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"code": "B19",
"name": "Вирусный гепатит неуточненный",
"icd_name": "Вирусный гепатит неуточненный",
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"age_min": 0,
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"cause": [
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"periodicity": 4,
"slug": "b19_virusnyy_gepatit_neutochnennyy",
"lead": "Нарушение здоровья, относящееся к группе вирусный гепатит",
"description": "Вирусные гепатиты – группа инфекционных заболеваний, вызываемых первично-гепатотропными вирусами, характеризующихся преимущественным поражением печени.",
"etiology": "<p>Гепатит может быть вызван многими причинами, но наиболее часто гепатит вызывается вирусами. На данный момент известно большое количество вирусов, способных вызвать вирусный гепатит: вирус гепатита A, вирус гепатита B, вирус гепатита C, вирус гепатита D, вирус гепатита E, вирус гепатита F и вирус гепатита G, вирусы гепатитов TTV и SEN, цитомегаловирус, вирус Эпштейна — Барр, ВИЧ и другие. Некоторые вирусы, вызывающие вирусный гепатит, недостаточно изучены.</p>\r\n<p>Известны также вирусы гепатитов животных:</p>\r\n<ul>\r\n<li>собак (аденовирус),</li>\r\n<li>мышей (коронавирус),</li>\r\n<li>уток (энтеровирус) и, вероятно,</li>\r\n<li>обезьян (пегивирус).</li>\r\n</ul>\r\n<p>Кроме того, гепатит может вызываться такими вирусами, как вирус желтой лихорадки, герпесвирусы, вирус краснухи, вирусы Коксаки, вирус лихорадки Ласса, вирусы лихорадок Марбург-Эбола и другими.</p>",
"pathogenesis": "<p>Вирусы гепатита попадают в организм разными путями: гепатит А и Е — через загрязненные пищевые продукты и воду; гепатит В — через небезопасную кровь и другие жидкости организма; гепатит С — в основном, через зараженную кровь и гепатит D — в качестве дополнительной инфекции при наличии гепатита В.</p>\r\n<p>Вирусы обладают тропностью к ткани печени, при этом они вызывают острое ее воспаление, повреждение и разрушение печеночных клеток (гепатоцитов), воспалительный отек и снижение функциональной деятельности органа. Недостаточность желчеобразующая функции печени является первопричиной повышенного накопления билирубина в крови (билирубинемии) и, как следствие, желтухи. Поскольку в тканях печени нет болевых рецепторных зон, болевой синдром редко выражен и связан с увеличением печени, растяжении ее хорошо иннервированной капсулы и воспалительными процессами в желчном пузыре.</p>\r\n<p>Хроническое воспаление, как правило, развивается вследствие нелеченного или недостаточно леченного острого гепатита. Нередко хронический гепатит постепенно переходит в цирроз печени.</p>",
"diagnostics": "<p><strong></strong></p>\r\n<p>Диагностика гепатитов осуществляется на основании анамнеза, клинических данных, данных физикального осмотра, функциональных и лабораторных исследований.</p>\r\n<p> </p>\r\n<p>Лабораторные исследования включают: </p>\r\n<ul>\r\n<li>Биохимический анализ крови (повышение уровня печеночно-клеточных ферментов – АЛТ, АСТ; повышение общего билирубина, изменение соотношения прямой и непрямой фракций билирубина);</li>\r\n<li>Общий анализ мочи – появление в моче билирубина, накопление уробилина;</li>\r\n<li>Коагулограмма – оценка свертывающей системы крови;</li>\r\n<li>Тимоловая и сулемовая пробы;</li>\r\n<li>ПЦР-диагностика крови – выявление генома (РНК или ДНК) вируса;</li>\r\n<li>ИФА – выявление в сыворотке крови специфических антител (иммуноглобулинов класса М)</li>\r\n</ul>\r\n<p> </p>\r\n<p>Инструментальные методы диагностики включают:</p>\r\n<ul>\r\n<li>УЗИ органов брюшной полости – отмечают увеличение печени и изменение ее звуковой проницаемости и, кроме этого, отмечают увеличение селезенки и, возможно, расширение полой вены;</li>\r\n<li>Реогепатография(исследование печеночного кровотока), </li>\r\n<li>Гепатохолецистосцинтиография(радиоизотопное исследование желчевыводящих путей), </li>\r\n<li>Пункционная биопсия печени.</li>\r\n</ul>\r\n<p> </p>",
"treatment": "<p>Лечение острого гепатита обязательно проводится в стационаре.</p>\r\n<p>Назначается:</p>\r\n<p>прописывается диета №5, полупостельный режим (при тяжелом течении – постельный);</p>\r\n<p> </p>\r\n<p>Этиотропная терапия</p>\r\n<ul>\r\n<li>Интерферон-а</li>\r\n<li>Индукторы интерферона</li>\r\n<li>Ламивудин</li>\r\n</ul>\r\n<p>Патогенетическая и посиндромная терапия:</p>\r\n<ul>\r\n<li>Интенсивная дезинтоксикационная инфузионная терапия, при необходимости экстракорпоральная детоксикация;</li>\r\n<li>Желчегонные препараты или тюбажи по Демьянову;</li>\r\n<li>Ферментные препараты;</li>\r\n<li>Гепатопротективные препараты;</li>\r\n<li>Глюкокортикоиды;</li>\r\n<li>Ингибиторы протеолиза;</li>\r\n<li>Поливитамины, витамино-минеральные комплексы, фитотерапия.</li>\r\n</ul>\r\n<p>Хорошие результаты по улучшению общего состояния при выраженной гипоксии дает кислородотерапия, оксигенобаротерапия. Если присутствуют признаки геморрагического диатеза, назначают витамин К внутривенно.</p>",
"prevention": "<p>Первичная профилактика вирусных гепатитов – соблюдение гигиенических предписаний, осуществление санитарно-эпидемических мер, санитарный надзор над предприятиями, могущими стать очагом распространения инфекции, вакцинация. Профилактикой других форм гепатитов является избегание действия гепатотравмирующих факторов – алкоголя, лекарственных средств, токсических веществ.</p>\r\n<p>Вторичная профилактика хронического гепатита заключается в соблюдении диеты, режима, врачебных рекомендаций, регулярном прохождении обследования, контроле клинических показателей крови. Больным рекомендовано регулярное санаторно-курортное лечение, водолечение.</p>\r\n<p> </p>\r\n<p> </p>",
"clinical_picture": "<p>Выделяют две основные формы клинического течения гепатитов: острую и хроническую.</p>\r\n<p>Острая форма течения наиболее характерна для гепатитов вирусной природы. Иногда начало гепатита напоминает грипп: с повышением температуры тела, головной болью, общим недомоганием, ломотой в теле. Как правило, это — так называемая «маска» начинающегося вирусного гепатита, характеризующаяся слабостью.</p>\r\n<p>При острой форме развития гепатита наблюдается заметное ухудшение общего состояния больного, развития признаков общей интоксикации организма и нарушения функции печени (повышение температуры тела, в ряде случаев развитие желтухи и др.), а также повышение уровня печеночных ферментов (трансаминаз) и общего билирубина крови. Моча темнеет, при выраженных нарушениях синтеза желчных кислот кал теряет цвет, становится беловато-глинистым.</p>\r\n<p>Больные могут отмечать такие симптомы, как кожный зуд, возникновение на коже красных точек – петехий, брадикардию, невротические симптомы.</p>\r\n<p>Острый гепатит, как правило, заканчивается полным выздоровлением больного, однако в некоторых случаях наблюдается переход острого течения болезни в хроническое.</p>\r\n<p>Клиническая картина при хроническом гепатите бедная, заболевание долгое время протекает бессимптомно. Хронический гепатит характеризуется постепенным развитием следующих клинических синдромов:</p>\r\n<ul>\r\n<li>астеновегетативный (слабость, повышенная утомляемость, расстройства сна, психическая лабильность, головные боли – обусловлен интоксикацией организма в связи с нарастающей печеночной недостаточностью;</li>\r\n<li>диспепсический (тошнота, иногда - рвота, понижение аппетита, метеоризм, поносы, чередующиеся с запорами, отрыжка горечью, неприятный привкус во рту) связан с нарушениями пищеварения в связи с недостаточностью выработки печенью необходимых для пищеварения ферментов и желчных кислот);</li>\r\n<li>болевой синдром (боль постоянного, ноющего характера локализуется в правом подреберье, усиливается при физических нагрузках и после резких нарушений диеты) – может отсутствовать или выражаться в умеренном ощущении тяжести в эпигастрии;</li>\r\n<li>субфебрилитет (умеренное повышение температуры до 37,3 – 37,5 градусов может держаться по нескольку недель);</li>\r\n<li>телеангиэктазии (сосудистые звездочки на коже) на шее, лице, плечах;</li>\r\n<li>геморрагический (петехии, склонность к образованию синяков и кровоподтеков, носовые, геморроидальные, маточные кровотечения) связан с понижением свертываемости крови вследствие недостаточного синтеза факторов свертываемости в клетках печени;</li>\r\n<li>желтуха – наиболее известный симптом, возникает, когда билирубин, не переработанный в печени, попадает в кровь и придаёт коже характерный желтоватый оттенок. Однако часто бывают и безжелтушные формы гепатита;</li>\r\n<li>увеличение печени, может сочетаться с увеличением селезенки.</li>\r\n</ul>\r\n<p> </p>",
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},
"code": "B18",
"name": "Хронический вирусный гепатит",
"icd_name": "Хронический вирусный гепатит",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
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],
"periodicity": 4,
"slug": "b18_hronicheskiy_virusnyy_gepatit",
"lead": "Клинико-морфологический синдром, который вызывается различными причинами и характеризуется определенной степенью некроза гепатоцитов и воспаления.",
"description": "Хронический вирусный гепатит — это воспалительный дистрофически-пролиферативный процесс в печени, генетически детерминированный дефицитом клеточного и макрофагеального звеньев иммунитета, длительно протекающий (более 6 месяцев), клинически проявляющийся астеновегетативным и диспептическим синдромами, стойкой гепатоспленомегалией, нарушением функции печени, гиперферментемией и диспротеинемией.",
"etiology": "<p>Установлена этиологическая связь хронического вирусного гепатита с острыми вирусными гепатитами В, С, D, F и G. При этом ведущее значение в формировании хронического процесса, как правило, принадлежит легко протекающим желтушным, безжелтушным и субклиническим формам острых вирусных гепатитов В, С, D, F и G с затяжным течением. Развитию хронического вирусного гепатита способствуют такие неблагоприятные факторы, как поздняя госпитализация больных с острым гепатитом, неправильное лечение, преждевременная выписка, отягощенный преморбидный фон, наличие сопутствующих и хронических заболеваний, употребление алкоголя, наркотиков, а также суперинфицирование другими гепатотропными вирусами, в частности дельта-вирусами при НВV-инфекции.</p>\r\n<full></full>\r\n<p><br /><br />Хронический гепатит С с большой частотой (до 90 %) формируется из острого вирусного гепатита. Важной особенностью вируса гепатита С является его способность к персистенции в организме и индуцированию хронического гепатита.<br /><br />Хронический гепатит D формируется в результате суперинфекции вирусом дельта-носителей НВV и больных хроническим гепатитом В.<br /><br />Ведущим механизмом поражения печени при хроническом вирусном гепатите является взаимодействие иммунокомпетентных клеток с вируссодержащими гепатоцитами. У больных с хроническим вирусным гепатитом отмечается иммунного ответа, в результате чего процесс распознавания антигенов на поверхности гепатоцитов и их элиминация нарушается и порой становится невозможной.<br /><br />Хронический вирусный гепатит вследствие недостаточности макрофагальной защиты и формируется в следующих условиях.<br /><br />I. Дефицита Т-системы иммунитета:<br /><br />— снижения уровня Т-лимфоцитов;<br /><br />— дисбаланса иммунорегуляции субпопуляций Т-хелперов и Т-супрессоров;<br /><br />— слабой сенсибилизации к антигенам вирусов.<br /><br />II. Депрессии макрофагов (снижения их функциональной активности).<br /><br />III. Ослабления системы интерфероногенеза.<br /><br />IV. Действия эффекторных клеток на мембраны гепатоцитов с экспрессией вирусных антигенов, а также печеночно-специфического липопротеина.<br /><br />V. Отсутствия эффективного специфического антителогенеза по отношению к антителам вирусов.<br /><br />VI. Активизации процессов перекисного окисления липидов и лизосомных протеаз.<br /><br />VII. Включения печени в аутоиммунный процесс.<br /><br />При различных формах хронического вирусного гепатита определяются особенности иммунологического реагирования.<br /><br />Хронический вирусный гепатит с минимальной степенью активности (хронический персистирующий вирусный гепатит) возникает в условиях генетически обусловленного слабого иммунного ответа. Все показатели клеточного звена иммунитета (Т-лимфоциты, Т-хелперы, Т-супрессоры, Т-киллеры и др.) пропорционально снижены, что затрудняет элиминацию вируссодержащих гепатоцитов. В печени воспалительные изменения слабо выражены.<br /><br />Хронический вирусный гепатит с низкой, умеренной и выраженной степенью активности (хронический активный вирусный гепатит со слабой, умеренной и выраженной степенью активности) развивается в условиях резчайшего дисбаланса иммунной регуляции. Наблюдается снижение Т-супрессоров при относительно неизменном уровне Т-хелперов, что приводит к активности В-клеток и выработке большого количества глобулинов. Избыток противовирусных антител способствует усилению цитотоксических реакций и в конечном итоге приводит к иммунокомплексному поражению печени. Липопротеиновые мембраны гепатоцитов приобретают свойства чужеродного антигена, индуцирующего атаку Т-киллеров, что может закончиться лизисом клеток-мишеней, т.е. паренхимы печени.<br /><br />Наиболее часто хронический вирусный гепатит протекает с преобладанием цитолитического синдрома (синдром интоксикации в клинике, повышение активности АлАТ, снижение протромбинового индекса, диспротеинемия). Реже диагностируются холестатический синдром ( кожи, повышение активности щелочной фосфатазы, ГГТП и уровня билирубина в крови, при этом активность АлАТ повышается в меньшей степени) и аутоиммунный (астеновегетативный синдром, артралгии, внепеченочные проявления, диспротеинемия, повышение активности АлАТ, гипергаммаглобулинемия, ЦЦК, наличие разного рода аутоантител).</p>",
"pathogenesis": "<p>Характер клинической симптоматики при хронических вирусных гепатитах зависит от степени активности воспалительного процесса в печени и длительности течения заболевания.<br /><br />Часто выявляется астеновегетативный синдром. Дети и взрослые обычно жалуются на повышенную \"> и , более выраженную при ходьбе, особенно после тяжелых физических нагрузок; становятся раздражительными, эмоционально лабильными, нередко агрессивными по отношению к близким. В части случаев наблюдаются \">, , , повышенная \">, . Особенностью интоксикации у детей при хроническом вирусном гепатите является ее нерезкая выраженность.<br /><br />Диспептический синдром при хроническом вирусном гепатите возникает как в связи с функциональной неполноценностью печени, так и в связи с весьма частым поражением желчевыводящих путей, гастродуоденальной зоны и поджелудочной железы. Отмечается чувство тяжести в правом подреберье и эпигастральной области, и , \">, и непереносимость жирных блюд. Вместе с тем ухудшение аппетита наблюдается лишь у небольшого числа больных.</p>\r\n<full></full>\r\n<p><br /> не относится к числу характерных для хронического вирусного гепатита симптомов. Заболевание, как правило, протекает без нарушений билирубинового обмена. Лишь у отдельных больных может отмечаться субиктеричность или легкая иктеричность склер, однако в особо тяжелых случаях хронического вирусного гепатита с переходом в цирроз становится постоянным симптомом, являясь проявлением печеночно-клеточной недостаточности. Синдром желтухи наблюдается также при редком варианте хронического процесса — хроническом холестатическом гепатите. У этих больных выраженность желтухи варьируется от легкой до интенсивной и может носить застойный характер, при котором цвет кожи со временем приобретает зеленовато-желтый оттенок.<br /><br />Геморрагический синдром отмечается у половины больных. Он характеризуется кожными кровоизлияниями в виде синяков, носовыми кровотечениями, петехиальными высыпаниями. Синяки чаще обнаруживаются на конечностях и на туловище. Носовые кровотечения весьма непродолжительны и спонтанно прекращаются. Петехиальные сыпи необильные и локализуются на коже лица, шеи, туловища, реже — конечностях. Геморрагические проявления обусловлены снижением синтеза протромбина и других факторов свертывания крови, в частности тромбоцитопенией.<br /><br />Сосудистые проявления (так называемые внепеченочные знаки) встречаются у 70 % больных. К ним относятся телеангиэктазии (сосудистые звездочки), капилляриты и пальмарная . Размер сосудистых звездочек колеблется от 1 до 10 мм в диаметре. Количество и величина их тем больше, чем тяжелее поражение печени. Капилляриты, или расширение капилляров, чаще выявляются на щеках и в межлопаточной области и реже на всей грудной клетке. Помимо капилляритов, порой диагностируется усиленный сосудистый рисунок (расширение вен) на груди.<br /><br />Механизм возникновения сосудистых знаков связывают с обменными нарушениями в печени и циркуляцией избыточного количества биологически активных веществ (кининов, простогландинов и др.) вследствие недостаточной инактивации их в печени. Активные гуморальные факторы вызывают периферическую вазодилатацию и открытие артериовенозных шунтов. Пальмарная (печеночные ладони) наиболее характерна для больных с умеренной и выраженной степенью активности хронического вирусного гепатита. Она выражается симметричным мелкопятнистым (иногда точечным) покраснением ладоней и подошв, более значительным в области тенара и гипотенара. Появление пальмарной эритемы связано с микроциркуляторными нарушениями.<br /><br /> — главный симптом заболевания. Она может быть единственным клиническим признаком хронического вирусного гепатита. Печень пальпируется из-под реберного края в пределах от 0,5 до 8 см, а верхняя граница перкуторно определяется в VI—IV межреберьях.<br /><br />Консистенция органа варьируется от плотноэластической до плотной в зависимости от степени активности хронического вирусного гепатита и стадии процесса (обострение или ремиссия). У многих больных отмечается чувствительность и даже болезненность печени, особенно в периоде обострения заболевания, а также при наличии воспалительных изменений со стороны желчевыводящих путей. Поверхность органа обычно гладкая, край закругленный или острый. В большинстве случаев отмечается равномерное увеличение правой и левой долей печени.<br /><br /> типична для хронического вирусного гепатита, но не столь постоянна, как . Поэтому отчетливый гепатолиенальный синдром наблюдается не у всех больных, с большей закономерностью проявляясь при умеренно выраженной степени активности хронического вирусного гепатита. Селезенка может выступать из подреберья на 0,5—5 см и больше, имеет плотноэластическую или плотную консистенцию с ровной поверхностью. В период обострения хронического вирусного гепатита гепатолиенальный синдром обнаруживается наиболее часто.<br /><br />Хронический гепатит В большей частью имеет клинически сглаженное малосимптомное течение. Диагноз нередко первично устанавливают на основании результатов лабораторных исследований (повышение уровня АлАТ, определение маркеров НВV) и биопсии печени.<br /><br />Отличительной особенностью хронического гепатита С является торпидное, латентное или малосимптомное течение; большей частью в течение длительного времени инфекционный процесс остается нераспознанным. Заболевание постепенно прогрессирует с дальнейшим бурным развитием цирроза печени и/или первичной гепатокарциномы.<br /><br />Существуют печеночные и внепеченочные проявления хронической HCV инфекции:<br /><br />— эндокринные — гипертиреоз, гипотиреоз, тиреоидит Хашимото, сахарный диабет;<br /><br />— гематологические — смешанная криоглобулинемия, идиопатическая тромбоцитопения, неходжкинская В-лимфома, макроглобулинемия Вальденстрема, апластическая анемия;<br /><br />— поражение слюнных желез и глаз — лимфоцитарный сиалоаденит, язвы роговицы, увеит;<br /><br />— кожные — кожный некротизирующий васкулит, поздняя кожная порфирия, красный плоский лишай, мультиформная , узловатая , лейкоплакия, крапивница;<br /><br />— нейромышечные и суставные — миопатический синдром, периферическая полинейропатия, синдром Гийена—Барре, артриты, артралгии;<br /><br />— почечные — гломерулонефрит;<br /><br />— аутоиммунные и другие — узелковый периартериит, интерстициальный легочный фиброз, легочный васкулит, гипертрофическая кардиомиопатия, CRST-синдром, антифосфолипидный синдром, аутоиммунный гепатит 1 и 2 типа, синдром Бехчета, дерматомиозит.<br /><br />Хронический гепатит D является основной формой болезни при НДV/НВV-суперинфекции и может протекать от клинически бессимптомной формы до манифестной, нередко быстрым прогрессирующим течением.<br /><br />Вирусоносители в подавляющем большинстве случаев оказываются больными хроническим вирусным гепатитом, причем нередко в фазе репликации.<br /><br />Клиническая симптоматика хронического вирусного гепатита во многом зависит от репликативной активности вирусов и выраженности воспалительного процесса в печени.</p>",
"diagnostics": "<p style=\"padding-bottom: 19px;\" align=\"justify\">Диагноз хронического вирусного гепатита устанавливается при длительно текущем (свыше 6 месяцев) инфекционном процессе, вызванном вирусами гепатита В, С, D, F, G; наличии гепатоспленомегалии, астенического, диспепсического и геморрагического синдромов.</p>\r\n<p style=\"padding-bottom: 19px;\" align=\"justify\">С целью верификации формы заболевания проводится определение маркеров вирусных гепатитов методом ИФА, обнаружение РНК вирусов с помощью ПЦР-диагностики. Из биохимических показателей функции печени наибольший интерес представляет исследование АлАт и АсАТ, щелочной фосфатазы (ЩФ), гамма-глутамилтранспептидазы (ГГТ), лецитинаминопептидазы (ЛАП), сывороточной холинэстеразы (ХЭ), лактатдегидрогеназы (ЛДГ), билирубина, холестерина и др., позволяющих судить о степени повреждения паренхимы печени при хроническом вирусном гепатите. С целью оценки состояния гемостаза производится исследование коагулограммы, определение количества тромбоцитов.</p>\r\n<p style=\"padding-bottom: 19px;\" align=\"justify\">УЗИ печени позволяет увидеть изменения печеночной паренхимы (, , склерозирование и пр.). С помощью реогепатографии изучается информация о состоянии внутрипеченочной гемодинамики. Проведение гепатосцинтиграфиипоказано при признаках цирроза печени.</p>\r\n<p style=\"padding-bottom: 19px;\" align=\"justify\">Биопсия печени и морфологическое исследование биоптата выполняется на заключительном этапе обследования для оценки активности хронического вирусного гепатита.</p>",
"treatment": "<p style=\"padding-bottom: 19px;\" align=\"justify\">В стадии ремиссии хронического вирусного гепатита необходимо придерживаться диеты и щадящего режима, проводить профилактические курсы приема поливитаминов, гепатопротекторов, желчегонных средств. Обострение хронического вирусного гепатита требует стационарного лечения.</p><p style=\"padding-bottom: 19px;\" align=\"justify\">Основу базисной терапии хронического вирусного гепатита составляет диетический стол № 5; назначение препаратов, нормализующих кишечную микрофлору; ферментов; гепатопротектор. Целесообразен прием настоев и отваров, обладающих противовирусным (календула, зверобой), спазмолитическим и слабым желчегонным и действием (спорыш, мята).</p><p style=\"padding-bottom: 19px;\" align=\"justify\">При цитолитическом синдроме необходимы внутривенные инфузии белковых препаратов и свежезамороженной плазмы, проведение плазмафереза. Купирование холестатического синдрома проводится с помощью адсорбентов, препаратов ненасыщенных жирных кислот. При аутоиммунном синдроме назначаются иммунодепрессанты, глюкокортикоиды, делагил, проводится гемосорбция.</p><p style=\"padding-bottom: 19px;\" align=\"justify\">Этиотропная терапия хронического вирусного гепатита требует назначения противовирусных препаратов.</p>",
"prevention": "<p style=\"padding-bottom: 19px;\" align=\"justify\">Пациенты с хроническим вирусным гепатитом находятся на пожизненном диспансерном учете у инфекциониста-гепатолога. Неблагоприятное течение хронические вирусные гепатиты приобретают при отягощенном фоне: одновременном инфицировании несколькими вирусами, злоупотреблении алкоголя, наркотической зависимости, ВИЧ-инфекции. Исходом хронических вирусных гепатитов служит цирроз и рак печени.</p><p style=\"padding-bottom: 19px;\" align=\"justify\">Профилактика хронизации инфекционного процесса заключается в выявлении малосимптомных форм вирусного гепатита, проведении адекватного лечения и контроле за реконвалесцентами. Пациенты, перенесшие вирусные гепатиты, должны придерживаться рекомендуемой врачом диеты и образа жизни</p>",
"clinical_picture": "<p>Нередко хронический гепатит протекает бессимптомно несколько лет, постепенное перерождение печени приводит к ухудшению самочувствия: появляются диспептические нарушения, , , боли в правом подреберье, иногда возникает , селезенка увеличена, нередко имеет место анемия (так как печень принимает участие в кроветворении).</p>",
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"code": "B17.2",
"name": "Острый гепатит E",
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"description": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Вирусный гепатит Е – это заболевание печени, возбудителем которого является вирус гепатита Е, с фекально-оральным механизмом передачи.</span></p>",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Главная причина заражения – употребление сырой воды, в которую попали фекалии больного человека. Реже отмечаются случаи, когда вирус проникает в организм через плохо обработанное мясо животных или сырых моллюсков, обитающих в пресной воде. Их способность переносить вирус и служить источником инфекции доказана в ходе многочисленных лабораторных исследований. Переливание зараженной донорской крови здоровому человеку неизменно станет причиной заболевания последнего. Также для вируса характерен трансплацентарный способ передачи вируса от больной матери к плоду. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В единичных случаях возбудитель гепатита Е попадает в организм через грязные руки, плохо вымытые овощи и фрукты.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Наличие в структуре вируса РНК без оболочки делает возбудителя уязвимым для любого температурного воздействия – как переохлаждения, так и нагревания. Условия пребывания в пресной воде для него относительно благоприятны, способствуя интенсивному размножению. Риск заражения повышается вследствие бессимптомного протекания начальных стадий гепатита Е. Человек, не ощущающий признаков патологии, ведет привычный образ жизни, но его фекалии содержат значительное количество возбудителя и способны стать причиной заражения другого человека.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Входные ворота инфекции — рот. Оттуда вирус попадает в тонкий кишечник, в котором происходит первичное размножение возбудителя. После вирус попадает в кровь и мигрирует в печень. Там он связывается со специфическими рецепторами на поверхности гепатоцитов — основных клеток печени — и проникает внутрь них.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Во время своей жизни вирус напрямую провоцирует дегенеративные изменения в гепатоцитах, в т.ч. вызывая их гибель по типу баллонной дистрофии — переполнение клетки жидкостью. После этого готовые вирусные частицы распространяются и заражают новые здоровые клетки.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">С высокой степенью точности установить наличие в организме вируса гепатита Е позволяют такие формы лабораторных и инструментальных исследований, как:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">анализ крови на специфические иммуноглобулины IgM и IgG;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">ПЦР-реакция для обнаружения следов РНК вирусной инфекции;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">коагулограмма для уточнения параметров свертываемости крови;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">печеночные пробы;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">ультразвуковое и магнитно-резонансное исследование печени.</span></li>\r\n</ul>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Лечение легкой и среднетяжелой формы больных с вирусным гепатитом Е производят в инфекционных отделениях стационара, назначается диета (показан стол №5 по Певзнеру - щадящая диета с пониженным содержанием жирных кислот и богатая клетчаткой), обильное питье. Симптоматическая терапия (спазмолитические, антигистаминные средства) по показаниям. При необходимости производится оральная дезинтоксикация раствором 5% глюкозы.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При тяжелом течении больные лечатся в отделении интенсивной терапии, производится инфузионная дезинтоксикационная терапия (солевые растворы, глюкоза, электролитные смеси), ингибиторы протеаз, по показаниям вводят преднизолон. При угрозе развития геморрагического синдрома назначается пентоксифиллин, этамзилат. При массивных внутренних кровотечениях – переливают плазму, тромбоцитарную массу.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Особое внимание уделяется лечению беременных женщин. Вопрос о преждевременном родоразрешении решается индивидуально, нередко принимаются меры к экстренному прерыванию беременности.</span></p>",
"prevention": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Риск инфицирования и передачи инфекции можно снизить с помощью следующих мер:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">поддержание высоких стандартов общественного водоснабжения;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">создание надлежащих систем утилизации санитарных отходов.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">На уровне отдельных людей риск инфицирования можно снизить с помощью следующих мер:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">соблюдение гигиены, такой как мытье рук безопасной водой, особенно перед обращением с пищевыми продуктами;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">воздержание от употребления питьевой воды и/или льда неизвестной чистоты;</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">соблюдение безопасных методов ВОЗ в отношении пищевых продуктов.</span></li>\r\n</ul>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Для заболевания характерен продолжительный инкубационный период, когда патология ничем не выдает своего присутствия в организме. В некоторых случаях симптомы не проявлялись в течение 50-70 дней после факта заражения. У детей признаки заболевания выражены слабо, у пациентов молодого и среднего возраста они чаще очевидны. В числе наиболее характерных симптомов так называемого преджелтушного периода – слабость, снижение аппетита и тошнота. В следующей, желтушной фазе пациенты жалуются на:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">повышение температуры тела до 38 градусов;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">болезненность области желудка и правого подреберья;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">окрашивание слизистой и кожных покровов в желтушный оттенок;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">потемнение мочи и осветление стула.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Гепатит Е при пальпации отмечается увеличение размеров и смягчение структуры печени. Если заболевание протекает в тяжелой форме, возможно появление признаков внутреннего кровотечения, следы крови в моче, симптомы кровотечений в полости матки и органов системы ЖКТ. Спустя несколько недель все перечисленные факторы сходят на нет, а нормальные показатели лабораторных анализов отмечаются спустя месяц или два после заражения.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Если вирус гепатита Е атаковал организм человека с ослабленным иммунитетом, в числе характерных симптомов присутствует чувство сухости во рту, апатичное состояние, непродолжительная боль в затылочной части головы. В течение так называемого продромального периода между инкубацией и основной стадией больной может отмечать:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">проблемы с ориентацией в пространстве;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">тремор, постоянное замерзание;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">чувство агрессии или подавленность;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">ухудшение умственной деятельности;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">колебания температуры тела;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">нарушения сна, бессонницу.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">На клинической стадии гепатита Е отмечаются все признаки поражения печени: увеличение размеров органа, нарушения стула с изменением его окраски, чувство тяжести и вздутия живота, желтушность кожи. У пациента пропадает аппетит, отмечается боль в правом подреберье и потемнение мочи.</span></p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"image": null,
"image_alt": null,
"standard_type": 0,
"danger": 50,
"published": 1,
"parent": 6110,
"block_rubric": 12,
"standards": []
}
]
}
