Acute hepatitis

Introduction:

·         Acute hepatitis should be reserved for patients who present with a syndrome of anorexia, jaundice and elevated ALT.

·   It is most often caused by viruses that are hepatotropic  ( hepatitis A, B, C, D, and E). Cytomegalovirus (CMV), herpes simplex, coxsackievirus, and adenovirus may also occasionally affect the liver.

Clinical features:

·         Anorexia, Nausea, Vomiting,

·         Jaundice

·         Dark urine,

·         Low grade fever,

·         Tender hepatomegaly

Investigation:

• ·         S. Bilirubin,  ALT
• ·         USG of HBS
• ·         CBC
• ·         Viral Marker-- Anti-HAV ,  Anti HEV, HBsAg
• ·         Prothombin Time

 

N. B. ALP should done in  clinical suspicion of  Obstructive jaundice ( Jaundice, Pale stool and generalized itching)

Management :

·         Supportive:

--Give i.v. fluids- if unable to take per oral

--Anti emetic- if needed

-- Constipation- Lactulose : 20-30 ml per day

--Correct prothombin time-By Vitamin K 10 mg I/V for 3 days

·         Specific :

-- No antiviral for HAV, HEV

--Antiviral for HBV  is be decided by specialist.

·         Stop all OCP, NSAID, Sedatives and Paracetamol. Vitamin supplementation is of no use.

N.B: Look for Altered consciousness, Flaps, Sleep disturbance, Bradycardia and High BP (signs of fulminant hepatic failure) and consider immediate referral.

Indication of hospitalization:

·         Deep jaundice

·         Intractable vomiting

·         High fever

·         Features of encephalopathy (grade I & II)

·         Pregnancy

   Grade I: Changes in behaviour with minimal change in level of consciousness

   Grade II: Disorientation, drowsiness, asterixis, inappropriate behaviour

   Grade III: Marked confusion, incoherent speech, sleeping but rousable

   Grade IV: Comatose, unresponsive, decorticate or decerebrate posturing

Referral to a specialist is recommended under the following circumstances:

·         Gradual deterioration of general condition

·         Progessively increasing prothombin time

·         Signs of encephalopathy (grade III & IV)

·         Pregnancy with HEV infection

HBV for further evaluation and management.

Helminthiasis

Introduction:

Helminthiasis is infestation with one or more intestinal parasitic worms (nematodes and cestodes), which   are commonly associated with poor personal and environmental hygiene and transmitted through contaminated soil.  Infection contributes to anemia, vitamin A deficiency, malnutrition and impaired growth, delayed development, and intestinal blockages.

Clinical features  :

·         Asymptomatic

·          Abdominal pain 

·          Diarrhoea

·         Vomiting 

·         Itchy anus

·         Fatigue  

·         Fever  

·         Cough 

·         Malabsorption 

·         Anaemia

·         Weight loss

Warning sign: Severe anaemia, Generalized oedema, Malabsorption

Complication:

·         Small-bowel obstruction, sometimes complicated by perforation, intussusception, or volvulus. 

·         Biliary colic, cholecystitis, cholangitis,  pancreatitis when large worm can occlude the biliarry tract

Diagnosis:

·         Microscopic examination of feces for eggs or ova of  helminths

·         CBC with PBF—Microcytic  hypochromic  anaemia with eosinophilia

·         In case of complication:  Plain X-ray abdomen , USG of  whole abdomen and   CXR                                                                                                                                               

Treatment:    Drug of choice: ( Any one can be used)

Levamisole, 120 – 150 mg (3 – 4 tablets) P.O. to be taken as a single dose

OR

Albendazole, 400 mg P.O. as a single dose, for children:1 – 2 years, 200 mg as a single dose.

OR

Mebendazole, 100 mg P.O.BID for 3 days

·         Mild iron-deficiency anemia -oral iron .

·          Hypoproteinaemia - nutritional support and oral iron replacement .

·         In case of  acute abdomen   --NPO

                                             --Nasogastric suction,

                                             -- IV antibiotics  ( Ciprofloxacin 200 mg BD)

                                             -- IV Nutrition.

                                             -- If no improvement / deterioration of  condition - Referral

N.B: In pregnancy- Drug of choice- Pyrantel pamoate (11 mg/kg once; maximum, 1 g) . Other drug is contraindicated.