Hepatitis | Pathophysiology of Viral Hepatitis

[Music] what's up ninja nerds in this video we are going to talk about hepatitis a through e in this video we're going to talk about the epidemiology the etiology we'll talk a little bit about the virology of hepatitis viruses we'll talk about how they infect the the hepatocytes how that leads to multiple clinical manifestations and then we'll get into the nitty-gritty stuff which is the serology which is kind of a lot of questions that you see on your constant board exams all right let's go and get started iron engineers so before we start getting into

all the pathophysiology of hepatitis we got to talk about the different types of hepatitis right so i want you guys to know is three basic things about these viruses what is the route of transmission okay i want you to know is it going to cause an acute infection or chronic infection or both and then the third thing is i want you to know a little bit about the virus structure so first things first hepatitis a virus what do we know about this one is it going to cause an acute infection or a chronic infection it's

pretty simple it's acute infection a lot of this stuff is just kind of going to be a little bit of memorization so i want you to remember acute infection acute infection is described as though you can rid the virus from the body usually this only lasts you know less than six months in duration if it's greater than six months of duration and you're still infected it's more of a chronic infection so hiv is usually cleared pretty well by the human body okay second thing what is the route of transmission it's usually transmitted through fecal oral

contamination okay so fecal oral route okay so it's a fecal oral route it helps me to remember a anus so feces comes from the anus so i know that because of that that's going to give me a little easy way to remembering that the fecal oral rot is going to be the main way that the hav virus is going to be transmitted right third thing that we got to know about the virus is a little bit about its structure and its composition one of the big things that you want to know about this virus the

hiv virus is that it doesn't have an envelope so remember it's no envelope and what that means is it doesn't have that kind of like lipid bilayer that's surrounding these blue proteins here which is called your capsid so you have these blue proteins and they're made up of capsimirs that makes up this nice little capsid structure inside of that capsid you have different types of enzymes all these little pink dots are representative of different types of enzymes and then inside of there there's a nice little nucleic acid structure and what happens to be here is

a single stranded rna virus okay and if you guys really want to be specific they call this a positive sense a positive sense single stranded rna okay and all the positive sense means is that this rna can use the host cell's ribosome to make proteins translation wise okay so that covers that one b is it acute or chronic or both well it actually causes an acute infection but then it can actually stay within the liver cell and continue to cause damage to the liver cell for greater than six months so it's both so i want

you guys to remember that hbv is both an acute and chronic infection okay so it can cause both an acute and chronic infection the next thing is how is it transmitted three ways i want you to remember three ways one sex two is usually through blood okay and the third way is perinatal in other words you can transmit it to the child okay so these are the things that i want you guys to remember hpv acute and chronic infection and is transmitted through sexual intercourse it can be spread through blood right so needle sticks different

types of uh transfusions and things like that perinatal it can be passed from the mother to the child a little bit about the viral structure we're not going to go into tons of detail because we're going to talk about in the pathophys but i just want you guys to remember that it does have an envelope it does have this nice lipid bilayer on it so it does have an envelope and inside of this it's going to have these nice capsid mirrors which is going to make up your capsid and then inside of that you're going

to have this nice like dna structure it's actually double stranded dna and we're going to be a little bit specific and we're going to put a p in front of that and all that means is is it's partially double-stranded dna i just want you guys to remember that it's a dna virus okay next thing hcv is it going to be acute or chronic or both it's it's actually both so again this one can cause an acute infection but it can actually stay within the liver and continue to cause damage for greater than six months so

this one can also cause an acute and chronic infection how is it transmitted it's the same as b it can be transmitted through sex it can be transmitted through the blood and it can be transmitted perinatal so in other words from mother to child okay when you look at its structure again it has this purple like envelope so it does have an envelope so we'll put here it does have an envelope and it has these capsids or these capsimears and inside of that it has this actual nucleic acid structure and this is going to be

single stranded rna and again to be specific it's positive sense single stranded rna the next thing hdv hdv is a type of delta virus and this virus is very interesting we have a third point that i want you guys to know about this one well we're going to talk about this is mainly a chronic infection it's mainly a chronic infection and we'll explain why in just a second now it can cause an acute infection but i want you to mainly remember chronic infection and we'll explain why second thing how can it be transmitted it's the

same way as b and c so it can be transmitted through sex it can be transmitted through blood or it can be transmitted perinatal okay in other words from mother to child third thing that i want you to remember especially for hdv or this delta virus is that it needs hbv in order to be able to infect the host so you need hbv and there's two ways okay one is it's called a co-infection in other words you take this cell let's say here i have a cell i have to have hbv and hdv infect this

cell at the same time that's a co-infection that's the only way that the hdv will work the second way is called a super infection and this is a little bit simpler all it is is you have a cell here the hbv virus will actually infect this cell and then throughout a little bit more over time then as this hpv virus is actually causing damage to the cell then the hdv virus will actually come so it comes later so super infection hpv causes infection later in time hdv that infects the cell or co-infection both the hpv

and the hdv infect the cell at the same time okay structure we notice it has an envelope and we notice that it has a circular stranded structure it's not double stranded it's a circular stranded rna and we actually call this single stranded rna but here's where it's a little bit different this is a negative sense okay it's a negative sense last one here hev okay hepatitis e virus does this cause acute infections chronic infections or both it's mainly acute there is certain situations in patients who are immunocompromised where it can cause chronic infections but it's

not that common it's more specifically acute infections how can it be transmitted remember we said a fecal oral was for a right well i remember a is for anus and e is to eat okay so if you want to it's i know it's nasty but anus you poop out if someone who's infected with hav or hev they poop and into some type of water source and that water source is contaminated and then you drink it or you eat from that source then you can also become infected so a and e anus eat fecal oral okay

so this is going to be fecal oral route okay last thing about this virus is does it have an envelope there is no envelope okay so you want to remember that there's no envelope on this it does have these capsid mirrors and these capsid proteins and inside it does have a nucleic acid and this is single stranded rna positive sense so what i want you to remember all of them all of these viruses except for hpv is rna okay he's the only one that has a dna virus a and e fecal oral and acute bcd

can cause acute and chronic infections and they're mainly blood sex and perinatal transmission all right now that we've covered that let's go into the pathophys all right so now let's go ahead and take a look at how these viruses infect the hepatocytes so we're going to zoom in on a big hepatocyte and look to see how these viruses infect the cell and how when they're inside of the cell they cause all this havoc okay it's pretty cool actually so let's take for example we start off with our our viruses right so if you guys remember

we kind of at the end i classified these viruses into two different things right we said that one of them is going to be single stranded rna that was our if you guys remember which ones those were it was the h a v h e v h c v and even h d v is your single single-stranded rna okay we're not going to worry about the positive and negative for right now just for right now to remember that it's single-stranded rna the other virus that we talked about is going to have dna okay and that's

a double stranded dna so this one's going to be double stranded dna and if you really want to be particular you can put the p in there remember that it's partially double-stranded not all of the entire thing is double-stranded and this is specific for hbv so let's see how when these viruses get inside how they use the cell's machinery to make these different proteins and replicate their viruses and cause havoc on this cell so what happens is these viruses get inside the cell through endocytosis mechanism and then they shed off their outer coating so they

shut off the envelope they shed off their capsamers and they release out here that single stranded rna now that single stranded rna is really cool because guess what it does it goes down to the host's ribosome and uses the host cell's ribosome to synthesize proteins okay so it'll synthesize these different types of proteins let's show here just as an example here we'll use this orange okay it's going to start synthesizing all these different types of proteins what are some of these proteins that it's going to synthesize from that it's going to make proteins such as

maybe capsomeres which are important because they make up the capsid it might make certain types of antigens that they put on the surface okay and there's other things that we can make like polymerases maybe we can make some rna polymerases maybe we can even make some dna polymerases and then what we'll do is we'll send these guys to the golgi or endoplasmic reticulum-like complex and they'll get synthesized and we'll make these nice little vesicles that'll contain all these different proteins that we need okay so inside of this we'll have all these different proteins that we

need and then we'll actually make our virus we'll see how okay but here's what's cool if the ribosome synthesizes these enzymes and proteins what's one of the interesting ones this rna polymerase why is that important and it's actually very specific it's we should call it the rna-dependent rna polymerase if i get more of these viruses right i get another single-stranded rna in here and i made proteins right from using the host cells machinery and i make this rna-dependent rna polymerase guess what can happen now i can take that single stranded rna and make more rna

right so that rna-dependent rna polymerase will put here rna dependent rna polymerase it can take and make more rna so now if i have more rna and i have all of these proteins capsulmers different antigens more polymerases and i combine these two what am i going to get out of this i'm going to make my virus and my virus is going to have that rna i'm going to have all the different proteins that i need to make up the capsid to make up the envelope all of that stuff isn't that crazy how it can do

that and then from there we can just release these viruses out of the hepatocyte and go cause it to damage other nearby apatocites that's that's rough stuff right there in the same way the hbv virus it gets inside of the cell right so it undergoes this endocytosis mechanism when it gets inside of the cell it will uncoat release off the envelope and release off all those antigens and put into this nucleus so this is going to be the cell's nucleus and it sheds off and releases this partial double stranded dna now there is these little

repair enzymes called dna repair enzymes and what they do is they come in and they just finish off the double strand because if i were to give you an example just give you an example how much of this is double stranded let's say it's 75 percent these dna repair enzymes will then come in and then completely finish it off to what's 100 double-stranded dna okay so it's a simple concept there now what will happen is this double-stranded dna we're then going to do two things with it one is i can use the cell's rna polymerases

okay so i'm going to use this cell's rna polymerases so let's say here i have a rna polymerase that double-stranded dna will then get transcribed and then from that i'm going to make rna and this is again viral rna that rna can then do two things right i could have rna and this could be specifically mrna so viral mrna that viral mrna can then go to the ribosome where it'll then be what translate it and make proteins what kind of proteins guys capsimirs different types of surface antigen or envelope antigens different types of rna polymerases

are dna polymerases isn't that cool another thing that can happen is it can make this specific type of rna which is called pre-genomic rna so pre-genomic rna and this pre-genomic rna is very very interesting here's the reason why hepatitis b virus is actually a type of retrovirus so it has a specific enzyme inside of it and we're going to mark this enzyme in a very interest let's do pink there's a specific enzyme that's present inside of this virus and it's called a retrovirus okay and it's called a reverse transcriptase so we're going to have an

enzyme here called reverse transcriptase reverse transcriptase basically takes its reverse of transcription so we're taking rna and making dna so it takes this rna and then makes from it dna and then this dna that we're going to get eventually it will get converted into double-stranded dna and if you really want to be specific it's going to be that partially double-stranded dna from here what can then happen that partially double-stranded dna can then come and combine with these capsamers and with these antigens that are being synthesized and have some rna polymerases and dna polymerases and other

enzymes that are going to be combined into that actual vesicle and make you a nice little virus and then that virus can then be released out of this cell isn't that insane that's a pretty cool process another thing that's also really interesting is that this double-stranded dna it can complete it can continue to replicate onto itself because it can use the host cells dna polymerase so that's another thing it can actually get incorporated into the host genome and it can continue to keep replicating itself so you can continue to make more double-stranded dna use the

host cells rna polymerase to make more rna make more of these viral proteins and continue to make more of this pre-genomic rna and then use that reverse transcriptase from the virus to make more double-stranded dna and just keep replicating these viruses it's crazy and this is one of the things that they relate to maybe this hbv causing uh hepatocellular cancer and we'll talk a little bit about that later okay now one more thing i want you guys to understand because obviously whenever these viruses start being developed they cause destruction of the cell so whenever they

actually accumulate within a cell they do lead to lysis they do lead to lysis of the apatocite and that lysis is going to lead to cell death okay so that's one thing that's important and that's how the hepatitis c can get damaged another way that the hepatocyte can get damaged all of these proteins that are being synthesized okay sometimes what happens is your the the actual cells here will actually make uh these antigens intake and through some type of specific shuttler and send these antigens and put them onto a protein that we express on our

cell membrane all nucleated cells should have this protein this is called mhc1 protein it's called the major histocompatibility complex now what happens is let's say that we take these proteins and we'll mark these proteins as we'll switch the color a little bit and we'll turn this into this this maroonish color here and let's say that these proteins that the virus is making some of this protein gets exposed and put with this mhc-1 complex on its surface okay and we're going to call this one here this is going to be the viral proteins okay what happens

is when you're having this infection your body releases different types of interferons which activate macrophages which activate t cells those t cells are then going to come to this area of where this infection is guess what kind of t cells come to this area the good old cytotoxic t cells so then these cytotoxic t cells when they come over to this area here they're going to have a specific protein that they use to recognize this mhc-1 molecule okay they're going to have specifically a molecule here which is going to hook onto this and this is

going to be called cd8 so cd8 positive meaning that it has this protein that interacts with the mhc-1 it also should have another protein here let's do this one in black and we'll have it cross over a little bit it's supposed to be able to recognize the maybe if there's any types of self antigens on the cell now what happens is if the cd8 cytotoxic t cell doesn't recognize this abnormal viral protein it gets set on alert and it starts to secrete specific types of molecules such as perforins and these perforins are then going to

come into the cell and put holes into the cell membrane okay so they're going to put holes in the cell membrane then from there after we put holes in the cell membrane let me go ahead and sit down guys my knees are killing me it's going to secrete another molecule here and this next molecule that it's going to release is going to be called granzymes and these granzymes what they do is they leak in through these perforins that were made and they induce apoptosis and apoptosis is obviously cell death and so then this cell is

going to die that's kind of sad right so now you understand how these viruses promote such damage how they replicate themselves how the replication eventually can can lead to lysis of the hepatocyte and cell death or how our immune system can respond to this because again what happens is if you guys remember these hepatocytes whenever they're damaged they can secrete interferons and the particular type of one is interferon gamma that activates macrophages and then the macrophages will then come and stimulate these different t cells and this is particularly a t cytotoxic t cell okay and

then they'll come here and cause destruction of these cells so this is how you get inflammation and destruction of the liver cells all right so we've set the stage okay liver cells have been damaged all we did was we kind of took one of these liver cells right here we zoomed in on and saw how it was damaged as these liver cells start getting damaged what starts happening well let's kind of talk about that when there's liver damage your body your liver starts producing specific types of uh you know cytokines some of them are going

to be like interleukin-1 whenever there's significant inflammation interleukin-6 and tumor necrotic factor alpha what do these guys do well if you guys remember they get into your circulation they go to your central nervous system and they trigger a specific prostaglandin process in the brain they cause pg e2 and maybe pg f2 production and what that does is that changes the hypothalamic thermostat and leads to a fever okay and with fever always comes general malaise and discomfort right so you're going to get fever and you're also going to get malaise that general discomfort of the body

so that's one thing that's going to happen the next thing that's going to happen is is whenever there's like damage to the liver right so the liver is being damaged all these cells are starting to die toxins can start building up in the blood right a lot of these toxins can start building up and as these toxins start building up in the blood let's say toxins that the liver is supposed to be filtering these hepatotoxins we'll call them hepatotoxins okay they start accumulating because the liver isn't able to perform its function as well these hepatotoxins

will then leak into the actual bloodstream and they'll go up to the central nervous system when they get to the central nervous system there's an area in the brain stem okay and that area if we were to kind of like write like a structure here you have what's called the chemo trigger zone okay and the chemo trigger zone is sensitive so right here we're going to call this the chemo trigger zone it's sensitive to these hepatotoxins and it acts on certain receptors that stimulate the chemo trigger zone the chemo trigger zone will then activate another

structure in the brainstem just nearby let's do it here in pink and when it stimulates this next structure just kind of anterior to it nearby this structure is called the ammetic center okay so you have the chemo trigger zone the chemo trigger zone will then stimulate the ammetic center once we stimulate the ammetic center that'll activate nerves that are going to go to the gastrointestinal tract and guess what it's going to do it's going to cause the this kind of retro peristaltic action and this retro peristaltic action is going to cause certain types of food

and gastrointestinal contents to be pushed in the direction opposite of what it wants to go you want to go from mouth to anus this is going to cause reverse peristalsis where now all of this actual food and contents is going to move upwards and out of the body so this is going to lead to vomiting so nausea and vomiting and that nausea and vomiting what's important about that if you're if you're nauseous and you're vomiting and you're throwing up a lot of stuff this can lead to dehydration so a decrease in blood volume you also

can spit out a lot of electrolytes so it can lead to we'll put electrolyte e for electrolyte and we'll put plus and minus because there's different types electrolyte changes right what else could it lead to if it's happening over a long period of time it might even lead to weight loss so a decrease in weight right that's crazy so within the first part of when someone is infected and their liver cells start actually becoming infected the liver function starts decreasing all of these molecules can come into the actual circulation into the central nervous system and

what are their symptoms initially fever nausea vomiting electro abnormalities maybe some weight loss some general malaise and you know what else it's also going to alter the gi motility downstream so guess what else can happen not only will they have nausea and vomiting they might also have diarrhea so they're going to present with what's called this prodromal phase so this first part here is the first stage of when someone is infected and we call this the prodromal phase okay so this is phase one the prodromal phase is fever general malaise discomfort nausea vomiting some weight

loss and even some diarrhea okay then liver cells continue to get more and more damaged as they get more and more damaged guess what else starts happening inside of these liver cells you guys know that inside of these liver cells there is what's called bilirubin right so you guys remember whenever you have hemoglobin whenever somebody has like you know their heat the red blood cells get broken down hemoglobin can get broken down into heme and then that heme gets broken down into bilirubin but the type of bilirubin it gets broken down into is called unconjugated

bilirubin that unconjugated bilirubin is then taken to the liver where it's supposed to be reacting with an enzyme and this enzyme is called ugt uridine glucoronicile transferase it's supposed to stimulate the conversion of unconjugated bilirubin into bilirubin conjugated bilirubin but now your liver cells are going to start dying and so now this ability for the unconjugated bilirubin to get converted into conjugated bilirubin that's going to decrease some of the cells might still be able to do this but some of the cells might not be able to and again what happened these cells are going to

start lysing and dying and whenever they start lysing and dying what comes out of these cells both of these things unconjugated bilirubin and conjugated bilirubin so now let's bring over the unconjugated bilirubin that's going to increase in the blood let's bring over the conjugated bilirubin that's going to start increasing into the blood as well and if you want to be specific here's something you got to really think about whenever somebody has inflammation of the liver this biliary system is in the liver so sometimes when there's liver damage there's also this colon stasis-like effect and what

that means is that some of enzymes and some of the molecules that's present inside of this actual biliary system can back up and one of those is the other point which is your bile salts so your bile salts are bile acids and these can also kind of accumulate in the blood so you might also get an accumulation of bile salts or bile acids they're the same thing really and what happens with this their concentration the bilirubin concentration in the blood starts increasing so much that it can start to deposit into certain tissues one of the

areas that it deposits in is into this tissue of the eye the sclera it really loves to deposit into the area of the sclera and what happens is it gives the sclera a different type of color and it's kind of like a yellowish discoloration so they get a yellow sclera and we call a yellow sclera we call it ecterus so icterus is the yellowish discoloration of the sclera that's one thing the next thing is that this conjugate of bilirubin and unconjugated bilirubin also start to deposit into the tissues the thick skin so palms of the

hand soles of the feet and when it starts depositing into the skin it gives a discoloration to the skin and this is going to be more commonly in the palms of the hand so two areas palms and soles and this is going to cause a yellowish discoloration of the skin in this area and again we're going to call this that jaundice type of effect right so jaundice like effect another thing remember your kidneys your kidneys are responsible for excreting bilirubin but they only excrete conjugated bilirubin okay now if your liver cells are dying you're getting

an increase in the conjugated bilirubin in the blood that means more conjugated bilirubin is going to the kidneys that means the kidneys are filtering more of this conjugated bilirubin if you have a lot of conjugated bilirubin in the urine guess what that means it's going to give the urine a darker type of appearance so now the urine is going to have a dark urine appearance so that's one thing so first thing you get the flu-like symptoms secondly over a period of time after the liver continues to get damaged bilirubin levels in the blood particularly conjugated

and unconjugated start to accumulate sometimes greater than two we say it deposits in the sclera causing icterus deposits in the skin thick skin palms in the hands soles of the feet causing this jaundice-like appearance and a lot more of it gets excreted through the kidneys specifically the conjugated bilirubin and that causes this dark current appearance last thing that you also have to understand here with this phase is that if the liver activity is decreasing right so the liver isn't actually producing a lot of the normal things it happens to produce which is one of those

things is bile if there is a decrease in the biliary production right so less bile that means within bile remember what's one of the components of bile bilirubin right if your liver isn't producing bile there's a decrease in bile that means that there's a decrease in the concentration of bilirubin and again what happens is if you guys remember bilirubin once inside of the actual the gut it gets broken down by bacteria into what's called euro bolenogen and then urabilinogen is further broken down by bacteria into what's called sterco billin now why is that important if

you have decreased bile because the liver is failing that means that you get decreased bilirubin in the actual intestines less bacteria break down the bilirubin into urobilinogen if you have less urobilinogen broken down by bacteria you have less stercobilin and that means that you have less cerebral belly guess what stercobilin is it gives that brownish pigmentation to the stool so if you have decrease in circle building guess what that indicates you're going to have what's called clay colored so clay colored or they also call it a colic because you're you're have you're not you don't

have bile salts within it or you don't have this bile within it a colic or clay colored stools basically they're going to be pale they're not going to have to pigmentation to it so to summarize this phase here in this next phase you get clay colored stools you get yellowish discoloration of the sclera you get a yellowish discoloration of the skin or this jaundice-like effect palms with hand soles of the feet you get dark colored urine and one more thing if the liver is getting damaged that's inflammation as a response to inflammation a lot of

immune system cells a lot of blood flow is going to come to the area and the liver is going to get inflamed so one more thing that you also want to remember over here and we'll just kind of draw another liver just for the sake of this phase here is the liver is going to start increasing in size and so we'll put like little will make this like it's inflamed okay and they call this hepato and hepatomegaly produces pain where is it where's the liver in the right upper quadrant okay so that's called right upper

quadrant abdominal pain so it'll produce right upper quadrant abdominal pain all right this phase where you see the jaundice right upper quadrant abdominal pain dark urine and acolytic stools this phase is called the ectaric phase okay it's called the icteric phase another thing that starts happening here is as your liver continues to get damaged what is also inside of these cells remember those enzymes those liver enzymes so as your cells continuously get beat up and they start popping and releasing out all these different contents like the bilirubin guess what else starts leaking out other enzymes

know note other enzymes start accumulating inside of the blood ast again that's an indicator of liver damage what else starts accumulating alt starts accumulating also remember right next to these hepatocytes within the liver is actually going to be your biliary circulation and so whenever the liver is damaged the biliary circulation will also subsequently be damaged so guess what else is going to increase a little bit there's enzymes in this alk-phosphatase okay alkaline phosphatase ggt that is also going to increase a little bit what else you know your liver makes clotting proteins so it makes so

many different types of clotting proteins right so what happens if you decrease the number of clotting proteins well it depends right clotting proteins there's two pathways there's an intrinsic pathway that we use them for and there's an extrinsic pathway remember if you decrease clotting proteins you decrease the proteins in the intrinsic pathway and you decrease the proteins in the extrinsic pathway what specific test monitors the activity of the intrinsic pathway it's the ptt and what happens is if you have less proteins to cause a clot the time it takes for it to bleed i mean

the time it takes for the clot to form is going to increase so your ptt is going to increase extrinsic if you have less proteins for that how it's going to take so long because you don't have enough proteins to cause a clot so the time it takes for it to clot is going to increase this is your pt or your inr oh man so what does that mean you get an increase in your pt inr with this ectaric phase you get an increase in the ptt you get an increase in all of these liver

enzymes you get an increase in this bilirubin oh my gosh there's so many things that happen in the ectaric phase another thing to finish off how this can happen here sometimes in certain situations particularly hepatitis b virus and hepatitis c virus they can also cause infections of other tissues besides these ones so what happens is the viruses can cause what happens is imagine here you have the virus right and your body is gonna try to produce uh immune system like reaction to it right so your plasma cells if you guys remember your plasma cells they're

going to produce antibodies against this virus what happens is these antibodies and the virus combine together and they make an immune complex and these immune complexes get deposited into various different tissues which causes an immunological reaction and a lot of inflammation so what are the some of the tissues that it can get deposited into it can get deposited into the synovial joints and cause arthritis different types of inflammatory arthritis it can get deposited into the blood vessels walls and cause a specific type of vasculitis one of the more common ones especially with hbv is polyarteritis

nodosa and again you see this more with hbv the immune complexes can also deposit into the pericardium or into the myocardium of the heart and what can this cause this can cause myocarditis and pericarditis they can also deposit into the glomerular basement membrane of the kidney and cause glomerulonephritis so there is two types it's called membranous glomerulonephropathy and membranoproliferative glomerular nephropathy so those are the two types it can cause but again one of the things that you want to remember with all of these is you see this more common with hep b and hep c

another thing is that guess what these anti these little complexes can also bind to platelets they can bind with red blood cells and they can also affect your uh grant your granulocytes okay your neutrophils and so it can decrease your platelets what is that going to call it what's that called that's called thrombocytopenia it can decrea it can cause destruction of your red blood cells that's called hemolytic anemia it can decrease the number of neutrophils that's called neutropenia but it can do one more thing whenever you have a viral infection what do we say it

increases it does just don't forget this one it does in situations where you have a viral infection it increases your lymphocytes so whenever you have a viral infection if you did a cbc with a diff you would find that they have an increase in lymphocytes and if you did a blood smear you'd look at the lymphocytes would be huge they call it atypical lymphocytes but you'll see a drop in neutrophils you might see a hemolytic anemia and you might see a drop in platelets but these are some of the extra hepatic manifestations so to kind

of summarize these different phases remember first phase that you have whenever the liver cells are infected is the prodromal phase that's when you start showing these signs of like the flu-like symptoms right second thing that happens you go through the echteric phase so what happens within the ectaeric phase is you get the hepatomegaly right upper quadrant pain dark urine there's jaundice and then these acolytic stools right the third phase if you guys really want to remember this one is called the third phase is whenever your body starts to resolve the infection so it's called the

convalescent period okay so the convalescent phase and this is very simple it's just you're starting to resolve so what does that mean that means that the flu-like symptoms pretty much are going away the jaundice starts resolving you might not have as much sclero jaundice or ictarus you might not have as much jaundice of the skin the urine might not might stop becoming so dark the hepatomegaly site might start going away the stools might become normal color your liver enzymes might start going down your pt ptt ptinr they might start going down as well your body's

resolving from that infection but don't forget patients with hepatitis b virus and hepatitis c virus they can cause chronic infections for a long time and they can produce damage to other tissues through these immune complexes and again we call this the extra hepatic manifestations okay and again you see this mainly with who you see this mainly with hepatitis b virus so again you see this with hepatitis b virus and hepatitis c virus so these are called your extra hepatic manifestations so i want you to remember that specifically there is one other thing but it's just

simple thing hepatitis c virus hepatitis b virus whenever you it's really weird in really cold temperatures these immune complexes can attack your clotting proteins and enhance clotting and they call it cryoglobu anemia it is another type of extra paddock manifestation but i think that this is good enough to put this point home last thing i want you guys to understand in certain situations again going with the hbv and hcv remember they can cause chronic hepatitis so what is that what does that mean remember we said that these these viruses are infecting the cells right so

it kind of goes like this you have your cells here right so here's going to be a hepatocyte right and then these viruses the hbv virus and the hcv virus they infect these cells and as a result of that infection these cells undergo cell death right now with that there's a couple options we can take this cell death and we can try to undergo after the cell death is occurring we can have a fibrosis process where there's going to be fibrous tissue formation right or we can try to regenerate some of these cells okay so

we can try to do what's called mitosis right and we're going to try to regenerate these cells over time though if you have increased hbv infections and hcv infections you're going to increase the cell death right that increases the level of fibrosis and that increases the number of mitosis that this this actual cell is going to be undergoing what's the problem with that with increasing fibrosis increases the risk of cirrhosis and with increasing mitosis what's the issue whenever you have a lot of replication a lot of replication means what there's a chance for a mistake

within the actual replication process and therefore there's an increased risk of cellular dysplasia and with that cellular dysplasia comes the increased risk of what's called hepatocellular carcinoma cancer so this is the things that you got to worry about when we talk about the chronic infection so this is the the scary thing with the chronic infections but specifically your hepatitis b virus c virus and if you guys really want to remember even the hepatitis d virus but again if someone has hepatitis d virus that means that they have a hepatitis b virus all right engineers so

in this video we covered the types of hepatitis viruses a all the way to e we went into deep pathophysiology and even the viral life cycles we talked about how these viruses can produce multiple different types of clinical manifestations as well as the labs that you can also pick up within this process as well i hope all of this made sense i hope you guys did enjoy and if you guys did please hit that like button comment down in the comment section and please subscribe thank you guys for just being such awesome ninja nerds and

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