[...] [The United States Army presents FG 8-6, MCMLII] [Viral Hepatitis] [Music fades] [Narrator:] Throughout the course of the military history of all nations, epidemics of jaundice have occurred. [...] The Revolutionary War, the Civil War, the Franco-Prussian War, the Boer War, in World War I, in World War II, in all armies, East and West, throughout the world. [...] Research in World War II developed for the first time an understanding of the epidemiology of viral hepatitis. [Epidemiology] [...] Viral hepatitis is a generalized infection involving the entire body but producing its outstanding manifestations by damaging the liver. [...] The infecting virus has two forms, IH and SH. The IH virus causes epidemic hepatitis. [...] Endemic hepatitis has a seasonal distribution. [...] In civil life, epidemic hepatitis is more common in the younger age groups, especially between the ages of eight and fourteen. In the armed forces, it is also more common in the younger age groups. [...] Both the IH and the SH virus may cause homologous serum hepatitis. The SH virus is the more common etiologic agent. Infection is due to the presence of these viruses in needles and syringes and blood products. There is no seasonal variation. [...] Periods of increased use of blood and blood products cause peaks of incidents. The two viruses cause essentially the same clinical and pathologic pictures with one major difference, the length of the incubation period. For the IH virus, it is 15 to 35 days to the appearance of jaundice. [...] And for the SH virus, 50 to 140 days to the appearance of jaundice. [...] Active infection with either IH or SH virus seems to produce immunity to that particular virus. Cross immunity does not exist. Previous infection with IH virus will not prevent a later SH infection. [...] Conversely, previous SH infection will not prevent IH infection. [...] Transmission of the disease occurs from both active cases and asymptomatic carriers. Only blood and feces have been proved infectious. [...] No insect vector or animal host has been found that will maintain or pass the virus. [...] The possibility of transmission by other means cannot be excluded. [...] Feces may contain the IH virus. Fecal contamination of the water supply is not controlled by routine chemical water purification. [...] Poor personal hygiene in troops, especially in food handlers, may lead to foodborne epidemics. [...] Blood may contain either the IH or the SH virus. Homologous serum hepatitis results from the use of virus-contaminated blood and equipment. As little as 1/100 of a cc of blood or tissue fluid may contaminate a syringe. Inadequate sterilization of syringes and other instruments or the use of the multiple dose syringe will spread the virus. [...] Contaminated blood rarely comes from jaundiced donors but rather from asymptomatic carriers. The incidence of infection from whole blood is less than 1%. [...] Because of pooling of plasma from many donors during processing, the incidence of infection from plasmais seven to 20%. [...] [The Clinical Story] [...] During World War II, several hundred thousand cases of viral hepatitis were reported. A classical picture is now recognized. The most common early symptom is anorexia. [...] Inflammation in both the liver and the gastrointestinal tract may explain the abdominal discomfort and vomiting after meals. [...] Headache is often a prominent symptom. Mild chills and fever are the rule. There is often a definite photophobia. [Bilirubinuria] The first specific sign of liver damage is dark urine due to the presence of bilirubin. The pre-icteric phase, lasting seven to ten days, is followed by the appearance of scleral and generalized jaundice. [...] Physical examination may show no jaundice in the prodromal stage of hepatitis. In some cases, it never appears. Conjunctivitis is seen in the early stages. It may be associated with orbital pain and pain on motion of the eyes. The lymph glands are involved early. [...] In the absence of jaundice, the most reliable sign of hepatitis is hepatic tenderness either to palpation, or to fist percussion over the right lower chest. Sometimes, hepatic tenderness is the only definite finding. [...] Splenomegaly may be present in early hepatitis. The non-specific symptoms and signs tend to disappear shortly after jaundice appears. If the history and physical findings suggest hepatitis, the patient should be hospitalized. [...] Laboratory findings confirm the diagnosis. The test for bilirubin in the urine is easily performed, and is frequently the first definite indication of hepatic abnormality. [...] To confirm the diagnosis of hepatitis, the thymol turbidity and cephalin-cholesterol flocculation tests are essential. [...] [Thymol turbidity 13.0 units elevated, liver function] [Cephalin flocculation, ++++, liver function] Serum bilirubin determinations may be used to follow the progression and regression of jaundice. [Serum bilirubin, one minute 2.5 mg., total 7.4 mg., elevated, liver function] [...] Strict bed rest should be instituted at once and maintained. This may include bathroom privileges for bowel movements only. [...] Therapy should include a well-balanced, high caloric diet. Fat restriction is not indicated in hepatitis. [...] If food intake is satisfactory, dietary supplements such as choline or methionine are not necessary. Vitamins may be given. [...] Bed rest should be maintained for at least four weeks or until the serum bilirubin falls to normal. [...] After the serum bilirubin reaches normal, gradual ambulation of the patient is started. [...] Supervised ambulation should allow not more than four hours out of bed at the start. The time is gradually increased in the second and third weeks. [...] If ambulation produces clinical or laboratory evidence of relapse, the patient should be put back to bed. [...] A normal bromsulfalein dye excretion test is an important criterion for return to duty. [...] A period of fairly strenuous reconditioning may be advisable before return to duty. [...] The histologic changes of acute hepatitis have been studied in biopsy and post-mortem material. Here is a diagram of a normal liver cord and portal area. [...] In acute hepatitis, one of the earliest findings is a diffuse cellular infiltration. [...] There may be marked cellular necrosis and condensation of the hepatic parenchyma. The clinical severity of the disease may not parallel the histologic severity. Necrosis is followed by cell regeneration. Nuclear changes and variations in cell size and staining occur early and may persist after clinical recovery. [...] Viral hepatitis may occur with or without jaundice. Hepatitis with jaundice may be confused with obstructive jaundice, hemolytic jaundice, infectious mononucleosis, cirrhosis, metastatic carcinoma in the liver, toxic hepatitis, Weil's disease, and amoebic hepatitis. These diseases must be ruled out. [...] From a practical point of view, the most common problem in differential diagnosis is the exclusion of obstructive jaundice. [...] This is most commonly caused by an impacted gallstone in the common bile duct. [...] Many other lesions may produce obstructive jaundice, for example, carcinoma of the head of the pancreas. Obstructive jaundice is ruled out by history, positive flocculation and turbidity tests, normal or borderline alkaline phosphatase, negative X-ray findings, and liver biopsy. [...] Excessive breakdown of red blood cells causes anemia and jaundice. [...] Hemolytic jaundice is ruled out by lack of anemia, normal test for hemolysis, the presence of bile in the urine, and normal fecal urobilinogen. [...] Infectious mononucleosis with jaundice has many features in common with viral hepatitis. [...] Infectious mononucleosis is ruled out by a normal heterophile antibody titer. [...] An episode of hepatic failure and cirrhosis of the liver may resemble acute hepatitis. [...] Cirrhosis may be ruled out by the lack of a history of alcoholism or malnutrition, but liver biopsy may be the only means of making this distinction. [...] Metastatic carcinoma within the liver may produce jaundice. [...] This is ruled out by the lack of a primary lesion and by liver biopsy. [...] Toxic hepatitis may be produced by various chemicals, especially carbon tetrachloride. [...] It may be ruled out when there is no history of exposure and the flocculation and turbidity tests are markedly positive. [Weil's disease] Leptospiral infections may cause jaundice but are ruled out by the absence of leptospira in blood or urine. [...] Jaundice may be present in amebiasis of the liver. [...] Amebic hepatitis is ruled out when amebae are absent or when there is no response to specific treatment. [...] In summary, each of these diseases has differentiating characteristics which permit its exclusion. [...] Hepatitis without jaundice, because of its systemic and gastrointestinal manifestations, must be considered in the diagnosis of many conditions of acute onset. [...] The systemic manifestations include chills, fever, malaise, and headache. The gastrointestinal manifestations are anorexia, nausea, vomiting, diarrhea, and abdominal pain. In a patient with any of these symptoms, hepatitis should be considered. [Enlarged tender liver] [...] An enlarged, tender liver and positive liver function test establish the diagnosis of hepatitis without jaundice. [...] The importance of the disease to the Army lies in the duration of the illness. [...] The average case is disabled for twelve weeks. Attempts to hasten this process may result in acute relapse. This is frequently caused by premature overactivity, ingestion of alcohol, and in some cases, the cause of the relapse remains unknown. Hepatitis persisting more than six months is considered chronic hepatitis. Cases of chronic hepatitis often have a history of inadequate treatment during the acute phase. [...] The most common symptoms are anorexia, weakness, easy fatiguability, and upper abdominal discomfort. Physical signs may include an enlarged, tender liver, splenomegaly, and spider nevi. Liver function tests may be positive. Liver biopsy is necessary to establish the diagnosis. The histologic picture is that of continuing inflammatory and regenerative changes. [...] In a few cases, the appearance of bile duct proliferation and fibrosis suggest the development of cirrhosis. The treatment of chronic hepatitis is discouraging. It involves prolonged periods of bedrest, continued dietary therapy, and abstinence from alcohol. [...] There is indication that Aureomycin is beneficial in some cases. Many cases of chronic hepatitis will recover eventually. The outcome in others is unknown. [...] [Prognosis] The prognosis of acute hepatitis is good. Only a fraction of one percent of patients die during the acute stage. About two percent have persistent chronic hepatitis at the end of a year. [...] The rest recover completely. [...] Viral hepatitis is a common disease in the Army. Diagnosis is seldom difficult if the possibility is considered. [...] The disease is self-limited; the course is prolonged. There is no specific treatment. Bed rest must be maintained until evidence of active disease has subsided. Strict adherence to this regimen will decrease the incidence of acute relapse and the development of chronic hepatitis. [Music] [The End, FG 8-6, MCMLII]