【正文】 closed circular DNA，cccDNA 在乙肝病毒的復(fù)制過程(gu242。,28,Epidemiology: Susceptible population,Hepatitis A Most adult has antiHAV due to covert infection. Infant under 6m acquired antibody from mother. Young children is susceptible. Hepatitis B Person who are antiHBs negative. Infants are susceptible to HBV. HBV infection developed in medical staff, people who receive blood transfusion, dialysis or drug abuse.,第二十八頁，共九十四頁。)急性感染模式,10周,20周,30周,2 4 6 8 10 年,感染(gǎnrǎn)HBV后時間,第二十頁，共九十四頁。,16,Etiology: Hepatitis B virus (HBV),Three antigenantibody system HBsAg—antiHBs HBeAg—antiHBe HBcAg—antiHBc pres1, pres2—antipres1, antipres2,第十六頁，共九十四頁。,8,Etiology: Hepatitis A virus (HAV),Seven gene types, 1, 2, 3, 4 types from human body Only one antigenantibody system. AntiHAV IgM is diagnostic evidence of recent infection, IgG is protective antibody. During acute stage of infection, HAV can be found in blood and feces of infected human,第八頁，共九十四頁。nɡ)表現(xiàn)（慢肝和重肝） HBV抗原抗體系統(tǒng)的組成和意義 慢性HBV、HCV的治療 HBV的母嬰阻斷,第二頁，共九十四頁。,2,難點(n225。) HCV感染易轉(zhuǎn)為慢性的原因 HBV抗原抗體系統(tǒng)的組成和意義 各型病毒性肝炎的傳播途徑 病毒性肝炎的臨床分類 重型肝炎的并發(fā)癥 慢性乙肝、丙肝的藥物治療 意外暴露HBV后的預(yù)防,第三頁，共九十四頁。,11,Etiology: Hepatitis B virus (HBV),Three particles in serum Spherical particles with a diameter of 22nm and tubular particles, composed of HBsAg Large particles with a diameter of 42 nm, named Dane particle. It is a complete infectious HBV particles, consists of an outer protein shell (envelope, contain HBsAg) and an inner body ( core, contain HBcAg, HBeAg, HBVDNA and DNAP ),第十一頁，共九十四頁。) 窗口期：HBV感染時，HBsAg已消失，抗HBs尚未出現(xiàn)，血中僅能檢出抗HBc/抗HBe，此期可能有傳染性,第十八頁，共九十四頁。,23,Etiology: Hepatitis D virus (HDV),HDV is a kind of defective virus, the replication of HDV depends on HBV or other hepadnavirus, coated by HBsAg in blood HDV genome is a circular single strand RNA and contains 1.7kb HDV has one antigenantibody system HDAg and antiHDV can be detected by RIA or ELISA in serum HBV and HDV coinfection or super infection, especially the latter may make the disease exacerbation and may lead to fulminant hepatitis,第二十三頁，共九十四頁。,31,Epidemiology: Epidemic feature,Outbreak epidemic Due to food and water are contaminated lead to outbreak of HA and HE Seasonal distribution HA: most cases developed in autumn and winter HE: most cases developed in summer and autumn,第三十一頁，共九十四頁。,37,Pathogenesis: Hepatitis B,肝損傷(sǔnshāng)機制 細胞免疫介導(dǎo) 自身免疫介導(dǎo) 細胞因子介：TNF、IL1,第三十七頁，共九十四頁。,41,Clinical manifestation,Clinical types Acute viral hepatitis: icteric or anicteric Chronic viral hepatitis Mild, Moderate, Severe Hepatitis gravis Acute, Subacute, Chronic Cholestatic viral hepatitis Postnecrotic cirrhosis,第四十一頁，共九十四頁。,48,Clinical manifestation,Hepatitis gravis All of five kinds of hepatitis virus can cause this type of hepatitis. The incidence is only 0.20.5%, but the mortality is the highest.,第四十八頁，共九十四頁。n)升高的現(xiàn)象，提示肝細胞大量壞死,第五十四頁，共九十四頁。 y236。,4. 既往感染過乙肝，現(xiàn)仍有免疫力，屬不典型恢復(fù)期，也可能為急性感染期,5. 既往有乙肝感染，屬于急性感染恢復(fù)期，也少數(shù)人仍有傳染性,6. 過去有乙肝感染或現(xiàn)在正處于急性感染,7. 以前打過乙肝疫苗或以前感染過乙肝,8. 急性乙肝恢復(fù)期，以前感染過乙肝,9. 急性感染早期或者慢性乙肝表面抗原攜帶者傳染性弱,10. 慢性乙肝表面抗原攜帶者易轉(zhuǎn)陰或者是急性感染趨向恢復(fù),11. 急性HBV 感染早期，HBV復(fù)制活躍，傳染性強,12. 急性乙肝感染趨向恢復(fù)或者為慢性攜帶者,第六十頁，共九十四頁。,67,Diagnosis,Etiological diagnosis HA: Serum antiHAVIgM, Feces HAV HB: HBsAg HBeAg HBcAg antiHBc HBVDNA DANp HC: antiHCV IgM IgG HD: HBsAg HDAg antiHDV HE: antiHEV IgM IgG HEVRNA HEV particals in feces,第六十七頁，共九十四頁。ng)HBV感染,慢性乙型肝炎 HBeAg陽性慢性乙型肝炎 HBsAg、HBV DNA和HBeAg陽性，抗HBe陰性(yīnx236。 非活動性HBsAg攜帶者：血清HBsAg陽性、HBeAg陰性、抗HBe陽性或陰性，HBV DNA檢測不到或低于最低檢測限，1年內(nèi)連續(xù)隨訪3次以上，ALT均在正常范圍，肝組織學(xué)檢查顯示病變輕微。li225。,Treatment,慢性乙型肝炎抗病毒治療的一般適應(yīng)證 對達不到上述治療標準者，應(yīng)監(jiān)測病情變化，如持續(xù)HBV DNA陽性，但有以下情形之一者，也應(yīng)考慮抗病毒治療 對ALT大于ULN且年齡＞40歲者，應(yīng)考慮抗病毒治療 對ALT持續(xù)正常但年齡較大者（＞40歲），應(yīng)密切隨訪，最好進行肝活組織檢查；如果肝組織學(xué)顯示炎癥壞死≥G2或纖維化≥S2，應(yīng)積極給予抗病毒治療 動態(tài)觀察發(fā)現(xiàn)(fāxi224。li225。,83,Treatment,Hepatitis gravis Symptomatic therapy Infection contral Hemorrhage: fresh blood, prothrombin complex, platelet Hepatorenal syndromes Hepatic encephalopathy Prevention and treatment of amino poisoning Recovery normal neurotransmitter Sodium glutamate and arginine Treatment of cerebral edema Prevention and treatment of renal failure Promoting the growth of liver cells,第八十三頁，共九十四頁。,88,Prevention: HBV,乙型肝炎疫苗的接種對象主要是新生兒，其次為嬰幼兒和高危人群(r233。)功能低下或無應(yīng)答者，應(yīng)增加疫苗的接種劑量和針次；對3針免疫程序無應(yīng)答者可再接種3針，并于第2次接種3針乙型肝炎疫苗后1~2個月檢測血清中抗HBs。,92,Reference,中華醫(yī)學(xué)會肝病學(xué)分會和中華醫(yī)學(xué)會感染病學(xué)分會，《慢性(m