Transcript for:
Lecture Notes on Viral Hepatitis

hello everyone in this session we are going to discuss a very important topic that is viral hepatitis we will be discussing five type of hepatitis that is Hepatitis A Hepatitis B hepatis C hepatis D and hepatitis E in your University exam very frequently you get a long question as well as short question on the viral hepatitis long question most frequently Asked on Hepatitis B but they can be asked on other hepatitis also and for short question all of them are Ultra important viral hepatitis let's start it so first of all I will let you know the overview usually I always let you know the overview for all the topics the headings under which I'm going to discuss the session so first of all I will let you know the anatomy of the normal liver because you can't understand the morphology of the heitis if you don't know the normal anatomy and normal hystology of the liver so first of all I will let you know the normal anatomy and normal hystology of a normal liever then I will explain you the Dual blood supply of the liver and then I will let you know the classical lobule model model of the liver which is the most commonly used model acceptable model for the lver is classical lul model after that we will start our topic so in our topic I will be discussing five type of hepatitis first of all I will give you a comparative table between the five type of hepatitis hepatitis A B C D E we will discuss the five type of hepatus under a fixed set of heading I will let you know the positive agent for each of them the morphology of the virus mode of transmission incubation period clinical features and lab diagnosis for each of them and finally we will see the clinical pathological Spectrum I will let you know the microscopy of acute heitis and microscopy of chronic heitis so if it is a long question long question usually not asked on all type of heus you will get one of them in your exam so either you will get a question on A or B or C or D or E so you have to write down that portion only along with the microscopy of acute and chronic which is relevant to that particular hi hepatis so I will correlate everything okay so this is the overview first of all understand the overview so whenever any long question come in your exam the first thing that should come in your mind the headings under which you're going to frame your answer I always say those things to the students okay so if the headings and subheadings are clear with a pencil write down the heading and subheading and then start writing in your copy the main copy first write the heading and subheading on a rough paper so that it's clear in your mind that you are not missing anything and then you describe in your own words try to draw maximum flowcharts maximum diagrams believe me if you're following the strategy you are going to get a gold or distinction in your University exams okay so let's start the topic viral hepatitis okay so before that I will let you know the anatomy of the normal liver okay so see liver is the largest organ the largest and largest organ in human body okay you can see and in the liver there are two loopes the right L and the left L you can see the right lobe and the left lobe the right lobe is four times larger than the left lobe you can see this is normal liver now let me explain you the normal dual blood supply of the liver now in this diagram can you see the liver let me highlight the liver now let me explain you what do you mean by the Dual blood supply of the liver please understand it well if you can understand the Dual blood supply then only you can understand the classical lobule model and then only you can understand the microscopy of acute and chronic hepatis so please it's important so this is the lever now all organs have one blood supply but liver is unique organ it is having dual blood supply so all the organs get pure blood oxygenated blood from the left side of the heart via aota liver also receives pure blood oxygenated blood from the left side of the heart via aota VIA hepatic artery so from the aota hepatic arter is coming a branch of aota is hepatic artery and this hepatic artery supplies Pure or oxygenated blood to the liver so out of the Dual blood supply this is the first blood supply this is the first blood supply to the liver now the second blood supply have a look on the git so the veins of the git the veins of the git drain in portal vein and portal vein drains in the lever so the second blood supply of the lver is the portal vein that contains deoxygenated blood so look at the arrows the liver is getting dual blood supply one the pure oxygenated blood via hepatic artery one the De oxidated Blood via portal vein so that is the Dual blood supply of the liver after the two bloods coming inside the liver they just distribute everywhere the branches are formed they just distribute now the exit is one the supply is two the inlet is two the supply is two but the exit is one so what is the common exit that is a vein the hepatic vein so let me highlight highight the hepatic vein here so here I'm trying to highlight the hepatic vein look at the arrow look at the exit so the exit is the common exit that is known as hepatic vein or Central vein that drains the blood the both the Bloods are coming the hepatic artery blood is also coming and the portal vein blood is also coming both are coming Distributing in entire liver and after that they are exiting from a common exit the common exit is the hepatic artery hepatic vein also known as Central vein and it is impure blood now so it will drain it in the right side of the heart right right side of the heart and from the right side it will go to the lungs for the purification so this is the drainage you can see drainage is only one so liver have dual blood supply the Dual Inlet one is hepatic artery one is portal vein but the drainage is one that is hepatic vein Central vein hepatic or Central vein drain into the right side of the heart it will drain into the right side of the heart via uh uh inferior vanava via IVC via inferior vanava got it now lever this is lver lver synthesize bile in the lver there are hepatocytes these are the hepatocytes present in the inside the liver so the hepatocytes inside the liver they synthesize bile so all the bile collected from all the synthes from all the hepy They exit from the liever and the bile is drained into the intestine into the deinum Via ampul of V this is B duct so in the liver there are two Inlet and there are two Outlet so the two Inlet is the Dual blood supply you can see what is the two Inlet the two Inlet is hepatic artery and portal vein these are coming and the two Outlet one is hepatic vein that is Central vein and one is B duct so you can understand this is the normal dual blood supply normal anatomy of the liver now we divide the entire liver into multiple classical lobules now please understand please understand in this diagram I want you to understand there are three things one is hepatic artery what is the DU blood supply one is hepatic artery so hepatic arter is coming inside and forming multiple branches one is portal vein portal vein is also coming inside and form multiple branches but the exit is one so exit is one is hepatic vein hepatic vein also have multiple branches and B duct also have multiple branches so there are four things okay you can see the four things hepatic artery portal vein hepatic vein and bile duck so these are four things they all have branches inside the liver so three of them are breast best friend I mean best friend they are the triplate they are the tripod the branches of three of them travel together which three the branches of three of them travel together which three the branches of the hepatic artery the branches of the portal vein and the branches of the bile duct so the branches of these three travel together but branches of hepatic vein separately travel they don't travel with them it is not a good friend of them so there is a triplate what is a triplate hepatic artery portal vein and bile duct this is the triplet okay so we divide the entire level into multiple classical lobules can you see this is a classic IAL lobu it's a hexagon so we divide the entire LEL into multiple hexagons these are known as classical lobule in each classical lobule at the center there is a branch of hepatic vein or Central vein that is traveling separately it don't have any friends and at the corners the six corners have the portal Triad so these are known as portal Triad in each portal Triad there is a hepatic artery there is a portal vein and there is a branch of bile duct so there is a branch of hepatic artery branch of portal vein and branch of bile duct I told you these are the best friend so branches of them travel together and they are traveling at the corners of the lobule and this is known as portal Triad so at the center there is a hepatic vein there are four to six portal Triads at the corner each portal Triad contain a branch of V duct a branch of hepatic artery a branch of portal vein and there are cords of hepatocytes connecting them you can see this is the central vein you can see this is the portal Triad so you can see the cords of hepatocytes hepatocytes are the cells present in the liver so these are the cords of hepy connecting them the cords of the heyes are the Bogies of the train they are like Bogies of train one behind the other by a cord I mean the Train the Bogies of a train one behind the other so the the connection between the central vein and the portal Triad is C of heite everywhere I not drawn everywhere but you can draw it everywhere everywhere in the entire liver it's like this in the entire liver it's like this now between two adjacent trains between two adjacent cords there are sinusoids these are the sinusoids I'm drawing Ides are the blood capillaries so between two adjacent cords you can see it here you can see it here can you see this is a cord this is a cord so between two adjacent cords you can see the sinusoids the sinusoids are lined by the endothelial cells the cides are lined by the endothelial cells and few kufer cells interspersed kuffer cells so that is the sinusoid sinusoids now here you can see the same so this is a classical lobu I call it classical lobule of lver in entire lver we have millions of classical lobule okay at the center of each lobu there is a hepatic vein also known as Central vein and at the corners there are portal triod each portal triod have a hepatic artery a portal vein and a b duct I mean a branch of hepatic artery a branch of portal vein and a branch of B duct connecting between the central vein and the portal triart is the carts of aptoite I want to appreciate the cords of hpy can you appreciate the Cs of hocy here these are the cords of hocy these are the Cs of hpy between two adjacent CS of hepatocytes are the cides so appreciate the sinoses the sinoses are the blood capillaries which are lined by endothelial cells and Inter interpers coal so you can see it same here see the central artery see the portal Triads see the Cs of heite connecting them same you can appreciate here you all can appreciate this is the central vein or hepatic vein this is the portal Triad appreciate the cords of Hite connecting them appreciate these are the cords of Hite I'm talking these are the cords of Hite I'm talking here connection okay now we divide the lever into multiple classical lobules so let me draw the multiple classical lobules here let me draw multiple millions of classical lobules okay so here you can see the four things two are Inlet two are Outlet so out of the two Inlet two Outlet can you see this can you see this one this is the central vein so branch of the central vein is present at the center this is this is why it is known as Central vein this is the reason hepatic vein is known as Central vein because it is present at the center of the lulle and the remaining three things that is hepatic artery portal vein and B duct their branches are present at the periphery the branches are present at the periphery forming the portal Tri this is a normal diagram of the liver I hope you all got it one more thing I would like to tell you here imagine inside the hexagon this is one cord of hepy okay this is a cord of hepy connecting the Central arter and the central vein and the portal Triad this is another cord of hepy another train of heaty okay again connecting the central vein and hepatic vein and the portal Triad okay and between the two cords there is a sinusoid so let's draw a sinusoid the sosid is a blood capillary I will call it sinusoid it is lined by endothelial cell so let's draw the endothelial cell and few in interspersed kuer cell so let let me draw a few interspersed kufer cells also please understand okay this is kufer cells now there is a space can you see a space I'm talking about a space between the cords of heyes and the sinoses there is a space there is a space between the cords of hepatocytes and the sinusoids the cords of hepatocytes and the sinusoids there is a space this space is known as space of dis this space is known as space of dis pleas is Lear and it contains a special cell the contain a special cell that cell is known as EO cell normally EO cell are fat storing cell they store fat and they are required for vitamin A synthesis the EO cell but whenever the hepatocytes are injured due to any injurious agent the injurious agent can be alcohol can be AIS of iron in hemochromatosis can be access of copper in Wilson's disease can be anything can be bile can be a virus I'm teaching you hepatitis now so it can be a virus so at that time the EO cell get stimulated EO cell convert into myofibroblast and it start forming collagen collagen means fibrosis so EO cells are responsible for for fibrosis they form collagen and they form the fibrosis etosell convert into myofibroblast Whenever there is a injury to the hpy especially with the with any agent So currently I'm teaching you viral hepatitis so injury will be with the viruses hyptis a b c d e so that is the thing and that leads to curosis so this is the normal anatomy of the lever you have learned the same thing you can see it here you can see a classical hexagon here appreciate the classical hexagon let me show you this is a classical hexagon we have talked about you can see the central vein you can see the portal Triads here only three portal Triads are shown they can be 3 to six okay now these are the Cs of heyes we are talking about okay now let me Zoom it here you can see this is the um this is one of the one of the train these are the cords of apoyes this is another train I'm in another cord of heyes between the two cords of heyes I want you to note is the sinusoid so this is a sinusoid see the lining of the sosid this is endothelial cell and I want you to appreciate interspersed kuffer cell also now I want you to appreciate the space the space of theay so where is the space of theay I'm talking about this space this space is space of theay and it contain a special cell which is known as EO cell so notice EO cell here so that's all about it now let's start the topic vpus nobody's going to ask you all this but you can't understand the topic if you don't know this so that is the point so if it is coming in your exam the viral hitis no need to write down all these Bluff Bluff no don't write it is for your understanding now you will have a better understanding now start the topic viral hepatitis so what is viral hepatitis there are five viruses hepatis a virus hiotis B virus hiotis C virus hiotis d virus and edus E virus the five viruses belong to different families I will let you know they are families also okay these are different viruses they affect the lever and they cause injury to the liever and that is known as hepatitis so since the viruses are causing the injury to the liver it is known as viral hyptis we have already seen the anatomy of the lever the classical lobular model of the lver now it will be very easy to understand how does the virus attack the liever and which thing is affected okay now that is the five type of hepatitis we are going to see in detail what are the five type of hepatis hyptis a virus causing hiotis a hiotis B virus causing hiotis b hippus c virus causing hitis C D causes d and e causes e likewise okay so there are five type of viruses causing five type of hepatitis so first of all you know there are two type of viruses have you read virology in microbiology there are two type of viruses what are the two type of viruses DNA viruses and RNA viruses these are the two type of viruses okay so among the five type of viruses which I'm currently interested I'm teaching you the five type of viruses hyptis a b c d e so among them Hepatitis B virus is a DNA virus and rest all are RNA so hyptis a virus hyptis C virus hyptis d virus and hyptis E virus they all are RNA only one among them that is b b Hepatitis B virus is a DNA virus so please learn so the same thing is highlighted hyptis B virus is a DNA virus and rest all are RNA RNA RNA RNA so a c d e is RNA but B is DNA now learn their families their families are important so hyptis a virus belongs to picorna viid family in the picorna viid family it belongs to antovirus 72 family hyptis B virus which which is a DNA virus it belongs to hipad viid family hippus C belongs to flavy varid hitis d d for Delta D for Delta it belongs to Delta V and hyptis E belongs to hip it belongs to hip so learn their families learn their families now if you see the diagram of these five viruses I will show you the diagrams also A and D don't have envelope but b c d have the envelop so here envelope is absent in A and E but BCD envelope is present so first learn about the viruses five type of viruses which of them is DNA which of them is RNA learn the families of all of them and learn which of them are enveloped which of them are non enveloped the first thing you have to learn that the first thing you have to learn that now coming on the root of transmission the root how does they transmit so A and E transmit by FICO oral root BCD do not transmit by FAL root what do you mean by f oral root so fic oral root is seen in A and E what do you mean by that imagine there is a person this person have either hyptis a or hiotis E so hyptis A and E have a property they are excreted in the faces of the person in the stools of the person hepatis a virus comes in the stool it is excreted in the stool it is sheded in the stool e also sheded in the stool now these are the stool the stool will contaminate food and water these stools will come and contaminate the food and water and this food and water is consumed by another person in this way the another person will also have hepatis a or hepatis C so how the hepatitis A and B A and E is transmitted from one person to another this is person a a this is person B so how it is transmitted from A to B how what is the root so this root is known as F oral root so hippus A and E is transmitted by F oral root so from feis to oral F oral root this root is known as F oral root so this F oral root is seen in hpus A and E not others this root is known as FAL root what about the remaining three what about hippus b c and d what about hippus B virus C virus and d virus how they get transmitted they don't transmit by ficor root because they are not shedded in the stools so they are transmitted by three different Roots let me show you imagine this is person a and this is person B now person a have either hiotis B virus infection or C virus infection or d virus infection these three viruses do not shed in the stool so how it is transmitted from A to B what are the ways it is not FAL it cannot be FAL because BCD do not shed in the stool Like A and E A and E do shed in the stool they do shed that's why from the stool they can cause the fal transmission but here FAL transmission is not possible so how does the most common way they are transmitted is the blood products or the common syringe or the common needle so if we are using a needle and the same nle here or we are using a syringe or same syringe here or we are taking the blood or blood product from here and transmitting to here so this root is known as parentral root parental the parentral root is common nles common syringes and the blood products blood products are organ transplant so that is the parentral roote the most common roote of transmission of b c d the second common is the sexual bya sexual roote they can be transmitted so a person having hyptis b c d can transmit the infection to another person via sexual root by sexual but this root is very rare it's very rare and the third root is the vertical vertical what do you mean by vertical now imagine this is a mother having BCD and she is pregnant and inside the uterus she's having a fetus so via placenta she can transmit the infection to the fetus so BCD can transmit can cross the placenta and Via placenta it can be transmitted from pregnant lady to the fetus that root is known as vertical root so the three roots are parentral sexual and vertical so you can see the three roots are in front of you parentral sexual and vertical parentral is most common by parentral I mean via blood the common nle common syringe and the blood and blood products the second is the sexual which is very rare and vertical vertical is there from uh in a pregnant lady from mother I mean the pregnant lady to the fetus viia placenta so that is the roots between okay the root of transmission now after the root of transmission I am interested in incubation period what do you mean by incubation period so you have to learn the incubation period so when the virus enters the human body the time after which it presents with the first symptom so that duration is known as incubation period so learn the average so for hyptis a it's 30 days for hyptis E it's 40 days and for hyptis C it's 50 30 40 50 days for B and for B and D it's 60 to 90 so this is how I learned this is how I learned so let me tell you what we have learned till now and then we will move further so I'm teaching you the hippitus hippus a b c d and e the five type of Hiatus virus Hiatus a b c d e okay so first of all tell me the virus the virus is DNA virus or RNA virus tell me that then tell me the family of the virus we have seen the family then tell me which of them is enveloped and non- enveloped so envelop is present or absent you have to tell me that after that you have to tell me the root of transmission mode of transmission or root of transmission and after that you have to tell me the incubation period so these five things we have already learned till now and then I will continue the table ahead now hyptis a virus hyptis B virus out of the five only B is DNA and rest all are RNA so the a is RNA C is RNA D is also RNA and E is also RNA these all are RNA and only B is DNA among the family among the family A belong to picorna VI family in the picor viid family also it belongs to antovirus 72 you have to learn the name b belongs to hipad viid C belongs to flavy D belongs to Delta and E belongs to hip so learn the family that you have to learn okay now what is the mode of transmission the mode of transmission we have SE seen A and E transmitted by FICO oral route ah before that envelop so A and E don't have envelope the remaining three have envelope A and E don't have envelope head guus a virus and E virus don't have envelope but remaining three have the envelope now root of transmission a and is transmitted by fural root the remaining three transmitted either by blood that is parentral most commonly or sexual or vertical vertical is V placenta transplacental now tell me the incubation period the incubation period of hitis is 30 days e is of 40 days and C is of 50 days this is how I write 30 40 50 and now the remaining two that is B and D is 60 to 90 this is how I learned and I never forget so this is the incubation period this is how you can learn now after that you tell me what I'm teaching you what is the topic I'm teaching you I mean I'm teaching you hippitus hyptis is of two type acute and chronic acute the most severe form of acute is known as fulminant the most severe form of acute is fulminant so you can see there are three type of hitis acute a version of acute that is fulminant and chronic now you tell me among the five that is a b c d and e there are five type of htis now which of them present with acute hitis which of them present with chronic and which of them present with fulminate can you tell me the answer the most important question which causes acute hitis among the five which causes fulminant among the five which causes chronic among the five so let's talk about them one by one acute is caused by all of them so all of them causes acute there is no problem in that all of them causes acute now since all of them can cause acute and acute 99% of them is recovered but one person can convert into fulminant so one person can convert into fulminant in all of them in all of them fulminant can occur one % 1% of the acute can convert into fulminant most commonly fulminant occurs in E especially in the pregnancy please learn that okay now what about chronic what about chronic so acute occurs in all five we learned that fulminant also occurs in all five chronic never occurs in a and d so chronic occurs in B CD chronicity never cured in acute I told you 99% is recovery only 1% converted to fulminant and fulminant the ultimate prognosis is very poor and it is death but chronic chronic occurs in BCD okay chronic never cured it is very rare to P chronic but chronic can convert into three things chronic can convert into HCC in future hell carcinoma chronic can convert into curosis in future so ceris can occur in all three the oncogenicity that is malignancy HCC hepatocellular carcinoma hepatocellular carcinoma can occur in all three ceris can occur in all three and chronic can convert into carrier so carrier State can be present in all three so these all three can have HCC sosis and carrier these things are absent in A and D because they don't have chronic no chronic means no carrier no HCC no sosis A and D don't have any carrier they don't convert into HCC in future they don't convert into chronicity in future they don't convert into sosis in future but there is always a possibility of these three things in BCD so that is the most important concept you are learning here please learn so see about acute what we have learned acute is present in all five acute IDI is it is present in A B C D E in all five the acute is present fulminant is also there is a rare chance so. 1% 1% 1% here 5 to 20% here 1 to 2% so fulminant can also occur in all five fulminan in pregnancy fulminant hitis in pregnancy most common in E what about chronicity now what about chronicity chronicity never occur in a and d as I told you chronicity can occur in BCD chronicity can occur in BCD since chronicity can occur in BCD the three things can occur in BCD is carrier oncogenicity and sosis by oncogenicity I mean hpto cellular croma so there is always a chance of ceris carat and oncogenicity in BCD but these three things are never seen in A and E because in A and A and E chronicity is not there I hope you're getting the concept what about the prognosis so A and E have excellent prognosis a and he but here prognosis depends if it is acute it's good but if it is chronic it's not good so that is the prognosis profilaxis and treatment you can learn by your own so that is the table we have seen now we will start the details of the five type of hepatis one by one so first of all I will give you the detail of a followed by b c d e in the sequence we will see now we will describe them under a fixed set of heading we have already have a overview now it's very easy to understand now okay now first of all we will see the positive agent in each of them then the morphology of the virus in each of them mode of transmission we already know we will revise incubation period we already know we we will revise in clinical features we already know which cause is acute which causes chronic and lab diagnosis okay so in these headings we will divide that's why before starting the details I have given you an overview so you tell me acute is caused by all five yes acute is caused by all five what about chronic chronic is not caused by a chronic is not caused by uh e chronic is caused by BCD so this is the thing we have learned till now since A and E are causing only acute so they are the most common cause of acute so they are the most common cause of acute so most common cause of acute hepatitis in children is a and most common cause of acute hepatitis in adults is e so learn that also for your mcqs most common cause of acute heitis in children is a and most common cause of acute heitis in adults is e because they cause only acute they don't cause it but what about chronicity so what is the most common cause of chronicity among the three what is the most common so if you see prevalence wise in the world B is more prevalent so you will find more cases of B so prevalence wise it's B but if you find 100 cases of B and 100 cases of C so among B only 10% will convert into chronicity and among C 80% will convert into chronicity so chronicity is more common in C as compared to B so if we see percentage wise but if we see prevalence wise in the world C is not very common B is more common so that is the thing so I hope you got the concept here okay so we will start the five type one by one let's start the chapter now till now I I was just giving you an overview the real chapter I'm starting now so let's start with hepatis a I will be discussing five type of hepatis let's start hepatitis A let's start with hyptis a hyptis A the positive agent it's caused by a virus hyptis a virus that belongs to pav family I have already told you so it is having RNA virus I told you only hiotis B is DNA rest all or RNA it's a RNA virus and it don't have the envelope you can see the Symmetry is iosa hydral but the envelope is absent the root of transmission is FCO oral I told you for A and E so a is sheded in the stool e is also sheded in the stool once it comes in the stool it can contaminate the food and water and the contaminated food and water can be consumed by another person so this root is known as Pico oral root so the most common root of transmission here only one FAL it is not transmitted by sexual root not by the Ral blood or vertical FAL rout incubation period I told you 30 days so you have to learn okay I have told you already now clinical features it causes only acute no chronic so rather it is the most common cause of acute hitis in children no chronic no carrier no HCC no ceris because no chronic no other three things so carrier Etc and ceris will occur only if chronic occurs so there is no chronic no carrier no etcc RIS no oncogenicity no no sosis it causes only acute 98% recovery one to two% convert into fulminate so that is the clinical course okay patient present with join this and it usually occurs on children onset is very abrupt and sudden so whenever a child coming to your clinic with the parents and the child is having jointness the parents are complaining the child is looking yellow the skin and the Scara I mean the Jo child is having joines and child is having loss of appetite so and child is having fever also so the child is having a typical case of acute hepatitis the most common cause of acute hepatis in children is hepatis a virus so that is the diagnosis based on the clinical ground we suspect now in the lab diagnosis what we can test what we can test so you tell me what we can test so you can see this is the person having hepatitis A this is a child having hepatitis A virus infection so what I can do so hyptis a virus is present in the blood so let me draw the blood vessel this is the blood vessel of this person so hyptis a virus is present in the plant okay the hyptis a virus is shed in the stool also so in the stool also we can find so hyptis a virus can be present in the blood also we can take the blood sample and check for the virus we can take the stool sample and we can check the virus so the virus is present in the blood as well as in the stool we have understood that testing the stool is easy as compared to testing the blood so it is shedded in the stool so we usually check the virus on the stool but the body form antibodies against the virus so in the blood you get two type of antibodies against hepatis a virus IGM antibodies and IGG antibodies IGM represent recent infection G represent past infection so whenever a person have Hepatitis A IGM will come and go after few weeks but G will remain forever so IGG represents the fast past infection not the present so in the blood in the blood we will get two type of antibody one antigen and two antibody so in the blood I can test the hyptis a virus antigen and I can test the two type of antibodies anti-ig antibodies and anti-igm antibodies IGM represent recent infection and G represent past infection I hope you got it but but in the stool we don't have antibody in the stool we have only antigen so what is the summary what is the diagnosis in the diagnosis we can take the blood sample and the stool sample the first thing you tell me the sample what samples you can take for diagnosis you tell me so it's very common sense it's very easy to understand so what samples you can take so we can take a blood sample and we can take a stool sample okay in the stool we get only virus hyptis a virus which is shedded in the stool in the blood we can get the h let is a virus okay but along with the virus we can get the two type of antibodies IGM and IGG okay depending is it a recent infection or past infection so the two type of antibodies is anti virus IGM or anti-hav virus IG IGM represent acute infection and IG represent past infection or recovery and in the stools we can get in the stools we can get only virus not the antibod so have a look on the graph in the graph first virus will come so can you see this this green color so this green color graph is virus first virus will come then IGM antibodies will be formed the body will form antibodies so can you see the purple one so this is IGM antibody it will form it will have a peak and it will go away after few weeks and then can you see this orange color IGG will come but it will remain forever forever forever so today if I check the blood of a child and I get only IGG so it represents in the past child have infection but currently child don't have infection but if I'm taking the blood of a child and I'm getting the virus and IGM together it means currently the child is having the infection I hope you have to draw this graph in your exam so in your exam you have to draw the graph like this so what we will get we will get three things number one we will get the virus first of all the virus will come then we will get the antibodies the two type of antibodies what are the two type of antibodies first IGM will come it will go and then IG will come and it will never go so just label them just label them so what is the labeling how we will do so first hyptis a virus will come in the blood in the stool also in the blood as well as tools this is IGM antibody and this is IGG antibody this represent recent infection this represent past infection and it is forever it will never touch the Baseline again igg1 so this is how you have to draw this graph and label it you can label the weeks 2 4 six if you wish but if you don't label also this pattern is important so this pattern is important and labeling is important in the three things what you are labeling first label the virus then IGM and then IGG IGG will never touch the Baseline it will be forever so you have to draw so this is the lab diagnosis so we are done with a so can we revise it what is the positive agent it's hepatis a virus which belongs to picorna we family it don't have envelope and it is icosahedral in the morphology don't have envelope it is the icosahedral I told you mode of transmission is f oral okay incubation period is 30 days clinical features it causes only acute 98% recovery 2% fulminant but it never crosses chronic since there is no chronic so no oncogenicity no carrier and no therosis you have to write down it is the most common cause of acute heitis in children and in the lab diagnosis you have to draw the graph and mention about the three things the virus and the two antibodies IGM and IGG in the blood you can get all three but in the stools you get only virus you have to mention all these things and it's very simple if you have understood it now the most important hippius is hippius B so let's start hippius B A is done now in this sequence only we are going to cover all five can I start B you very frequently get a long question on B and B is difficult among the five so please I'm warning you to concentrate I'm not scaring you but I'm warning you please concentrate on your gazet so let's start it will become CB for you just concentrate for few minutes okay hepatis B positive agent it's a virus it's a virus belong to hip okay we have seen the family morphology this virus have three forms spherical form tubular form and complete form so this is the spherical form this is tubular form and this is complete form complete form is also spherical but a little bit smaller so learn there are three forms the complete form is known as D particle Dane is the name of the scientist who discovered so it is known as Dane particle mode of transmission we already know A and E transmitted by FAL root but BCD get transmitted by three Roots I told you now if a person have B or C or D it is transmitted by three root number one the parentral root parentral is why Blood product or common syringes common syringe common nle so if a person have Hepatitis B you are using a syringe or nle and the same syringe nle you are using in another person so that infection can be transmitted if you're transmitting the blood of of a person having having hepatis B to another person so infection can be transmitted it can be via sexual route between male and female infected male or infected female if they are doing sexual intercourse so they can transmit the infection to the sexual partner and third is the vertical in the vertical it is transmitted via placenta from the impacted pregnant lady to her fetus so that is the vertical roote that vertical root is also known as perinal root so these are the three Roots we have seen this is Parental this is sexual this is perinal or vertical incubation period we can learn here it is you can learn UH 60 to 90 days is the average okay average is 60 to 90 we have already learned the incubation period now no clinical feature it causes acute as well as chronic Subacute acute as well as chronic okay since it causes chronic since it causes chronic it can lead to carrier stage it can lead to hpos carcoma that is oncogenicity and it can lead to sosis also okay so there are three F so what is the percentage what is the percentage so out of all the persons who have hepatitis B virus infection 65% have subclinical infection and they recover 65% have subclinical infection they recover nearly 5% are the carrier nearly 5% are the carrier okay and 25% have acute hepatitis 99% of them recover but 1% of them can have fulminant hepatitis and only 10% can have chronic if they have chronic they have two fate either therosis or hos carca recovery is very rare in chronic once The Chronic occur either the person dies person ultimately dies either the person dies with sosis or the person dies with hear CA if the person have chronic but if the person have acute now recovery is very common okay so recovery occurs uh in acute so 65% is subclinical 25% is acute and 10% is chronic you can learn like that okay so out of all the persons who have Hepatitis B virus infection so subclinical acute and chronic what is subclinical patient don't have the symptom or very mild symptom that is no treatment required and some have directly carrier so you can say out of the 100% 5% are carrier 65% are subclinical okay and acute occurs in 25% chronic occurs only in 10% okay learn the percentage now learn the Fate learn the Fate subclinical 100% recover acute 99% recover okay 1% convert into fulminant that is the Fate carrier always remain either subclinical or they recover or the remain as carrier only but chronic never recover hardly one or 2% recover but either they convert into HCC or they convert into therosis and ultimate fate is death so that is The Chronic so you have to draw this percentage wise okay percentage are important okay so that is the clinical course most important thing in hepatis B wirus to understand is the lab diagnosis okay so there are antigenic markers and antibody markers please understand these are the serological markers it's very difficult to understand but I will make super simplified for you believe me but please concentrate so see this is the diagram of hyptis B virus hippus B virus have three antigens on that please concentrate what are the three antigen the first antigen is hippus s antigen s for surface hippus s antigen hippus s antigen s for surface s for surface because it is present on the surface second is hepatus e antigen e for envelope e hpus e antigen e for envelope because it is present on envelope so one is s one is e the S is surface it is present on Surface e is envelope because it is present in envelope the third antigen is c c for core because it is present deep inside and that is core so learn the three antigen what are the three antigen s for surface e for envelope and C for core the three antigens are there please learn that the three antigens now imagine imagine this virus enters someone's body so this is the blood vessel of a human being in which this virus have entered you can see this is the endothelial lining this is the blood vessel in which this virus is present so this is the virus present in the blood vessel you can see okay now the body will form antibodies against the antigen so against the s body will form NTS okay against the S the body form ants you will say very simple to learn against the E body form NT body form now when this virus is coming in the blood now S and E leaks out so s antigen leaks out so body form antibodies against that e also leaks out so body form antibodies against that c never leak out C remains inside the code because it is deep inside the code it never leak out it never come in the blood it never leak out in the blood this leak in the blood this leak in the blood it never leak in the blood but even if don't leak in the blood body forms antibodies against that also so body is forming antibodies since it is not coming in the blood it is feeling bad that I'm not coming in the blood I'm not leaking in the blood my other two friends who are the other two friends S and E are leaking in the blood but I'm not leaking in the blood so the C is feeling very bad so be said to C that don't worry if you're not coming in the blood it's okay we we will form your two antibodies so it just a way of learning okay I'm telling you a trick to learn so C antigen never come in the blood and that's why body form two antibodies for that so anti C is of two type antcs of two type IGM and IGG so IGM and IGG are the two types of antc so total four antibodies are there one is ants it don't have any further type one is anti one is ant s one is anti it don't have any further type and one is anti-c antc is of two type IGM and IGG so if you take the blood sample in a test tube we have two antigens and four antibodies can I say it again so see this is the virus let me draw the virus so this is the virus I'm talking about on the surface of virus there's an antigen that is s antigen known as hepatitis s antigen s for surface there is another antigen on the envelope it is known as hyptis e antigen e for envelope and the third antigen is present deep inside that is hippus C antigen C for core hippus c antigen okay now in the blood two will leak out s will leak out in the blood and E will leak out in the blood C never leak out in the blood so whenever this this virus is present in the blood vessel out of the three two are coming in the blood so if we collect the blood in a test tube we get S and E we never contain we never get C C never leak out because it is present deep inside now let's talk about their antibodies so the body is forming antibodies against them antibodies are formed against all three okay so against s the body will form ants anti HBS against e body form an hbe anti HB again C body form anti HBC but since C is not coming it's feeling bad so anti HBC is of two type that is IGM anti HBC and IGG anti HBC so learn the basics so we have four antibodies the two antigens and the four antibodies are known as serological markers so I'm marking the two antigens which leak in the blood that is S and E they leak in the blood C never leak in the blood and now I'm marking the antibodies which leak in the blood four antibodies the I mean not leak in the blood the body will form four antibodies so antihbs is formed antib is formed and two types of anti HBC is formed that IGM and IGG so four type of antibodies so two antigen see the yellow four antibodies see the green these are known as serological markers of hitis B two antigens and four antibodies so in the blood we can get two antigen and we can get the four antibodies these are known as serological markers now among the serological markers I want to teach you two things first tell me the sequence in which they are coming can you tell me the sequence so obviously first antigen will come then antibody will come body cannot form antibody before antigen so first of all as soon as the virus is coming in the blood so I told you two leaking now so s leaks first first s come in the blood and then e leak e leak e come in the blood C never come in the blood so first s is coming and then e is coming so this is the sequence s followed by E so first s is coming then e is coming this is the sequence of antigen first s antigen leak and come in the blood then e antigen leak and come in the blood see don't leak let's talk about antibody nobody start forming antibodies so in which sequence body form the antibody body have to form four antibodies one for S one for e and two for C IGM and IG so C is not coming now C is feeling bad so body is saying it's okay I will form your antibody first so first antibody is NTC but there are two type of antc so this one is IGM IGM antc okay then the antibod is formed for E okay ante then the antibod is formed again for C but this time it's IGG and lastly the antibod is formed for s that is NTS so here four mcqs arise in your exam tell me the first antigen which come tell me the last antigen which come tell me the first antibody which come tell me the last antibody come so these are the MC the first antigen is s the last is e because there are only two antigen which leaks out the third is not leaking Out Among the antibody the first antibody is C that is IGM and last antibody is s if you can notice here the first antigen is s the first antigen is s and its antibod is last okay so all these are the questions mcqs and the concepts okay so this is the sequence the second thing I want to tell you sequence you got it can we revise the sequence once quickly so s followed by E this is a sequence for antigen in the antibody the sequence is c e c s this is the sequence so sequence for antigen is s e so first s antigen followed by E antigen and for antibodies the sequence is c e CS the first C is IGM obviously and then the next C is IG obviously so c e CS you can learn a pneumonic if you wish if you're getting confused so that is a sequence now now the thing I want to tell you is the relevance so why it is important to see the six markers the two antigen and the four antibodies what does they indicate I mean what does they indicate I mean so let me tell you the Rance of all of them so in the relevance of all of them we will talk about the pairs let's talk about the pair of s antigen and S antibody let's talk about this Paar so in this Spar the S antigen and S antibody they never come together if antigen is present antibody will be absent if antibod is present antigen will be absent they are mutually exclusive please learn as antigen and antibody they never present together because s antigen represent infection and S antibody represent recovery the person cannot have infection and Recovery together either the person is infected or the person is recovered so if the person have the infection it means s antigen is present in the blood and if the person have recovery it means s antibodies present in the blood that is the first thing s antibody also represent immunization or vaccination so I'm vaccinated for hepatis B virus I guess you all are vaccinated all Healthcare Providers should be vaccinated so we all have anti SN number blood okay antibody of Des they are protective in nature okay so that is the thing so that is the first paer coming on the second paer the second paer is e e antigen and E antibody again these two never come together if e antigen is present antibody is absent if e antibody is present antigen is absent okay again these are mutually exclusive like the S okay so e antigen represent High infectivity infectivity not infection it's infectivity or communic communicability okay and E antibody represent low in in activity infectivity infectivity is the tendency to infect others imagine I am doing some procedure on a patient okay just second I'm taking a blood sample I'm operating I'm doing some procedure on a patient and I'm using scalpel okay and uh the scalpel I'm using I got a cut by mistake to myself okay by mistake it is very frequent very frequent it happens in hospitals in hospital settings in healthcare providers so or I'm giving an injection to a patient the same nle prick I got by mistake and I got AF FR I got scared and I have checked the profile of that patient after that and I found oh my God this patient is hepatitis s Hepatitis B virus positive so this patient is having an infection of hepatitis B virus and that can be transmitted by Common syringe common needle common instrument that is the most common way that is parentral way it get transmitted and I got scared so I will check the Hepatitis E antigen and antibody of that patient if the patient is having hepatitis E antigen there are high chances I will also have infection because the person is having high infectivity high communication and if the antibodies are present so there are rare chances that I will have the infection still I have to take the prophylaxis in both the cases but that indicates the impacct impacct is the tendency to impact others so that indicates e e antigen and E antibody coming on the last pair the last pair is c c antigen don't come in the blood so we have only two antibodies but there are two antibodies so what does IGM represent what does IG represent both of them are antc what does they represent so s represent infection s antigen represent an infection but it is not telling us whether the infection is acute and chronic so if IGM antibodies are present it means acute infection and if IGG antibodies are present it means chronic infection chronic or past infection so that is the relevance you want a point so s antigen and antibody what does they represent what does they represent e antigen and antibody what does they represent what does represent and C for C we don't have antigen we have only two antibodies the IGM antibodies what does it represent and IGG antibodies what does it represent tell me the relevance so s antigen represent infection but whether it is acute or chronic we don't know acute and chronic we will come to know from here so if s antigen is positive then the next we have to see C antibodies so if it is IGM it is acute infection acute hepatitis and if it is IGG it is chronic chronic or past hepatitis but if s antibodies are there there is no infection there is either recovery or immunization or vaccination so that is a re relevance what about e e and anen represents high infectivity and E antibody represents low infectivity so how these markers are relevant to us okay so see the sequence I have already told you the sequence first s will come s antigen then e antigen so that's about the antigen now talk about the antibodies in the antibodies the first antibody is anti C but this time it's IGM then anti then again antc but this time it's IGG and then ants so I told you a pneumonic to learn c e CS that is for antibodies and among the antigen It's s for Follow by E so you have to show the same in the graph in the graph you can see the first antigen is s along with the S only e have shown so S and E shown together here by this line S and E shown together here by this line so s followed by ideally two lines should be shown first s then e but here they have shown only one line S and E together so can you see this graph let me highlight okay let me use a can you see this one it represent S and E together antigens now let's talk about antibodies now let's talk about antibodies one by one so first of all which one is coming NTC that is IGM so this is IGM NTC okay you can see this is IGM NTC after that so this is IGM NTC which is shown by red color then ante is coming so let me show you the ante ante is shown by this the next next is the ante can you see this is NT then IG NTC is coming so this one is IGG NT C this one is IGG NTC okay and last one is NTS NTS so this one is NTS so last two will never go back they will never touch the base line so NTS will remain forever and IG will remain forever the rest all will come and go so if I want to draw a graph it's very easy it's very easy I will draw two antigens and four antibodies total six curve so what are the two antigens I will draw I will draw the first antigen HBS and HB like this so these are my two an antigens this one is HBS antigen and this one is HB antigen we can show one also if you are confused we can merge and show one because hardly there is any gap between them now let's talk about antibodies the antibodies are important the first antibod is coming is NTC IGM that is the first the second which is coming is uh antibe okay the third one which is coming is IGG NBC that will never go back and last one which is coming is NT HBS which will never go back so this is how I will draw and I can label it this one is NTC but this one is IGM this one is nte this one is NTC but this one is IG that's why never going back and this one is NTS you you can draw draw like this and you can write the weeks if you wish but if you don't write also the pattern is important and the labeling is important so please write down the sequence and draw the graph okay the relevance also I have told you now the sequen is the approach is look for s first look for S whether antigen is present or antibody if antigen is there if antigen is there the person have the infection if antibod is there the person have the recovery then look for E if antigen is present the person have high infectivity if antibody is there the person have low infectivity then look for c c have only antibodies no antigen if IGM is there person have acute infection if IGG is there person have chronic so this is the sequence we look for so whenever you have a serological marker report in your hand of any patient this is how we interpret now this is important for your interpretations also you can get a question on that in your University exam and this is more important for McQ purpose so you get a question in which the serological profile is given to you okay and you have to interpret what is the diagnosis of the patient let me tell you so see this is the pair of s s antigen s antibody first look that one of them will be positive one will be negative okay then the e e pair e antigen and E antibody again one of them is positive one of them is negative and last C antibody C don't have antigen so see antibodies IGM or IGG so see here in the first all of these the S antigen is present antibodies absent but in the last one antibod is present antigen is absent so what does s represent either infection or recovery so they all have infection the last one is the recovery the last one is the recovery they all have infection my next question to you is it high infectivity or low infectivity so that will be decided by E so look at the E if e antigen is there that's high infectivity if e antibodies is there low infectivity E antigen is there high infectivity e antibody is there low infectivity and finally have a look on antihbc antibody I mean they don't have antigen so if it's IGM it's acute infection if IGG it's chronic so IGM is acute IGG is chronic so this is how you make the diagnosis okay diagnosis is not one uh you know based on one marker so acute infection of high infectivity or acute infection of low infectivity chronic infection of high infectivity or I infection of low infectivity that is decided based on all these markers and whether it is a recovery so based on all these markers we decide our result and that that is the interpretation I hope you got it so we are done that was all about lab diagnosis of B so we are done with hepatitis A and hepatitis B so let's surise Hepatitis B Hepatitis B the causitive agent is Hepatitis B virus that belongs to hipad it's a DNA virus rest all are RNA virus and that have the envelope that have the envelope and on the surface there are three antigens you can show hippus s antigen hitis e antigen and hitis C antigen so you can draw the diagram okay in the mode of transmission I told you there are three mode of transmission the mode of transmission either parental root or sexual root or vertical roote incubation period we know the incubation period is 60 to 90 days as average clinical features I have drawn the diagram so 65% are subclinical 25% are acute and only 5 to 10% are chronic they recover they recover but chronic never recover so chronic have either HCC as a fate or ceris as a fate so you have to draw that flowchart so that is the thing and most important and most difficult to understand is the lap diagnosis in the lab diagnosis I want you to to write about the three two antigen which come in the blood and the four antibodies which are formed in the blood so total six markers draw their sequence and write their relevance and draw that table the interpretation table I have shown you so that is the lab diagnosis the antigens the antibodies antigens are two which come in the blood the third antigen never come in the blood and antibodies are four you know which four antibodies so that's all about B now coming on C CDE okay so C first we will see c c is caused by hyptis C virus it belongs to family flavy viid it belongs to virus flavy viid it's a RNA virus I told you only B is DNA rest all are RNA and it's spherical and it is having the envelope I told you A and E don't have envelope BCD have envelope so envelope is present and it is having many antigens in that like it is having C Core antigen it is having e envelop antigen and it is having ns1 ns2 NS 3 ns4 many NS antigens okay these are the many transmembrane proteins are there these are the antigens present in the structure of the virus mode of transmission are the same three as that of B so it can be transmitted most commonly by parentral roote what do you mean by parentral either by Blood transmission or common nle or common syringe it can be transmitted by sexual root from infected male partner or female partner to the another sexual partner and by vertical or perinal roote via placenta from infected pregnant lady to her to her feetures incubation period on an average at 50 days learn that average it's 50 days we have seen the incubation period now clinical features again it can cause asymptomatic acute and chronic but here The Chronic percentage is very high it's 80% so along with hepatitis it causes extra hepatic manifestations also so first time I'm telling you apart from hepatitis it causes other infections also so it is the only hepatitis among the five which causes extra hepatic manifestation it can cause C mixed cryoglobulin Amia it can cause GL nefritis and arthritis and joint pain so it can involve other organs also apart from Lever that is extra hepatic manifestations in the lab diagnosis we will get the antigens and the antibodies okay we can get the antigen and we can get the antibodies the antibodies are of many if you want to learn it's not important but if you want to learn we divide the antibodies into three generation first generation third generation Second Generation and third generation first of all third generation come in the blood you can see first antigen is coming this is antigen and then the three type of antibodies are coming so this is third generation antibody third generation antibody is against NS ns5 against ns5 I told you ns5 protein is present in the virus now the second generation is again against against c33 against c33 or c200 that is Core protein and first generation is against c00 c00 so you can see the structure of the virus in the structure of the virus you can see first of all the third generation antibodies are coming that is ns5 you can see ns5 this is third generation they are coming earliest the antibodies against this protein against this protein the second generation is C c200 and first generation is c00 so in the C there is c200 also c00 also so there is second generation and third uh Second Generation and first generation if you want to learn that's not very important you can learn the antigens and the antibodies that's it so we are done with hyptis C virus also now coming on D now coming on d d is defective D is Delta and defective what is the defect I will let you know the defect okay so D for defective it's a virus which belongs to Delta v d for Delta D for Delta but it's a defective virus D for defective so learn 2 d d for Delta de or defa Delta is the family but what is the defa you know some people are very shy they always require a friend with them okay the helper friend so they are very shy they don't go alone anywhere they always take their friend with them okay are you one of them there are many people they're very shy okay so they take the friend the best friend with them you also come with me then only I will go otherwise I will not go you are my best friend you everywhere you come with me so hepatitis D virus is a defective virus and that is a shy virus so it requires a friend always it requires a friend to cause the infection so the friend virus is the hippus B virus D cannot cause hippus without B so if D enters alone in someone's body D cannot cause the hippus no but if D enters along with B then it can cause hyptis that is the defect so D for defective the defect is that it always require a helper virus the name of the helper virus is hyptis B virus so D always require B that is my point D always require B it is a single standard RNA virus I told you only B is DNA virus rest all are RNA and it is having an envelope also on the envelope it is having two antigen one is D antigen and one is hyptis B antigen which is derived by hyptis B virus that's why it's defective so it requires the antigen which is derived by b hyptis bs antigen as for surface so this antigen is given by the B virus and then only it can cause heitis only D antigen cannot cause the hepatitis so that is the defective mode of transmission are same three it can be transmitted by parentral root that is blood products and common nle common syringe it can be transmitted bya sexual root and it can be transmitted by vertical or perinal in the pregnant lady via placenta incubation period averages 60 to 90 days now there are two type of clinical features that is coinfection and super infection what do you mean by that I told you it always require b d alone cannot cause idus if D is present with B in the lever both are present then only they cause Hiatus if B alone is present it can cause Hiatus but if D alone is present it cannot cause so it always requires the helper the friend virus the helper virus it is known as helper virus it always require be so there are two possibilities what are the two possibilities coinfection and super infection what do you mean by that what do you mean by that let me explain you what do you mean by Co infection and what do you mean by super infection please understand please understand the difference between them so listen there is a healthy person imagine there is a healthy person any healthy human being so which don't have anything in the liver absolutely healthy so B and D enter enter together so D is asking B also you also come with me I'm very shy I will not go alone so let's enter together in this person so in a human being B and D enter together together is co infection so after entering they will cause the hpus okay so B and D enter together B also come together D also come together so either both of them are coming by parental way both of them coming by sexual way or both of them are coming by vertical way so by whatever way it is coming so b d together cause the hepatus but see the second possibility the person is already a carrier of B I told you now in B there are 5% carriers are there so person is a carrier of B person is asymptomatic carrier who's a carrier carrier is a person who don't have any symptoms okay but it can transmit the infection to others so person is having a B virus but that is a carrier the person himself don't have any symptoms and the D is entering alone so B is already present in the liver and D is also coming so that is super infection super means one above the other so first B is there and over D is coming one by one they are coming so again in the liever both are present and they cause the htis you may be thinking ma'am does it matter whether they enter together or whether they enter one by one if they enter together you are seeing Co infection there also the person have hepatitis and if they enter one by one first B and then D then you are calling it super infection then also the person have hepatitis in the liver does it matter does it matter Co infection or super infection yes it matters matters the percentage of acute and chronic if they're anting entering together I mean if there is co infection if there is co infection so 90% have acute heitis and they will recover only 10% have chronic or fulminant only 10% have chronic or fulminant that will not recover so 90% will recover but if it is super infection the percentage is reversed so 80% of them will chronic and 20% will have uh 10% will have uh acute and 10% will have fulminate okay so the percentage is reversed you got my point so what is co infection and what is super infection so in Co infection B and D tra enter together in a healthy individual in super infection the person is already a carrier of B and now the D is entering D alone is entering okay so what is the percentage here so let's divide in three percentage here let's divide in three percentage here so here the percentage is 90% 5% 5% okay I mean let's what are the three things here so here also we have acute fulminant and chronic here also we have three things acute fulminant chronic acute always recover but fulminant and chronic don't recover so what is the percentage here acute is 90% fulminant and chronic are 55% so here this is the best one so 90% will recover but these 10% will not recover in in um hippius I mean Super infection acute is only 10% fulminant is also only 10% but chronic is 80% so these 90% will not recover they will not recover only 10% recover so here recovery is 90% And here recovery is 10% so if the person have co- infection recovery is 90% but if the person have super infection recovery is only 10% so that matters so I hope the concept is crystal clear to you you have learned that lab diagnosis whether it is co infection or super infection how you will come to know in Co infection as well as super infection you will get antibodies against the D but you have to see the antibodies against the B if the antibodies against the B are IGM type I mean it's it's the acute infection so it's a CO infection but if the antibodies against B are IGG type IG type I mean the person is having a chronic carrier of B and that indicates chronic infection so the antibodies of B matters here the B and the core antigen of the B I mean anti HBC is it IGM or IGG IGM means it is entering right now and IGG means it was already present so that will that will differentiate the co infection and the super infection anti is present in both of them anti anyhow D is entering so anti will be present you got my point so we are done with d also I hope you got it I hope you got it let me explain you the antibodies once more before coming on the last one that is heitis e let me explain you the concept of the antibodies if anybody have missed it okay listen so co-infection both of them are entering together so body will form antd anti hbd and hdv antibodies and it will form anti hbv also among the anti hbv it is against the core antigen Okay C and since it is recent it will be IGM type okay here also body will form anti hdv because d is entering anti hdv is present here also it is present here also but here the body will form anti hbv anti hbv but here anti hbv against the core antigen this time it is IGG because the person is Carrier the B is already already present in the body so it is present since ears it is a carrier okay so it is the antibody B whether it is IGM or IGG that differentiate the co- infection from Super infection anti hbd is not differentiating it is present in both of them that was my point I hope you got the same concept here now coming on the last one the last hyptis is hitis EV virus last one hippius EV virus here the positive agent is hipes e virus it belongs to family hip virus it is also RNA virus okay it is non- enveloped A and E are non enveloped restol are enveloped okay and uh only B is DNA restol or RNA it's RNA virus it transmit by FAL roote I told you now A and E are shedded in stool and the stool will contaminate food and water and the contaminated food and water is consumed by another person and this root is known as FICO oral root so FICO oral root is seen in A and E currently I'm studying I'm teaching you e so FAL root and average incubation period is 40 days okay clinical features it causes only acute no chronic no chronic no carrier no HCC and no ceris since there is no chronic the other three things are absent it causes only acute acute it causes there is complete recovery but in 1 to 2% it causes is fulminant hepatitis it is the most common cause of fulminant hitis especially in pregnant ladies in pregnant ladies there is high risk of fulminant hitis caused by htis C that's all in the lab diagnosis you will get the virus and you will get the antibodies the two type of antibodies IGM and IGG that's it now you got the concept so I hope we have covered all five type of hepatitis right now so we have already covered all five type of hepatitis you know the positive agent of each of them you know the morphology of the virus mode of transmission in a and e is FAL in the remaining three either it's parentral or it's sexual or it's tical incubation period here 30 days here 40 days here 50 days in the remaining two that is B and D it's 60 to 90 60 to 90 okay clinical features I told you acute is caused by all of them fulminant is caused by all of them chronic is never caused by A and D it is caused by BCD and since it is causing the chronic they can lead to carrier State also and they can lead to atcc and they can lead to ceris also lamp diagnosis I have told you the antigen antibody in all of them now the last last thing you have to understand the clinical pathological Spectrum here of the acute as well as chronic so as I told you the acute is caused by all five A B C D E I told you there are five type of hitis acute is caused by all five so if I do a lever biopsy in acute hitis what is the morphology and chronic is caused by only by BCD not by uh A and E so if I do a lver biopsy in acute heitis the morphology is same in all five we do not get any difference if it is hitis a B or C or D or E if it is acute the morphology wi it same that is the point if it is chronic morphology Wise It's same okay whether it is caused by B or C or D morphology wise it same so I want you to learn two diagrams one of acute hyptis morphology microscopy I mean and one of chronic Hiatus morphology so let me tell you the two diagrams you have to learn the two microscopy of acute and chronic so if they ask you acute caused by A or B or C or D or E you have to draw the same dagram in The Chronic if they ask you for B or C or D you have to draw the same diagram chronic is not caused by A and D so let's see the diagram of acute can you see the diagram of acute heitis so acute heitis microscopy it is same for all five it is same for all five in your exam don't get confused whether they ask you to draw the diagram of acute hitis a or acute B acute C acute D or acute e you draw this diagram it is acute now the diagram of acute is same whether it is a b CDE e that is my point so in the diagram you have to show the uh you have to show the uh this thing I mean classical lobule in the classical lobule there is a central vein at the center and there is a portal Triad there are six portal Triad I will not show all six I will show one Central vein and one portal Triad so in this box see the diagonals always look at the diagonals I always say look at the diagonals so at one of the diagonal you will get central ve and at one of the diagonal you will get Bal Triad connecting them see the Cs of Hite now in the Cs of Hite I want to show you four things now some of the hpy show balloon degeneration some of the hpy let me highlight can you see this hpy can you see this this one can you see this one this one this one it is swelled swelled and having granular eosinophilic cytoplasm granular pink color cytoplasm since it is swelled it is looking like balloon that's why it is known as balloon degeneration number one so some of them show balloon degeneration some of them let me highlight which one some of them can you see this one can you see this one it is having intense pink color cytoplasm that is known as conselman body so in the cytoplasm dark pink color is there and no nucleus picnotic nucleus no nucleus these are conselman bodies so some of them randomly show conselman body some of them show balloon degeneration some of them show um some of them show conselman bodies now see these one can you see this one let me highlight with a marker okay let me use a marker to highlight can you see these one all these you can see only outline you can see only outline of the cell you don't see anything else it is the necrotic cell the cell got necrosed we see only outline and nothing inside it is known as Dropout necrosis so some of them show Dropout necrosis Dropout necrosis and the fourth thing is not shown here the complete row of the hpto side the complete train of the hppy show The necrosis that is bridging necrosis so Bridges so you have to show four things here okay you have to show the four type of injury I will show you all four in a diagram I will draw the diagram apart from the four type of injury the four type of fular injury you have to draw the inflammatory infiltrate everywhere especially in the portal dard in the portal dard the three things you can see where is the artery vein and uh I mean hepatic artery this is the hepatic artery this is portal vein this is BCT we got it okay but what are these dot dot dot dot dot these are these all are lymphocytes so I can see multiple lymphocytes are there in the portal Triad so portal Triad inflammation portal Triad inflammation with the lymphocytes and kuffer cell hyperplasia so can you see few kuer cells between two rows of hpy we have cocy and cides are lined by endothelial cells and interspersed kuer cell so these are the kuer cells can you see kuffer cells we can see many places kuer cell hyperplasia is there so I will draw it for you don't worry so I'm drawing the diagram of acute hepatitis whether it is a b c d e doesn't matter that is a diagram of acutus at one diagonal I will draw Central vein or hepatic vein at another diagonal I will draw the portal Triad in the portal Tri I will show you three things hepatic artery portal vein and PCT connecting them I will show you the Cs of heyes so these are the cords of hepatocytes connecting them can you see the cords of heyes these are the cords of heyes connecting them these are the Cs of heyes now in some of them I will show four type of injury in some of them I will show ballooning balloon degeneration in some of them I will show conselman body in some of them I will show Dropout necrosis and in some of them I will show bridging necrosis I want to show three four things so some of them I will do the swelling they just swelled out randomly anyone they just swelled out and they have eosinophilic cytoplasma I will just swell them USIC cytoplasm and I label them as balloon degeneration okay you have to draw like this in some of of them I will do a dark pink color and no nucleus dark pink color and no nucleus in some of them and I will label them as conselman bodies conselman bodies number two in some of them I draw the only outline no nucleus nothing only outline and I label them as Dropout necroses and in some of them I will draw the complete rows necross and I will label them as bridging necroses so you have to draw it people I'm trying hard to explain you how to draw and how to label in your exam apart from that in the portal Triad show many lymphocytes and label it inflammatory infiltrate okay and you can draw the kufer cells hyperplasia at many places you can draw the kufer cells between the rose of heite and label it coer cell hyperia if you wish it's not important but these four types of injury is important so you have to show four types of injury in some of them show balloon degeneration some of them conselman body some of them Dropout necrosis some of them the complete bridging necrosis so that is the thing so that is acute now coming on chronic one more last diagram that is chronic hyptis so chronic hyptis is seen in hitis B C D A and D don't have chronicity so in your exam whether you are getting the question on chronic B hepatitis chronic C or chronic B the diagram is say this is the diagram let me show you the diagram this diagram you have to draw this is normal and this is chronic hepatitis any it can be B CD okay the diagram is same okay you have to understand the normal lobu in a normal lobu there is a central vein at the center and there are six portal Triad I will draw only one so in this normal diagram first understand the normal diagram can you see this is a central vein say yes can you see this is a portal Triad say yes in the portal Triad say this is artery this is vein this is duct one of them is artery one of them is vain one of them is B duct so this is a portal triod so and this is the Cs of Hite connecting them these are the Cs of Hite connecting them here in the lob will also see the Cs of aptoite connecting them can you see this is the first train this is the second train this is the third train actually the two CS I call them trains because they have Bogies one behind the other where is the engine where is the engine uh the engine I mean the first first hpy of all of them so this is this the first first hpy of all of them is known as limiting plate it forms a plate it forms a plate that is limiting plate limiting plate so first first Hite form a plate that is known as limiting plate limiting plate the engines of all the trains so where is the limiting plate in this diagram see normal first abnormal don't see first understand normal so here is the limiting plate the first firstto side so what I can see in a normal diagram in a normal diagram can we revise so say ma'am in a normal diagram in a normal diagram we can see there is a central vein okay there is a portal Triad containing the three things that is artery vein and duct portal hepatic artery portal vein and B duct and we can see a CS of hpy connecting them okay and the first first hpy is the limiting plate now compare this diagram what are the changes what are the changes you can see first see the limiting plate okay okay let me tell you the sequence in which I'm going to teach you so first I will tell you two changes at the limiting plate here okay then I will tell you two changes in the portal Triad there then I will tell you the two or three changes in the C of aptoite there okay in the sequence we will cover so first see the limiting plate so see limiting plate here and see limiting plate there can you see limiting plate here huh can you see limiting plate there say no m'am I can't see the limiting plate so limiting plate is disappeared that is known as necrosis so necrosis of the limiting plate is known as peac me necrosis there are two changes in the limiting plate first it get necrosed it get necrosed it is known as piece meal necrosis it is piece by piece it is piece by piece so first a little bit is gone then then then then complete is gone so complete limiting plate is disappeared that is known as peace meal necrosis and instead of that I can see the inflamation there so the piece the the limiting plate is gone I agree but instead of that I can see the lymphocytes I can see the lymphocytes there so that is known as interface hepatitis so first the limiting plate is gone that is PE me necrosis and in of that I'm having inflammation that is itis hepatitis interfaced M junctional it's a junctional hepatitis okay so the words are catchy the meaning is very simple but the words are catchy what are the two catchy words we have learned here so peace meal necrosis and interface hepatitis occurs at limiting plate so here I can see a normal limiting plate but here I can't see the normal limiting plate instead of that I can see two things number one peace meal necrosis it is gone and instead of that there are lymphocytes that is interface heitis so learn the two things limiting plate limiting plate me two things there are two things in the limiting plate what are the two things peace meal necrosis and interface hitis I have a draw it for you okay please understand now second thing see the portal Triad portal track have a look of portal track here and have a look on the portal track here what you can see in the normal portal track where is the normal portal track see the normal portal track first and see the portal track in chronic hepatitis compare compare in the normal portal track you can see the three thinks this is artery this is vein this is B duct here you can see this is artery okay one artery here this is vein okay one vein but there are many B ducts oh my God this is this is this is this is many B duct so first thing is B duct proliferation so we have many B ducts artery is still one portal vein is still one but B ducts are many so first thing we got is bile duct proliferation bile duct proliferation number one and number two here there is no inflammation in the background background is clean clear here in the background I can found many lymphocytes many lymphocytes in the background so that is inflammation so inflammation is the portal Triad is tritis itis is the inflammation itis Triad tritis inflammation is the portal Triad triaditis inflammation is the portal Triad so we found two things at the limiting plate and two things in the portal Triad what are the two things in the limiting plate in the limiting plate we have peace meal necrosis and interface heitis and what are the two things in the portal Triad bile duct proliferation and triaditis inflammation of the portal trius tritis so learn the catchy catchy words learn two things in the limiting plate and two things in the portal Triad and learn two things in the carts of hepy here see the carts of heyes are normal here some of them show conselman bodies it is not shown here but in some of them show the dark eosinophilic body that is conselman body or acidophilic body in some of them you can show so some of them show conselman bodies and ceral hyperplasia kersel hyperia now the most important feature here is bridging F bridging necrosis as well as bridging fibrosis so there we have only bridging necrosis what is bridging necrosis I told you there the complete row of HTO side is gone and it is necrosed that is bridging necrosis so here also we have bridging necrosis in like acute and chronic also but here bridging fibrosis is something unique which is present only only in U chronic hepatitis not in acute heitis so there are three type can you see a lobu there are three type of bridging fibroses there are many lobules in the lver in the liver there are millions of lobules so if the fibrosis is occurring from one Central vein to other so all the heyes between one Central vein to another are necros or fibros all the heyes between one Central vein to another Central vein are fibrosed so there is a band of fibrosis this is known as Centro Central Centro Central Centro Central number one the second all the hepatocytes between two portal Triads are any2 portal Triads any2 portal Triads they are fibrosed this is known as PTO portal this is known as Pho portal so we have Centro Central Pho portal type of fibrosis Centro Central type of fibrosis and third you got it Centro portal the third one it can be between it can be between one Central vein and any one portal Triad so this is centr Portal so I mean to say there are three type of fibrosis Centro Central PTO portal and centr portal cental Central is between two Central vein see the blue color between any two Central vein P portal means any two portal R see the right color and Central portal is one Central vein and one portal see the green color you can use different colors so you there are three type of fibroses so all the heyes between them they get fibrosed so that is the three type of necrosis as well as three type of fibrosis the same thing is written in front of you you can see this is Centro Central this is Centro Central this is Central portal so you can see the same better I have drawn it I guess okay so that is the thing so we are done with this also I hope we are done so acute and chronic so what are the features of chronic Hiatus how you will draw it can I draw it can I try to draw it the the The Chronic Hiatus so first of all I will draw Central vein I will draw portal Triad in the portal Triad I will draw artery hepatic artery portal vein and bile duct okay then I will draw the rows of hpy connecting them at least I will draw three four rows to show you the changes I will draw two three rows to show you the changes like this this is the diagram I'm trying to draw this is a normal diagram the first first heaty here is forming the limiting plate so this is the limiting plate okay so first I will show you two changes at the limiting plate at the limiting plate my two changes are number one I will do the necrosis here known as PE meal necrosis and I will do inflammation here that is known as inter inter face hepatitis okay interface hepatitis so I will just disappear these hepatocytes and instead of this first first first hepy there instead of this first first first ocy I will draw I I I will draw the uh lymphocytes there I will draw the inflammation lymphocyst and interface heitis now I will show two changes in the portal Triad what are the two changes I will show you in the portal Triad number one I will draw many bile ducts one artery one vein but many bile duct I will label it bile duct proliferation and number two I will show the inflammation in the background I will draw many lymphocytes and I will label it as tritis inflammation the in the portal Tri now I will show two changes in the hepatocytes number one some of them some of them show conselman bodies so some of them I will show dark pink color no nucleus dark pink color eosinophilic cytoplasm I will label them and number two I will show kuer cell hyperia here and there kufer cell hyperplasia so number two I will show kufer cell hyperplasia apart from that I will show either there is bridging necrosis or bridging fibrosis so bridging necrosis is common in acute and chronic but bridging fibrosis is unique feature each of them is of three three types Centro Central PTO portal Centro portal that's all about it all the things I have labeled I tried my best to explain you so this is The Chronic hepatitis so I have explained you acute also chronic also so we are done so don't forget to have a look on all the long question short question very short question including mcqs of this topic which are given in the notes section of the app as well as question Bank subjective objective question Bank of the app so please after each video follow this sequence thank you so much hi friends hope you enjoyed the video and learned the concept behind that this was one of the video from our complete course of pathology that is pathology prop buster if you want to watch more such free videos from this course you have to visit our course you have to just click on the link given in the iard to visit our course and there are ample of free videos available in this course if you want to connect with me on various social media platform you have to uh scan this QR 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