Viral hepatitis D



OVERVIEW

Definition

Viral hepatitis D is an infectious disease caused by infection with the hepatitis D virus, which primarily damages the liver.

The hepatitis D virus depends on the hepatitis B virus to replicate in the body, so co-infection with both is common.

Viral hepatitis B is more likely to become chronic and can be exacerbated by the presence of concurrent hepatitis D virus infection.

Epidemiology

Hepatitis D virus infection occurs worldwide. Countries along the Mediterranean Sea, the Middle East, Africa, and the Amazon basin in South America are high prevalence areas for hepatitis D virus infection.

The rate of hepatitis D virus infection among hepatitis B surface antigen (HBsAg)-positive people across China is 0% to 32%, lower in the north and higher in the south.

Source of infection: mainly people who have been infected with hepatitis B virus and then infected with hepatitis D virus.

Transmission pathway

Susceptible people: people infected with hepatitis B virus, especially those who have been transfused blood or blood products several times, and those who are addicted to intravenous drugs.

Types

According to the duration of the disease can be divided into:

Acute viral hepatitis D, i.e. the duration of the disease does not exceed 6 months after infection.

Chronic viral hepatitis B, i.e. the duration of the disease is more than 6 months after infection.

Causes

Causes

Viral hepatitis D is caused by infection with the hepatitis D virus.

Pathogenesis

Overlapping infection with hepatitis D virus and hepatitis B virus can exacerbate the disease and predispose it to chronicity, but the exact mechanism is not fully understood.

Overlapping infection means that the original infection has been infected with hepatitis B virus and later infected with hepatitis D virus.

There are two possible mechanisms by which hepatitis D virus damages the liver: direct damage to liver cells and immune damage.

Symptoms

The incubation period after simultaneous infection with hepatitis D virus and hepatitis B virus is about 6 to 12 weeks, and the incubation period for overlapping infections is about 3 to 4 weeks. Because of the close relationship between the two, the symptoms of viral hepatitis D are also related to the hepatitis B virus infection status.

Acute viral hepatitis D

Acute hepatitis occurs partially after the incubation period, with the following symptoms.

Weakness.

Easy fatigue.

Lack of appetite.

Nausea and vomiting.

Oil aversion.

Upper abdominal discomfort.

Bloating.

Right upper abdominal pain.

Fever, partly low below 38°C, and in a few cases above 39°C.

Jaundice: manifested by yellowing of the skin and white eyeballs (sclera), yellow or strong tea-like urine, etc. It may be accompanied by itching of the skin and light-colored stools, which may occur twice.

A few have dark red palms (liver palms) and red moles (spider moles) on the skin that fade after pressure.

These symptoms can occur when the hepatitis D virus is infected with the hepatitis B virus at the same time, or when the hepatitis D virus is infected on top of the hepatitis B virus already infected (overlapping infection). However, symptoms are relatively more severe in overlapping infections and may even lead to severe hepatitis.

Chronic viral hepatitis D

Chronicity can be considered to have occurred if there are still manifestations of hepatitis and abnormalities in liver function 6 months after the onset of acute hepatitis. Mild cases of chronic viral hepatitis D may be asymptomatic or mildly symptomatic, and those who develop symptoms may exhibit the following.

Weakness.

Loss of appetite.

Bloating.

Nausea and vomiting.

Dark skin.

Yellowing of the skin, white eyes, and deepening of the color of the urine.

Susceptibility to bleeding, e.g. bleeding from the mouth when brushing teeth.

Spider moles.

Liver palms, etc.

Severe Hepatitis

Deep jaundice.

Severe gastrointestinal reaction with frequent vomiting.

Extreme malaise, which may be accompanied by persistent high fever, abnormal behavior, drowsiness, or even coma.

Significant bleeding tendency, prone to gum bleeding, development of subcutaneous bleeding spots, etc.

Complications

Viral hepatitis D can cause complications such as cirrhosis, liver failure and liver cancer if it becomes chronic.

Seek medical attention

Conditions that require medical attention

If symptoms such as fatigue, lack of appetite, anorexia, nausea, vomiting, jaundice, fever, etc. occur, you should seek medical attention promptly.

If you have had viral hepatitis B and have similar symptoms, you should seek medical attention.

Suggested Departments

Department of Infection.

Preparation for consultation

If there are no special circumstances, you need to register through the hospital’s official website, official app, 114 and other regular channels, prepare the social security card (medical insurance card) and other medical information, bring the previous medical information, and apply for the record for those who have to go to a different place for medical treatment.

What questions the doctor may ask

What’s wrong?

When did the symptoms appear? Have they decreased or worsened?

Have you had any blood transfusions or contact with other people’s blood?

Have you ever had unprotected sexual contact?

Have you ever had viral hepatitis B? What was the treatment?

Have you been immunized against viral hepatitis B?

Have you had any tests and treatments? Any drug allergies?

Questions you can ask your doctor

What kind of disease do I have?

When will the test results be ready?

How long will the treatment take?

Do I need to be retested?

Diagnosis

Disease Diagnosis

Medical History

Close contact with someone who has viral hepatitis B, or is a carrier of the hepatitis B virus.

Previous blood transfusion, or exposure to blood products.

Clinical manifestations

There are gastrointestinal symptoms such as fever, lack of appetite, anorexia, nausea, and vomiting.

Yellowing of urine, skin, and sclera, which may gradually deepen in color.

Laboratory Tests

The main test is to check for antibodies to hepatitis D virus in the blood, which is a sign of hepatitis D virus infection. A positive result is the most common basis for the diagnosis of viral hepatitis D.

In chronic hepatitis D virus infection, anti-hepatitis D virus immunoglobulin M can be consistently positive, and the level can reflect the level of hepatitis D virus replication.

Blood biochemical indicators include alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum bilirubin, serum albumin and globulin, prothrombin time, gamma-glutamyltranspeptidase, serum alkaline phosphatase (ALP), total bile acids, cholinesterase and other indicators.

Fasting is required for blood biochemistry tests, and a temporary dietary ban is required after dinner the night before the test until the blood draw is completed.

Alanine aminotransferase (AAT), aspartate aminotransferase (AAT): these are the most commonly used indicators to determine the extent of hepatocellular damage, and the more severe the damage, the greater the elevation.

Serum bilirubin: Hepatocellular damage can lead to elevated serum bilirubin. Liver failure is characterized by elevated serum bilirubin and decreased alanine aminotransferase and aspartate aminotransferase.

Serum albumin and globulin: The liver synthesizes albumin, and if albumin levels fall, liver synthesis is impaired. As the disease worsens, the albumin to globulin ratio may gradually decline.

Gamma-glutamyl transpeptidase: Acute hepatitis, chronic active hepatitis, and decompensated cirrhosis will show mild or moderate elevation, and if cholestasis occurs, it can be significantly elevated.

Serum alkaline phosphatase: mainly excreted through the hepatobiliary system, excessive production or obstruction of excretion can be elevated, which can be used to observe the development of the disease and treatment.

Total bile acids: can be elevated in case of hepatocellular damage or intrahepatic or extrahepatic bile duct obstruction.

Cholinesterase: reflects the reserve function of the liver.

It is primarily a test for hepatitis D virus RNA in the blood, and a positive result is direct evidence of a confirmed diagnosis.

In addition to being diagnostic, it can help determine the prognosis of chronic hepatitis D virus infection.

Imaging tests

The most commonly used test for liver imaging is abdominal ultrasound.

The advantages are simple operation, convenient examination, no trauma, and visualization of results; the disadvantages are that it is easily limited by equipment, body position, operator’s skill and experience.

Abdominal ultrasound can determine the size and shape of the liver and spleen, the condition of important blood vessels in the liver, and whether there are any space-occupying lesions.

CT is a radiologic examination that can observe the morphology of the liver and find out whether there is cirrhosis or space-occupying lesions.

If space-occupying lesions are found, it can also generally determine whether they are benign or malignant.

Magnetic Resonance Imaging (MRI) is non-radioactive and can show changes in liver tissue structure more clearly.

With the help of contrast media and dynamic enhancement scanning, it is possible to differentiate between good and malignant occupations more effectively.

Other

Liver histopathology is an invasive test in which liver tissue is taken, processed, and observed under a microscope.

It can provide insight into changes such as inflammation in the liver and can help distinguish it from other liver diseases.

Hepatitis D virus RNA can be detected in the tissue and a positive result can be used as a basis for diagnosis.

Differential Diagnosis

Viral hepatitis D needs to be differentiated from other causes of hepatitis, such as other viral hepatitis, drug-induced hepatitis, alcoholic liver disease, and autoimmune liver disease. Jaundice also needs to be differentiated from other causes of jaundice.

Other causes of hepatitis

Similarities: Lack of appetite, nausea, vomiting, jaundice and other symptoms may occur, and laboratory tests may reveal abnormal liver function.

Differences: Hepatitis D virus serology results can be used as a basis for differentiation from, and hepatitis B virus serology is usually done at the same time to help with exclusion. Drug-induced hepatitis and alcoholic liver disease can be found by taking drugs that can cause liver damage, excessive alcohol consumption, etc., which can also help in differentiation.

Other causes of jaundice

Similarities: Both may present with jaundice, and laboratory tests may reveal abnormal bilirubin levels.

Differences: Other jaundice may be due to medications, infections, cholecystitis, cholelithiasis, pancreatic head cancer, liver cancer, etc. Viral hepatitis D may have symptoms such as fever, lack of appetite, malaise, nausea, and vomiting, while other jaundices have symptoms of the original disease. Serologic testing for hepatitis D virus can be used to differentiate.

Treatment

There is no effective treatment for viral hepatitis D. Medication is the mainstay of treatment, and the only effective treatment for end-stage is liver transplantation, which is also needed to minimize the recurrence of viral hepatitis B and viral hepatitis D.

Drug therapy

Alpha Interferon

Is the only drug currently approved for the treatment of chronic hepatitis D.

It helps to inhibit hepatitis D virus RNA (HDV-RNA) replication, and can turn some serum HDV-RNA negative.

However, the dosage of the drug is large, the course of treatment is long, and the efficacy is limited.

Polyethylene glycol-interferon alpha-2a or alpha-2b

are both used to treat chronic hepatitis D (CHD).

A gradual decline in HDV viral load, HDV-IgM antibody titer, transaminase levels, and HBsAg titer occurs during treatment, and treatment can be extended as needed.

Nucleoside (acid) analogs have no effect on HDV-RNA despite their strong inhibitory effect on hepatitis B virus DNA (HBV DNA). Because of their ability to gradually reduce HBsAg concentrations, there may be a potential benefit to long-term use of nucleoside (acid) analogs.

Novel drugs

It can inhibit the farnesylation of the CXXX box at the carboxy-terminal end of the encoded protein L-HDAg, blocking HDV assembly and reducing the release of viral particles into the bloodstream, thus achieving the therapeutic effect of CHD.

The drug is currently in clinical trials.

It can specifically inhibit the binding of envelope protein HBsAg to human sodium taurocholate cotransporting polypeptide (hNTCP), blocking the process of HDV entry into the cells, reducing new infections of hepatocytes, and exerting antiviral effects.

End-stage hepatitis D

Liver transplantation is the only effective therapeutic measure, and the use of a combination regimen (pre-transplant and post-transplant administration of antiviral drugs combined with hepatitis B immunoglobulin) is effective in reducing the recurrence rate of viral hepatitis B and viral hepatitis D.

Liver transplantation

For end-stage viral hepatitis D, liver transplantation is the only effective treatment.

Liver transplantation involves removing the diseased liver and transplanting in a healthy liver.

The healthy liver has a high regenerative capacity and can grow gradually after transplantation, allowing liver function to gradually return to normal.

A combination regimen is required for liver transplantation to reduce the recurrence rate of viral hepatitis B and viral hepatitis D.

Prognosis

Cure

If hepatitis D virus and hepatitis B virus are infected at the same time, the course of the disease may be relatively short, with most recovering within 12 weeks, and 2% of concurrent infections progressing to chronicity. Very few may develop severe hepatitis due to heavy concurrent infections.

Overlapping infections may exacerbate the original condition, and 70% to 90% of acute hepatitis D virus infections may become chronic.

Hazards

Hepatitis D virus is contagious and can infect people with hepatitis B virus infection.

Overall, concurrent or overlapping infections with hepatitis D virus are more likely to become chronic or develop severe forms of the disease than infections with hepatitis B virus only, and they shorten the time it takes for chronic hepatitis to develop into cirrhosis.

The majority of asymptomatic chronic hepatitis B surface antigen carriers with overlapping hepatitis D virus infections will become chronic. Those who become chronic are often sicker, 15% develop cirrhosis within 1 year, 70% slowly develop cirrhosis, and 15% may remit on their own.

Daily life

Daily life

Take medication as prescribed by your doctor. As the liver function is impaired, the metabolism of medication mostly needs to pass through the liver, so do not take other medications or change the dosage of medication on your own.

Do not share razors, nail clippers, and other items with people with viral hepatitis D. Avoid contact with their blood.

General contact that does not involve blood will not cause infection, and family members and friends need not be unduly alarmed or discriminated against.

Clothes contaminated with blood, etc. should be washed separately.

When itching occurs, do not scratch the skin to prevent bleeding and infection.

You can wash your skin with water, and do not rub your skin hard or use irritating detergents when bathing.

When you have fatigue or fever, it is best to rest in bed and wait for your body to recover gradually before getting out of bed.

Keep a regular routine and avoid staying up late and being tired. You can choose to walk, tai chi and other low-intensity exercise, the time is not too long, do not feel fatigue can be.

Avoid sexual intercourse until the infectiousness disappears, or insist on using condoms.

Eat three regular, small meals, binge eating is strictly prohibited, eight minutes full can be, to maintain a suitable body weight.

Due to the impaired function of the liver, the diet needs to avoid greasy, do not eat high salt and high fat food, such as fat meat, deep-fried, barbecue pickled food.

Priority should be given to low-fat foods, such as low-fat milk or yogurt (1~2 cups a day), beans, egg whites (no more than 3 whole eggs a week), skinless chicken or fish and shrimp (the size of a poker box a day).

Replace animal oils with vegetable oils and use peanut, olive, corn and soybean oils when cooking.

Don’t limit your staple food to refined white rice and noodles, and alternate variations of all kinds of coarse grains, mixed beans and potatoes.

Eat less high-sugar foods, as little as possible, white sugar, candy, sweet drinks, pastries, concentrated fruit juice, jam, honey, etc..

Eat more vegetables (about 500 grams, i.e. 1 pound, per day), especially green leafy vegetables; eat about 1 fist-sized piece of fruit per day.

Stop drinking alcohol to prevent further damage to the liver.

Take vitamin supplements as prescribed by your doctor.

Intake of moldy food and substandard drinking water is strictly prohibited.

Chronically infected people need to be revisited every 6 months.

Those who receive antiviral treatment need to follow the doctor’s request for follow-up during the course of the medication, usually every 1 to 2 weeks during the first month; every month for the first 3 months after the start of treatment; and every 3 to 6 months after the condition is stabilized.

Liver function should be rechecked every month for 3 months after stopping the drug, and every 3 months thereafter.

If there is cirrhosis, the alpha-fetoprotein and abdominal ultrasound, etc. should be rechecked every 3 months.

Chronic hepatitis has a long treatment period and requires objective understanding, optimism and adherence to treatment.

Prevention

Prevention of viral hepatitis D consists of two aspects: prevention of infection with hepatitis B virus and prevention of transmission of hepatitis D virus among people susceptible to hepatitis B virus.

Vaccination against viral hepatitis B protects people who are not infected with the hepatitis B virus and thus prevents hepatitis D virus infection from occurring.

If you are going to undergo operations that may damage the skin and mucous membranes, such as earrings, tattoos, injections, etc., you should go to a regular place, where standardized sterilization can reduce the risk of infection.

If there are wounds on the body, they need to be bandaged to prevent contamination with other people’s blood or other body fluids.

Do not share personal items such as nail clippers, cups, razors, toothbrushes, etc. with others.

Insist on the use of condoms when having contact with sexual partners of unknown health status.

Wear gloves when cleaning personal items of unknown health status.

Medical workers, cleaning staff in hotels and hospitals should observe the code of practice, wear gloves and protect skin and wounds when working.

Refuse to take drugs. Sharing needles may lead to infections such as hepatitis B virus and even human immunodeficiency virus (HIV).

After the diagnosis of viral hepatitis B, you need to pay attention to the following aspects to prevent transmission to others: