2. IMMUNE MEDIATED
LIVER DISEASES AND
VIRAL HEPATITIS
Speakers :
• Ammara Farouqi
• Anam Hassan

3. IMMUNE-MEDIATED DISEASES
Immune-mediated diseases are conditions which result from
abnormal activity of the body's immune system.
Autoimmune diseases are a subset of immune-mediated diseases.
Autoimmune liver diseases (AILDs) Autoimmune liver diseases
(AILDs) are common leading causes for liver cirrhosis and terminal
stage of liver disease.
Primary biliary cirrhosis, primary sclerosing cholangitis and
autoimmune hepatitis are the three major immune-mediated
liver diseases.

4. AUTOIMMUNE HEPATITIS
Characterized by continuing hepatocellular inflammation and
necrosis, tending to progress to cirrhosis.
The disease often is associated with other autoimmune diseases.
It is associated with other autoimmune diseases.

5. TYPES OF AUTOIMMUNE HEPATITIS:
1. TYPE 1 :
most common
occur at any age but most often starts in young
adulthood
associated with other autoimmune disorders
like type 1 diabetes, proliferative
glomerulonephritis, thyroiditis and ulcerative
colitis.
2. TYPE 2 :
less common
typically affecting girls aged 2 to 14

6. SYMPTOMS OF
AUTOIMMUNE HEPATITIS:
1. Fatigue
2. an enlarged liver
3. jaundice
4. itching
5. skin rashes
6. joint pain
7. abdominal discomfort
8. spider angiomas, or abnormal blood
vessels, on the skin
9. nausea
10. vomiting
11. loss of appetite
12. dark urine
13. pale or gray-colored stools

7. DIAGNOSIS :
1. Blood tests
2. Liver Biopsy
TREATMENT:
1. Corticosteroids
2. Immunosuppressant Therapy
3. Liver transplantation

8. PREDNISOLONE
. Prednisolone is a synthetic adrenal corticosteroid
Corticosteroids have potent anti-inflammatory
properties, and are used in inflammatory conditions such as
arthritis, asthma, bronchitis, certain skin rashes, hepatitis and
allergic or inflammatory conditions of the nose and eyes.
1. weight gain
2. anxiety and confusion
3. thinning of the bones, a condition called
osteoporosis
4. thinning of the hair and skin
5. diabetes
6. high blood pressure
7. cataracts
8. glaucoma

9. CONTRAINDICATIONS:
1. peptic ulcer
2. Lactation
3. Osteoporosis
4. Diabetes
5. hypertension

10. AZATHIOPRINE
Azathioprine is an Immunosuppressant.
Prodrug (a precursor of a drug) which is converted in the body to
its active form called mercaptopurine (Purinethol).
It suppresses the proliferation of T and B lymphocytes and defend
the body against both infectious diseases & foreign materials.
Azathioprine is found in breast milk.
SIDE EFFECTS:
1. Lowering of the white blood cell count
2. cause nausea, vomiting, and loss of appetite
3. cause liver toxicity
4. fatigue, hair loss, joint pains, and diarrhea

11. CONTRAINDICATION:
1. Not given to Hypersensitive
patients
2. Not given to pregnant women

12. PRIMARY BILIARY CIRRHOSIS
Irritation and swelling (inflammation) of the bile ducts of
the liver leading to cirrhosis.
Characterized by positive antimitochondrial antibody
Its cause is still unknown.
Commonly affects middle-aged women
It is associated with autoimmune disorders such as
Hypothyroidism and Sicca syndrome (dry eyes or
mouth)

13. SYMPTOMS:
1. Abdominal pain
2. Enlarged liver
3. Fatigue
4. Fatty deposits under the
skin
5. Fatty stools
6. Itching
7. Jaundice
8. Soft yellow spots on the
eyelid

14. DIAGNOSIS:
1. Elevated immunoglobulin M level
in the blood
2. Liver biopsy
3. Anti-mitochondrial antibodies
(results are positive in about 95%
of cases)
4. ultrasound imaging of the liver,
TREATMENT:
1. Medicines
2. Vitamin Replacement
Therapy
3. Liver transplant
4. AMA Test

15. CHOLESTRAMINE OR
COLISTEPOL
It reduces Cholestrol level.
It cures itching which is in some cases is a result of
of accumulation of bile acids in the skin.
It ease the elimination of bile acids from the body
and skin.
SIDE EFFECTS:
1. constipation
2. bloating
3. stomach pain
4. gas
5. upset stomach
6. vomiting
7. diarrhea
8. loss of appetite
9. heartburn
10. indigestion

16. CONTRAINDICATION:
•Hypersensitivity can cause complete biliary obstruction.
•Renal impairment
•Constipation

17. URSODEOXYCHOLIC
ACID:
It is one of the secondary bile acids, which
are metabolic byproducts of intestinal
bacteria.
Ursodiol dissolve gallstones in patients
who avoid surgery.
Also prevent formation of gallstone by
decreasing the production of cholesterol.
SIDE EFFECTS:
1. diarrhea
2. constipation
3. indigestion
4. dizziness
5. vomiting
6. sore throat
7. Cough with runny nose
8. muscle and joint pain
9. hair loss

18. CONTRAINDICATIONS:
acute inflammation of the gall bladder
impaired contract ability of the gall bladder
hypersensitivity to bile acids
pregnant or breastfeeding
chronic liver disease, peptic ulcers or in those with
inflammatory diseases of the small intestine and colon.

19. PRIMARY
SCLEROSING
CHOLANGITIS
chronic and progressive
disease of the bile ducts.
infection in the bile ducts that
leads to cirrhosis and liver
failure.
It can occur alone as well as in
association with Crohn's
disease (Inflammatory Bowel
Disease).

20. SYMPTOMS:
1. Fatigue
2. Itching
3. Yellowing of the skin and eyes
(jaundice
4. Enlarged liver
5. Enlarged spleen
6. Loss of appetite and weight loss
7. Repeat episodes of cholangitis.
8. Abnormally elevated blood
levels of liver enzymes
9. Abdominal pain

21. DIAGNOSIS:
1. Blood Tests
2. Radiological Tests
3. Liver Biopsy
4. Colonoscopy
TREATMENT:
1. Medications such as Cholestyramine, Ursodeoxycholic acid, Fat-
soluble vitamins (D, E, A, K) and that quiet the immune sys.
(prednisone, azathioprine, cyclosporine, methotrexate)
2. Liver transplant

22. VIRAL HEPATITIS
Speakers:
• Rabia
• Sundus

23. What Is Hepatitis ?
Hepatitis (plural hepatitides ) is a medical condition defined by the
inflammation of liver and characterized by the presence of
inflammatory cells in the tissues of organ .

24. Causes Of Hepatitis:
•Drugs
•Alcohols
•Chemicals
•Auto-immune disease
•Viruses
•Blood transfusions

25. Symptoms :
. For those who do develop symptoms of viral hepatitis, the
most common are flu- like symptoms including:
• loss of appetite
• nausea
• vomiting
• Fever
• weakness
• tiredness
• aching in the abdomen
Less common symptoms include:
• dark urine
• light-colored stools
• fever
• jaundice (a yellow appearance to the skin and white portion of
the eyes)

26. Types Of Viral Hepatitis
There are several viral hepatitis caused by specific
viruses, they have been named as :
• Hepatitis A virus (HAV)
• Hepatitis B virus (HBV)
• Hepatitis C virus (HCV)
• Hepatitis D virus (HDV)
• Hepatitis E
• Hepatitis F
• Hepatitis G (not confirmed yet).

27. Hepatitis A (HAV)
At one time, hepatitis A was
referred to as "infectious
hepatitis" because it could be
spread from person to person like
other viral infections. Infection
with hepatitis A virus can be
spread through the ingestion of
food or water, especially where
unsanitary conditions allow water
or food to become contaminated
by human waste containing
hepatitis

28. Hepatitis B (HBV)
Type B hepatitis was at one time
referred to as "serum hepatitis," because
it was thought that the only way
hepatitis B virus (HBV) could spread was
through blood or serum
About 6-10% of patients with hepatitis B
develop chronic HBV infection (infection
lasting at least six months and often
years to decades) and can infect others
as long as they remain infected. Patients
with chronic hepatitis B infection also
are at risk of developing cirrhosis, liver
failure and liver cancer.

29. Hepatitis C (HCV)
Type C hepatitis was previously referred to
as "non-A, non-B hepatitis,
Patients with chronic hepatitis C infection
are at risk for developing cirrhosis, liver
failure, and liver cancer.
The hepatitis C virus (HCV) usually is
spread by shared needles among drug
abusers, blood
transfusion, hemodialysis, and needle
sticks. Approximately 90% of transfusion-
associated hepatitis is caused by hepatitis
C

30. Types D, E, F, and G
Hepatitis
There also are viral hepatitis types D, E, F (not
confirmed yet), and G. The most important of
these at present is the hepatitis D virus
(HDV), also known as the delta virus or agent. It
is a small virus that requires concomitant
infection with hepatitis B to survive. HDV
cannot survive on its own because it requires a
protein that the hepatitis B virus makes (the
envelope protein, also called surface antigen)
to enable it to infect liver cells.

31. Who Is At Risk For Viral
Hepatitis?
People who are most at risk for developing viral
hepatitis are:
• Workers in the health care professions
• People with multiple sexual partners
• Intravenous drug users
• Hemophiliacs
• Blood transfusion
• By piercing body (tattooing).

32. Tests Used to Diagnose Viral Hepatitis
• Liver enzyme tests
• Test for antibodies
• liver biopsy
A number of conditions have the same symptoms as viral hepatitis.
• Mononucleosis
• Reaction to medicines, such as birth control pills, certain antibiotics, or
acetaminophen (Tylenol®)
•Autoimmune hepatitis
•Infections caused by certain viruses, such as herpes simplex virus,
cytomegalovirus, or coxsackievirus
• Congestive heart failure
• Wilson's disease
• Liver cancer

33. How is viral hepatitis treated?
Treatment of acute viral hepatitis and chronic viral hepatitis are different.
Acute Hepatitis:
In patients with acute viral hepatitis, the initial treatment consists of relieving
the symptoms of nausea, vomiting, and abdominal pain. Careful attention
should be given to medications which can have adverse effects in patients
with abnormal liver function. Only those medications that are considered
necessary should be administered since the impaired liver is not able to
eliminate drugs normally, and drugs may accumulate in the blood and reach
toxic levels. In addition, sedatives and "tranquilizers" are avoided because
they may accentuate the effects of liver failure on the brain and
cause lethargy and coma.
It occasionally is necessary to provide intravenous fluids to
prevent dehydration caused by vomiting.

34. Medications for chronic hepatitis C infection include:
Chronic Hepatitis:
Treatment of chronic infection with hepatitis B and hepatitis C
usually involves medication or combinations of medications to
eradicate the virus.
Medications for chronic hepatitis C infection include:
• Injectable interferon
• Oral ribavirin
Medications for chronic hepatitis B infection include:
• Injectable interferon
• Oral lamivudine (epivir)
• Oral adefovir (hepsera)
• Oral entecavir (baraclude)

35. RIBAVIRIN :
Ribavirin (brand names:, Rebetol, Ribasphere, Vilona
and Virazole) is an anti-viral drug indicated for severe ,
hepatitis C infection . Ribavirin is a prodrug.
Mechanism:
ribavirin is known to enhance host T-cell-
mediated immunity against viral infection
through helping to switch the host T-cell
phenotype from type 2 to type 1.
Contraindications
Women who are pregnant or men
whose female partners are
pregnant; hypersensitivity to
ribavirin or any component of the
product.

36. Medications for chronic infection with hepatitis B and hepatitis C are not
always effective. Prolonged treatment (6 months to years) often is
necessary
Fulminant hepatitis. Treatment of acute fulminant hepatitis should be done in
centers that can perform liver transplantation since acute fulminant hepatitis has a
high mortality without liver transplantation.

37. How Is Viral Hepatitis Prevented?
Prevention of hepatitis involves measures to avoid
exposure to the viruses, using immunoglobulin in
the event of exposure, and vaccines.
Hepatitis A. Two hepatitis A vaccines are
available, Havrix andVaqta. Both contain inactive
(killed) hepatitis A virus.
For active vaccination, a harmless hepatitis B
antigen is given to stimulate the body's immune
system to produce protective antibodies against
the surface antigen of Hepatitis B. Vaccines that
are currently available are made (synthesized)
using recombinant DNA technology(joining DNA
segments
There is currently no vaccine for Hepatitis C.