Acute Viral Hepatitis

Question 1

What is hepatitis?

Answer 1

Inflammation of the liver caused by viruses or non-infectious agents

Question 2

What are the 5 viruses that can cause viral hepatitis?

Answer 2

Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E

Question 3

How do we define an acute episode of hepatitis?

Answer 3

Systemic infection present for <6 months (often less than 6 weeks)

Question 4

How do we define when a hepatitis infection has become chronic?

Answer 4

Presence of virus in blood for >6 months

Question 5

What are the symptoms of chronic infections?

Answer 5

Typically asymptomatic (patient unaware) until development of late-stage disease complications
- Ascites
- Encephalopathy

Question 6

How does hepatitis lead to ascites?

Answer 6

Damaged liver is unable to process blood properly. Increased pressure leads to portal hypertension.
Forces fluid to leak out into abdominal cavity.

Question 7

How does hepatitis lead to encephalopathy?

Answer 7

Liver is damaged to the point it can no longer effectively filter toxins like ammonia from the blood.
Toxins accumulate and reach brain (neurological symptoms).

Question 8

Can hepatitis B be cured?

Answer 8

No, hepatitis B cannot be cured.

Question 9

If hepatitis B cannot be cured, how can we have acute infection?

Answer 9

Hepatitis B cannot be can’t be “cured” in the sense that the virus can be completely eradicated, but it can still present as an “acute” infection, meaning the illness has a sudden onset and typically resolves within a short period of time, allowing the body to fight off the virus without long-term damage

Question 10

What is the preferred painkiller in hepatitis B patients?

Answer 10

Tylenol

Question 11

Which two types of hepatitis virus can occur as a co-infection?
Why does this happen?

Answer 11

Hepatitis B and D
Hepatitis D (delta) is a defective virus that requires Hepatitis B to survive.

Question 12

What is a HDV co-infection?
What is a HDV superinfection?

Answer 12

Co-infection: simultaneous infection of HBV and HDV

Super-infection: patient already has chronic HBV, but then HDV infection follows
- exacerbates liver disease, progresses to severe

Question 13

Which virus types are the hepatic viruses?

Answer 13

HAV= RNA
HBV= DNA
HCV= RNA
HDV= RNA
HEV= RNA

Question 14

How is HAV transmitted?

Answer 14

Fecal-oral

Question 15

How is HBV transmitted?

Answer 15

Percutaneous
Sexual
Perinatal

Question 16

How is HCV transmitted?

Answer 16

Percutaneous
Sexual
Perinatal (uncommon)

Question 17

How is HDV transmitted?

Answer 17

Percutaneous
Sexual
Perinatal

Question 18

How is HEV transmitted?

Answer 18

Fecal-oral
Zoonotic
Parenteral
Perinatal

Question 19

Which of the hepatitis viruses can progress from acute to chronic disease?

Answer 19

HAV= No
HBV= Yes (most common in neonates)
HCV= Yes (common)
HDV= common in superinfection and rare in co-infection
HEV= No, unless patient is immunocompromised

Question 20

Which of the hepatitis viruses most commonly progresses from acute to chronic infection?

Answer 20

Hepatitis B
Hepatitis C

Question 21

Why is it the most common for hepatitis C to progress from acute to chronic?

Answer 21

Acute infection is rarely diagnosed and up to 80% become chronically infected

Question 22

Which hepatitis virus has immunization for prevention?

Answer 22

HAV, HBV, HDV (from immunization of B)

Question 23

Since HCV and HEV does not have immunization, what can we do for prevention?

Answer 23

HCV= blood donor screening, risk behaviour modification
HEV= ensure safe drinking water and adequately cooked pork products

Question 24

Most acute infections of hepatitis are asymptomatic, but 25-30% will experience symptoms.

When there are symptoms, they appear to be similar in all types of viruses. What are they?

Answer 24

May include:
- Fever
- Myalgias
- Arthralgias
- Headache
- Constant Fatigue
- Right upper quadrant pain
- Jaundice
- Dark-urine
- Clay coloured stools
- Tender hepatomegaly
- Rise in aminotransferases (ALT>AST)

Question 25

Can acute infection lead to acute liver failure? Is it common? Who is at increased risk?

Answer 25

Yes, but rare. Pregnant patients are at particular risk

Question 26

When should we put in an immediate referral for acute hepatitis?

Answer 26

- Prolonged INR - Jaundice - Encephalopathy

Question 27

What are some drugs that can cause drug-induced hepatitis?

Answer 27

Acetaminophen Herbal products: - Buckthorn - Chaparral - Comfrey - Germander - Nutmeg - Valerian

Question 28

How do we identify what type of hepatitis virus is present?

Answer 28

Serologic markers (blood)

Question 29

What do the following HAV markers indicate? + Total anti- HAV + Anti-HAV IgG + Anti-HAV IgM

Answer 29

+ Total anti- HAV Total IgG and IgM Acute, resolved infection or immunity + Anti-HAV IgM Acute HAV infection + Anti-HAV IgG Immunity from either vaccination or previous exposure (detectable for life and means lifelong protection)

Question 30

What do the following HBV markers indicate? + HBsAG + Anti-HBs + HBsAg and Anti-HBs + Anti-HBc - Anti-HBc + Anti-HBc IgM + HBeAg + Anti-HBe + HBV-DNA

Answer 30

+ HBsAG Infection (either acute or chronic) + Anti-HBs Immunity + HBsAg and Anti-HBs Infection persists despite immunity (chronic infection) + Anti-HBc Immunity developed from prior infection - Anti-HBc Immunity developed from vaccination + Anti-HBc IgM Indicates acute infection or severe flare up of chronic infection + HBeAg High degree of HBV infectivity and replication + Anti-HBe Low degree of infectivity + HBV-DNA Marker of viral replication/infectivity and used to monitor treatment

Question 31

What do the following HCV markers indicate? + Anti-HCV - Anti-HCV + HCVRNA - HCVRNA

Answer 31

+ Anti-HCV Indicates infection (acute or chronic) Will remain positive for life despite clearance of infection + HCVRNA Ongoing viremia - HCVRNA No active infection

Question 32

When do we check HDV markers?

Answer 32

Only if HBsAg is positive

Question 33

What do the following HCV markers indicate? + Anti-HEV + Anti-HEV IgM + Anti-HEV IgG

Answer 33

+ Anti-HEV Antibodies for HEV + Anti-HEV IgM Indicates acute infection Can last up to 16 weeks + Anti-HEV IgG Appears following infection and can last for years

Question 34

What is the treatment of choice for acute viral hepatitis?

Answer 34

Often self-limiting, so antiviral therapy is mostly not indicated Supportive therapy allows for majority of patients to recover completely Exception: Hep C, treatment leads to favourable outcomes so should be considered on a case-to-case basis.

Question 35

If we do decide to treat Hepatitis C infection, what drug do we use?

Answer 35

Direct-acting antiviral (DAA) agents This is the same treatment for chronic hepatitis C

Question 36

What are some non-pharms to recommend for hepatitis patients?

Answer 36

Avoid alcohol until full recovery

Question 37

What vitamin supplementation is good for hepatitis?

Answer 37

No role for vitamin supplementation

Question 38

What diet is good for hepatitis patients?

Answer 38

No dietary restrictions are needed

Question 39

Does physical activity help with hepatitis patients?

Answer 39

No

Question 40

Does hepatitis lead to increased or decreased INR? Why?

Answer 40

Increased INR Liver is in charge of producing majority of blood clotting factors. Damage leads to less clotting (increased INR)

Question 41

What do we do if patient has prolonged INR (>1.5) in acute hepatitis?

Answer 41

Vitamin K 10mg PO or IV

Question 42

Can the Vitamin K be administered in different route?

Answer 42

IM and SC is available but increases risk of hematoma and bleeding

Question 43

Do we need to treat acute symptomatic hepatitis B?

Answer 43

No. Immune competent adults are able to clear the infection.

Question 44

Is there an exception to if we treat acute hepatitis B?

Answer 44

- Acute liver failure - Severe course (bilirubin >1.5mg/dL, INR>1.5) - Encephalopathy - Ascites

Question 45

In these exception cases of acute Hepatitis B, what do we use to treat patient?

Answer 45

Oral antivirals - Tenofovir disoproxil - Tenofovir Alafenamide - Entecavir

Question 46

What drug is contraindicated in acute hepatitis B?

Answer 46

Peginterferon-alpha therapy

Question 47

If acute hepatitis B patient fails to clear infection after 6 months, how should they be managed?

Answer 47

Treat like chronic HBV

Question 48

Is pre-or postexposure prophylaxis of HCV infection recommended?

Answer 48

No Risk of transmitting through exposure is low and DAA can easily and effectively treat acute episodes. Therefore, don't recommend prophylaxis

Question 49

Regardless of cause, if patient has acute liver failure, what should we consider?

Answer 49

Liver transplantation

Question 50

Most patient with hepatitis E will not require therapy. For those with more complicated symptoms (neurologic), what therapy should they consider?

Answer 50

Ribavirin

Question 51

Is ribavirin safe in pregnancy and breastfeeding?

Answer 51

No, contraindicated

Question 52

What is the best way to prevent viral hepatitis?

Answer 52

Vaccination

Question 53

Hepatitis A vaccine is drug of choice for pre-exposure prophylaxis. How long of protection does it confer?

Answer 53

Up to 10 years

Question 54

When are antibodies detectable following vaccine?

Answer 54

1 month in most patients

Question 55

What is the dosing schedule for hepatitis A vaccine?

Answer 55

1st dose at 0 month 2nd dose 6-12 months later

Question 56

What products do Hep A vaccines come in?

Answer 56

Single vaccine= Havrix Combo vaccine with Hep B= Twinrix Combo with typhoid= Vivaxim

Question 57

Hepatitis B vaccine induces anti-HB production. Response generally decreases with age. how do we boost protection?

Answer 57

1. Revaccinating with single booster (complete 3-dose series) 2. Using higher concentration vaccines

Question 58

How long does anti-Hbs levels last? Does protection diminish after those levels diminish?

Answer 58

10-15 years Long-lasting protection remains due to immune memory

Question 59

If patient is immunocompetent and vaccine was successful, is there a need for routine booster doses?

Answer 59

No

Question 60

What is the dosing schedule for Engerix B (hep B vaccine)?

Answer 60

3 doses given at 0, 1, and 6 months

Question 61

When is hepatitis B immune globulin preferred over the vaccine?

Answer 61

When someone has been exposed to Hep B but hasn't been vaccinated (need immediate protection, as vaccine takes time) No response to vaccine

Question 62

What is the impact of hepatitis A in pregnancy?

Answer 62

No birth defects reported but may have increased risk of miscarriage or premature labour.

Question 63

How do you manage hepatitis A infection during pregnancy?

Answer 63

No treatment. Mainly supportive.

Question 64

How do you manage hepatitis A in breastfeeding?

Answer 64

Breastfeeding can be continued

Question 65

What is the impact of hepatitis B on pregnancy?

Answer 65

No teratogenic effects, but there is an increased rate of miscarriage or premature labour. Also risk of vertical transmission.

Question 66

What increases the risk of vertical transmission. How do we manage this?

Answer 66

High viral load in mom Antiviral therapy

Question 67

If pregnant patient has high viral load, how do we manage this?

Answer 67

Treatment in third trimester if HBV DNA>200 000 units/mL Tenofovir Lamivudine Telbivudine (rare in Canada) Started at 28 weeks gestation and continued for 1 month postpartum

Question 68

Of the antivirals, which is preferred?

Answer 68

Tenofovir - better efficacy - higher genetic barrier to viral resistance

Question 69

Which antiviral is contraindicated in pregnancy?

Answer 69

Entecavir (teratogenicity)

Question 70

Does mode of delivery affect likelihood of HBV transmission?

Answer 70

No

Question 71

How do we further lower the risk of parent to child transmission on the newborn's side?

Answer 71

Immunization at birth with hepatitis B immune globulin (HBIg) and hepatitis B vaccine

Question 72

How do we manage hepatitis B in breastfeeding?

Answer 72

Safe to breastfeed if infant has received HBIg and HB vaccine within 12 hours of birth

Question 73

When is breastfeeding contraindicated in hepatitis B patients?

Answer 73

If mother is experiencing cracking and bleeding of nipples. Can restart if nipples heal.

Question 74

If patient is on antiviral therapy, is breastfeeding ok?

Answer 74

Yes, breastfeeding is not contraindicated

Question 75

How do we manage hepatitis C infection in pregnancy?

Answer 75

Mainly supportive Treatment of patient is delayed until postpartum No effective way to reduce vertical transmission. Mode of delivery does not modify risk

Question 76

How do we manage hepatitis C in breastfeeding?

Answer 76

Safe to breastfeed as long as no cracks or bleeding

Question 77

In summary, what are 4 initial biomarkers that should be tested with acute viral hepatitis?

Answer 77

ALT>AST INR Bilirubin Albumin