Viral hepatitis in the elderly
Introduction
Introduction to viral hepatitis in the elderly Viral hepatitis is an infectious disease mainly caused by liver diseases caused by various hepatitis viruses. It is mainly characterized by loss of appetite, nausea, upper abdominal discomfort, liver pain and fatigue. Some patients may have jaundice, fever and liver, accompanied by liver damage. Some patients can be chronic, even develop into cirrhosis, and a few can develop liver cancer. basic knowledge The proportion of illness: 1% of the specific population Susceptible people: the elderly Mode of infection: fecal-oral transmission, blood transmission, mother-to-child transmission Complications: liver cirrhosis, hepatic encephalopathy
Cause
The cause of viral hepatitis in the elderly
Causes
The pathogen classification of viral hepatitis has been recognized as five hepatitis viruses of A, B, C, D, and E, which are written as HAV, HBV, HCV, HDV, HEV, respectively, except for hepatitis B virus as DNA virus. All of them are RNA viruses. Hepatitis has been reported, but pathogen isolation has not been successful so far. The relationship between TTV of hepatoma virus belonging to flavivirus and single-stranded DNA obtained by representative difference analysis in recent years is still controversial.
Hepatitis B (30%):
Hepatitis B is a disease caused by hepatitis B virus (HBV), which is mainly caused by inflammatory lesions of the liver and can cause damage to multiple organs. Hepatitis B is widely prevalent in all countries of the world, mainly invading children and young adults, and a small number of patients can be converted into cirrhosis or liver cancer. Therefore, it has become a worldwide disease that seriously threatens human health, and it is also the most widespread and most harmful disease in China. There is no certain epidemic period for hepatitis B virus, which can occur all year round, but it is mostly distributed. In recent years, the incidence of hepatitis B has increased significantly.
Hepatitis C (20%):
Hepatitis C virus infection is the root cause of the disease. Under the influence of external factors, such as drinking alcohol, fatigue, long-term use of drugs with hepatotoxicity, can promote the development of the disease. The pathological changes of hepatitis C are very similar to those of hepatitis B, with hepatocyte necrosis and lymphocyte infiltration. Chronic hepatitis can occur in the portal area fibrous tissue hyperplasia, severe cases can form pseudolobules that become cirrhosis.
Pathogenesis
The pathophysiological changes of hepatitis caused by various hepatitis viruses are basically the same except for type A and hepatitis E. The basic pathological features are: hepatocyte degeneration, necrosis, apoptosis, regeneration, inflammatory cell infiltration, Quality (extracellular matrix) hyperplasia, acute hepatitis with inflammation, degeneration, necrosis, fibrosis is not obvious, chronic hepatitis shows varying degrees of hepatocyte necrosis and inflammation, mainly in the portal area, around the portal area and hepatic lobules, severe lesions There may be hepatic lobular structure destruction, fibrosis and nodular regeneration to form cirrhosis, acute jaundice hepatitis is a large number of hepatocyte necrosis, and no fibrous tissue hyperplasia, subacute severe hepatitis in addition to massive necrosis of hepatocytes, hepatocyte regeneration and Collagen fiber, regenerating nodules, chronic severe hepatitis, pathological changes of subacute severe hepatitis on the basis of chronic hepatitis and cirrhosis, pathological changes of cholestatic hepatitis for acute hepatitis lesions based on obvious intracranial cholestatic , the formation of bile plugs.
Prevention
Viral hepatitis prevention in the elderly
Hepatitis A is infected by ingesting food contaminated with hepatitis A virus, so the prevalence rate depends largely on the environmental sanitation of the place. The degree of transmission is closely related to the economic conditions of life and the level of health knowledge. The main cause of hepatitis B virus The transmission factor is blood, so the most important mode of transmission is vertical transmission of mother and child and iatrogenic infection. Therefore, the preventive measures for viral hepatitis are:
1. Manage the source of infection
Isolation of patients with acute hepatitis A to contagious disappearance, chronic hepatitis and asymptomatic HBV, HCV carriers should ban blood donation and work on diet, child care, etc., according to their symptoms, signs and laboratories for HBV-positive liver disease patients The results of the examination were separately treated and managed.
2. Cut off the route of transmission
A, hepatitis E focuses on preventing fecal-oral transmission, strengthening water source protection, food and personal hygiene, and strengthening manure management. The focus of hepatitis B, C, and D-type hepatitis is to prevent blood and body fluid transmission, strengthen blood donor screening, and strictly control blood transfusion and Blood product application, if it is found or suspected of wound or acupuncture infection with hepatitis B virus, high-priced hepatitis B immunoglobulin, syringe, interventional examination and treatment equipment should be strictly disinfected to control mother-to-child transmission.
3. Protect susceptible populations
Artificial immunization, especially active immunization, is a fundamental measure to prevent hepatitis. However, some hepatitis viruses (such as HCV) have no widely used vaccines due to genetic heterogeneity. Hepatitis A vaccine has been applied, and hepatitis B vaccine has been promoted in China. To achieve better results, HBsAg, HBeAg-positive pregnant women, born within 24h of birth high-priced hepatitis B immunoglobulin (HBIG), while inoculation of a hepatitis B vaccine, 1 month after birth, re-injection of HBIG and vaccine .
Early detection of viral hepatitis, early diagnosis, early isolation, early reporting, early treatment and early treatment of epidemic sites to prevent epidemics and improve efficacy.
Complication
Viral hepatitis complications in the elderly Complications, liver cirrhosis, hepatic encephalopathy
Can be complicated by portal hypertension, bleeding tendency, cirrhosis, hepatic encephalopathy and so on.
Symptom
Symptoms of Viral Hepatitis in the Elderly Common Symptoms Abnormal Liver Function Hepatosplenomegaly Weak Lips Yellow Abdominal Discomfort Nausea Hepatic Cell Necrosis Appetite Loss Liver Palm Spider
According to the viral hepatitis prevention and treatment program, hepatitis can be divided into five clinical types.
Acute hepatitis
It is divided into acute jaundice hepatitis and acute jaundice-free hepatitis. The incubation period is between 15 and 45 days, with an average of 25 days. The total course of disease is 2 to 4 months.
(1) Early stage of jaundice: there is chills, fever, fatigue, loss of appetite, nausea, irritability, abdominal discomfort, liver pain, and urine color gradually deepen. This period lasts an average of 5 to 7 days.
(2) jaundice period: heat retreat, sclera skin yellow staining, jaundice appears and the symptoms have improved, liver, with tenderness, sputum pain, partial mild splenomegaly, this period 2 to 6 weeks.
(3) Recovery period: The jaundice gradually subsided, the symptoms were alleviated and disappeared, the liver and spleen retracted, and the liver function gradually returned to normal. The current period lasted 2 weeks to 4 months, with an average of 1 month.
2. Chronic hepatitis
In the past, there were B, C, D hepatitis or HBsAg carrying history or acute hepatitis for more than half a year, but there are still hepatitis symptoms, signs and liver dysfunction can be diagnosed as chronic hepatitis, common symptoms are fatigue, general malaise, appetite Decreased, liver discomfort or pain, abdominal distension, low fever, signs for dull complexion, scleral yellow staining, may have spider mites or liver palm, liver, medium or full-feeling, pre-pressure and pain, more splenomegaly, Severe cases may have deepening of jaundice, ascites, lower extremity edema, bleeding tendency and hepatic encephalopathy. To reflect the degree of liver damage, the clinical can be divided into:
(1) Mild: The condition is mild, the symptoms are not obvious or there are symptoms and signs, but the biochemical indicators are only 1 to 2 mild abnormalities.
(2) Moderate: Symptoms, signs, laboratory tests are between mild and severe.
(3) Severe: There are obvious or persistent symptoms of hepatitis, such as fatigue, anorexia, bloating, loose stools, etc., may be accompanied by liver disease, liver palm, spider mites or hepatosplenomegaly, excluding other causes and no portal In patients with hypertension, laboratory tests for repeated or continuous increase in serum alanine aminotransferase: albumin reduction or abnormal A/G ratio, gamma globulin increased significantly, where albumin 32g / L, bilirubin > 85.5mol / L One of the three tests for prothrombin activity, 60% to 40%, can be diagnosed as chronic hepatitis.
3. Severe hepatitis
(1) Acute severe hepatitis: rapid onset, rapid progress, deep jaundice, small liver, rapid neuropsychiatric symptoms within 10 days after onset (hepatic encephalopathy II or more), obvious bleeding tendency, and liver odor, ascites , liver and kidney syndrome, prothrombin activity below 40% and exclude other causes, low cholesterol, abnormal liver function.
(2) Subacute severe hepatitis: After 10 days of onset, there is still extreme fatigue, anorexia, severe jaundice (bilirubin >171mol/L), abdominal distension and ascites formation, and more obvious bleeding, generally liver shrinkage is not prominent Hepatic encephalopathy is more common in the later stage, severe damage to liver function: elevated serum ALT, or increased elevation is not obvious and total bilirubin is significantly increased, ie: bile enzyme separation, A/G ratio inverted, gamma globulin increased, Prothrombin time is prolonged and prothrombin activity is <40%.
(3) Chronic severe hepatitis: Chronic hepatitis, cirrhosis or history of hepatitis B surface antigen carrying, or although there is no history of appeal, but imaging, laparoscopic or liver puncture support chronic hepatitis, and subacute severe disease The clinical manifestations and laboratory changes of hepatitis are chronic severe hepatitis.
4. Cholestatic hepatitis
The onset is similar to acute jaundice hepatitis, but the symptoms are often mild, with obvious liver, itchy skin, light stool, serum alkaline phosphatase, -transpeptidase, cholesterol are significantly increased, jaundice, bilirubin The increase in priming is mainly due to direct increase, the symptoms of digestive tract are not obvious, the increase of transaminase is small, the prothrombin time and prothrombin activity are normal, and the mild clinical symptoms and deep jaundice are not parallel.
5. Hepatic cirrhosis after hepatitis
Early cirrhosis is difficult to diagnose by clinical data alone and must rely on pathological diagnosis. Imaging (ultrasound, CT, etc.) diagnosis and laparoscopy are the most valuable. Clinical diagnosis of cirrhosis refers to chronic hepatitis patients with evidence of portal hypertension, such as the abdominal wall. And esophageal varices, ascites, imaging findings of liver shrinkage, splenomegaly, portal vein, spleen vein diameter widened, and exclude other causes of portal hypertension, according to the degree of hepatitis activity is divided into active and stationary cirrhosis.
For elderly patients with hepatitis, the following aspects should be noted on the basis of the above five clinical types:
(1) The disease is often atypical: due to the decline of the physiological function and immune function of the elderly, some elderly patients with viral hepatitis have been infected with chronic hepatitis or become chronic carriers. Once the resistance is reduced, the symptoms will increase. Hepatitis and severe complications occur in hepatitis. Therefore, the mortality rate is also high. People who drink alcohol are susceptible to hepatitis B and hepatitis C, and these two kinds of hepatitis cause chronic hepatitis, and cirrhosis is more common. Developed into hepatocellular carcinoma.
(2) The clinical symptoms of senile hepatitis are heavier: there is fatigue, nausea, bloating, liver enlargement, jaundice, and jaundice is deep, and regression is slow. Cholestatic hepatitis is also common.
(3) senile viral hepatitis is often very deep jaundice: symptoms are atypical and sometimes difficult to distinguish from extrahepatic obstructive jaundice, such as gallstones or liver cancer, pancreatic head cancer and cholangiocarcinoma, so biochemical tests related to liver function and hepatitis antigen B-ultrasound or CT examination is sometimes applied outside the antibody system.
(4) more comorbidities: the elderly often suffer from a variety of chronic diseases, such as hypertension, coronary heart disease, chronic bronchitis, emphysema, etc., the elderly's resistance is also low, so it will have a certain impact on the diagnosis, If heart failure is accompanied by hepatitis, it should be differentiated from abnormal liver function caused by heart failure itself.
Examine
Examination of viral hepatitis in the elderly
1. Liver function test
(1) Serum enzymology test: the concentration of alanine aminotransferase (ALT) in hepatocytes is 104 times higher than that of serum. As long as 1% of hepatocytes are necrotic, serum concentration can be increased by 1 time, and acute liver positive rate Up to 80% to 100%, but lack of specificity, aspartate aminotransferase (AST) has the highest concentration in the myocardium, so when determining the impact on liver function, the impact of heart disease should be ruled out first, AST 80% In the mitochondria of liver cells, liver damage is generally caused by elevated ALT. If the serum AST is significantly increased, it indicates that the liver cells are severely necrotic. The mitochondria are released into the blood by AST. The increase of serum transaminase is roughly parallel with the severity of the lesion, but In severe hepatitis, bilirubin may increase continuously and transaminase may decrease, that is, bile enzyme separation, which is the result of hepatocyte necrosis.
(2) Serum protein detection: serum protein is often used as a biochemical indicator of liver protein metabolism. Chronic hepatitis and cirrhosis often have serum albumin decreased, globulin levels increase, and -globulin is elevated.
(3) Detection of serum bilirubin: The liver has the functions of ingestion, transport, binding and excretion in bilirubin metabolism, and the bilirubin level is increased due to liver function damage. In addition to cholestatic hepatitis, bilirubin levels and The severity of liver damage is directly proportional.
(4) Prothrombin time (PT): It can be sensitive to the synthesis of blood coagulation factors II, VII, IX, X in the liver. The length of PT in liver disease is positively correlated with the degree of liver injury.
2. Hepatitis virus logo detection
(1) Hepatitis A: Patients with acute hepatitis are positive for anti-HAVIgM, which can be diagnosed as a recent infection with HAV. Anti-HAV-IgG positive indicates previous infection and immunity.
(2) Hepatitis B:
1HBsAg and anti-HBs: HBsAg positive indicates that HBV is currently in the infection stage, anti-HBs are immunoprotective antibodies, positive indicates that immunity against HBV has been produced, and the diagnosis of chronic HBsAg carriers is based on no clinical symptoms and signs, liver Normal function, HBsAg continued to be positive for more than 6 months.
2HBeAg and anti-HBe: HBeAg positive is an indicator of HBV active replication and strong infectivity. The serum of the test is changed from HBeAg positive to anti-HBe positive, indicating that the disease is relieved and the infectivity is weakened.
3HBcAg and anti-HBc: HBcAg positive suggest the presence of intact HBV particles, direct response to HBV active replication, due to complex detection methods, clinical use, anti-HBc is a marker of HBV infection, anti-HBcIgM positive suggestion is in the early stage of infection, in vivo Viral replication, in chronic mild hepatitis B and HBsAg carriers, HBsAg, HBeAg and anti-HBc are all positive, highly contagious, indicators are difficult to negative.
Molecular biological markers: Detection of HBV DNA in serum by molecular hybridization or PCR, positive direct reaction HBV active replication, infectious.
(3) Hepatitis C: Hepatitis C because the amount of antigen in the blood is too small to be detected, so only antibodies can be detected. Anti-HCV is a marker of HCV infection, not a protective antibody, and is detected by nested reverse transcription PCR. Serum HCV-RNA positive indicates that the virus is actively replicating and infectious.
(4) Hepatitis D: HDV is a defective virus, which can be replicated by relying on HBsAg. It can be manifested as HDV-HBV infection at the same time. HDAg appears only in the blood for several days, followed by IgM type anti-HD, chronic HDV infection, anti- HDIgG continues to rise, and detection of HDV-RNA from serum is a more direct and more specific diagnostic method.
(5) Hepatitis E: anti-HEVIgM antibody was detected in the serum of patients with acute hepatitis. In the recovery period, the IgG antibody titer was very low. The anti-HEV IgG persisted in serum for less than 1 year, so anti-HEVIgM, anti-HEV -HEV IgG can be used as an indicator of recent HEV infection.
(6) Hepatitis G: RT-PCR can detect HGV RNA, which is an effective method for early diagnosis and monitoring of viremia in HGV. Anti-HGV IgM and IgG antibodies are not yet mature, and the detection rate is low and RT- The PCR results do not match.
3. Liver biopsy
It is the main indicator for the diagnosis of various types of viral hepatitis. It is also the definitive evidence for the diagnosis of early cirrhosis. However, it is not popular because it is a traumatic examination.
Ultrasound and computed tomography (CT): Ultrasound is widely used. The diagnostic indicators for chronic hepatitis and hepatitis cirrhosis are clear, and can help identify liver cirrhosis with liver cancer and jaundice. CT examination is also of great value to the above diagnosis. However, due to various conditions, it is currently not universal.
Diagnosis
Diagnosis and diagnosis of viral hepatitis in the elderly
diagnosis
According to the history and clinical manifestations, elevated transaminase and other auxiliary examinations can be diagnosed.
Differential diagnosis
In the differential diagnosis, liver damage caused by other causes should be excluded, such as other viruses (EBV, CMV, etc.) or drug-induced liver damage, infection with toxic hepatitis and alcoholic hepatitis, etc., should also pay attention to hemolysis, caused by extrahepatic obstruction Identification of astragalus.
