1.8.3-5 Hepatitis

Question 1

Describe the route of transmission, symptoms, and special details for the following:

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E
• Hepatitis G

Answer 1

• Hepatitis A
  
  • Oral-fecal route, enteral virus
  • Outbreaks from contaminated food and water
  • Sx onset 2-6 weeks
  • Symptoms
    
    • Acute fever, malaise, anorexia, nausea, vomiting, RUQ discomfort
    • Urine dark, light stools, scleral icterus, jaundice
  • Illness duration: 3 wks
  • Mortality: Low
  • Chronicity: None
• Hepatitis B
  
  • Blood borne virus in saliva, semen, vaginal secretions
  • Transmitted by blood, blood products, sex, mother-fetus
  • Sx: like hep A but more insidious onset and more severe process
    
    • Fever - higher
    • Rash
    • 1% risk fulminant hepatic failure
  • Hepatitis C
    
    • Blood borne
      
      • Injection drug, transfusion, txpl, occ exposure needle sticks, iatrogenic, birth-mother, sex, multi sex partners
    • Incubation 5-10wks
    • Acute illness 2-12 wks
    • Carrier state: Yes
    • Chronicity: Yes
    • Severity promoted by:
      
      • Age > 40 at time if infxn
      • HIV co-infection
      • Male gender
      • CHronic HBV co-infection
• Hepatitis D
  
  • Defective RNA virus
  • Causes hepatitis ONLY in conjunction with Hep B
  • IV drug users primarily
  • Chronic Hep B w superinfected Hep D = more often fulminant hepatitis w higher mortality rate
  • Carrier state: Yes
  • Chronicity: Yes
• Hepatitis E
  
  • Oral-fecal waterborne
  • Similar to Hep-A
  • Self-limiting
  • Mexico, India, Afghan, Asia, Africa
  • Carrier: No
  • Mortality: Pregnant women 10-20%
• Hep G
  
  • Flavivirus percutaneously transmitted
  • Chronic viremia for 10 years
  • Present in:
    
    • 50% IV drug users
    • 30% HD patients
    • 20% hemophiliacs
    • 15% co-infected with Hep B/C
  • Liver: Mild disease

Question 2

What are the clinical manifestations of hepatitis?

Answer 2

• Pre-Icteric
  
  • Prodromal phase - days to weeks
  • Constitutional/GI symptoms
    
    • Malaise, fatigue, anorexia, N/V, myalgia, HA
    • Aversion to smoking and EtOH
• Icteric
  
  • Weight loss, jaundice, pruritis, RUQ pain, light stools, dark urine, low grade fever, cough, pharyngitis, hepatosplenomegaly

Question 3

What lab abnormalities would you expect in a patient with hepatitis?

Answer 3

• CBC
  
  • WBC low to normal
• UA
  
  • Proteinuria, bilirubinuria
• AST/ALT
  
  • Elevated 500-2000
  • Rise prior to onset of jaundice
  • Fall after onset of jaundice
• LDH, bili, alk phos, PT, albumin
  
  • Normal or slightly elevated

Question 4

Describe expected serology for Hep A

Answer 4

• Hepatitis A
  
  • Anti-HAV and IgM peak during 1st week of clinical illness and disappear in 3-6 months
  • IgG peaks after 1 month and can persist for years
    
    • Not diagnostic for acute Hep A, but indicates exposure, noninfectivity, and immunity

Question 5

Describe expected serology for Hep B

Answer 5

• Hepatitis B
  
  • HBsAg: first evidence of HBV
    
    • Establishes presence of infxn and infectivity
  • Anti-HBc
    
    • Antibody to Hep B core antigen
    • IgM anti-HBC
  • HBeAg
    
    • Found in HBsAg positive serum
    • Indicates viral replication and infectivity
    • Persists > 3 months: indicates likelihood of developing chronic HBV
  • Anti-HBs: antibody to HBV surface antigen
    
    • Positive in late convalescence
    • Confers immunity
  • HBV DNA - degree of viral replication
    
    • Predicts response to therapy

Question 6

Describe expected serology for Hep C

Answer 6

• Hepatitis C
  
  • Anti-HCV
    
    • Antibody to a group of recombinant HCV peptides
    • Positive - 12 weeks after exposure
    • Persistent in acute, chronic, or past infection
  • HCV-RNA

Question 7

Describe expected serology for Hep D

Answer 7

• Hepatitis D
  
  • Anti-HDV
    
    • IgM or IgG antibody to HDV
    • Acute/chronic infxn
    • Seen with HBsAg
    • Not protective

Question 8

Describe expected serology for Hep E & Hep G

Answer 8

• Hepatitis E
  
  • Anti-HEV (IgM or IgG) - antibody to HEV
• Hepatitis G
  
  • Anti-HGV - antibody to HGV

Question 9

Your patient has hepatitis. What are the key components of management?

Answer 9

• Supportive tx
  
  • Rest, fluids (3-4L per day), high carb low fat diet
• Avoid EtOH and drugs detox’d by liver
• Vit K if PT>15s
• Hep C
  
  • Interferon, 3million units 3x/week for 6 months may decrease risk of chronic Hep C
• Education
  
  • Hygiene, hand washing
• Imunizations
  
  • Hep A and B vax’s

Question 10

What are the most common complications of hepatitis?

Answer 10

• Cholestatic hepatitis
• Fulminant hepatitis
• Chronic hepatitis

Question 11

Your patient has chronic hepatitis - how do you define? What are possible causes?

Answer 11

• Hepatic inflammatory process that does not resolve in 6 months
• Cause:
  
  • Difficult to ID
  • Drug induced vs autoimmune
  • Misdiagnosed cholestatic liver injury
    
    • Primary biliary cirrhosis
    • Primary sclerosing cholangitis
  • Chronic viral hepatitis

Question 12

Your patient has Hepatitis B.

• What do you suspect re: serology?
• What are the phases of Hep B?
• What is the treatment?
• Other recommendations?

Answer 12

• Serology
  
  • HBsAg and HBeAg positive with elevated HBV DNA
    
    • Highly replicative phase
• Phases
  
  • Immune-tolerant phase
    
    • Little hepatic inflammation with normal liver tests
    • Elevated HBV DNA and positive HBV e antigen
  • Immune-Active Phase
    
    • Hepatic inflammation with elevated liver enzymes
    • Decreased HBV DNA compared with immune-tolerant phase
    • Ultimate loss of HBV e antigen and HBV e antibody
  • Inactive Carrier Phase
    
    • Normal LFTs and low HBV DNA levels
  • Reactivation Phase
    
    • Normal/high LFTs
    • High HBV DNA levels
    • Remain HBV e antigen negative OR revert to HBV e antigen positive
• Treatment
  
  • Immune-Tolerant Chronic Hep B
    
    • No antiviral therapy indicated for most
    • Consider antiviral therapy if:
      
      • > 40 years olf
      • Normal ALT
      • Elevated HBV DNA (> 1mil units)
      • Liver biopsy indicates mod-severe necroinflammation or fibrosis
  • Immune-Active Chronic Hep B
    
    • HBeAG-neg or HBeAG-pos
    • Antiviral therapy recommended to reduce risk of liver complications
    • Preferred drugs: Entecavir and Tenofovir
      
      • Peginterferon and nucleoside/nucleotide analogs (NAs)
  • Other Recommendations for HBV positive
    
    • Houshold/sexual contacts vax’d
    • Barrier protection during sex
    • Don’t share toothbrushes, razors, injections, glucose testing
    • Cover open cuts, clean blood w bleach
    • Do not donate fluids
  • Children HBsAG positive
    
    • Can do all activities
    • Do not exclude or isolate

Question 13

Your patient has Chronic Hep C.

• What is risk of cirrhosis?
• What is treatment?
• What is cancer risk?

Answer 13

• 20% Chronic Hep C become cirrhotic
• Treatment
  
  • Glecaprevir 300mg / pibrentasvir 120mg taken with food for 8 weeks
  • Sofosbuvir 400mg / velpatasvir 100mg for 12 weeks
• Hep B and C (chronic) are both at high risk for developing HCC

Question 14

Your patient has EtOH Hepatitis.

• What is defintion?
• Pathology?
• Dx studies?
• Mgmt?

Answer 14

• Liver injury induced by excessive EtOH
  
  • Hepatic toxicity of metabolites
  • Induction of cytochrome P450 and cytokine pathways perpetuate hepatic injury
• Pathology
  
  • Fatty liver
  • EtOH Hepatitis
  • Cirrhosis
• Dx studies
  
  • AST > ALT in 2:1 ratio = EtOH
  • ALT > AST = suggestive of infectious origin
• Mgmt
  
  • High calorie diet
  • Vitamins: Thiamine, Folic Acid
  • Stop drinking
  • Evaluate for cirrhosis