WEBVTT

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[...]

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[The United States Army presents FG 8-6, MCMLII]

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[Viral Hepatitis]

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[Music fades]

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[Narrator:] Throughout the course of the military history of all nations, epidemics of jaundice have occurred.

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[...]

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The Revolutionary War, the Civil War, the Franco-Prussian War,

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the Boer War, in World War I, in World War II, in all armies,

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East and West, throughout the world.

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[...]

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Research in World War II developed for the first time

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an understanding of the epidemiology of viral hepatitis.

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[Epidemiology]

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[...]

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Viral hepatitis is a generalized infection involving the entire body

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but producing its outstanding manifestations by damaging the liver.

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[...]

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The infecting virus has two forms, IH and SH.

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The IH virus causes epidemic hepatitis.

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[...]

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Endemic hepatitis has a seasonal distribution.

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[...]

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In civil life, epidemic hepatitis

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is more common in the younger age groups, especially between the ages of eight and fourteen.

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In the armed forces, it is also more common in the younger age groups.

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[...]

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Both the IH and the SH virus may cause homologous serum hepatitis.

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The SH virus is the more common etiologic agent.

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Infection is due to the presence of these viruses in needles and syringes

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and blood products.

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There is no seasonal variation.

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[...]

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Periods of increased use of blood and blood products cause peaks of incidents.

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The two viruses cause essentially the same clinical and pathologic pictures with one major difference,

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the length of the incubation period.

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For the IH virus, it is 15 to 35 days to the appearance of jaundice.

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[...]

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And for the SH virus, 50 to 140 days to the appearance of jaundice.

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[...]

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Active infection with either IH or SH virus

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seems to produce immunity to that particular virus.

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Cross immunity does not exist.

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Previous infection with IH virus will not prevent a later SH infection.

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[...]

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Conversely, previous SH infection will not prevent IH infection.

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[...]

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Transmission of the disease occurs from both active cases and asymptomatic carriers.

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Only blood and feces have been proved infectious.

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[...]

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No insect vector or animal host has been found that will maintain or pass the virus.

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[...]

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The possibility of transmission by other means cannot be excluded.

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[...]

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Feces may contain the IH virus.

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Fecal contamination of the water supply is not controlled by routine chemical water purification.

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[...]

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Poor personal hygiene in troops, especially in food handlers,

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may lead to foodborne epidemics.

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[...]

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Blood may contain either the IH or the SH virus.

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Homologous serum hepatitis results from the use of virus-contaminated blood and equipment.

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As little as 1/100 of a cc of blood or tissue fluid may contaminate a syringe.

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Inadequate sterilization of syringes and other instruments

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or the use of the multiple dose syringe will spread the virus.

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[...]

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Contaminated blood rarely comes from jaundiced donors

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but rather from asymptomatic carriers.

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The incidence of infection from whole blood is less than 1%.

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[...]

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Because of pooling of plasma from many donors during processing,

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the incidence of infection from plasma
is seven to 20%.

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[...]

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[The Clinical Story]

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[...]

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During World War II, several hundred thousand cases of viral hepatitis were reported.

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A classical picture is now recognized.

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The most common early symptom is anorexia.

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[...]

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Inflammation in both the liver and the gastrointestinal tract

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may explain the abdominal discomfort and vomiting after meals.

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[...]

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Headache is often a prominent symptom.

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Mild chills and fever are the rule.

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There is often a definite photophobia.

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[Bilirubinuria]

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The first specific sign of liver damage is dark urine due to the presence of bilirubin.

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The pre-icteric phase, lasting seven to ten days,

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is followed by the appearance of scleral and generalized jaundice.

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[...]

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Physical examination may show no jaundice in the prodromal stage of hepatitis.

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In some cases, it never appears.

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Conjunctivitis is seen in the early stages.

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It may be associated with orbital pain and pain on motion of the eyes.

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The lymph glands are involved early.

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[...]

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In the absence of jaundice, the most reliable sign of hepatitis

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is hepatic tenderness either to palpation,

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or to fist percussion over the right lower chest.

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Sometimes, hepatic tenderness is the only definite finding.

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[...]

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Splenomegaly may be present in early hepatitis.

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The non-specific symptoms and signs tend to disappear shortly after jaundice appears.

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If the history and physical findings suggest hepatitis,

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the patient should be hospitalized.

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[...]

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Laboratory findings confirm the diagnosis.

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The test for bilirubin in the urine is easily performed,

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and is frequently the first definite indication of hepatic abnormality.

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[...]

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To confirm the diagnosis of hepatitis,

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the thymol turbidity and cephalin-cholesterol flocculation tests are essential.

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[...]

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[Thymol turbidity 13.0 units elevated, liver function]

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[Cephalin flocculation, ++++, liver function]

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Serum bilirubin determinations may be used to follow the progression and regression of jaundice.

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[Serum bilirubin, one minute 2.5 mg., total 7.4 mg., elevated, liver function]

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[...]

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Strict bed rest should be instituted at once and maintained.

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This may include bathroom privileges for bowel movements only.

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[...]

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Therapy should include a well-balanced, high caloric diet.

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Fat restriction is not indicated in hepatitis.

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[...]

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If food intake is satisfactory, dietary supplements such as choline or methionine are not necessary.

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Vitamins may be given.

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[...]

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Bed rest should be maintained for at least four weeks

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or until the serum bilirubin falls to normal.

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[...]

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After the serum bilirubin reaches normal,

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gradual ambulation of the patient is started.

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[...]

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Supervised ambulation should allow not more than four hours out of bed at the start.

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The time is gradually increased in the second and third weeks.

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[...]

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If ambulation produces clinical or laboratory evidence of relapse,

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the patient should be put back to bed.

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[...]

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A normal bromsulfalein dye excretion test is an important criterion for return to duty.

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[...]

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A period of fairly strenuous reconditioning may be advisable before return to duty.

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[...]

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The histologic changes of acute hepatitis have been studied in biopsy and post-mortem material.

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Here is a diagram of a normal liver cord and portal area.

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[...]

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In acute hepatitis, one of the earliest findings is a diffuse cellular infiltration.

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[...]

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There may be marked cellular necrosis and condensation of the hepatic parenchyma.

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The clinical severity of the disease may not parallel the histologic severity.

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Necrosis is followed by cell regeneration.

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Nuclear changes and variations in cell size and staining occur early and may persist after clinical recovery.

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[...]

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Viral hepatitis may occur with or without jaundice.

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Hepatitis with jaundice may be confused with

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obstructive jaundice, hemolytic jaundice,

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infectious mononucleosis, cirrhosis,

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metastatic carcinoma in the liver, toxic hepatitis,

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Weil's disease, and amoebic hepatitis.

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These diseases must be ruled out.

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[...]

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From a practical point of view, the most common problem in differential diagnosis is the exclusion of obstructive jaundice.

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[...]

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This is most commonly caused by an impacted gallstone in the common bile duct.

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[...]

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Many other lesions may produce obstructive jaundice,

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for example, carcinoma of the head of the pancreas.

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Obstructive jaundice is ruled out by history, positive flocculation and turbidity tests,

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normal or borderline alkaline phosphatase, negative X-ray findings, and liver biopsy.

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[...]

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Excessive breakdown of red blood cells causes anemia and jaundice.

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[...]

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Hemolytic jaundice is ruled out by lack of anemia,

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normal test for hemolysis, the presence of bile in the urine,

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and normal fecal urobilinogen.

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[...]

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Infectious mononucleosis with jaundice has many features in common with viral hepatitis.

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[...]

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Infectious mononucleosis is ruled out

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by a normal heterophile antibody titer.

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[...]

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An episode of hepatic failure and cirrhosis of the liver may resemble acute hepatitis.

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[...]

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Cirrhosis may be ruled out by the lack of a history of alcoholism or malnutrition,

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but liver biopsy may be the only means of making this distinction.

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[...]

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Metastatic carcinoma within the liver may produce jaundice.

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[...]

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This is ruled out by the lack of a primary lesion and by liver biopsy.

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[...]

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Toxic hepatitis may be produced by various chemicals, especially carbon tetrachloride.

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[...]

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It may be ruled out when there is no history of exposure

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and the flocculation and turbidity tests are markedly positive.

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[Weil's disease]

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Leptospiral infections may cause jaundice

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but are ruled out by the absence of leptospira in blood or urine.

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[...]

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Jaundice may be present in amebiasis of the liver.

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[...]

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Amebic hepatitis is ruled out when amebae are absent

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or when there is no response to specific treatment.

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[...]

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In summary, each of these diseases has differentiating characteristics which permit its exclusion.

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[...]

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Hepatitis without jaundice, because of its systemic and gastrointestinal manifestations,

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must be considered in the diagnosis of many conditions of acute onset.

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[...]

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The systemic manifestations include chills, fever, malaise, and headache.

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The gastrointestinal manifestations are anorexia, nausea, vomiting,

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diarrhea, and abdominal pain.

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In a patient with any of these symptoms,

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hepatitis should be considered.

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[Enlarged tender liver]

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[...]

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An enlarged, tender liver and positive liver function test

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establish the diagnosis of hepatitis without jaundice.

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[...]

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The importance of the disease to the Army lies in the duration of the illness.

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[...]

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The average case is disabled for twelve weeks.

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Attempts to hasten this process may result in acute relapse.

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This is frequently caused by premature overactivity,

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ingestion of alcohol, and in some cases,

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the cause of the relapse remains unknown.

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Hepatitis persisting more than six months is considered chronic hepatitis.

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Cases of chronic hepatitis often have a history of inadequate treatment during the acute phase.

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[...]

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The most common symptoms are anorexia, weakness,

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easy fatiguability, and upper abdominal discomfort.

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Physical signs may include an enlarged, tender liver,

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splenomegaly, and spider nevi.

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Liver function tests may be positive.

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Liver biopsy is necessary to establish the diagnosis.

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The histologic picture is that of continuing inflammatory and regenerative changes.

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[...]

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In a few cases, the appearance of bile duct proliferation and fibrosis suggest the development of cirrhosis.

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The treatment of chronic hepatitis is discouraging.

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It involves prolonged periods of bedrest,

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continued dietary therapy,

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and abstinence from alcohol.

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[...]

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There is indication that Aureomycin is beneficial in some cases.

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Many cases of chronic hepatitis will recover eventually.

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The outcome in others is unknown.

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[...]

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[Prognosis]

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The prognosis of acute hepatitis is good.

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Only a fraction of one percent of patients die during the acute stage.

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About two percent have persistent chronic hepatitis at the end of a year.

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[...]

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The rest recover completely.

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[...]

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Viral hepatitis is a common disease in the Army.

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Diagnosis is seldom difficult if the possibility is considered.

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[...]

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The disease is self-limited; the course is prolonged.

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There is no specific treatment.

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Bed rest must be maintained until evidence of active disease has subsided.

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Strict adherence to this regimen will decrease the incidence of acute relapse and the development of chronic hepatitis.

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[Music]

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[The End,  FG 8-6,  MCMLII]