Table Of ContentHepatitis Prelims 4/11/04 11:49 am Page i
Management of
Chronic Viral Hepatitis
Second Edition
Hepatitis Prelims 4/11/04 11:49 am Page ii
Hepatitis Prelims 4/11/04 11:49 am Page iii
Management of
Chronic Viral Hepatitis
Second Edition
GRAHAMR FOSTER,PHD, FRCP
Professor of Hepatology
Queen Mary’s School of Medicine and Dentistry
Barts and The London NHS Trust
The Royal London Hospital
London, UK
ROBERTD GOLDIN, MD, FRCPATH
Senior Lecturer in Histopathology
Imperial College Faculty of Medicine
and Consultant Histopathologist
Department of Cellular Pathology
St Mary’s Hospital
London, UK
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Hepatitis Prelims 4/11/04 11:49 am Page v
Contents
Preface vii
Abbreviations viii
1. Chronic viral hepatitis – persistence,
prevalence and transmission 1
2. Hepatitis C – virology, natural history and
pathology 17
3. Diagnosis and management of chronic
hepatitis C virus infection 41
4. Hepatitis B – virology, natural history and
pathology 63
5. Management of chronic hepatitis B virus
infection 81
6. Combined infections 99
7. Non-hepatic manifestations 111
8. Difficult-to-treat patient groups 119
9. Hepatocellular carcinoma 129
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Preface
Chronic viral hepatitis affects over 500 million people
worldwide and leads to cirrhosis and liver cell cancer in a large
proportion of infected individuals. The optimal management of
those who are infected requires close collaboration between the
pathologist, who identifies the grade and stage of the disease,
and the physician who implements therapy.
In this updated edition of this succinct guide, two
experienced teachers present a complete guide to the
investigation and management of chronic viral hepatitis. The
authors outline the mechanisms underlying persistent viral
infection and go on to describe the epidemiology, virology and
diagnosis of chronic viral hepatitis before outlining a
comprehensive guide to modern, biopsy-based management.
This well-written second edition describes the use of the
latest therapies, including the pegylated interferons, and will
be of value to hepatologists, gastroenterologists and infectious
disease physicians who care for patients with chronic viral
hepatitis.
Graham R Foster
Robert D Goldin
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Abbreviations
AFP alfa-fetoprotein
AIDS acquired immunodeficiency syndrome
cccDNA covalently closed circular DNA
CT computed tomography
ddI didanosine
DNA deoxyribonucleic acid
HAI histological activity index
HBcAg hepatitis B virus core antigen
HBeAg hepatitis B e antigen
HBIg hepatitis B immunoglobulin
HBsAg hepatitis B virus surface antigen
HIV human immunodeficiency virus
HLA human leucocyte antigen
IL interleukin
iu international units
MRI magnetic resonance imaging
NS non-structural
PCR polymerase chain reaction
RNA ribonucleic acid
Hepatitis CH01 4/11/04 11:49 am Page 1
Chronic viral hepatitis – persistence,
prevalence and transmission
1
Most adult humans suffer from at least four or five viral
infections every year. In almost all cases antiviral defence
mechanisms recognize and rapidly eliminate the virus so that
the illness is usually trivial and short-lasting.
Infection with the chronic hepatotropic viruses is very different
– these pathogens commonly evade the antiviral defence systems
and cause a long-lasting, persistent infection. The prolonged
nature of the infection ensures that every infected person has
ample opportunity to transmit the virus to others, allowing many
millions of people worldwide to become infected. Three viruses
commonly cause chronic hepatitis – hepatitis B virus (HBV),
hepatitis C virus (HCV) and the delta virus (HDV). Virologically,
these three pathogens are remarkably different but all have
developed mechanisms that allow persistent infection, and overall
they infect over 500 million people worldwide.
Mechanisms of persistence: how do
hepatotropic viruses cause chronic infection?
Most viral infections are transient – after infection the virus is
rapidly eliminated by the combined effects of the innate and
the acquired immune systems. To cause persistent infection a
virus must avoid the host defences, and the hepatotropic
viruses have developed elaborate strategies to achieve this.
Avoiding the innate immune system
The innate immune system is the first line of defence against
pathogens. It consists of an arsenal of preformed circulating
