Hepatitis

Question 1

What is hepatitis?

Answer 1

Inflammation of the liver

Varies from a chronic low level inflammation to acute and severe inflammation that leads to large areas of necrosis and liver failure

Question 2

Caues of hepatitis (5)

Answer 2

Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)

Question 3

How does hepatitis present?

Answer 3

Abdominal pain
Fatigue
Pruritis (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever (viral hepatitis)

Question 4

What does hepatitis show on LFTs?

Answer 4

Deranged with high transaminases (AST/ALT)

Proportionally less of a rise in ALP

Bilirubin can also rise as a result of inflammation in liver cells

Question 5

What are transaminases?

Answer 5

Liver enzymes that are released as a result of inflammation

Question 6

Types of hepatitis and transmission

Answer 6

Hep A - faecal-oral
Hep B - blood or bodily fluids (vertical transmission)
Hep C - blood and body fluids
Hep D - (Hep B)
Hep E -  faecal oral route

Question 7

Hepatitis A

Answer 7

Presents with nausea, vomiting, anorexia and jaundice
Can cause cholestasis with dark urine and pale stools and moderate hepatomegaly

Resolves without treatment in 1-3 months

Management - analgesia
(notifiable to Public Health)

Question 8

How is Hep B transmitted?

Answer 8

Blood or bodily fluids

Sexual intercourse
Sharing needles (IVDU, tattoos)
Contact between cuts
Vertical transmission

Question 9

How may people get chronic hepatitis B?

Answer 9

Most recover within 2 months

10% become chronic hepatitis B carriers
Virus DNA has integrates into patients DNA - they continue to produce the viral proteins

Question 10

Which viral marker signals active infection?

Answer 10

Surface antigen (HBsAg)

Question 11

Which viral marker implies past or current Hep B infection?

Answer 11

Core antibodies (HBcAb)

IgM implies an active infection (high titre with an acute infection and a low titre with a chronic infection)

IgG indicates a past infection where the HBsAg is negative

Question 12

Which viral marker implies vaccination, past, or current Hep B infection?

Answer 12

Surface antibody (HBsAb)

Demonstrates an immune response to HBsAg

Question 13

What is E antigen (HBeAg)?

Answer 13

Marker of viral replication and implies high infectivity
Positive in acute phase

When they HBeAg is negative but the hepatitis B e antibody is positive this implies virus was replicating but now stopped replicating and they are less infectious (immune response)

Question 14

What is the management for hepatitis B? (8)

Answer 14

Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases

Refer to gastro, hepatology or infectious diseases for specialist management

Notify Public Health (it is a notifiable disease)

Stop smoking and alcohol

Education about reducing transmission and informing potential at risk contacts

Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Antiviral medication can be used to slow the progression of the disease and reduce infectivity

Liver transplantation for end-stage liver disease

Question 15

How may people get chronic hepatitis B?

Answer 15

1 in 4 makes a full recovery

3 in 4 progress to chronic

Question 16

How do you test for Hep C?

Answer 16

Hepatitis C antibody is the screening test

Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype

Question 17

What is the management of Hepatitis C?

Answer 17

Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases

Refer to gastro, hepatology or infectious diseases for specialist management

Notify Public Health (it is a notifiable disease)

Stop smoking and alcohol

Education about reducing transmission and informing potential at risk contacts

Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype. They successfully cure the infection in over 90% of patients. They are typically taken for 8 to 12 weeks

Liver transplantation for end-stage liver disease

Question 18

What medication is available for hep b?

Answer 18

Peginterferon alfa-2a
Injection once a week for 48 weeks

Antiviral medicines - enofovir or entecavir

Question 19

What is autoimmune hepatitis?

Answer 19

Rare cause of chronic hepatitis

Could be associated with a genetic predisposition and triggered by environmental factors e.g viral infection that causes a T cell-mediated response against the liver cells

Question 20

Types of autoimmune hepatitis?

Answer 20

Type 1: occurs in adults

Typer 2: occurs in children

Both diagnosed by liver biopsy

Question 21

Who/How does type 1 autoimmune hepatitis present/effect?

Answer 21

Women in their late forties or fifties around or after the menopause

Fatigue and features of liver disease on examination

Less acute course than type 2

Question 22

Who/How does type 2 autoimmune hepatitis present/effect?

Answer 22

Teenage or early twenties present with acute hepatitis with high transaminases and jaundice

Question 23

What autoantibodies are associated with type 1 autoimmune hepaititis?

Answer 23

Anti-nuclear antibodies (ANA)

Anti-smooth muscle antibodies (anti-actin)

Anti-soluble liver antigen (anti-SLA/LP)

Question 24

What autoantibodies are associated with type 2 autoimmune hepaititis?

Answer 24

Anti-liver kidney microsomes-1 (anti-LKM1)

Anti-liver cytosol antigen type 1 (anti-LC1)

Question 25

What is the treatment for autoimmune hepatitis?

Answer 25

High dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine, are introduced

Immunosuppressants usually induce remission (usually required life long)

Liver transplant may be required in end stage liver disease (can recur in transplanted livers)