Jaundice and Acute Viral Hepatitis

Question 1

Jaundice (icterus)

Answer 1

-increased serum bilirubin
-Yellow appearance due to deposition of bile pigment in the skin and mucous membranes
-Bilirubin is a waste product of hgb metabolism
-Interruption of the breakdown pathway
-Marked increase in load due to RBC destruction
-Results in increased serum bilirubin and (if high enough) clinical jaundice
-sclera and conjunctiva

Question 2

causes of jaundice

Answer 2

-classified as:
(1) hemolysis
(2) genetic defects in bilirubin handling
(3) hepatocellular disease*
(4) obstruction

Question 3

Functional or anatomic obstruction at any level in pathway results in increase in serum bili—->jaundice

Answer 3

pathways:
-hemoglobin breakdown
-uptake by the hepatocellular membrane
-excretion into biliary system

Question 4

unconjugated bilirubinemia (indirect)

Answer 4

-Breakdown products of hemoglobin (e.g., hemolytic anemia)
-Impaired uptake and storage (Gilberts, Crigler Najjar, drug reactions)
-Hemolysis, genetic ds, drug rx
-Stool and urine color are normal
-Indirect bilirubin increased

Question 5

conjugated bilirubin (direct)

Answer 5

-Hereditary cholestatic syndromes
-Hepatocellular dysfunction (hepatitis, cirrhosis, biliary cirrhosis, infections, etc)*
-Biliary obstruction (choledocholithiasis, biliary atresia, pancreatic ds, ca)
-Hepatocellular ds, biliary obstruction or impaired flow
-Urine dark, stool light
-Direct bilirubin increased

Question 6

liver labs

Answer 6

-total bilirubin labs can be broken down into unconjugated and conjugated
-ALT/AST- show liver injury
-AST- alcohol injury
-ALT- viral liver disease
-alkaline phosphatase
-albumin and total protein- liver function
-bilirubin-
-GGT- alcohol injury
-prothrombin time- time to blood clot
-AMA, ANA, anti smooth muscle antibodies, alpha 1 antitrypsin- chronic

Question 7

acute hepatitis: prodromal phase

Answer 7

-Onset: abrupt or insidious
-Malaise, myalgias, arthralgias, fatigability , URI symptoms, anorexia
-Nausea, vomiting, diarrhea, or constipation
-RUQ or epigastric pain

Question 8

acute hepatitis: icteric phase

Answer 8

-Jaundice occurs after 5-10 days if at all
-not everyone gets jaundice
-Acholic stools (light stools)
-May occur with prodromal symptoms

Question 9

acute hepatitis: convalescent phase

Answer 9

-Increasing sense of well being
-Appetite returns
-Jaundice, fatigue and pain resolve

Question 10

general signs of acute hepatitis

Answer 10

-Hepatomegaly >50%
-Liver tenderness
-Splenomegaly-15%
-Lymphadenopathy- Cervical and epitrochlear

Question 11

acute hepatitis labs

Answer 11

-WBC normal to low- Large atypical lymphocytes
-Mild proteinuria (some liver illness affect kidney as well)
-Bilirubinuria often precedes jaundice
-Strikingly elevated AST/ALT ***
-PT/INR may be prolonged and correlates with increased mortality

Question 12

general supportive tx for acute hepatitis

Answer 12

-Bed rest
-IV fluids if hospitalized otherwise oral
-If encephalopathic or severe coagulopathy hospitalize
-Avoid strenuous exercise, alcohol and hepatotoxic agents
-No morphine

Question 13

course and complications of acute hepatitis

Answer 13

-Acute illness usually subsides over 2-3 weeks
-Complete clinical and laboratory recovery by:
-6-9 weeks in HAV
-16 weeks in HBV
-5-10% of cases may take longer
-1% will have a fulminant course
-Hepatitis B, D, C, G may become chronic**

Question 14

viral hepatitis types

Answer 14

-Hepatitis A Virus (HAV)
-Hepatitis B Virus (HBV)
-Hepatitis C Virus (HCV)
-Hepatitis D Virus (HDV)
-Hepatitis E Virus (HEV)
-Hepatitis G Virus (HGV)

Question 15

hepatitis A

Answer 15

-RNA Hepativirus
-Route: Fecal-oral
-Common Source: Water/food
-Incubation: Average 28 days-excreted in feces 2 weeks prior
-Mortality rate is low
-No chronic carrier state**
-Serology: Anti HAV IgM and IgG
-Treatment: Supportive
-Prognosis: Excellent: DOES NOT CAUSE CHRONIC LIVER DISEASE!
-Vaccination: Children and at risk adults
-Usually subsides over 2-3 weeks
-Complete resolution by 9ish
-Can relapse but recovery is the rule

Question 16

hepatitis B

Answer 16

-DNA Virus
-8 Genotypes
-Route:
-Infected blood/blood products, bodily fluids
-Common in homosexual men, IVDU, but greatest number of transmission is via heterosexual contact
-vertical transmission common- mom to child
-Incubation: 1-5 months (average: 3 mos)- LONG
-Treatment of acute Hepatitis B ds: supportive
-Prognosis: Very good but chronic disease depends on when acquired (Child vs adult)
-if you get it as a child -> higher chance of chronic
-Mortality for acute ds: 0.1-1% but higher with superimposed D
-Vaccinate all children and adults

Question 17

hepatitis B: HBsAg

Answer 17

-First evidence of infection appearing before biochemical evidence of liver disease and persists throughout clinical illness
-YOU ARE INFECTIOUS IF YOU HAVE HBsAg IN YOUR BLOOD
-Implies infectivity
-Persistence=Chronic ds

Question 18

hepatitis B: anti HBs

Answer 18

-Appears after clearance of HBsAg, or with vaccination
-Recovered and no longer infectious
-recovered or vaccination
-you dont have anti HBs with HBsAg

Question 19

hepatitis B: anti HBc

Answer 19

-Appears shortly after HBSag detected
-HBcAg DOES NOT APPEAR IN SERUM
-Fills the serologic gap (window period) in patients who have cleared HBSag but not yet made Anti HBs
-fills serologic gap
-no antigen and no antibody -> this HBc fill this gap to show presence of the disease

Question 20

hepatitis B: HBeAg

Answer 20

-Found only in HBsAg positive serum
-Appears during incubation period
-Indicates viral replication and infectivity**
-Persistence in serum >3mos indicates increased likelihood of chronic HBV
-Disappearance often followed by anti HBe
-lots of replication, very infectious

Question 21

hepatitis B: HBV DNA

Answer 21

-Sensitive and precise marker of viral replication and infectivity
-Small amounts can persist long after recovery
-sits dormant in liver
-if you are immunosuppressed-> can reactivate

Question 22

hepatitis D (delta agent)

Answer 22

-Defective RNA virus requiring coinfection with HBV
-D needs B to survive
-Specifically needs HBsAg
-May coinfect or superinfect (worse)
-Usually percutaneous exposure
-Serology: Anti HDV or HDV RNA

Question 23

hepatitis C

Answer 23

-RNA Virus, 6 genotypes
-Exposure/Risk: Exposure to infected blood:
-Blood transfusions, IVDU, intranasal cocaine, body piercing, hemodialysis, tattoos
-Low risk of sexual and maternal-neonatal transmission
-More than 58 million people infected worldwide
-Estimated 2.5 million cases of chronic Hep C in US
-75% unaware of dx (asymptomatic)
-When infected, high rate of chronic hepatitis -> 14-50%
-Incubation: 14-180 days (average range 14-84 days)
-Anti HCV: DOES NOT MEAN RECOVERY -> simply means you have been exposed *****
-HCV RNA PCR- Must always order this to see if they are infected still
-ALT labs vary- not a marker

Question 24

acute hepatitis C treatment

Answer 24

-Some clear on own
-Controversial-Treat immediately or at 12 weeks
-see if they clear it -> if not treat at 12 weeks
-Sofosbuvir-velpatasvir for 12 weeks or glecaprevir-pibrentasvir for eight weeks (DONT NEED TO KNOW)
-Can be used for any genotype.

Question 25

hepatitis E

Answer 25

-HEV is a RNA virus
-Exposure: waterborne
-India, Burma, Afghanistan, Algeria, Mexico, Sudan, and Iraq
-Rare in US
-Self limited illness and NO CARRIER STATE*
-High mortality rate in pregnant women(10-20%) **

Question 26

hepatitis G

Answer 26

-HGV is a RNA Virus
-Exposure: percutaneous
-HGV coinfection may improve survival in patients with HIV
-needle

Question 27

NO VACCINATION

Answer 27

for hep C

Question 28

prevention/general recommendations

Answer 28

-Wash hands !!
-After contact with bedding, utensils, clothing
-After bowel movement
-Screening blood and pregnant women
-Vaccination: A and B for infants and at risk adults

Question 29

prevention of hepatitis A

Answer 29

-Post Exposure: Vaccinate if within 2 weeks and in some instances, give immunoglobulin
-Routine vaccination

Question 30

hepatitis B prevention

Answer 30

-Post exposure: Vaccinate, and give hepatitis B immune globulin in certain situations.
-Routine vaccination

Question 31

acute hepatic failure

Answer 31

-fulminant- hepatic encephalopathy within 8 weeks after onset of acute liver disease
-subfulminant- above occurs between 8 weeks and 9 months

Question 32

causes of acute hepatic failure

Answer 32

-Acetaminophen toxicity is most common cause (usually children or suicide)
-Idiosyncratic drug reactions
-Viral hepatitis (12%)
-Reye Syndrome- viral illness and aspirin
-Budd Chiari syndrome
-Shock, hypo/hyperthermia
-Malignancy
-Wilsons ds, autoimmune hepatitis
-Parvovirus B 19**
-Epstein barre virus

Question 33

viral hepatitis

Answer 33

-12% of all cases of acute liver failure
-Declined from 70% due to hepatitis B vaccine
-Hep E in endemic areas
-Hep C rare cause of acute failure unless superimposed A or B

Question 34

clinical findings in acute hepatic failure

Answer 34

-Acute liver atrophy
-Systemic inflammatory response
-GI symptoms
-Hemorrhagic phenomena
- +/- jaundice early

Question 35

treatment of acute hepatic failure

Answer 35

-Directed toward correcting metabolic abnormalities:
-Coagulation defects
-Electrolyte imbalance
-Acid base disturbances
-Renal failure
-Hypoglycemia
-Encephalopathy

-Acetaminophen toxicity treatment:
-N-acetylcysteine (NAC)- Free radical scavenger and replenishes the stores of intracellular glutathione -> rids toxicity -> Improves cerebral blood flow and oxygenation
-Antiviral therapy may be helpful in HBV
-Liver transplant

Question 36

persistence of which HBV antigen in blood indicates carrier state

Answer 36

-HBsAg