Chronic viral hepatitis in children

Chronic viral hepatitis is a disease caused by hepatotropic viruses with parenteral infection, accompanied by hepatosplenic syndrome, increased activity of liver enzymes and long-term persistence of the causative viruses.

ICD-10 codes

• B18. 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. Other chronic viral hepatitis.

Epidemiology

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

The source of infection in chronic viral hepatitis is a person suffering from acute hepatitis B, C, D, G or chronic viral hepatitis of the specified etiology, as well as carriers. Hepatitis B, C, D, G viruses are transmitted through parenteral manipulations, in the ante- and perinatal periods, during blood and blood product transfusions, surgical interventions, intravenous use of psychotropic substances, and sexually. Tens of thousands of new cases of chronic viral hepatitis are constantly registered in all countries. In Russia, hepatitis B and C are the most common; the share of chronic liver diseases caused by hepatitis D and G viruses is no more than 2%. Currently, due to widespread vaccination against hepatitis B, the number of people newly infected with this disease is sharply decreasing.

Screening

Testing for viremia caused by hepatitis B and C viruses shows that these viruses occur in the population with a frequency of 0.5-10%, and in individuals from the risk group (patients with oncohematological processes, hemophilia, receiving hemodialysis, etc.) - with a frequency of 15-50%. Upon further examination, acute and chronic hepatitis B and C are detected in individuals with B- or C-viremia.

Classification of chronic viral hepatitis

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

Classification of chronic hepatitis

Type of hepatitis	Serological markers	Activity level	Degree of fibrosis
Chronic hepatitis B	HbsAg, HbeAg, HBV DNA	Minimal Low Moderate Severe	No fibrosis Mild fibrosis (mild fibrosis) Moderate fibrosis Severe fibrosis Cirrhosis
Chronic hepatitis D	HbsAg, anti-HDV HDV RNA
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 liver and kidney microsomes
Autoimmune, type III	Antibodies to soluble liver antigen and hepatopancreatic antigen
Drug-induced	There are no markers for viral hepatitis and autoantibodies are rarely detected.
Cryptogenic	No markers of viral and autoimmune hepatitis

The etiological agents of chronic viral hepatitis are hepatitis viruses with a parenteral mechanism of infection, primarily hepatitis B and C viruses, and to a much lesser extent hepatitis D and G.

Pathogenesis of chronic viral hepatitis

Chronic viral hepatitis is formed as a result of the failure of the T- and B-immune systems, as well as the ineffectiveness of the mononuclear phagocyte system, leading to the stable persistence of pathogens and the maintenance of the inflammatory process in the liver due to the immune cytolysis reaction.

Symptoms of chronic viral hepatitis

The main symptoms of chronic viral hepatitis are considered to be asthenovegetative and hepatosplenic syndromes; in 50% of cases, extrahepatic signs are found in the form of telangiectasias, capillaritis and palmar erythema. Jaundice in chronic viral hepatitis is almost never seen, with the exception of cases of concomitant pigment hepatosis (usually in the form of Gilbert's syndrome), as well as cholestasis syndrome.

Diagnosis of chronic viral hepatitis

Anamnesis

Family history is important (parents and siblings may have had or are suffering from acute or chronic hepatitis B, C, D, G). Antenatal, perinatal and parenteral routes of infection of the child are possible.

Physical examination

The general condition of the patient, signs of asthenodyspeptic syndrome, enlargement and change in the consistency of the liver, enlargement of the spleen, extrahepatic signs and hemorrhagic elements are taken into account.

Laboratory research

A biochemical blood test is performed (total bilirubin and its fractions, transaminase activity, serum protein spectrum, sedimentation tests), clinical blood test (hemogram, white blood cell count, platelet count, prothrombin index). Serological testing for virus markers is mandatory: for hepatitis B virus - HBsAg, anti-HBc, HBV DNA; for hepatitis C virus - anti-HCV, HCV RNA; for hepatitis D virus - HBsAg, anti-HDV, HDV RNA; for hepatitis G virus - HGV RNA.

Instrumental research

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

Differential diagnostics

In chronic liver disease, serological tests are of crucial importance to detect markers of hepatitis B, C, D, G viruses. Differential diagnostics are carried out with liver diseases caused by hereditary pathology (Wilson-Konovalov disease, glycogenoses, a1-antitrypsin deficiency, Alagille syndrome, Gaucher disease, liver damage in cystic fibrosis, fatty liver dystrophy).

Indications for consultation with other specialists

The need for consultation with a surgeon-hepatologist arises when there is a possibility of liver cirrhosis formation. Concomitant somatic pathology also requires contacting consultants taking into account the profile of the somatic pathology.

The goal of treatment of chronic viral hepatitis

Suppression of replication of the causative virus, reduction of inflammation and fibrosis of the liver.

Indications for hospitalization

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

Non-drug treatment

Patients with chronic viral hepatitis follow a diet similar to diet No. 5.

Drug treatment

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

The main drug is interferon-a, prescribed to children under 3 years of age exclusively in the form of Viferon (rectal suppositories), and to children over 3 years of age - in the form of Viferon or parenteral forms (reaferon, realdiron, etc.) at the rate of 3 million IU/m2 ^of the child's body area per day for 6-12 months. In chronic hepatitis B, if interferon-a is ineffective, children over 2 years of age are prescribed the nucleoside analogue lamivudine at a daily dose of 2 mg/kg of body weight. Phosphogliv in capsules is prescribed as a hepatoprotector for 6 months.

Surgical treatment

When established liver cirrhosis, a decision is made on the advisability of surgical treatment.

Further management

Children with chronic viral hepatitis are constantly monitored in outpatient settings. After treatment in hospital, a control examination is necessary after 1 month and then every 3 months for 1 year. Subsequently, if the condition does not worsen, dispensary observation is indicated every 6 months. If necessary, treatment is adjusted and additional examinations are prescribed.

Forecast

Chronic viral hepatitis is characterized by long-term persistence of the causative virus, possibly in combination with an active pathological process. Chronic hepatitis B is characterized by a steady decrease in disease activity over 5-10 years; 10% of patients are freed from the virus due to accumulation of antibodies to the surface antigen (anti-HBS), with stable normalization of AST and ALT activity, recovery occurs. Cirrhosis develops in 1-1.5% of cases, and long-term remission with HBsAg carriage occurs in the remaining 89%. Chronic hepatitis D has an unfavorable prognosis - in 20-25% of cases the process develops into cirrhosis of the liver; liberation from the pathogen does not occur. Chronic hepatitis C is a long-term, "soft" disease, without cessation of viremia for many years, with a periodic increase in transaminase activity and a very pronounced tendency to fibrosis.

Prevention of chronic viral hepatitis

According to the National Immunization Schedule, vaccination against hepatitis B has begun. Children are vaccinated in the first day of life, then after 3 and 6 months. Children who have not been vaccinated before the age of 1 year and who do not belong to risk groups are vaccinated according to the “0-1-6 months” schedule. Adolescents aged 11-13 years are required to be vaccinated against hepatitis B according to the same schedule. Newborns from mothers with any variant of hepatitis B are vaccinated from birth according to the “0-1-2 months” schedule with revaccination at 12 months.

Healthcare workers and people at risk of contracting hepatitis B are widely vaccinated. Vaccination against hepatitis B leads to a gradual decrease in the level of infection of the population with the hepatitis B virus.

A vaccine against hepatitis C has not yet been developed, and therefore hepatitis C prevention is based on preventing all possibilities of parenteral (including transfusion) infection.

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