Hepatitis

Question 1

Liver histology

Answer 1

Hepatocytes (do all the work)

• synthesize serum proteins (albumin, coagulation factors, hormonal and growth factors)
• produce bile
• regulate nutrients (glucose, glycogen, lipids, cholesterol, amino acids)

Also: Kupffer cells

Question 2

Patterns of Liver Disease

Answer 2

Hepatocellular

• Viral hepatitis, alcohol induced liver disease
• Livery injury and inflammation

Cholestatic (obstructive)

• Obstruction, primary biliary cirrhosis, primary sclerosing cholangitis, drug induced
• Inhibition of flow is primary issue

Mixed: features of both

Question 3

Presenting symptoms

Answer 3

scleral icterus, jaundice

fatigue and malaise

itching (b/c high bilirubin)

RUQ pain

abdominal distention

N/V

lack of appetite

acholic stools (clay colored b/c bile deficiency), steatorrhea

drark urine

Question 4

Lab work to consider

Answer 4

LFTs: ALT/AST, alk. phos, bilirubin, albumin, PT/INR

Hepatitis A/B/C antibodies

Autoimmune antibodies

<50 Ceruloplasmin (Wilson’s)

TSH

Iron, ferritin (hemachormatosis)

Question 5

Imaging Indicated

Answer 5

Perform US first

Can add dopler if concerned for portal vein thrombosis

CT if concerned about pancreas

MRI can be more helpful when evaluating liver masses

Question 6

Liver Biopsy

Answer 6

Indicated when:

Imaging not consistent with persistently elevated LFT’s

To confirm specific diagnosis:

• Autoimmune
• Wilson’s
• PBC
• Hemachromatosis

Question 7

Acute vs. Chronic Hepatitis

Answer 7

Acute

• <6 months
• Jaundice present
• Sx: anorexia, malaise, dark urine, fever, abdominal pain

Chronic:

• Often no sxs. Sometimes see sxs of cirrhosis
• At risk of cirrhosis, HCC

Question 8

Causes of hepatitis (both acute and chronic)

Answer 8

Viruses

Drugs

EtOH

Toxins

Autoimmune

PBC/PSC

Wilson’s/A1A/Hemochromatosis

Ischemia

Question 9

Fulminant Liver Failure

(definition, etiology, sxs, labs, tx)

Answer 9

The presence of acute liver failure within 8 weeks of the onset of jaundice in a pt without previous liver dz

MC causes: acetominophen, idiopathic, idiosyncratic drug rxn, viral, ischemia

Symptoms: malaise, nausea, jaundice

Labs: Very high AST/ALT, elevated bilirubin and INR

Tx: Transplant

Question 10

Definition of Acute Liver Failure

Answer 10

Any degree of encephalopathy

**Increased INR (>1.5)

In a pt without cirrhosis with an illness less than 26 weeks duration

Question 11

Hepatitis A Risk Factors

Answer 11

Live/travel to underdeveloped areas

Exposure to infected individuals

IVDU

More likely to develop sxs when >6 y.o.

Question 12

Hepatitis A Presenting Sxs

Answer 12

Fever

Fatigue

Anorexia/Nausea

Jaundice

Dark urine, acholic stools

Joint pain

Sxs usually last for less than 2 months

Question 13

Hepatitis A Lab tests

Answer 13

HAV Antibody can be present for decades

Question 14

Hepatitis A Tx and Immunization

Answer 14

Treatment: support, self limited infecction

Immunization for: IVDU, pts with chronic liver dz, travelers, health care workers, immunosuppressed

*incidence of hep A has substantially decreased due to vaccine

Question 15

Hepatitis B Epidemiology

Answer 15

New infections have declined substantially because universal vaccination campaigns

Common becomes chronic viral hepatitis.More common to become chornic infection in children.

Mortality due to complications secondary to disease.

Common in Asia and Africa where transmited vertically

Question 16

Acute Hep B Symptoms

Answer 16

Fever

Fatigue

Anorexia/Nausea

Vomiting

Dark urine/acholic stools

Joint pain

Jaundice

Question 17

Chronic Hep B symptoms

Answer 17

Asymptomatic

Can present with a broad range of sxs from chronic hepatitis to HCC

Question 18

Hep B Serological Markers

Answer 18

There are many different markers that can help differentiate stage of disease and/or vaccination status

Question 19

Hep B Treatment

Answer 19

Acute: supportive

Chronic: depends on LFTs, serologies, and fibrosis level of the liver

Monitoring Chronic Hep B: AFP and Liver US every 6 months (for specific populations)

Question 20

Chronic Hep B Phases

Answer 20

Active Disease: high viral level and increased LFTs

Carrier: low viral level and normal LFTs

Immune tolerant: high viral level and normal LFTs

Question 21

Chronic Hep B Complications

Answer 21

Majority remain asymptomatic until cirrhosis develops

Chronically infected may die prematurely of cirrhosis or liver CA (15-25%)

Question 22

Hepatitis C Risk Factors

Answer 22

Those born 1945-1965 (Baby Boomers)

Blood transfusion prior to 1992 when anti-HCV was introduced

Tattoos and body piercing

IVDU/Nasal DU

HIV +

Usually do not see vertical transmission

Question 23

Acute vs. Chronic Hep C.

Answer 23

Don’t often see pts with acute infections because they will usually clear virus without seeing any symptoms

75-85% of pts progress to chornic Hep C (chronic liver disease, cirrhosis, or HCC can develop)

Question 24

Lab Testing

Answer 24

HCV RNA by PCR most sensitive

Can first be detected 10 weeks after exposure

Also get HCV genotype:

• 1a, 1b: MC, but most difficult to tx
• 2, 3: easier to tx

Question 25

Hepatitis C Tx

Answer 25

Avoid usage of alcohol Should check with provider before using any medications Medical treatment depends on genotype of virus

Question 26

Medication Induced Hepatitis

Answer 26

Usually cholestatic pattern of injury Ingestion of drug may be weeks before sxs, adn can take months to resolve (3-12mo) Need liver biopsy to confirm dx Some example drugs: doxy, minocycline, augmentin, amiodarone, and tylenol

Question 27

Autoimmune liver diseases

Answer 27

Autoimmune Hepatitis Primary Sclerosing Cholangitis (PSC) Primary Biliary Cirrhosis (PBC)

Question 28

Autoimmune Hepatitis

Answer 28

MC middle aged women Usually associated with other autoimmune diseases Sxs: Can vary from only fatigue to fulminant hepatitis. Jaundice, RUQ pain, joint aches Labs: High IgG, ANA, smooth muscle antibody (autoimmune markers), and elevated total protein Liver bx needed to make dx

Question 29

Primary Sclerosing Cholangitis

Answer 29

MC in ~40 y.o. men with diffuse inflammation and fibrosis of biliary tree Associated with UC Sxs: fatigue, pruritis. Rarely RUQ discomfort Labs: Alk phos 3-4X normal; may see elevated bilirubin Imaging: MRCP, if not conclusive do ERCP

Question 30

Primary Biliary Cirrhosis (PBC)

Answer 30

MC 30-50y.o. women Causes destruction of interlobular and septal bile ducts Unknown etiology Sxs: fatigue, pruritis, jaundice PE: excoriations, xathelasmas on eyelids, xanthomas on extensor surfaces Labs: Alk. phos 3-4X normal, ALT/AST mild to moderately elevated, elevated IgM, elevated cholesterol and HDL

Question 31

Metabolic Liver Diseases

Answer 31

Alpha 1 Anti-trypsin Deficiency Wilson's Disease Hemochromatosis

Question 32

A1A Deficiency

Answer 32

A1A is a liver enzyme that helps break down trypsin adn other proteases. In its absence, proteins are deposited into liver Causes pulmonary dysfunction first, and pts usually have FHx of emphysema. \*\*Refer to pulmonologist No tx once develop liver complications. Can consider transplant

Question 33

Wilson's Disease

Answer 33

Autosomal recessive disorder that leads to excessive copper deposition in liver, eyes, kidneys, joints, and RBCs MC presents as cirrhosis or neuro deficits (Also tremor, Kayser-Fleischer rings, arthropathy, hemolytic anemia) Rare disease, exclusively diagnosed before age 40. Decreased ceruloplasmin (Cu carrying protein in blood), inc'd urine copper, inc'd copper on liver bx Tx: Depends on type, but Cu Chelation or transplant

Question 34

Hemochromatosis

Answer 34

Autosomal recessive Abnormal iron storage==\> iron builds up in liver, heart, pancreas, and pituitary gland Sxs: fatigue, malaise, arthrlagias Women present later due to menses Dx: elevated iron saturation, ferritin; genetic testing; Gold Standard is liver bx Tx: phlebotomy

Question 35

Other systemic diseases that have liver involvement

Answer 35

Celiac disease Sarcoidosis Amyloidosis Tuberculosis