Transcript for:
Viral Hepatitis & Liver Anatomy

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 hepatitis if you don't know the normal anatomy and normal histology of the liver. So first of all, I will let you know the normal anatomy and normal histology of a normal liver, then I will explain you the Dual blood supply of the liver and then I will let you know the classical lobule model of the liver, which is the most commonly used model, acceptable model for the liver is classical lobule 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 hepatitis under a fixed set of heading. I will let you know the causative 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 hepatitis and microscopy of chronic hepatitis. So if it is a long question, long question usually not asked on all type of hepatitis, 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 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 these 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 NORMAL LIVER. So see liver is the largest organ, the largest organ in human body, okay. You can see and in the liver there are two lobes the right lobe and the left lobe, 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 hepatitis. So please it's important, So this is the liver, 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 aorta, liver also receives pure blood oxygenated blood from the left side of the heart via aorta via hepatic artery. So from the aorta, hepatic artery is coming, a branch of aorta 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 liver, So the second blood supply of the liver 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 Deoxygenated Blood via portal vein, So that is the Dual blood supply of the liver. After that 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 highlight 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, 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 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 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 inferior vena cava, (IVC) via inferior vena cava, got it. Now liver this is liver, liver synthesize bile, in the liver there are hepatocytes, these are the hepatocytes present inside the liver, So the hepatocytes inside the liver. They synthesize bile, So all the bile collected from all the hepatocytes, They exit from the liver and the bile is drained into the intestine into the duodenum, Via ampulla of Vater. This is Bile 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 Bile 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 dual blood supply, one is hepatic artery, So hepatic artery is coming inside and forming multiple branches. One is portal vein, portal vein is also coming inside and forming multiple branches. But the exit is one So exit is one, hepatic vein, hepatic vein also have multiple branches and Bile 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 duct. So these are four things, they all have branches inside the liver. So three of them are best friend. I mean best friend they are the triplet, they are the tripod, the branches of three of them travel together. Which of three of them the branches 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 travel separately. They don't travel with them, it is not a good friend of them. So there is a triplet, what is a triplet - hepatic artery, portal vein and bile duct, this is the triplet. Okay, So we divide the entire liver into multiple classical lobules, can you see this is a classic lobules, it's a hexagon. So we divide the entire liver 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 bile 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 hepatocytes connecting them. The cords of the hepatocytes are the Bogies of the train, they are like Bogies of train, one behind the other by a cord, I mean the Bogies of a train, one behind the other, So the connection between the central vein and the portal Triad is cords of hepatocytes. I have not drawn everywhere, but you can draw it 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. sinusoids 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 sinusoids are lined by the endothelial cells and few Kupffer cells, interspersed Kupffer cells, So that is the sinusoid, sinusoids. Now here you can see the same, So this is a classical lobule, I call it classical lobule of liver. In entire liver, we have millions of classical lobule, okay. At the center of each lobule, there is a hepatic vein also known as Central vein and at the corners there are portal triad, each portal triad have a hepatic artery, a portal vein and a bile duct. I mean a branch of hepatic artery. a branch of portal vein. and a branch of Bile duct. Connecting between the central vein and the portal triad is the cords of hepatocytes, I want you to appreciate the cords of hepatocytes. Can you appreciate the cords of hepatocytes? - here these are the cords of hepatocytes, these are the cords of hepatocytes. Between two adjacent cords of hepatocytes are the sinusoids, So appreciate the sinusoids. The sinusoids are the blood capillaries, which are lined by endothelial cells and Interspersed Kupffer cells. So you can see it same here, see the central artery, see the portal Triads, see the cords of hepatocytes 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 hepatocytes connecting them, appreciate these are the cords of hepatocytes I'm talking. These are the cords of hepatocytes, I'm talking here connection okay. Now we divide the liver 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, that is the central vein, So branch of the central vein is present at the center 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 lobule and the remaining three things, that is hepatic artery, portal vein and Bile duct, their branches are present at the periphery. The branches are present at the periphery, forming the portal Triad. 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 hepatocytes. Okay, This is a cord of hepatocytes, connecting the central vein and the portal Triad. This is another cord of hepatocytes, another train of hepatocytes, okay again connecting the central vein (hepatic vein) and the portal Triad, okay. And between the two cords, there is a sinusoid, So let's draw a sinusoid, the sinusoids is a blood capillary. I will call it sinusoid, it is lined by endothelial cell. So let's draw the endothelial cell and few interspersed kupffer cells, So let me draw a few interspersed kupffer cells also, please understand, Okay this is kupffer cells. Now there is a space, can you see a space. I'm talking about a space between the cords of hepatocytes and the sinusoids. 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 disse, this space is known as space of disse, please learn. And it contains a special cell, this space contain a special cell, that cell is known as ITO CELL, normally ito cell are fat storing cell, they store fat and they are required for vitamin A synthesis, the ito cell, but whenever the hepatocytes are injured due to any injurious agent, the injurious agent can be alcohol, can be excess of iron in hemochromatosis, can be excess of copper in Wilson's disease, can be anything. Can be bile, can be a virus, I'm teaching you hepatitis, So it can be a virus. So at that time the ito cell get stimulated, ito cell converted into myofibroblast and it start forming collagen. Collagen means fibrosis, So ito cells are responsible for fibrosis, they form collagen and they form the fibrosis. Ito cell convert into myofibroblast, Whenever there is a injury to the hepatocytes, especially with any agent. So currently I'm teaching you viral hepatitis, So injury will be with the viruses - Hepatitis A,B,C,D,E. So that is the thing and that leads to Cirrhosis. So this is the normal anatomy of the liver, 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 6, okay. Now these are the cords of hepatocytes we are talking about, okay. Now let me Zoom it, here you can see this is the, this is one of the train, these are the cords of hepatocytes. This is another train, I'm in another cord of hepatocytes, between the two cords of hepatocytes, I want you to notice, the sinusoid. So this is a sinusoid, see the lining of the sinusoid, this is endothelial cell and I want you to appreciate interspersed kupffer cell also. Now I want you to appreciate the space, the space of Disse, So where is the space of Disse, I'm talking about this space, this space is space of Disse and it contain a special cell which is known as ito cell. So notice ito cell here. So that's all about it, now let's start the topic viral hepatitis, 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 hepatitis, no need to write down all these, Bla.. bla.. 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, hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus, the five viruses belong to different families. I will let you know their families also. Okay, these are different viruses, they affect the liver and they cause injury to the liver and that is known as hepatitis. So since the viruses are causing the injury to the liver, it is known as viral hepatitis. We have already seen the anatomy of the liver, the classical lobular model of the liver, now it will be very easy to understand how does the virus attack the liver 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 hepatitis, hepatitis A virus causing hepatitis A, hepatitis B virus causing hepatitis B, hepatitis C virus causing hepatitis 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 hepatitis A,B,C,D,E. So among them Hepatitis B virus is a DNA virus and rest all are RNA. So hepatitis A virus, hepatitis C virus, hepatitis D virus and hepatitis E virus, they all are RNA only. One among them that is B, Hepatitis B virus is a DNA virus, So please learn. So the same thing is highlighted hepatitis B virus is a DNA virus and rest all are RNA, RNA, RNA. So A,C,D,E are RNA but B is DNA. Now learn their families their families are important, So hepatitis A virus belongs to PICORNAVIRIDAE family, in the picornaviridae family it belongs to Enterovirus 72 family. Hepatitis B virus which is a DNA virus, it belongs to HEPADNAVIRIDAE family. Hepatitis C belongs to FLAVIVIRIDAE, hepatitis D, D for Delta, D for Delta, it belongs to DELTAVIRIDAE, and hepatitis E belongs to HEPEVIRIDAE, it belongs to hepeviridae, 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 E don't have envelope, but B,C,D have the envelop. So here envelope is absent in A and E but B,C,D 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 route of transmission, the route, how does they transmit? So A and E transmit by faeco - oral route; B,C,D do not transmit by faeco - oral route. What do you mean by faeco - oral route? - So faeco - oral route is seen in A and E. What do you mean by that, imagine there is a person, this person have either hepatitis A or hepatitis E, So hepatitis A and E have a property they are excreted in the faces of the person, in the stools of the person. hepatitis A virus comes in the stool, it is excreted in the stool it is shedded in the stool, E also shedded 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 hepatitis A or hepatitis E. So how the hepatitis A and E, is transmitted from one person to another, this is person A, this is person B, So how it is transmitted from A to B, what is the route? - So this route is known as Faeco - oral route. So Hepatitis A and E is transmitted by Faeco - oral route, So from faeces to oral, Faeco - oral route, this route is known as Faeco - oral route. So this Faeco - oral route is seen in hepatitis A and E, not others, this route is known as Faeco-oral route? What about the remaining three, what about Hepatitis B,C and D? What about Hepatitis B virus, C virus and D virus? How they get transmitted? They don't transmit by Faeco - oral route, because they are not shedded in the stools, So they are transmitted by three different routes. Let me show you, imagine this is person A and this is person B, now person A have either hepatitis 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 Faeco-oral route, it cannot be Faeco-oral route, because B,C,D 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 Faeco-oral transmission. But here Faeco-oral 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 needle 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 route is known as parenteral route, parenteral, the parenteral route is common needle, common syringes and the blood products, blood products and organ transplant. So that is the parenteral route, the most common route of transmission of B,C,D. The second common is the sexual, via sexual route they can be transmitted. So a person having hepatitis B,C,D can transmit the infection to another person via sexual route. But this route is very rare, it's very rare. And the third route is the vertical, what do you mean by vertical, now imagine this is a mother having B,C,D 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 B,C,D can transmit, can cross the placenta and Via placenta it can be transmitted from pregnant lady to the fetus, that route is known as vertical route. So the three routes are parenteral, sexual and vertical. So you can see the three routes are in front of you parenteral, sexual and vertical. Parenteral is most common, by parenteral I mean via blood the common needle, common syringe and the blood and blood products. The second is the sexual, which is very rare and vertical, vertical is there from, in a pregnant lady, from mother I mean the pregnant lady to the fetus via placenta. So that are the routes, okay. The routes of transmission. Now after the route 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 hepatitis A, it's 30 days, for hepatitis E it's 40 days and for hepatitis C it's 50. 30, 40, 50 days. For B, 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 hepatitis, Hepatitis A,B,C,D and E, the five type of hepatitis virus. Hepatitis A,B,C,D and E, okay. So first of all tell me the virus. the virus is DNA virus or RNA virus tell me. than 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 route of transmission, mode of transmission or route of transmission and after that you have to tell me the incubation period. So these five things we have already learnt till now and then I will continue the table ahead. Now hepatitis 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 picornaviridae family, in the picornaviridae family also it belongs to enterovirus 72. You have to learn the name, B belongs to Hepadnaviridae, C belongs to Flaviviridae, D belongs to Delta and E belongs to hepeviridae, So learn the family, that you have to learn, okay. Now what is the mode of transmission, the mode of transmission, we have seen A and E are transmitted by faeco-oral route. Before that envelop, So A and E don't have envelope, the remaining three have envelope. A and E don't have envelope, A virus and E virus don't have envelope but remaining three have the envelope. Now route of transmission, A and E is transmitted by faeco-oral route, the remaining three transmitted either by blood that is parenteral, most commonly or sexual or vertical, vertical is via placenta, transplacental. Now tell me the incubation period, the incubation period of hepatitis A 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'm teaching you Hepatitis, Hepatitis 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 hepatitis, 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 hepatitis. Now which of them present with acute hepatitis, which of them present with chronic and which of them present with fulminant. Can you tell me the answer, the most important question, which causes acute hepatitis 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 1% can convert into fulminant. So one person can convert into fulminant in all of them, in all of them fulminant can occur 1%. 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 E. So chronic occurs in B,C,D; chronicity is 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 B,C,D; okay. Chronic is never cured, it is very rare to cure chronic, but chronic can convert into three things. Chronic can convert into HCC in future, Hepatocellular Carcinoma, chronic can convert into CIRRHOSIS in future, So Cirrhosis can occur in all three, the oncogenicity that is malignancy, HCC (hepatocellular carcinoma), hepatocellular carcinoma can occur in all three, Cirrhosis 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, Cirrhosis and carrier. These things are absent in A and E, because they don't have chronic, no chronic means no carrier, no HCC, no Cirrhosis. A and E 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 Cirrhosis in future. But there is always a possibility of these three things in B,C,D. 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 hepatitis, it is present in A,B,C,D,E; in all five, the acute is present. Fulminant is also there, a rare chance, So 0.1%, 0.1%, 0.1%. here 5 - 20%, here 1 - 2%. So fulminant can also occur in all five, fulminancy in pregnancy, fulminant hepatitis in pregnancy - most common in E. What about chronicity? Now what about chronicity, chronicity never occur in A and E, as I told you chronicity can occur in B,C,D; chronicity can occur in B,C,D. Since chronicity can occur in B,C,D; three things can occur in B,C,D is carrier, oncogenicity and Cirrhosis. By oncogenicity, I mean HCC. So there is always a chance of Cirrhosis, carrier and oncogenicity in B,C,D; but these three things are never seen in A and E; because in 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 E. 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. Prophylaxis 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 hepatitis, 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 have a overview. Now it's very easy to understand now, okay. Now first of all we will see the causative 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 will revise, clinical features we already know which causes 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 E; chronic is caused by B,C,D. So this is the thing we have learnt 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 hepatitis in children is A and most common cause of acute hepatitis in adults is E, because they cause only acute they don't cause chronicity, 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, if we see percentage wise. 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 hepatitis A.. I will be discussing five type of hepatitis, let's start hepatitis A. Let's start with hepatitis A. Hepatitis A, the causative agent, it's caused by a virus - hepatitis A virus, that belongs to picornaviridae family. I have already told you. So it is RNA virus, I told you only hepatitis B is DNA, rest all are RNA. It's a RNA virus and it don't have the envelope. You can see the Symmetry is icosahedral, but the envelope is absent. The route of transmission is fecal-oral. I told you for A and E, So A is shedded in the stool, E is also shedded 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 route is known as fecal-oral route. So the most common route of transmission. here only one fecal-oral. It is not transmitted by sexual route, not by the Parenteral, blood or vertical; fecal-oral route. 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 hepatitis in children, no chronic, no carrier, no HCC, no cirrhosis. Because no chronic, no other three things, So carrier, HCC and cirrhosis will occur only if chronic occurs. So there is no chronic, no carrier, no HCC, no oncogenicity, no cirrhosis. It causes only acute, 98% recovery, 1-2% convert into fulminant, So that is the clinical course, okay, Patient present with JAUNDICE, 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 Jaundice, the parents are complaining the child is looking yellow, the skin and the sclera I mean the child is having Jaundice and child is having loss of appetite and child is having fever also. So the child is a typical case of acute hepatitis. The most common cause of acute hepatis in children is hepatitis 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 hepatitis A virus is present in the blood, So let me draw the blood vessel, this is the blood vessel of this person. So hepatitis A virus is present in the blood okay, the hepatitis A virus is shed in the stool also, So in the stool also we can find, So hepatitis 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 hepatitis A virus, IgM antibodies and IgG antibodies. IgM represent recent infection, IgG 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 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 hepatitis A virus antigen and I can test the two type of antibodies anti-IgG antibodies and anti-IgM antibodies. IGM represent recent infection and G represent past infection, I hope you got it. 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, hepatitis A virus, which is shedded in the stool. In the blood we can get the hepatitis 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-hav virus IgM or IgG. IgM represent acute infection and IgG represent past infection or recovery. And in the stools, we can get in the stools, we can get only virus not the antibody. So have a look on the graph, in the graph first virus will come, So can you see 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. 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. 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 IgG 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 hepatitis A virus will come in the blood, in the stool also. In the blood as well as stools. 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, IgG. So this is how you have to draw this graph and label it ,you can label the weeks 2,4,6; 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 causative agent it's hepatis A virus which belongs to picornaviridae 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 fecal-oral okay, incubation period is 30 days. Clinical features, it causes only acute, 98% recovery 2% fulminant, but it never causes chronic. Since there is no chronic, So no oncogenicity, no carrier, and no cirrhosis. You have to write down, it is the most common cause of acute hepatitis 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 hepatitis, hepatitis B. So let's start hepatitis 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 gadget. So let's start it will become easy, for you just concentrate for few minutes, okay. Hepatis B, causative agent it's a virus, it's a virus belong to hepadnaviridae, 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 Dane 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 fecal-oral route; but B,C,D get transmitted by three routes, I told you now if a person have B or C or D it is transmitted by three route number one the parenteral route, parenteral is by Blood product or common syringes, common syringe, common needle. So if a person has Hepatitis B, you are using a syringe or needle and the same syringe, needle you are using in another person; So that infection can be transmitted, if you're transmitting the blood of a person 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 route, that vertical route is also known as perinatal route. So these are the three routes we have seen this is Parenteral, this is sexual, this is perinatal or vertical. Incubation period we can learn here, it is, you can learn 60 to 90 days is the average, okay. Average is 60 to 90, we have already learned the incubation period. Now 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 HCC, that is oncogenicity and it can lead to cirrhosis also okay. So there are three fates. 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 cirrhosis or hepatocellular carcinoma. Recovery is very rare in chronic. Once The Chronic occurs, either the person dies, person ultimately dies, either the person dies with cirrhosis or the person dies with HCC, if the person has chronic. But if the person has acute, recovery is very common, okay. So recovery occurs 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 1-2% recover, but either they convert into HCC or they convert into cirrhosis and ultimate fate is death, So that is The Chronic. So you have to draw this percentage wise okay, percentage are important. So that is the clinical course, most important thing in hepatis B virus, 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 hepatitis B virus, Hepatitis B virus have three antigens on them, please concentrate. What are the three antigen? the first antigen is Hepatitis s antigen, s for surface, Hepatitis s antigen, Hepatitis s antigen, s for surface, s for surface, because it is present on the surface. Second is hepatitis e antigen, e for envelope, hepatitis 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 antigens, what are the three antigens, s for surface, e for envelope and c for core. The three antigens are there, please learn that three antigens. Now imagine, this virus enters someone's body. So this is the blood vessel of a human being in which this virus has 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 anti s, okay. Against the s, the body form anti s. You will say very simple to learn. Against the e body form anti e. 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 core, because it is deep inside the core, 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 we said to c, that don't worry, if you're not coming in the blood it's okay; we will form your two antibodies. So it is 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 types anti c of two type IgM and IgG. So IgM and IgG are the two types of anti c. So total four antibodies are there. one is anti s, it don't have any further type. One is anti s, one is anti e, it don't have any further type and one is anti-c. Anti c is of two type IgM and IgG. So if you take the blood sample in a test tube. we have 2 ANTIGENS and 4 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 hepatitis e antigen, e for envelope. And the third antigen is present deep inside that is Hepatitis c antigen, c for core, Hepatitis 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 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 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 anti HBS, against e body form an HBE, against 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, I mean not leak in the blood, the body will form four antibodies. So anti Hbs is formed, anti Hbe is formed and two types of anti Hbc is formed that IgM and IgG. So four type of antibodies. So two antigens - see the yellow; four antibodies - see the green, these are known as serological markers of hepatitis 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 are leaking, So s leaks first, first s come in the blood and then 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. Let's talk about antibody, Now body 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 IgG. 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 Anti c, but there are two type of anti c, So this one is IgM, IgM anti c, okay. Then the antibody is formed for e okay, anti e; then the antibody is formed again for c but this time it's IgG. And lastly the antibody is formed for s that is Anti s. 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 which come. So these are the MCQs, the first antigen is s, the last is e, because there are only two antigens 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 antibody 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 the 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, c, s; the first c is IgM obviously and then the next c is IgG obviously. So c, e, c, s; you can learn a mnemonic, if you wish, if you're getting confused. So that is a sequence, 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 relevance 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 Pair. So in this s pair, the s antigen and s antibody, they never come together; if antigen is present antibody will be absent, if antibody is present antigen will be absent. They are mutually exclusive. please learn s 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 antibody is 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 s in our blood, okay. Antibody of s they are protective in nature, okay. So that is the thing. So that is the first pair. Coming on the second pair, the second pair 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 communicability, okay. And e antibody represent low infectivity, infectivity is the tendency to infect others. Imagine, I am doing Some procedure on a patient okay, I'm taking a blood sample, I'm operating, I'm doing Some procedure on a patient and I'm using scalpel okay, and 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. Or I'm giving an injection to a patient, the same needle prick I got by mistake and I got afraid, I got scared and I checked the profile of that patient after that. And I found, oh my God this patient is 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 parenteral 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 communicability 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 infectivity. Infectivity is the tendency to infect others, So that indicates 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 antibodies, but there are two antibodies. So what does IgM represent, what does IgG represent, both of them are anti c. 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 got the point. So s antigen and antibody, what does they represent, what does they represent; e antigen and antibody, what does they represent what does they represent; and c for c we don't have antigen, we have only 2 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 the relevance. What about e, e antigen 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 e, then again anti c but this time it's IgG and then anti s. So I told you a pneumonic to learn c,e,c,s ; that is for antibodies. And among the antigen, it's s for followed 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 e. 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. 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, anti c, that is IgM, So this is IgM anti c okay, you can see this is IgM anti c. After that; So this is IgM anti c which is shown by red color. Then anti e is coming. So let me show you the anti e; anti e is shown by this; the next is the anti e, can you see this is anti e. Then IgG anti c is coming, So this one is IgG anti c, this one is IgG anti c, okay. And last one is anti s, anti s. So this one is anti s. So last two will never go back. they will never touch the base line. So anti s will remain forever and IgG 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 Hbe like this. So these are my two antigens, this one is Hbs antigen and this one is Hbe 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 antibody coming is anti c IgM, that is the first; the second which is coming is anti e okay; the third one which is coming is IgG anti c, that will never go back and last one which is coming is anti Hbs, which will never go back. So this is how I will draw and I can label it. This one is anti c but this one is IgM; this one is anti e; this one is anti c, but this one is IgG, that's why never going back; and this one is anti s. You can 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 sequence 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 has the infection; if antibody 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 has 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 MCQs 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 has antigen. So see antibody is IgM or IgG. So see here in the first, all of these the s antigen is present, antibodies absent; but in the last one antibody 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 anti hbc antibody I mean c 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 based on one marker. So acute infection of high infectivity or acute infection of low infectivity, chronic infection of high infectivity or chronic 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 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 revise Hepatitis B, Hepatitis B the causative agent is Hepatitis B virus that belongs to hepadnaviridae, 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 Hepatitis s antigen, Hepatitis e antigen and Hepatitis 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 parenteral route or sexual route or vertical route. 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 cirrhosis 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 lab diagnosis. In the lab diagnosis I want you to write about the 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,D,E okay. So C, first we will see C. C is caused by Hepatitis C virus, it belongs to family Flaviviridae, it belongs to virus Flaviviridae. 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; B,C,D 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, NS3, NS4. Many NS antigens okay, 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 parenteral route, what do you mean by parenteral - either by Blood transmission or common needle or common syringe. It can be transmitted by sexual route from infected male partner or female partner to the another sexual partner and by vertical or perinatal route via placenta from infected pregnant lady to her to her fetus. Incubation period on an average is 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 manifestations. It can cause mixed cryoglobulinemia, it can cause glomerular nephritis and arthritis and joint pain. So it can involve other organs also apart from Liver, 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, 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 NS5, against NS5. I told you NS5 protein is present in the virus. Now the second generation is against C33 against C33 or C200, that is Core protein. And first generation is against C100, C100. 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 C200 and first generation is C100. So in the C, there is C200 also, C100 also So there is 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 Hepatitis 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 Deltaviridae, D for Delta, D for Delta, but it's a defective virus, D for defective. So learn 2 D, D for Delta, D for defective. Delta is the family, but what is the defect. 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, 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 Hepatitis B virus, D cannot cause Hepatitis without B. So if D enters alone in Someone's body, D cannot cause the Hepatitis. But if D enters along with B then it can cause Hepatitis, 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 Hepatitis 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 Hepatitis B antigen, which is derived by Hepatitis B virus, that's why it's defective. So it requires the antigen which is derived by B, Hepatitis B s antigen, s for surface. So this antigen is given by the B virus and then only it can cause Hepatitis. Only D antigen cannot cause the hepatitis, So that is the defect. Mode of transmission are same three, it can be transmitted by parenteral route, that is blood products and common needle, common syringe, it can be transmitted via sexual route and it can be transmitted by vertical or perinatal 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 SUPERINFECTION. What do you mean by that, I told you it always require B, D alone cannot cause Hepatitis. If D is present with B, in the liver, both are present then only they cause Hepatitis, if B alone is present it can cause Hepatitis 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 B. 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 Coinfection 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, which don't have anything in the liver, absolutely healthy. So B and D 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 hepatitis okay. So B and D enter together, B also come together, D also come together, So either both of them are coming by parenteral 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 Hepatitis. But see the second possibility, the person is already a carrier of B. I told you now in B there are 5% carriers. 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 liver both are present and they cause the Hepatitis. 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 superinfection? Yes it matters, the percentage of acute and chronic, if they're entering together, I mean if there is co infection, if there is co infection; So 90% have acute hepatitis 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 10% will have acute and 10% will have fulminant, 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 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, 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 5%, 5%, So here this is the best one, So 90% will recover, but these 10% will not recover. In hepatitis, 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 the 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 the acute infection, So it's a Co-infection. But if the antibodies against B are IgG type, IgG 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 D is present in both of them, anti D, anyhow D is entering, So anti D 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 hepatitis 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 anti D (anti Hbd) 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 present in the body. So it is present since years, 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 hepatitis is - hepatitis E virus, last one hepatitis E virus. Here the causative agent is hepatitis E virus, it belongs to family hepeviridae, it is also RNA virus, okay. It is non- enveloped; A and E are non enveloped, rest all are enveloped okay. And only B is DNA, rest all are RNA, it's RNA virus, it is transmitted by fecal-oral route, 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 route is known as fecal-oral route. So fecal-oral route is seen in A and E. Currently I'm teaching you E, So fecal-oral route. And average incubation period is 40 days okay. Clinical features, it causes only acute, no chronic; No chronic, no carrier, no HCC and no cirrhosis. 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 fulminant hepatitis, it is the MOST COMMON CAUSE of FULMINANT HEPATITIS, especially IN PREGNANT ladies. In pregnant ladies there is high risk of fulminant hepatitis caused by hepatitis E, 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 causative agent of each of them, you know the morphology of the virus. Mode of transmission in A and E is fecal-oral, in the remaining three either it's parenteral or it's sexual or it's vertical. 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 E, it is caused by B,C,D and since it is causing the chronic they can lead to carrier state also, and they can lead to HCC, and they can lead to cirrhosis also. Lab diagnosis, I have told you the antigen antibody, in all of them. Now the 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 hepatitis, acute is caused by all five. So if I do a lever biopsy in acute hepatitis, what is the morphology. And chronic is caused by only by B,C,D not by A and E. So if I do a liver biopsy in acute hepatitis, the morphology is same in all five, we do not get any difference, if it is hepatitis A or B or C or D or E; if it is acute the morphology is 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 is same. So I want you to learn two diagrams, one of acute hepatitis microscopy and one of chronic hepatitis 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 diagram, 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 E. So let's see the diagram of acute, can you see the diagram of acute hepatitis. So acute hepatitis 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 hepatitis 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,C,D,E, that is my point. So in the diagram you have to show the, you have to show, this thing; I mean classical lobule, in the classical lobule there is a central vein at the center and there are portal triads, there are six portal Triads. 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 vein, and at one of the diagonal you will get portal triad; connecting them see the Cords of hepatocytes. Now in the Cords of hepatocytes, I want to show you four things. Now Some of the hepatocytes show BALLON DEGENERATION, Some of the hepatocytes, let me highlight can you see this hepatocyte, 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 COUNCILMAN BODY, So in the cytoplasm dark pink color is there and no nucleus, pycnotic nucleus, no nucleus these are Councilman bodies. So Some of them randomly show Councilman body. Some of them show balloon degeneration, Some of them show, Some of them show Councilman 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 hepatocytes, the complete train of the hepatocytes, 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 hepatocellular injury; you have to draw the inflammatory infiltrate everywhere, especially in the portal triad. In the portal triad the three things you can see, where is the artery, vein and, I mean hepatic artery, this is the hepatic artery, this is portal vein, this is Bile duct, 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 kupffer cell hyperplasia. So can you see few kupffer cells. Between two rows of hepatocytes, we have sinusoids and sinusoids are lined by endothelial cells and interspersed kupffer cell. So these are the kupffer cells, can you see kupffer cells. We can see many places, kupffer 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 acute. At one diagonal I will draw Central vein or hepatic vein at another diagonal I will draw the portal triad, in the portal triad, I will show you three things hepatic artery, portal vein and bile duct. Connecting them I will show you the Cords of hepatocytes. So these are the cords of hepatocytes, connecting them can you see the cords of hepatocytes, these are the hepatocytes, connecting them these are the Cords of hepatocytes. 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 Councilman body. In Some of them I will show Dropout necrosis. And in Some of them I will show bridging necrosis. I want to show 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 cytoplasm, I will just swell them using cytoplasm and I label them as balloon degeneration, okay; you have to draw like this. In Some 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 Councilman bodies, Councilman bodies number two. In Some of them, I draw the only outline, no nucleus nothing only outline and I label them as Dropout necrosis. And in Some of them, I will draw the complete rows necrosis and I will label them as bridging necrosis. 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 kupffer cells hyperplasia at many places, you can draw the kupffer cells between the rows of hepatocytes and label it kupffer cell hyperplasia, 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 Councilman 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 hepatitis, So chronic hepatitis is seen in hepatitis B, C, D. A and E don't have chronicity. So in your exam whether you are getting the question on chronic B hepatitis, chronic C or chronic D; the diagram is same, 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, C, D okay. The diagram is same okay. You have to understand the normal lobule, in a normal lobule there is a central vein at the center and there are six portal triads. 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 vein, one of them is Bile duct; So this is a portal triad. And this is the cords of hepatocytes connecting them these are the cords of hepatocytes connecting them. Here in the lobule also see the cords of hepatocytes connecting them. Can you see this is the first train, this is the second train, this is the third train. Actually the two cords, I call them trains; because they have Bogies, one behind the other, where is the engine where is the engine, the engine I mean the first hepatocyte of all of them, So this is this the first, first hepatocyte 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 hepatocyte 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 hepatocyte. 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. Hepatic artery, portal vein and bile duct and we can see cords of hepatocytes connecting them okay and the first hepatocyte 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. 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 cords of hepatocytes 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, can you see limiting plate there; say no mam, 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 PIECEMEAL NECROSIS. There are two changes in the limiting plate; first it get necrosed, it get necrosed, it is known as piecemeal 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 piecemeal necrosis and instead of that I can see the inflammation there. So 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 piecemeal necrosis and in place of that I'm having inflammation that is 'itis', hepatitis, interface means 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 piecemeal 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 piecemeal necrosis, it is gone and instead of that there are lymphocytes that is interface hepatitis. So learn the two things limiting plate, limiting plate means two things, there are two things; in the limiting plate what are the two things piecemeal necrosis and interface hepatitis. I will draw it for you okay, please understand. Now second thing, see the portal Triad, portal track. Have a look on 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 things; this is artery, this is vein, this is bile duct. Here you can see; this is artery okay, one artery, here this is vein okay, one vein, but there are many bile ducts, Oh my God. This is, this is, this is, this is.. many bile duct. So first thing is BILE DUCT PROLIFERATION, So we have many bile ducts. Artery is still one, portal vein is still one, but bile 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 TRIADITIS, itis is the inflammation, itis. Triaditis, inflammation in the portal triad; triaditis - inflammation in 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 piecemeal necrosis and interface hepatitis. And what are the two things in the portal triad; bile duct proliferation and triaditis, inflammation of the portal triad. So learn the catchy words, learn two things in the limiting plate and two things in the portal triad. And learn two things in the cords of hepatocytes, here see the cords of hepatocytes are normal, here some of them show COUNCILMAN BODIES. It is not shown here, but some of them show the dark eosinophilic body that is Councilman body or acidophilic body in some of them, you can show. So Some of them show Councilman bodies and KUPFFER CELL HYPERPLASIA, Kupffer cell hyperplasia. Now the most important feature here, is 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 hepatocytes is gone and it is necrosed, that is bridging necrosis. So here also we have bridging necrosis like acute, and chronic also but here bridging fibrosis is something unique which is present only in chronic hepatitis, not in acute hepatitis. So there are three type, can you see a lobule, there are three type of bridging fibrosis. There are many lobules in the liver, in the liver there are millions of lobules. So if the fibrosis is occurring from one Central vein to other, So all the hepatocytes between one Central vein to another are necrosed or fibrosed, all the hepatocytes 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, any 2 portal triads, any 2 portal triads; they are fibrosed, this is known as porto-portal, this is known as porto-portal. So we have Centro-Central, porto-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 centro-portal. So I mean to say there are three type of fibrosis, Centro-Central, porto-portal and centro-portal. Centro-Central is between two Central vein, see the blue color, between any two Central vein. Porto-portal means any two portal triads, see the red color and centro-portal is one Central vein and one portal triad, see the green color. You can use different colors, So you there are three type of fibroses. So all the hepatocytes 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 centro-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 hepatitis? How you will draw it, can I draw it, can I try to draw it. The Chronic hepatitis, 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 hepatocytes connecting them, at least I will draw 3-4 rows to show you the changes. I will draw 2-3 rows to show you the changes like this, this is the diagram. I'm trying to draw, this is a normal diagram. The first hepatocytes 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 piecemeal necrosis and I will do inflammation here that is known as interface hepatitis okay, interface hepatitis. So I will just disappear these hepatocytes and instead of this first, first, first hepatocytes there, instead of this first, first, first, hepatocytes, I will draw, I will draw the lymphocytes there, I will draw the inflammation lymphocytes and interface hepatitis. 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 triaditis, inflammation the in the portal triad. Now I will show two changes in the hepatocytes; number one, some of them, some of them show Councilman 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 kupffer cell hyperplasia here and there, kupffer cell hyperplasia. So number two I will show kupffer 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 types, Centro-Central, porto-portal, Centro-portal. That's all about it. All the things I have labelled, 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. 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