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Case Report

HEPATITIS VIRAL ACUTE

Guided by: dr. I Nyoman Suarjana, Sp. PD-KR

Presented by: Indah Noor Hayati S.Ked. NIM I1A006025

DEFINITION
Hepatitis : Acute parenchymal liver damage can be caused by many agents implies inflammation of the liver characterized by the presence of inflammatory cells in the tissue of the liver. The condition can be self-limiting, healing on its own, or can progress to scarring of the liver. Hepatitis is acute when it lasts less than six months and chronic when it persists longer.

ETIOLOGY
Major agents:

HAV HBV HCV HDV HEV

HGV TTV HFV ?

VIRAL HEPATITIS

5 common types: A: fecal-oral transmission B: sexual fluids & blood to blood C: blood to blood Vaccine D: travels with B Preventable
E: fecaloral transmission
Adapted from Corneil, 2003

ETIOLOGY
Other causes :
Drugs Toxins Alcohol Other infections (parasites, bacteria) Physical damage

PATHOLOGY
Infiltration of mononuclear cells Hepatic cells necrosis Kupfer cells hyperplasia Variable degrees of cholestasis

In more severe cases necrosis

: bridging

PATHOLOGY in Acute Viral Hepatitis


The degeneration of liver cells include ballooning degeneration, fatty degeneration, acidophilic degeneration Cell nucleus vacuolar degeneration Focal or spotty necrosis and regeneration The infiltration of mononuclear cell, plasmocyte ,lymphocyte in portal area Cholestasis and form of bile thrombus in bile capillaries of liver Piecemeal necrosis

CLINICAL STAGES
Incubation period Prodromal (preicteric) phase Icteric phase convalescence

Incubation Period
HAV:15-45 days HBV: 30-180 days HCV: 15-160 days HDV: 30180 days HEV: 14-60 days

Incubation Period
Considerable overlap Asymptomatic period Viral replication& Shedding

Preicteric Phase
Systemic & nonspecific symptoms Flue like & dyspepsia: Fever,sore throat,cough,headache Fever,anorexia,malaise,nausea, vomiting,abdominal pain Duration : 1-2 weeks

Icteric Phase
Clinical jaundice Dark urine:1-5 days before jaundice Patient may feel better Resolution of fever Pruritus

ICTERIC

Icteric Phase
Liver is enlarged,tender Cervical adenopathy(10 20 %) Splenomegaly(10 20 %) Fever is absent Venopuncture site Encephalopathy :Irritability, Letargy,confusion

Convalescence
Resolution of symptoms Liver is enlarged Pruritus Complete recovery: 1-2 months A,E 3-4 months B,C (3/4)

LABORATORY FINDINGS
CBC:leukopenia,lymphocytosis Atypical lymphocyte, Normal Hb ; except hemorrage Normal platelet ; except DIC ESR is normal

LABORATORY FINDINGS
Serum bilirubin: 5-20 mg/dl Direct bil = indirect bil SGOT,SGPT= 400-4000 iu Alk.phosphatase :mild elevation PT is usually normal:in severe hepatitis,PT is prolonged Hypoglycemia

SEROLOGIC DIAGNOSIS
Ig M anti-HAV HBs Ag and Ig M anti-HBc HCV Ab,HCV RNA PCR anti-HDV anti-HEV

PREVENTION
VACCINATION Washing hands thoroughly before handling food Not sharing needles to inject drugs Not sharing toothbrushes, razors, or other items that could get blood on them Practicing safe sexfor example, using barrier protection such as a condom Limiting the number of sex partners

CASE REPORT

Anamnesis
Identity Name Gender Age Address Religion Tribe : Mr . R : Male : 23 years old : Banjarmasin : Islam : Banjar

Admission at the Ulin Hospital : December 10th 2011

Anamnesis
Major complain : Nausea and vomitus. Present disease history : The patient complained of nausea and vomitus 3 days before reffered to the hospital, the frequency of vomitus is about more than five times contains of food that prior consumed by pasien and no blood found. Patient also complained about abdominal pain in the right upper quadrant, headache, and dark urine. This patient had no history of both genetic familial or metabolic diseases. He has had no blood transfusions, no alcohol use, no substance abuse, no travel in the last 10 years, and no relevant family history of serious disease. Friend of the patient had the same symptoms like patient and admitted to the hospital too.

Anamnesis
Past disease history :
History of liver disease (-), History of kidney disease (-). History of allergi (-). History of bleeding (-). History of recuring oral rash (-). History of hipertension (-).

History of coronary disease (-).

Anamnesis
Family disease history : Disease with the same sign in family (-) History of liver disease (-) History of hipertension (-) History of cardiovascular disease (-)

DM (-).
History of habit, social and economics : History contact with chemical material (-) History of use alcohol and cigarettes (-) History of eat fatty food in long period (-)

Physical Examination
General condition Awareness Vital sign Skin Head Eyes : look mild ill : Compos Mentis : 110/80 mmHg; 78 x/mnt;24 x/mnt; 37,5 oC. : Turgor good, Petechiae (-), Ikterus (+) : Deformity (-), Hair : Black colour, spread over, thick : Edema palpebra (-)/(-), Pale conjungtiva (-)/(-), Sclera icterik (+)/(+).

Physical Examination
Ear : Defect (-). Serumen (+) minimal. Secret (-).

Nose

: Deviasi septum (-). Secret (-). bleeding (-).


: Oral Hygine enough. Caries dentis (+) minimal.

Mouth and tooth

Fharing

: Hiperemis (-).

Neck : JVP (-). Trachea in the middle. > KGB (-) P: Inspection : Symmetrical. Palpation : Fremitus left/right normal.Depress pain (-). Percution : Sonor in left/right pulmo Auscultation : Vesikular. Rh (-)/(-). Wh (-)/(-).

Physical Examination
C :Inspection : Ictus Cordis in ICS 5 lin. midclav left. Palpation : Ictus Cordis in ICS 5 linea midklav left. Thrill (-), lift (-). Percution : Boundary of right cor 1 cm medial lin.sternalis (D) Boundary of left cor in midclavicula left line. Auscultation Palpation : Sound of cor I - II (N). Murmur (-). Gallop (-).

A :Inspection : Convex. Venectation (-)


: Depress pain (+) at right upper quadrant, liver was felt 1 cm below the right costal margin in the mid-clavicular line; it was smooth, soft, and mildly tender. Spleen was not palpable. Percution : Timpany, Shifting Dullness (-). : Intestine sound (+) normal Auscultation

Physical Examination
Extremities Upper : Edema(-/-),parese(-/-),tremor (-/-) Lower : Edema(-/-),parese(-/-),tremor (-/-)

Subject

Result 13,9 5,2 5,08 46,3 162 12,7 92,3 27,3 29,7 49,0 39,6 45 101 401 265 16 0,6 SPESIFIC TESTS Negatif 0,00 (Negatif) Negatif

Refference 13,0 17,5 4 10,5 4,5 6 40 50 150 350 11,5 14,7 80,0 97,0 27,0 32,0 32,0 38,0 50,0 70,0 25,0 40,0 4,0 11,0 < 200 16 - 40 8 45 10 - 45 0,4 1,4 Negatif 0,00 (Negatif) Negatif

Units g/dl ribu/ul juta/ul vol % ribu/ul % fl pg % % % % mg/ dL u/ L u/ L mg/ dL mg/ dL -

Hematology

Hemoglobin White blood cell Eritrocyte Hematocrit Platelets RDW CV MCV MCH MCHC

Diff. Count

Neutrofil % Limfosit % MID %

Blood glucose
Blood glucose

Liver Enzyme
SGOT SGPT

Kidney Function
Ureum Creatinine

Malaria
HbsAg Anti HCV

Ultrasound Examination
Results : hepatomegaly with hipoechoic intensity but no mass lesions, gallstones, or dilated bile ducts.

Diagnosis

ACUTE VIRAL HEPATITIS

Therapy
December 10 th 2011 Ringer Lactate infusion 20 drops/minute Ranitidine injection /12 hours Ondancetron injection /12 hours Antrain injection /8 hours.. December 11 14th 2011 Ringer Lactate infusion 20 drops/minute Ranitidine injection /12 hours Ondancetron injection /12 hours Antrain injection /8 hours Hepa-Merz 4 ampules mixed in 400 ml NS solution and administered to the patient by infusion for 4 hours .

DISCUSSION

Hepatitis Terms
Acute Hepatitis : Short-term hepatitis. Bodys immune system clears the virus from the body within 6 months Chronic Hepatitis : Long-term hepatitis. Infection lasts longer than 6 months because the bodys immune system cannot clear the virus from the body.

This patients is categorized as a acute hepatitis infection because the symptomps has just felt by the patient for three days before admitted to the hospital.

In this patient we found symptoms such as nausea, vomitus, abdominal discomfort, headache, and dark urine. In addition, from the physical examination we found the yellowing of the skin and the eyes, abdominal pain in the right upper quadrant, and tender hepatomegaly. The level of liver enzymes (AST and ALT) reached 401 u/L and 265 u/L. To established a diagnosis of spesific hepatitis we checked the serology test and the result is HbsAg (-) and Anti HCV (-).The patient had an ultrasound examination of the liver which showed hepatomegaly with hipoechoic intensity but no mass lesions, gallstones, or dilated bile ducts.

History Physical examination

Laboratory and USG

Acute Viral Hepatitis

TREATMENT
The treatment should be conservative and supportive. The management should focus on treating the symptoms and identifying the small proportion of patients with a particular risk of developing fulminant hepatic failure. The antiviral and interferon therapy was not necessary for this patient because Anti HCV didnt proved to be positive.

TREATMENT
Ranitidine is a histamine H2-receptor antagonist that inhibits stomach acid production and may be decrease the symptom of abdominal discomfort. Ondancetron is a serotonin 5-HT3 receptor antagonist used mainly as an antiemetic to treat nausea and vomiting, often following chemotherapy. Its effects are thought to be on both peripheral and central nerves. Antrain that contains metamizole is a powerful analgesic and antipyretic where as in this case used to relieve the abdominal pain and headache.

TREATMENT
Hepamerz is a stable combination of two important endogenous amino acids that consists of L-ornithine-Laspartate. It quickly breaks down into L-ornithine and Laspartate when administered in body. L-ornithine a substrate of urea cycle, converts toxic ammonia into nontoxic urea which is then eliminated through kidneys. It helps the diseased liver to carry out its normal detoxification. This mechanism lowers the raised level of ammonia in blood that is a common problem in liver cirrohsis. L-aspartate is a necessary component of citric acid cycle which liberates energy (ATP). It then helps in regeneration of damaged hepatocytes

CONCLUSION
Had been reported a 23-year-old man that was referred to Ulin Hospital on December 10th 2011 who complained of nausea and vomitus 3 days before reffered to the hospital. Patient also complained about abdominal pain in the right upper quadrant, headache, and dark urine. He has had no blood transfusions, no alcohol use, no substance abuse, no travel in the last 10 years, and no relevant family history of serious disease. Friend of the patient had the same symptoms like patient and admitted to the hospital too. On admission at the Ulin Hospital, the patients blood pressure was 110/80 mm Hg; heart rate 78 beats/minute; body temperature 37,5 oC; and respiratory rate 22 breaths per minute. Physical examination showed a deeply jaundiced man in mild distress due to fatigue and right upper quadrant discomfort. The liver was felt 1 cm below the right costal margin in the mid-clavicular line; it was smooth, soft, and mildly tender. The spleen was not palpable. From the laboratory investigation, level of liver enzymes (AST and ALT) reached 401 u/L and 265 u/L. To established a diagnosis of spesific hepatitis we checked the serology test and the result is HbsAg (-) and Anti HCV (-).The patient had an ultrasound examination of the liver which showed hepatomegaly with hipoechoic intensity but no mass lesions, gallstones, or dilated bile ducts. From the history, physical examination, and laboratory investigation we can diagnosed the patient with acute viral hepatitis. Patient stay in the hospital for 5 days and got ringer lactate infusion 20 drops per minute, ranitidin injection / 12 hours, ondancetron injection / 12 hours, antrain injection / 8 hours, and 4 ampules of Hepa-Merz / day given for 4 days. In the treatment period, patient got better and the doctors allowed the patient to dismissed and given oral
medication.