DSA 5: Acute Hepatitis and Acute Liver Failure

Question 1

what is the etiology of acute (fulminant) liver failure (ALF)

Answer 1

massive hepatic necrosis w/ impaired consciousness occurring w/i 8 weeks of the onset of illness

1. acetaminophen

2. idiosyncratic drug rxn

increased risk w/ DM & outcome is worse w/ obesity

statins can casue increase AST/ALT but rarely cause true hepatitis or ALF-no longer Cl in liver dz

Question 2

What are possible complications of ALF

Answer 2

cerebral edema (brainstem compression) & sepsis are the leading causes of death

mortality rate is exceedingly high (>80% pt w/ deep coma)

Question 3

what is the Hx/PE of ALF

Answer 3

rapidly shrinking liver size + rapidly rising bilirubin level + marked prolongation of the PT + clinical signs of confusion, disorientation, ascities, edema = hepatic failure w/ encephalopathy –> deep coma (cerebral edema)

life-threatening coagulation abnormalities (INR > 1.5)

Question 4

what is diagnositic of ALF

Answer 4

labs = rapidly rising bilirubin levels + marked prolongation of PT even as AST/ALT decreases

acetaminophen toxicity - AST/ALT > 5,000 u/L

ammonia level elevated –> encephalopathy & intracranial HTN

Question 5

how do you treat/manage ALF

Answer 5

support the pt - maintain fluids, circulation and respiration; control bleeding, correction of hypoglycemia & tx other complications

protein intake should be restricted

give oral lactulose/neomycin

meticulous intensive care + prophylactic ABx= one factor that improves survivial

early transfer to transplant center for liver transplantation should be considered

N-Acetylcysteine in acetominophen OD

Question 6

what is the etiology of acute hepatitis

Answer 6

viral, drugs, ischemia

Question 7

What are Hx/PE findings of acute hepatitis

Answer 7

stool - acholic

fever, malaise, myalgia, arthalgia, N/V, dirrhea, constipation

PE: RUQ pain = tenderness over liver, jaundice, hepatomegaly, skin changes

Question 8

what is diagnositic of acute hepatitis

Answer 8

CMP (AST/ALT, total bilirubin, ALP)

PT/INR

acetaminophen level

viral hepatitis serology

Question 9

what are treatments and managements of acute hepatits

Answer 9

some self-limited

based on etiology - NAC, supportive, anti-viral, stop offending meds, gastric lavage, ABx, liver transplant

Question 10

what family does HAV belong to?

what is the duration, RF and transmission

Answer 10

ssRNA

duration: acute; incubation = 2-3, up to 6 weeks

RF: international travel; contaminated water/food; inadequately cooked shellfish

transmission: fecal-oral route

Question 11

what is the presentation of HAV?

Answer 11

anorexia, N/V, malaise, constant/mild RUQ or epigastrum, aversion to smoking

stool may be acholic

illness more severe in adults than children

acute only

Question 12

what labs help diagnose HAV

Answer 12

marked increase in AST/ALT

increased bilirubin and ALP = cholestasis

Anti-HAV early in illness; both IgM & IgG anti-HAV soon after onset

detection of IgM anti-HAV = excellent test for diagnosing acute hep A

if IgG anti-HAV - indications of previous exposure, non=infectivity and immunity

Question 13

Is there a vaccine for HAV?

what is the mortality?

Answer 13

Vaccine available

good prognosis; low mortality

Question 14

what family does HBV belong to?

what is the duration, RF and transmission

Answer 14

partially dsDNA

duration - 2-26 week incubation, acute resolves 2-3 weeks & chronic = 5-10%

RF: M-sex-M, inject drugs, hemodialysis center, healthcare workers

transmission:

• parentral
• sexual
• perinatal : endemic in sub-saharan Africa & SE Asia (HBs-Ag (+) mom transmit HBV at delivery; risk of chronic infxn (90%)
• percutaneous (needle stick)

Question 15

what is the presentation of HBV?

Answer 15

fever (low-grade), enlarged & tender liver, jaundice

aversion to smoke, N/V, anorexia

association w/ polyarteritis nodosa, glomerulonephtritis, serum sickness

acute (90% recover)

5-10% is chronic

Question 16

what labs help diagnose HBV

Answer 16

normal-low WBC

increased ALT/AST early in course

no cholestatic pattern

increased bleed risk

many Ag, Ab, HBV DNA. useful for Dx

Question 17

Is there a vaccine for HBV?

what is the mortality?

Answer 17

Vaccine - high risk groups (prevention)

After unvaccinated person - HBIG immediately - 14 days after sex/birth + vaccine

mortality rate up to 60%

Question 18

What are complications of HBV

Answer 18

cirrhosis & HCC

Question 19

what is the window period of acute HBV infxn

Answer 19

window= btn HBsAg disappearing and HBsAb appearing (could be several weeks

pt is still considered to have ACUTE HBV, and infxn is only detectable w/ HBcAb IgM

This is very important when screening blood donations

Question 20

what is the serology of HBV w/

window period

acute infxn

prior infxn

chronic infxn (inactive)

chronic infxn (active)

immunized

Answer 20

Question 21

what family does HDV belong to?

what are the RF and mortality

Answer 21

defective RNA - required HBV for replication

RF: acute or chronic; either co-infected w/ HBV or superinfects a chronic HBV carrier

non-percutaneous /percutaneously in HBsAg+ IV drug users or hemaphiliac transfusion

mortality: increase severity of HBV infxn

Question 22

what labs help diagnose HDV

Can you prevent it?

Answer 22

labs: HDV RNA PCR; HDV Ag

Vaccine against HBV

Question 23

what family does HCV belong to?

what is the duration and RF

Answer 23

ssRNA

MC = chronic, incubation is 4-26 weeks; acute asymptomatic w/ wax/wane AST/ALT

RF: transfusion related hepatitis (HCV accounts for >90%), IV drug use (50% HCV cases), intranasal drug use; co-infection w/ HCV in 30% HIV infected persons; in developing world - unsafe medical practice; bloody fisticuffs & incarceration in prison

Question 24

what is the presentation of HCV?

what are possible complications of HCV

Answer 24

marked fluctuating elevation of AST/ALT

>50% chronic

complications: cirrhosis, HCC, HIV co-infxn; pathogenic factor in mixed cryoglobulinemia, chronic HCV - decreased serum cholesterol

Question 25

what labs help diagnose HCV Is there a vaccine or prevention method for HCV?

Answer 25

labs = **HCV Ab in serum** ; most sensitive indicator = **_HCV RNA_** occasionally - **anti-HCV in serum, w/o HCV RNA in serum --\> recovery from prior HCV infxn** vaccine: **_NONE_**, CLD-HCV pt vaccinated w/ HAV and HBV prevention = **birth cohort screening of persons born btn 1945-65 for HCV infxn; new recs all over 18 should have at least once in a lifetime screening for HCV;** HCV-pt _should practice safe sex_

Question 26

is HCV curable?

Answer 26

YES!

Question 27

what family does HEV belong to? what is the duration, RF and transmission

Answer 27

**ssRNA** duration: incubation = 4-5 wks RF : **immunoCOMPROMISED host;** endemic in **asia, middle east, N. africa, central america and india** transmission = **fecal-oral-** _waterborne epidemic_; **spread by swine**

Question 28

Is HEV acute or chronic what are complications of HEV?

Answer 28

**HEV is acute** w/ no carrier state; in **transplant pts** treated w/ **tacrolimus instance of chronic w/ progression to cirrhosis** arthritis, pancreatitis, monoclonal gammopathy, thrombocytopenia guillain-barre and peripheral neuropathy

Question 29

What labs will help Dx HEV?

Answer 29

IgM or IgG **HEV Ab** ## Footnote **PCR for HEV RNA**

Question 30

what is the mortality of HEV

Answer 30

**high (10-20%) mortality rate in pregnant women**

Question 31

What are causes of toxic/drug-induced hepatits (Drug-induced liver injury)

Answer 31

**Dose-dep:** w/i 48 hrs; mushroom poisoning, **acetaminophen,** tetracycline, valproic acid **Idiosyncratic:** variable dose & time of onset; fever, rash, arthralgia, eosinophilia; _isoniazid, sulfonamides_, halothane, phenytoim, methyldopa, carbamazepine, diclofenac, oxacillin

Question 32

hwo do you treat drug induced liver injury

Answer 32

**supportive:** withdraw agent; use gastric lavage & oral administration of activated charcoal/cholestyramine (_w/i 1 hour_ post ingestion is ideal) ## Footnote **liver transplantation if necessary** **NAC for acetaminophen OD**

Question 33

When do you use N-acetylcysteine (NAC)

Answer 33

for acetaminophen OD get a 4 hour acetaminophen level critical ingestion-tx interval for maximum protection against severe hepatic injury is btn 0-8 hrs (**begin therapy w/i 8 hours of ingestion**)

Question 34

what is the etiology of budd-chiari syndrome

Answer 34

occlusion of flow to **hepatic V** or IVC **caval webs, R-HF (--\> nutmeg liver)** predispose pt to **hepatic V obstruction** (aka Budd-Chiari) --\> hereditary and acquired **hypercoagulable states** (polycythemia vera)

Question 35

what are diagnostic findings for budd-chiari syndrome

Answer 35

**occlusion/absence of flow in hepatic Vs or IVC** imaging: * _prominent caudate liver lobe;_ * **screening test of choice is contrasted-enhanced (CEUS);** * _color/pulsed-doppler ultrasonography_ * _direct venography - deliniate caval webs_ & occluded hepatic Vs (_spider web pattern)_ **liver Bx: centriloular congestion (nutmeg liver)** & fibrosis

Question 36

What are complications of budd-chiari syndrome

Answer 36

chronic - bleeding varices, hepatic encephalopathy, hepatopul syndrome freq complicated by **HCC**

Question 37

What is the MCC of jaundice in pregnancy

Answer 37

**viral hepatitis**

Question 38

what are characterisitics of pre-eclampsia & eclampsia

Answer 38

preeclampsia - 3-5% - characterized by maternal HTN, proteinuria, peripheral edema, coagulation abnormalities **may be life-threatening** - hyperreflexia and convulusion occurs (eclampsia) **HELLP syndrome:** hemolysis, elevated liver enzyme and low platelets

Question 39

how does cholestasis of pregnancy present

Answer 39

_pruritus in 3rd trimester_ darkening of urine & occasionally light stool & jaundice sign of enigmatic syndrome

Question 40

what is the presentation of acute fatty liver of pregnancy

Answer 40

spectrum of disorder ranging from subclinical or modest hepatic dysfxn (increase AST/ALT) --\> **hepatic failure, coma and death**