Chronic viral hepatitis in children

Chronic viral hepatitis - diseases caused by hepatotropic viruses with parenteral infection, accompanied by hepatolienne syndrome, increased activity of liver enzymes and a prolonged persistence of viruses-pathogens.

ICD-10 codes

• Q18. Chronic viral hepatitis.
• 818.0. Chronic viral hepatitis B with delta-agent.
• 818.1. Chronic viral hepatitis B without delta-agent.
• 818.2. Chronic viral hepatitis C.
• B18.8. Another chronic viral hepatitis.

Epidemiology

According to WHO, about 2 billion people are infected with the hepatitis B virus in the world, of which more than 400 million are chronic carriers of this infection.

The source of infection for chronic viral hepatitis is a person carrying an acute form of hepatitis B, C, D, G or suffering from chronic viral hepatitis of said etiology, as well as carriers. Hepatitis B, C, D, G viruses are transmitted through parenteral manipulations, in the ante- and perinatal periods, blood transfusions and blood preparations, surgical interventions, intravenous use of psychotropic substances, and sexual transmission. In all countries, tens of thousands of new cases of chronic viral hepatitis are constantly registered. In Russia, the most common are hepatitis B and C; the proportion of chronic liver diseases due to hepatitis D and G viruses is not more than 2%. Currently, due to ubiquitous vaccine prophylaxis of hepatitis B, the number of newly infected with this disease sharply decreases.

Screening

Testing for viremia due to hepatitis B and C viruses shows that in the population of the given viruses occur with a frequency of 0.5-10%, and in persons at risk (patients with hematological hemophilia receiving hemodialysis, etc.) - with a frequency of 15-50%. At the further inspection at persons with В- or With-viremia find acute and chronic hepatitises In and With.

Classification of chronic viral hepatitis

Since 1994, a worldwide classification of chronic hepatitis has been adopted, according to which a patient with chronic viral hepatitis should verify the etiology of the disease, determine the degree of activity and the stage of the process.

Classification of chronic hepatitis

Type of hepatitis	Serologic markers	Degree of activity	Degree of fibrosis
Chronic Hepyatitis B	HbsAg, HbeAg, HBV DNA	Minimum Low Moderate Severe	No fibrosis Weak fibrosis (mild fibrosis) Moderate fibrosis Severe fibrosis Cirrhosis
Chronic hepatitis D	HbsAg, anti-HDV RNA HDV
Chronic hepatitis C	Anti-HCV, HCV RNA
Chronic hepatitis G	Anti-HGV, HGV RNA
Autoimmune, type I	Antibodies to nuclear antigens
Autoimmune, type II	Antibodies to microsomes of the liver and kidneys
Autoimmune, type III	Antibodies to soluble hepatic antigen and hepatic-pancreatic antigen
Drug-induced	No markers of viral hepatitis and rarely detect autoantibodies
Cryptogenic	There are no markers of viral and autoimmune; hepatitis

Etiological agents of chronic viral hepatitis - hepatitis viruses with parenteral mechanism of infection, especially hepatitis B and C viruses, to a much lesser extent - hepatitis D and G.

The pathogenesis of chronic viral hepatitis

Chronic viral hepatitis is formed as a result of insolvency of T- and B-systems of immunity, as well as inefficiency of the mononuclear phagocyte system, leading to persistent persistence of pathogens and preservation of the inflammatory process in the liver due to the reaction of immune cytolysis.

Symptoms of chronic viral hepatitis

The main symptoms of chronic viral hepatitis are asthenovegetative and hepatolienal syndromes; in 50% of cases, they detect extrahepatic signs in the form of telangiectasias, capillaritis and palmar erythema. Jaundice with chronic viral hepatitis practically does not happen, except for cases of concomitant pigmentary hepatosis (often in the form of Gilbert syndrome), as well as cholestasis syndrome.

Diagnosis of chronic viral hepatitis

Anamnesis

Important family history (possibly parents, siblings were ill or sick with acute or chronic hepatitis B, C, D, G). Ante- and perinatal, parenteral ways of infection of the child are possible.

Physical examination

Consider the general condition of the patient, signs of asthenodyspeptic syndrome, increase and change in the consistency of the liver, increase in the size of the spleen, extrahepatic marks and hemorrhagic elements.

Laboratory research

A biochemical blood test is performed (total bilirubin and its fractions, transaminase activity, serum protein range, sediment assays), a clinical blood test (hemogram, leukocyte count, platelet count, prothrombin index). Mandatory serological testing for the markers of viruses: hepatitis B virus - HBsAg, anti-HBc, HBV DNA; on the hepatitis C virus - anti-HCV, HCV RNA; on the hepatitis D virus - HBsAg, anti-HDV, RNA HDV; on the hepatitis G virus - HGV RNA.

Instrumental research

An ultrasound scan of the liver, gallbladder, spleen, pancreas is performed.

Differential diagnostics

In case of chronic liver disease, serological tests for detecting markers of hepatitis B, C, D, and G. Viruses are crucial. Differential diagnostics with hepatic diseases due to hereditary pathology (Wilson-Konovalov's disease, glycogenoses, a1-antitrypsin deficiency, Alajill syndrome, Gaucher's disease , liver damage in cystic fibrosis, fatty liver disease).

Indications for consultation of other specialists

The need for consultation of a surgeon-hepatologist arises when it is possible to form liver cirrhosis. The concomitant somatic pathology also requires treatment to consultants taking into account the profile of somatic pathology.

Purpose of treatment of chronic viral hepatitis

Suppression of replication of the virus-pathogen, reduction of inflammation and fibrosing of the liver.

Indications for hospitalization

Patients with chronic viral hepatitis after primary diagnosis of the disease are hospitalized in the department of viral hepatitis. After a comprehensive examination and treatment, further outpatient monitoring is possible. In the case of severe asthenodyspeptic complaints or the development of cholestasis, patients should be hospitalized again.

Non-drug treatment

Patients with chronic viral hepatitis observe a diet close to diet number 5.

Medication

According to existing international and domestic agreements, patients with chronic viral hepatitis are prescribed antiviral treatment for viremia and increased activity of transaminases. In chronic hepatitis In viremia, the detection in serum along with HBsAg is also HBeAg or HBV DNA; with chronic hepatitis D - HBsAg, HDV RNA; in chronic hepatitis C - RNA HCV: in chronic hepatitis G - RNA HGV.

The main drug is interferon-a, administered exclusively to children under 3 years of age in the form of viferon (suppositories rectal), and children older than 3 years - in the form of viferon or parenteral forms (reaferon, realiron, etc.) from the calculation of 3 million IU / m ² areas of the child's body per day for 6-12 months. For chronic hepatitis B, in the case of interferon-α failure, children over 2 years of age are prescribed a nucleoside analogue of lamivudine in a daily dose of 2 mg / kg of body weight. As a hepatoprotector prescribe phosphoglue in capsules for 6 months.

Surgery

When ascertaining the formed cirrhosis of the liver, the question of the advisability of surgical treatment is decided.

Further management

Children with chronic viral hepatitis are constantly observed in outpatient settings. After the appointment of treatment in the hospital, a checkup is necessary after 1 month and then every 3 months for 1 year. Subsequently, if the condition does not deteriorate, dispensary observation is shown every 6 months. If necessary, correct treatment and appoint additional examinations.

Forecast

With chronic viral hepatitis, a perennial persistence of the virus-pathogen occurs, possibly a combination with an active pathological process. With chronic hepatitis B for 5-10 years, there has been a steady decline in the activity of the disease; 10% of patients are released from the virus due to the accumulation of antibodies to the surface antigen (anti-HBs), with stable normalization of ACT and ALT activity, recovery occurs. In 1-1,5% of cases cirrhosis is formed, and in the remaining 89% there is a prolonged remission with the carrier of HBsAg. In chronic hepatitis D, the prognosis is unfavorable - in 20-25% of cases the process flows into cirrhosis of the liver; liberation from the pathogen does not occur. Chronic hepatitis C flows for a long time, "softly", without cessation of viremia for many years, with a periodic increase in the activity of transaminases and with a very pronounced tendency to fibrosis.

Prophylaxis of chronic viral hepatitis

According to the National Vaccination Schedule, vaccination against hepatitis B has been initiated. Children are vaccinated in the first day of life, then 3 and 6 months later. Children who are not vaccinated before 1 year and are not at risk, the vaccine is administered according to the scheme "0-1-6 months". Against hepatitis B, teenagers aged 11-13 must be vaccinated according to the same scheme. Newborns from mothers with any variant of hepatitis B are vaccinated from birth according to the "0-1-2 month" scheme with a booster at 12 months.

Widely vaccinated health workers and people at risk for infection with hepatitis B. Vaccination against hepatitis B leads to a gradual decrease in the level of infection of the population with the hepatitis B virus.

The vaccine against hepatitis C has not been developed to date, and therefore the prevention of hepatitis C is built on the suppression of all the possibilities of parenteral (including transfusion) infection.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],