Hepatitis B

Viral hepatitis B is an infection that is the most common cause of development of acute and chronic liver pathologies, cirrhosis and hepatocellular carcinoma, in addition HBV provokes most biliary dysfunctions. The main danger of the virus lies in the fact that according to WHO estimates in the world today there are about 300,000,000 diagnosed carriers of infection, it is logical to assume that there are much more unresolved virus carriers.

ICD-10 code

Q16. Acute form of hepatitis B: 

• B16.0 - acute hepatitis B with delta-agent (coinfection) and hepatic coma.
• B16.1 - acute hepatitis B with delta-agent (co-infection) without hepatic coma.
• B16.2 - acute hepatitis B without delta-agent with hepatic coma.
• B16.3 - acute hepatitis B without delta-agent and without hepatic coma.

Q18. Chronic form of hepatitis B: 

• В18.0 - chronic viral hepatitis with delta-agent.
• В18.1 - chronic viral hepatitis without delta-agent.

Epidemiology of hepatitis B

Hepatitis B until recently had several variants of names - serum, syringe, parenteral. These definitions really explain the main way of transmission of the virus into the blood: the infection enters the body through damaged mucous membranes and microdamages of the skin. For the first time, the HBV marker was isolated half a century ago, in 1963, as the antigen was found in the blood of the indigenous people of Australia, massively infected with hepatitis, it was called "Australian". Seven years later, a full-fledged virus was identified, which created the ground for a new nosological form to appear in the classification of infections - hepatitis B virus (HBV).

The epidemiology of hepatitis B is characterized by a unified source and pathway of infection. HBV infection can only be from an infected person parenterally (through damaged internal mucous membranes or external skin), several ways to penetrate the virus: 1.

The natural way: 

• Contact, when the virus through microtrauma, cracked skin, mucous membranes penetrates into the bloodstream. This occurs when the general use of hygiene items intended for personal use - razor, toothbrush, scissors. An object belonging to a virus carrier poses a potential threat to others.
• The vertical path is intrauterine infection of the fetus from the infected mother, infection of the child during passage through the birth canal or infection during the period of withdrawal (chewing food for the baby, close physical contact with the infected mother and so on). Through breast milk, the virus is not transmitted. 
• Sexual way, both in heterosexual and homosexual intercourse. 

Artificial route of infection: 

• Medical procedures - injections, drip infusions, blood transfusion (blood transfusion).
• Transplantation of donor organs, tissues.
• Drug addiction (injecting).

For the spread of the virus, a certain medium is needed - blood, seminal fluid, saliva, urine, vaginal secretions, thus, the HBV transmission pathway is almost identical with HIV infection variants. The epidemiology of hepatitis B is one of the most disturbing problems for the global health system. Its total prevalence has slightly declined over the past 5 years, thanks to the introduction of vaccination rules, but still the main sources and carriers of the virus are people who use injecting drugs and people with promiscuity. Vaccines have not yet come up against these two ills, so hepatitis In continues to take more than 2,000,000 lives annually.

The risk groups for hepatitis B infection include such categories of people: 

• Injecting addicts.
• People who prefer unconventional sexual orientation.
• People who lead a promiscuous sexual way of life (unprotected sex).
• Circle of persons who have constant close contact with a patient with HBV or a virus carrier.
• Patients who require injection therapy or transfusion (intravenous drip administration), blood transfusion (transfusion), transplantation, hemodialysis.
• Newborn children whose mothers are carriers of the infection or are sick with acute or chronic hepatitis B.
• Medical personnel who are constantly relevant to the blood (surgeons, dentists, manipulative nurses, lab technicians).

Hepatitis B - Epidemiology

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

The cause of hepatitis B

The etiology (cause) of hepatitis B is the causative agent of the disease, hepatitis B virus (HBV) from the group Hepadnaviridae, which has DNA in diameter reaching 45 nanometers, with a lipoprotein coat and a complex, double antigenic structure. Due to this, the HBV virus is extremely resistant to environmental influences in terms of temperature or disinfection. The causative agent of hepatitis B is able to maintain vital activity for about 10 years at room temperature, in the bloodstream it has been active for many years, sometimes without showing itself. The virus can be found on untreated injectable needles, dental instruments and even on bed linens containing elements of contaminated blood. To kill the hepatitis antigen is possible with the help of an autoclave, if you treat the infected objects in it for 45 minutes at a high temperature - up to 120 degrees. Also, the method of dry sterilization is applied to the virus for an hour. In addition, the disinfectants that are capable of inactivating the HBV virus are formalin, hydrogen peroxide, phenol or chloramine. Despite the existing methods of neutralizing the antigen, the virus constantly mutates. New mutant strains are resistant to many standard disinfection procedures.

The cause of hepatitis B is the penetration of the virus into the blood through microtrauma on the skin, mucous membranes. To get into the liver cells through the bloodstream and begin a gradual replication in the hepatocytes, without exerting obvious pathological effects on them. Hepatocytes are destroyed more likely not from the virus itself, but from the "fight" of the immune system with the pathogen. Cytolysis (the level of pathological damage) is directly related to the activity of the immune system and the structure of the virus itself, its variant. The severity of the course of the disease and the rate of its development is determined by the activity of T-lymphocytes on virus-infected hepatocytes. The liver gradually develops a necrobiotic process, and, after months, and more often years, it includes the entire biliary system of the body - bile ducts, gall bladder, spleen.

 Hepatitis B - Causes

Symptoms of hepatitis B

Clinical manifestations of hepatitis B depend on the form of the disease - chronic or acute. It is believed that the most common form of HBV, which is characterized by signs of jaundice and marked cytolysis.

The acute form of infection has the classical stages typical of all types of hepatitis: 

• Incubation.
• Pre-zheltushny period.
• Jaundice.
• The recovery period is reconvalescence.
• Hepatitis B - acute form.

The incubation stage of hepatitis B acute form lasts from 1.5 months to six months. The pre-zheltushny period takes about a week and is characterized by signs of intoxication of the body - dyspepsia, weakness. The patient constantly tends to sleep, dizzy, hurt and lump joints. Body temperature, as a rule, is not increased or increases slightly, without causing a febrile state. In the period of pre-palate, the spleen and liver begin to grow in size, the urine acquires a characteristic dark shade, the feces are depigmented. If a person undergoes medical examination or is specifically examined for hepatitis, at this stage laboratory tests show the presence of urobilinogen in the urine, bile pigments, and in the serum - HBsAg antigen and increased activity of ALAT (alanine aminotransferase).

Symptoms of hepatitis B in icteric period can not be seen. The duration of icteric stage varies from 14 to 40 days. This is the peak of the disease, which is accompanied by yellowing of the skin, a sclera of the eyes, a hard palate and the oral mucosa. Developing intoxication is manifested by severe weakness, headaches, insomnia, nausea and lack of appetite. The right side of the epigastrium can hurt, the disease at this stage is characterized by pain on the right in the hypochondrium after each meal. Appears skin itch, cardiac symptoms - systolic murmur, bradycardia. Despite the fact that the liver after a pathological increase decreases in size, its dysfunction and insufficiency develops due to necrosis of cells and compaction of the organ.

Symptoms of hepatitis B at this stage can manifest wavy - then fade, then recur, which indicates the transition of the disease into a chronic form.

The stage of recovery lasts at least one year, although the main signs of hepatitis can disappear within two to three months. The asthenovegetative state lasts the longest, accompanied by periodic pains on the right in the hypochondrium.

It should be noted that HBV also has latent, jaundiced forms that are characteristic of the chronic course of the pathological process.

The most serious symptoms of hepatitis B are acute liver failure and hepatic encephalopathy. These syndromes are manifested by pronounced neurological signs, skin itching and rashes, a drop in blood pressure, tachycardia and a typical "liver" odor from the mouth.

The most dangerous is hepatic encephalopathy, which develops in stages: 

1. Prekoma initial - delusional condition, insomnia, dizziness, cognitive impairment, tremor of the extremities, indomitable vomiting, skin itching and rashes. All these symptoms of hepatitis B develop against a background of jaundice. 
2. Prekoma in the second stage - a violation of coordination of movements, confusion, psychomotor agitation, which alternates with adynamia and weakness. Tremor is noticeable not only in the limbs, but also in the lips and tongue. Developing tachycardia, blood pressure changes dramatically from reduced to significantly elevated, up to hypertensive crises. The liver is reduced in size at this stage. 
3. Coma - loss of consciousness with preserved basic reflexes (breathing, swallowing) and reactions to intense stimuli. Violations of urination and defecation are disturbed. The syndrome of empty right hypochondrium develops, when the liver is not detected during palpation. 
4. Deep coma - consciousness is lost completely together with all reactions and reflexes.

Hepatic coma is most often the main consequence of a complex form of hepatitis B - fulminant. As a rule, the patient dies within 2-3 weeks.

Hepatitis B - Symptoms

Hepatitis B - a chronic form

Symptoms of chronic hepatitis B are a flaccid inflammatory process in the liver that lasts for years. This disease is clinically little manifested, the only sign that indicates hepatitis, can be hepatomegaly - an increase in liver size, and the spleen also increases.

Progression of the disease is possible with trigger conditions - concomitant inflammatory infections. In this case, hepatitis B is manifested by transient skin itching, the appearance of vascular asterisks on the skin, palmar erythema (red palms), nosebleeds. Jaundice can be seen only in the stage of slight exacerbation of the disease, dyspepsia and a slight increase in body temperature are also possible. Such a lingering course of the disease is dangerous because the pathological process lasts for many years, destroying the liver cells and provoking the development of cirrhosis.

Chronic hepatitis B

Diagnosis of hepatitis B

Diagnosis of hepatitis B is most often performed in people who have direct contact with already infected persons, as well as those who are at risk of infection. However, there is no medical examination for hepatitis B, patients and carriers of the virus are very rarely examined on their own, therefore, the diagnosis of hepatitis B is already underway when the disease progresses.

The parameters of HBV are HBs-antigen, the level of bilirubin in the blood, the level of transaminases. Diagnostic tests have the following markers, in terms of which HBV is determined: 

• Antigen HbsAg (surface antigen).
• HBeAg antigen (antigen replicating in the nucleus of the hepatocyte).
• ALT.
• HBV DNA.
• Antibodies to antigens.

Markers are determined using the PCR-polymerase chain reaction method. Diagnosis of hepatitis B with established clinical symptoms is established quickly, the main task of diagnostic measures is the differentiation of the virus and its strains. Also of great importance are the anamnestic data, which allows us to specify the onset of the disease and the route of infection.

Hepatitis B - Diagnosis

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Treatment of hepatitis B

Viral hepatitis B, which flows in a mild form, is treated mainly by maintaining a sparing diet (table number 5 in Pevzner), limiting physical and motor load, taking hepatoprotectors and vitamins.

Treatment of hepatitis B, which takes place more heavily, presupposes detoxification therapy, intake of enterosorbents, infusion of nutrients, water-salt physiological solutions, including Hemodez, Ringer's solution, glucose. Metabolic and restorative therapy is indicated after detox and neutralization of the main symptomatology, it includes hepatoprotectors, enzymes, vitamins and microelements. In addition, a sparing diet and abundant drinking are mandatory.

A serious condition is supervised by an increase in the volume of detoxification preparations, they are administered up to 3 liters per day. Also prescribe prednisolone or other glucocorticosteroids, antispasmodics, diuretics, less often antibiotics in the presence of concomitant infection.

Treatment of hepatitis B in the pre-coma (acute liver failure, encephalopathy) involves a complex of intensive care, and sometimes resuscitation.

The main drug in the treatment of many types of hepatitis, as well as in the treatment of hepatitis B, is alpha interferon. Its antiviral and immunomodulatory effect allows achieving good results provided timely treatment is started.

If viral hepatitis proceeds in a mild form that does not require hospitalization, then the therapy is performed at home and meets the following recommendations: 

• Abundant systematic drinking to accelerate detoxification and prevent dehydration (dehydration).
• Diet Pevzner № 5, which must be observed for at least six months.
• Refusal to self-medicate and prescribe medications. You can not experiment with the use of antibiotics and even hepatoprotectors, so as not to aggravate the course of the disease. Drug therapy is prescribed only by a doctor.
• Categorical refusal of alcohol, including beer and low-alcohol drinks.
• Limitation of physical and motor load. Gentle mode should last at least 2-3 months.

It should be noted that the treatment of hepatitis B in a serious condition, in the terminal stage of a chronic form, may involve surgical intervention. It is believed that hepatocellular carcinoma does not lend itself to drug therapy and requires donor liver transplantation.

Hepatitis B - Treatment

Prevention of hepatitis B

It is known that the main way of spreading the hepatitis B virus is parenteral. Consequently, the provision of sterile conditions for parenteral administration of drugs should neutralize the spread of the virus. Indeed, measures that include the prevention of hepatitis B are partly controlled by health professionals. However, the other half of the problem needs general discussion, government programs and total struggle against the global systemic epidemic - drug addiction

From the side of the world of medicine for 30 years, all necessary measures are taken to prevent iatrogenic factors of hepatitis B infection: 

• Dispensary examinations of contact persons.
• Strict control and verification of donor blood.
• Ubiquitous use of disposable syringes, tools, gloves.
• Strict control over the timely sterilization of tools and reusable devices, as well as the processing of household items and linen in hospital facilities.

More systemic prevention of hepatitis B is vaccination, for which different types of vaccines are used that counteract the HBV virus. Vaccination is carried out in three stages, and the primary inoculation is made to the newborn during the first 10-12 hours after birth. Immune protection is guaranteed for 5 years, but most often lasts 10 years or more. Passive vaccination is carried out in cases of suspected infection of adults. The introduction of immunoglobulin against hepatitis B (Neohepatect or analogue) is effective no later than two days after possible infection, and then the vaccination is carried out according to the standard scheme.

Also, the prevention of hepatitis B requires the implementation of simple rules from the people themselves. Following these recommendations, you can reduce the risk of infection by 90%. 

• Protected sexual contacts - the use of condoms and other ways to prevent infection, including STDs (sexually transmitted diseases).
• Use of disposable sterile instruments, syringes with injections and other medical procedures.
• Responsible and thoughtful approach to the desire to put a tattoo, including cosmetic.
• Use of personal, personal tools for nail treatment, shaving.
• When planning pregnancy, a medical examination is mandatory: you need to pass a test for the presence or absence of the hepatitis B virus.

Hepatitis B prevention

Vaccination against hepatitis B

The main reliable method of prevention, which guarantees long-term protection against the virus, is considered to be vaccination against hepatitis B. In many developed countries, a state program that counteracts the HBV epidemic is being implemented. Vaccination against hepatitis B (HBV) is mandatory for all newborn children, as well as for those who have close contact with infected persons. The vaccine against HBV is included in the mandatory list of childhood vaccinations in our country. This is due to the fact that the babies have not yet formed immunity and the risk of overgrowing the disease into a chronic form with primary infection is 100%. In addition, introduced in the first hours after birth hours of the vaccine, guarantees a lasting protection of the baby from HBV for many years. A vaccination against hepatitis B, carried out according to all the rules, creates a reliable immune response against the virus for 10-15 years.

It should be noted that the vaccination program was introduced not so long ago, respectively, the adult population was not covered by vaccinations. This is why WHO has consistently recommended the following vaccination procedures for these categories of people: 

• Patients with chronic diseases who are shown regular therapy with the help of injecting drugs.
• Patients who need blood transfusion.
• Patients who undergo hemodialysis.
• Employees of medical institutions who are constantly in contact with infected patients or with blood products.
• Children of preschool age.
• To all persons who in everyday life contact infected people.
• People who have an active sex life, including non-traditional orientation.
• People who go on a trip to regions with a high epidemiological threshold.
• Patients who suffer from chronic diseases of the biliary system.

Vaccination against hepatitis B is carried out by injecting the drug into the upper thigh of children under the age of 3 years, to older children and adults, the vaccine is injected into the shoulder. The only contraindication is a rare type of allergy to baker's yeast, and the vaccine is not administered to premature babies, whose weight does not reach 2 kilograms.

Forecast of hepatitis B

Before many patients infected with the HBV virus, the question arises as to how anxious the prognosis of hepatitis B is. Clinical practice shows that with timely diagnosis and treatment, half of the patients recover, especially if the disease occurs in acute form. The most severe outcome is possible with the fulminant flow of hepatitis B, when the lethal outcome is about 85-90% of the total number of infected HBV.

Also, the prognosis of hepatitis B, which proceeds in chronic form, is considered unfavorable. Chronic hepatitis usually ends with cirrhosis of the liver - up to 20%, and in 5-7% of liver carcinoma.

The prognosis of hepatitis B for asymptomatic carriers of infection is favorable, such people need to undergo scheduled clinical examinations, monitor their health and follow all recommendations for the prevention of the spread of the virus.

[13], [14], [15], [16], [17], [18],