Hep Intro + Hep A/B + DILI + ALD Flashcards
How do we diagnose acute liver failure?
- AST, ALT etc, are 2-3x ULN, jaundice, coagulopathy (bleeding/clot disorders)
- no underlying liver disease - Hepatic encephalopathy
- mental alterations
What is the cause of ALF in USA/UK
What is the management of ALF?
Cause
- USA/UK: acetaminophen
Management:
- ICU, emergency liver transplant
What is an advanced stage of liver disease characterized by: (4)
- Fibrosis
- Nodules
- architecture changes
- Disrupted hepatic blood flow
Fibrosis -> cirrhosis –> cancer
Differentiate between compensated and decompensated cirrhosis
Compensated
- nonspecific symptoms (fatigue, losing weight, N/V, fever)
- may not look or feel sick
- can still be managed
Decompensated (more severe)
- jaundice
- portal hypotension (ascites, encephalopathy, varicies)
- Hepatorenal syndrome
What are the 5 parameters in a child-pugh score?
Scoring of
Class A
Class B
Class C
ONLY FOR CIRRHOTIC PATIENTS
Ascites (subjective)
Bilirubin
Albumin
Prothrombin time
Encephalopathy (subjective)
Class A: Well-compensated
Class B: Sig. functional compromise
Class C: Decompensated
What does the MELD score tell us? Parameters (3)
Mortality predictor for those of end stage liver disease ELD and ALF
Parameters:
- INR
- Bilirubin
- Creatinine
Na+ MELD is for transplant consideration (uses Na+ value)
Hepatitis A
Transmission?
Potential for chronic infection?
Curable?
Transmission?
Fecal oral route
- person-toperson contact
- consumption of contaminated food/drink/water
Potential for chronic infection?
- No
Curable?
- self-limiting (virus shed out in stool)
- Supportive care
When are HAV infected people most infectious?
1-2 weeks prior to symptom onset
What are risk factors of Hep A (6)
- Sexual contact — esp. if MSM
- Crowded living conditions, homeless
- IV drug use
- Contaminated food, water
- Poor hygiene
- Older patients, underlying liver disease — more at risk of severe liver manifestations
What is the Hep A vaccine dosing?
1st dose (95%) then 2nd dose given 6-26 months after (100%)
Give combo with Hep B if needed
How do we prevent HAV? (2)
Good hygiene
+
Optimized cooking/water supply
Who should be vaccinated in Ontario where it is covered? (3)
- MSM
- IV drug user
- Chronic liver disease, HBV, HCV
When is PrEP for Hep A given? (3)
What is given
Hep A IgG vaccine (~3-month protection)
- Given <6 months when vaccine not approved
- Given if allergy to Hep A vaccine
- Given with vaccine if immunocompromised
What do you give for PEP in Hep A? When?
Give Hep A vaccine x1 dose within 2 weeks after exposure (ideally ASAP)
- the preferred strategy in these ≥6 months not previously vaccinated
Give both vaccine + IgG in immunocompromised
Hepatitis A
Lab Diagnosis
Presentation?
Lab diagnosis
Current infection: (+) anti-HAV IgM
- becomes (+) 2 weeks before symptoms and remains (+) for 6 months
Past infection or vaccine immunity: (+) anti-HAV IgG but (-) anti-HAV IgM
Presentation
- Fever
- Appetite loss
- N/V
- Jaundice
- Dark urine, pale stool, diarrhea
- Fatigue
- Stomach pain
- Joint pain
Hepatitis E
Transmission?
Potential for chronic infection?
Curable?
Transmission?
- Fecal-oral route
- contaminated food/water
Potential for chronic infection?
- Only for genotype 3
Curable?
- self-limited illness
Risk factors for Hep E
Overcrowding — refugee camp, natural disater camps
Asia, Middle East, Africa, Central America
What is the management of Hep E infection
IgG not effective as PrEP
Treatment for chronic HEV not well established
For genotype #3, use Ribavarin
What is the definition of clinically significant DILI (3)
- AST or ALT >5x , or ALP >2x on 2 separate occasions
- Bilirubin 2.5+mg/dL (221+ umol/L) with elevated AST, ALT, ALP
- INR 1.5+ with elevated AST, ALT, ALP
What are the 3 types of DILI
Causes?
Common agents?
- Direct hepatoxicity
- acetaminophen (intrinsically toxic) - Idiosyncratic hepatoxicity
- correspond to fever, rash, allergy (DRESS, SJS, TENS)
- Antibiotics
- hepatocellular, cholestatic, mixed - Indirect hepatoxicity
- Caused by drug activity and its action
- TNF, glucocorticoids, antineoplastic agents
- can be worsening of hep B or C
What is the equation for R ratio
What value suggests rasoning
Hepatocellular
Mixed
Cholestatic
ALT value/ ALT upper limit
divide by
Alk phos/ Alk phos upper limit
Hepatocellular: 5+
Mixed: 3-5
Cholestatic: 2 or under
How do we diagnose DILI
- Careful review of clinical history and drug exposure
- Exclusion of other causes of liver injury
What does RUCAM scale tell us
Causality assessment to assess if the injury was actually due to drugs
How do we manage DILI (4)
- No effective treatment, just stop drug and give supportive care
(corticosteroids can be proposed, but little evidence to support) - Liver may take a long time to improve
- Monitor to ensure lab work is improving
- Do NOT re challenge
