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Viral hepatitis And yes In — two independent nosological forms with preferential damage of a liver and a nervous system.
Etiology. The activator — various viruses A and B in the antigenic relation. By means of an immune submicroscopy in Calais of patients with infectious hepatitis A virus-like particles of spherical shape of 27 nanometers in size are found. The virus of serumal hepatitis B has difficult structure: he breeds in hepatocytes and consists of two components — the nuclear (internal) HBcAg antigen synthesized in kernels of hepatocytes, and the superficial HBsAg which is in cytoplasm of cells of a liver. It is assumed that the third component of a virus is antigen E which is synthesized in cytoplasm of cells of a liver. According to some researchers, antigen E is an indicator of transition of an acute hepatitis in chronic. In recent years in blood of patients with a viral hepatitis the unknown the delta agent called also by a hepatitis D virus is found earlier. The delta infection and viral hepatitis In represent multi-infection, and the first cannot exist without the second. The conducted researches indicate more frequent development of cirrhosis and more frequent lethal outcomes in such patients. Except main types existence of the viruses differing in the antigenic relation is supposed (not And, not In).
Epidemiology. The activator gets into an organism at hepatitis A in mainly enteral way; at hepatitis B — parenterally. Main stages of development of infectious process: infection — parenteral or enteral implementation of a virus; incubation, initially regional infection; a virusemia with the maximum transmissibility of patients during the preicteric period; the illness heat which is characterized by parenchymatous dissimination of a virus, intoxication and developing of jaundice though this characteristic sign is not obligatory; the repeated generalizations of a virus, autoimmune reactions leading to disturbance of recurrence of process, aggravations, recurrence, complications; the residual phase defining an outcome of the disease — recovery, chronic hepatitis, cirrhosis. At the favorable course of hepatitis the last stage of a pathogeny — virus relief of an organism and immunity forming. Repeated infections (reinfection) are possible, considering lack of a cross immunity between viruses A and B. Pathological process not always proceeds cyclically. Genetic features, character of defense reactions, a form of the activator and some other factors are the reason of a long persistirovaniye of a virus in cells of reticuloendothelial system and in a liver with its periodic reproduction. In some cases a long carriage of virus forms. Morphological researches of a liver reveal dystrophy of hepatocytes up to a massive necrosis of a parenchyma, death of the whole segments at acute dystrophy of a liver. Along with necrotic regeneration sites are found that testifies to considerable ability of a liver to recover the losses.
The clinic is characterized by variety of manifestations — from the easiest forms to the hardest from the outcome in an acute necrosis. Recurrence of disease allows to distinguish the next periods: incubatory, initial, heat and period of recovery. The incubation interval at infectious hepatitis lasts 3 — 4 weeks, at serumal — this term can increase till 8 — 10 months. Duration of an initial stage of a disease fluctuates from several days to 2 — 3 weeks and more. There are a weakness, apathy or an acrimony. The dispepsichesky phenomena, feeling of weight in epigastriß area, morbidity in the field of the right hypochondrium are typical. Fever is observed: the fever is replaced by heat, temperature is increased for 3 — 4 days, sometimes longer term. The catarral phenomena, skin rashes are possible, the skin itch is more often like small tortoiseshell or an erythema. Typical symptom of an illness is jaundice which arises in a heat phase. Duration of jaundice fluctuates over a wide range. Sometimes all illness is limited only to an ephemeral ikterichnost of scleras and skin. At a usual cyclic current duration of jaundice of 3 — 4 weeks, but in some cases it accepts a long current. From the first days of the icteric period the liver sizes increase. At the same time the spleen sizes increase. At more remote stages it can reach splenomegaly degree when the sizes of a spleen are increased more, than the liver sizes.
The stomach and pancreas are involved in pathological process, up to development of pancreatitis and a diabetes mellitus, especially at the persons receiving corticosteroids. Quite often, especially in hard cases, the muffled cordial tones, systolic noise are listened. Sometimes changes in a myocardium have diffusion character and can be considered as manifestations of a hepatogenous myocardial dystrophy. Bradycardia is typical for patients of young age. Developing of tachycardia is considered as an adverse symptom of a possible hepatargy. The tendency to lowering of arterial pressure is defined.
The picture of blood is characterized by the slowed-down or moderately increased SOE. The tendency to decrease in quantity of leukocytes is defined. Only at the malignant course of hepatitis there is a leukocytosis with a sharp deviation to the left to band neutrocytes. Also the monocytosis, existence of the plasmocytes, lymphoid, reticular, reticuloendothelial macrophages testimonial of activation of reticuloendothelial system are characteristic of an uncomplicated form lympho-.
Irritability of patients, sometimes apathy, the suppressed mood, frustration of a dream, headache; in hard cases profound changes, up to psychomotor excitement and a coma, speak about involvement in pathological process of a nervous system.
Characteristics have the associated forms of serumal hepatitis in combination with various associated diseases — a peptic ulcer, a diabetes mellitus, cardiovascular diseases, defeat of blood, kidneys.
At biochemical researches deep abnormal liver functions and a metabolism in general are found. The maintenance of the general, direct and indirect bilirubin changes, education and removal of urobilin (stercobilin) is broken. Thymol turbidity test indicators raise, the amount of albumine decreases. Activity of enzymes changes. Even long before emergence of jaundice activity of aminotransferases, an alkaline phosphatase increases, reflecting expressiveness of a cholestasia.
By the end 3 — the 4th week noticeable improvement is usually noted, there is an appetite, the general tone raises, but the residual phenomena are noted for a long time: the hyperbilirubinemia, vegetative disturbances, increase in the sizes of a liver, remains the alaninaminotranspherase raised activity. Permanent increase in blood serum of biochemical indicators — activities of alaninaminotranspherases, an adenosinedeaminase, an intestinal alkaline phosphatase, decrease in level of albumine and increase of content of gamma-globulin — allows to think of transition of an acute hepatitis to chronic.
The viral hepatitis can proceed in an easy, average and severe form. The easy form considerably meets at infectious hepatitis more often, is characterized by the low-broken state. Jaundice is short-term. Anicteric forms as the facilitated illness option are frequent. The severe form occurs mainly at patients with serumal hepatitis. The disease can accept the menacing current with development of acute and iodacute dystrophy of a liver.
The accruing intoxication — a headache, nausea, vomiting — can be considered as a hepatic unsufficiency sign. Thinking in a slowed-up way, "failures" in memory are observed. Progressiruyushche reduces the liver sizes. Sometimes it is possible to observe the "clapping" tremor of hands, a peculiar luscious and aromatic hepatic smell is caught. In most cases pulse becomes frequent. Hemorrhagic manifestations are frequent. The blood picture changes: the expressed deviation to the left due to increase in percent of band neutrocytes, a leukocytosis. The maintenance of nitrogenous products accrues, the acid-base state changes, the electrolytic balance towards a hypopotassemia and a hypernatremia is broken. The quantity of an indirect bilirubin increases, the content of crude protein, albumine, beta and alpha globulins decreases; sharply activity of alaninaminotranspherase against increase of level of an indirect bilirubin decreases. Diuresis decreases, hypostases and ascites develop. Dystrophic changes in kidneys quite often reach degree of a necrotic nephrosis.
In process of development of dystrophic process signs of psychomotor excitement die away and the coma develops. In recent years as a result of use of a complex of the remedies including corticosteroids, interferon, hyperbaric oxygenation, the lethality decreased.
Sometimes jaundice accepts wavy character and in a clinical picture into the forefront the cholestasia syndrome acts. Laboratory researches allow to reveal increase of content of bilirubin in blood, moderate activity of alaninaminotranspherase, sharply a superactivity of an alkaline phosphatase, the expressed change of a lipidic exchange: increase of content of triglycerides, cholesterol, phospholipids and beta lipoproteids at the normal level of free fatty acids.
At the expressed pathology of internals, the changed laboratory tests the general condition of patients remains low-broken: they are rather active, are quite often weighed upon a bed rest and on the behavior considerably differ from patients with parenchymatous hepatitis with the expressed weakness, an adynamia, drowsiness, a breakdown. Cholestatic hepatitis can accept quickly progressing character with possible development of biliary cirrhosis.