Dae Hee Choi M D Ph D Department

간염의 증상과 치료 Dae Hee Choi, M. D. Ph. D. Department of Internal Medicine Kangwon National University School of Medicine

간염 (Hepatitis)? hepat-, meaning“liver” -itis, meaning“inflammation” -inflammation of the liver ; presence of inflammatory cells in the tissue of the organ

간염의 원인 1) 바이러스성 간염 - A, B, C, D, E형… 2) 알코올성 간질환 (alcoholic liver disease) - 알코올성 간염 (alcoholic hepatitis) 3) 비 알 코 올 성 지 방 간 질 환 (nonalcoholic fatty liver disease) - 비알코올성 지방간염 (nonalcoholic steatohepatitis) 4) 약제 유발성 혹은 독성 간장애 5) 자가면역성 간염(autoimmune hepatitis) 6) 혈색소증(hemochromatosis) 7) 윌슨씨 병 (Wilson disease)

간염의 원인 1) 바이러스성 간염 - A, B, C, D, E형… 2) 알코올성 간질환 (alcoholic liver disease) - 알코올성 간염 (alcoholic hepatitis) 3) 비 알 코 올 성 지 방 간 질 환 (nonalcoholic fatty liver disease) - 비알코올성 지방간염 (nonalcoholic steatohepatitis) 4) 약제 유발성 혹은 독성 간장애 5) 자가면역성 간염(autoimmune hepatitis) 6) 혈색소증(hemochromatosis) 7) 윌슨씨 병 (Wilson disease)

간염의 원인 1) 바이러스성 간염 - A, B, C, D, E형… 2) 알코올성 간질환 (alcoholic liver disease) - 알코올성 간염 (alcoholic hepatitis) 3) 비 알 코 올 성 지 방 간 질 환 (nonalcoholic fatty liver disease) - 비알코올성 지방간염 (nonalcoholic steatohepatitis) 4) 약제 유발성 혹은 독성 간장애 5) 자가면역성 간염(autoimmune hepatitis) 6) 혈색소증(hemochromatosis) 7) 윌슨씨 병 (Wilson disease)

바이러스성 간염 간염바이러스의 종류 Hepatitis type Virus particle Morphology Genome Classification HAV 27 nm Nonenveloped 7. 5 -kb RNA, linear, ss, + Hepatovirus HBV 42 nm Double-shelled virion (surface and core) spherical 3. 2 -kb DNA, circular, ss/ds Hepadnavirus 27 nm Nucleocapsid core 22 nm Spherical and filamentous; represents excess virus coat material HCV 40 -60 nm Enveloped 9. 4 -kb RNA, linear, ss, + Hepaci-virus HDV 35 -37 nm Enveloped hybrid particle with HBs. Ag coat and HDV core 1. 7 -kb RNA, circular, ss, - Resembles viroids and plant satellite viruses HEV 32 -34 nm Nonenveloped 7. 6 -kb RNA, linear, ss, + Alphavirus-like

바이러스성 간염 급성간염의 임상양상 황달기 Interic phase - 우상복부 불편간, 통증 - 황달 jaundice, 간비대 경부림프절 비대 hepatomegaly, 비장비대 splenomegaly, cervical adenopathy (10 -20%) 회복기 Recovery phase (2 -12 weeks) - usually more prolonged in AHB and AHC - Complete clinical & biochemical recovery: 1 -2 months after AHA & AHE, 3 -4 months after AHB & AHC

바이러스성 간염 역학적 특징 HAV HBV HCV HDV HEV 15 -45 (30) 30 -180 (60 -90) 15 -160 (50) 30 -180 (60 -90) 14 -60 (40) acute Insidious or acute insidious Insidious or acute Acute Young adults, babies, toddlers Any age Young adults (20 -40 years) Fecal-oral Blood, body fluid Fecal-oral Severity mild Occasionally severe moderate Occasionally severe mild Fulminant 0. 1% 0. 1 -1% 0. 1% 5 -20% 1 -2% Chronicity None 1 -10% (90% of neonates) 50 -70% Common None Carrier None 0. 1 -30% 1. 5 -3. 2% variable None Cancer None + + None Excellent Worse with age moderate Acute, good; chronic, poor Good IG Inactivated vaccine HBIG Recombinant vaccine None HBV vaccine Unknown None IFN, LMV, ADV Peg-IFN + RBV IFN None Feature Incubation (days) onset Age Transmission Prognosis Prophylaxis Therapy

바이러스성 간염 역학적 특징 HAV HBV HCV HDV HEV 15 -45 (30) 30 -180 (60 -90) 15 -160 (50) 30 -180 (60 -90) 14 -60 (40) acute Insidious or acute insidious Insidious or acute Acute Young adults, babies, toddlers Any age Young adults (2040 years) Fecal-oral Blood, body fluid Fecal-oral Severity mild Occasionally severe moderate Occasionally severe mild Fulminant 0. 1% 0. 1 -1% 0. 1% 5 -20% 1 -2% Chronicity None 1 -10% (90% of neonates) 50 -70% Common None Carrier None 0. 1 -30% 1. 5 -3. 2% variable None Cancer None + + None Excellent Worse with age moderate Acute, good; chronic, poor Good IG Inactivated vaccine HBIG Recombinant vaccine None HBV vaccine Unknown None IFN, ETV, ADF. . Peg-IFN + RBV IFN None Feature Incubation (days) onset Age Transmission Prognosis Prophylaxis Therapy

바이러스성 간염 역학적 특징 HAV HBV HCV HDV HEV 15 -45 (30) 30 -180 (60 -90) 15 -160 (50) 30 -180 (60 -90) 14 -60 (40) acute Insidious or acute insidious Insidious or acute Acute Young adults, babies, toddlers Any age Young adults (20 -40 years) Fecal-oral Blood, body fluid Fecal-oral Severity mild Occasionally severe moderate Occasionally severe mild Fulminant 0. 1% 0. 1 -1% 0. 1% 5 -20% 1 -2% Chronicity None 1 -10% (90% of neonates) 50 -70% Common None Carrier None 0. 1 -30% 1. 5 -3. 2% variable None Cancer None + + None Excellent Worse with age moderate Acute, good; chronic, poor Good IG Inactivated vaccine HBIG Recombinant vaccine None HBV vaccine Unknown None IFN, LMV, ADV Peg-IFN + RBV IFN None Feature Incubation (days) onset Age Transmission Prognosis Prophylaxis Therapy

바이러스성 간염 급성 간염의 예후 n A형 간염 - virtually all previously healthy patients recover completely without sequelae - unusual variants: 재발성 간염relapsing hepatitis, 황달정체성 간염 cholestatic hepatitis

바이러스성 간염 급성 간염의 예후 n n B형 간염 - 95 -99%: favorable course and recover completely - advanced age, serious underlying medical disorders: prolonged course, severe hepatitis - 복수, 부종, 간성혼수를 증상으로 발현된 환자: 예후가 좋지 않다 - 혈액응고장애 prolonged PT, 저알부민혈증 low serum albumin, 저혈당 hypoglycemia, 심한 황달 very high serum bilirubin values : 심한 간세포 손상을 의미 C형 간염 - less severe during acute phase than hepatitis B - more likely to be anicteric

간염의 원인 1) 바이러스성 간염 - A, B, C, D, E형… 2) 알코올성 간질환 (alcoholic liver disease) - 알코올성 간염 (alcoholic hepatitis) 3) 비 알 코 올 성 지 방 간 질 환 (nonalcoholic fatty liver disease) - 비알코올성 지방간염 (nonalcoholic steatohepatitis) 4) 약제 유발성 혹은 독성 간장애 5) 자가면역성 간염(autoimmune hepatitis) 6) 혈색소증(hemochromatosis) 7) 윌슨씨 병 (Wilson disease)

알코올성 간염 술의 대사 NAD+ NADH+ ALD H ADH 아세트알데히드 술 Aldehyde oxidase Xanthine oxidase CYP 2 E 1 NADPH 아세트산 NADP+ O 2 -

위험 인자 Risk Factor Quantity 알코올성 간염 Comment In men, 40 -80 g/d of ethanol produces fatty liver; 80 -160 g/d for 10 -20 years causes hepatitis or cirrhosis. Only 15% of alcoholics develop alcoholic liver disease. Gender Women exhibit increased susceptibility to alcoholic liver disease at quantities >20 g/d. Hepatitis C HCV infection concurrent with alcoholic liver disease is associated with accelerated disease progression, more advanced histology, and decreased survival rates. Genetics Malnutrition The genetics of alcohol dehydrogenase, acetaldehyde dehydrogenase, and polymorphisms of cytochrome P 4502 E 1 need confirmation. A common misconception. Alcohol hepatoxicity does not require malnutrition. Patients with alcohol hepatitis should receive aggressive attention to nutritional requirements.

비알코올성 지방 간염 Potential Pathophysiologic Effects of Therapies GASTROENTEROLOGY 2008; 134: 1682– 1698

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