients, after an acute period, the phenomenon of cholestasis is observed, therefore, such patients are advised to adhere to a special diet for six months, after which complete recovery occurs.

Symptoms of Hepatitis B

The asymptomatic (hidden) period lasts 12 weeks, the first signs of the disease are revealed on average at the 12th week after infection. The blood test for the relevant markers will be positive during the first to the ninth week. The first signs of the manifestation of the disease are poor health, high fever, nagging pain in the joints, discomfort in the right hypochondrium. In addition, you can notice the darkening of the color of urine and increased foaminess. The patient's skin and eye whites turn yellow.

Hepatitis C indicators

Hepatitis C is a disease that is almost asymptomatic. Hepatitis C carriers are determined by doctors by chance when checking the patient for other ailments. The patient has weakness, asthenia and malaise. These signs are nonspecific and do not give an accurate picture of the development of the disease. With the appearance of cirrhosis of the liver, jaundice is observed, the abdomen (ascites) increases, and spider veins appear. Muscle aches and joint pain are observed. These indicators are also characteristic of a respiratory infection or flu. It is because of the latent course of the disease that a chronic process often develops. The virus does not give a person lasting immunity, the risk of re-infection is high, since the pathways of transmission of the pathogen are diverse. This means that a carrier of hepatitis C is contagious and may not suspect anything, however, he is dangerous to society.

Diagnostics

There are different ways to diagnose the disease, they include two stages: identifying signs of hepatitis and collecting blood for analysis for the presence of the virus. The disease is difficult to identify because the symptoms may come and go at different intervals. However, there are signs by which the presence of this virus can be suspected: general fatigue, weakness, loss of appetite, nausea and abdominal pain, discoloration of urine and feces, vomiting, diarrhea, jaundice.

In the laboratory, there are many tests to determine the presence of the virus. The main indicators in the analyzes can be bilirubin and ALT (liver enzymes). With the help of liver tests, the doctor will determine if there is damage to the liver and how serious it is. For example, if a decrease in protein levels is detected, this indicates a possible liver failure. According to the methods for detecting virus markers in the blood, the tests are divided into two groups. So, the immunological method of research determines the presence of antibodies and antigens in the blood under the influence of a virus. The genetic method allows you to identify the DNA and RNA of the virus in the blood. This method is more effective, as it allows not only to diagnose hepatitis, but also determines the amount of the virus and its type.