Define enteric vs parenteral?
Enteric - Occuring within the intestines
Parenteral - Occuring outwith the mouth & Alimentary canal
How many hepatitis viruses are there and are they enteric or parenteral?
A&E are enteric (normally self-limiting)
B,C,D are parenteral (often cause chronic disease)
How is HEP A transmitted?
How do we diagnose HEP A?
With an IgM antibody test in the acute stage and IgG detectable for life
Who gets a HEP A immunisation?
- Chronic Liver Disease Patients
- Those with occupational exposure (E.g. lab workers)
- Men who have Sex with Men (MSM)
What are the symptoms of hepatitis?
Short term hepatitis is often aymptomatic but can lead to:
- loss of appetite
- abdominal pain
Describe the antigens associated with hepatitis B?
Hep Surface antigen - HBsAg - Indicates presence of virus
Hep e antigen - HBeAg - Virus Actively Replicating (found in blood)
Hep Core Antigen - HBcAg - Active Replication (found in liver biopsy)
Describe the antibodies associated with Hep B
IgM anti-HBc = Shows acute illness
IgG anti-HBc = Shows chronic or past infection
Anti-HBe = Shows up as virus is being inactivated by treatment
Anti-HBs = Shows infection or immunisation induced immunity (fights HBsAg)
When do people normally clear a HEP B infection and how do we tell if they’re beyond this period?
Around 6 months
If they are ill and IgM -ve it means theryre past the acute stage and unlikely to kick it themselves.
Consequence of chronic HEP B?
Cirrhosis -> End stage liver disease
Some develop liver cancer
How do we treat HEP B?
Or more recently Oral Antivirals
How does HEP C present differently?
Most people have no symptoms acutely but will develop chronic infection.
They dont usually show symptoms until they’re cirrhotic
How do we test for HEP C?
Chronic Anti-HCV antibodies
What special about Hepatitis D?
Its a small RNA virus and doesnt code for its own protien coat.
So it attaches itself to HEP B and acts as a co-infection.
What do we know about HEP E?
Its self limiting
Its the most common acute hepatitis in grampian
We have no treatment or vaccine
Name some other viruses that can cause hepatitis?
EBV or CMV in the immunocompromised Herpes Simplex (rarely)
What is non-alcoholic fatty liver disease?
An umbrella term for:
- Simple Steatosis (large but harmless fat in liver cells)
- Non-alcoholic Steatohepatitis (Causing liver inflammation)
- Fibrosis & Cirrhosis (result after years of NAFLD)
Occuring due to a build up of fat in the liver
What are the risk factors or associations with NAFLD?
Diabetes Mellitus Obesity Hypertension Hypercholesterolaemia Hypertriglyceridemia Age Smoking Ethnicity (hispanics) Genetic Factors
How do we test for NAFLD?
Often picked up during a LFT (reduced AST/ALT ratio) or ultrasound.
Follow up with CT/MRI
How do we assess a NAFLD patient?
With a NAFLD score
Created from a set of criteria based on the patients test results and health/environmental factors to determine whether they are low or high risk
What are the treatments for NAFLD?
- Diet & Weight Reduction
- Weight reduction Surgeries
- Glucagon-like peptide-1 (GLP-1) analogues for chronic weight management.
- Control of risk factors (e.g. diabetes, hypertension etc)
- Vitamin E
- Insulin Sensitisers for the diabetes.
What are the commonest autoimmune liver diseasees?
- Autoimmune hepatitis
- Primary Biliary Cholangitis (PBC)
- Primary Sclerosing Cholangitis (PSC)
- Overlap Syndromes
- Autoimmune Cholangiopathy
- IgG 4 Disease
How do we classify autoimmune hepatitis?
By the type of auto-antibody, split into:
- Type 1
- Type 2
- Type 3
How do we diagnose and treat autoimmune hepatitis?
- Liver Biopsy -> Histological
- Elevated IgG
Treat with immunosupressants:
- Steroids (prednisalone)
What is primary biliary cholangitis
Chronic granulomatous inflammation of the bile ducts
- > Loss of the intra-hepatic bile ducts
- > Eventually Cirrhosis
May be down to an environmental trigger + genetic predisposition leading to immune intolerance to self-mitochondirla proteins
How do we test for Primary Biliary Cirrhosis? (PBC)
- Elevated Serum Alkaline Phosphatase (ALP)
- Test for antimitochondrial antibodies
Which gender is more likely to get Primary Biliary Cholangitis?
Whereas Primary Sclerosing Cholangitis is male predominant
What are the symptoms of PBC?
Fatigue & Pruritis
Eventually Jaundice from backup of bilirubin
Eventually cirrhosis and liver failure
How do we treat Primary BIliary Cholangitis?
UDCA (Urodeoxycholic acid) - a secondary bile acid - reduces cholestasis & improves LFTs
Otherwise treat symptoms and eventually need a liver transplant.
What is primary sclerosing cholangitis? (PSC)
Progressive cholestasis with bile duct inflammation & fibrose stricture formation
What other conditions are associated with PSC?
Associated with IBD
Also increases risk of cholangiocarcinoma
Bile duct cancer (cancer of the epithelial lining of the biliary system).
How do we test for Primary Sclerosing Cholangitis?
pANCA test. (neutrophil antibodies)
Magnetic Resonance Cholangiopancreatography (MRCP)
How does PSC present?
Reccurent Cholangitis & Jaundice
Also pruritis & fatigue
How do we treat PSC?
What criteria deserve a liver transplant?
- Chronic liver disease with poor survival prediction
- Chronic liver disease with poor quality of life
- Hepatocellular Carcinoma
- Acute Liver Failure
- Genetic Diseases e.g. tyrosenimia, primary oxaluria
Tyrosenimia? Primary Oxaluria?
Tyrosenimia is an inbuilt error of metabolism where you cant break down tyrosine
Primary Oxaluria, inherited condition causing excess oxalate in urine
Contraindications of a liver transplant?
- Active extrahepatic malignancy
- Hepatic malignancy with macrovascular or diffuse invasion
- Active substance abuse
- Uncontrolled infection outside hepatobiliary system
- Severe cardiopulmonary or other cormobid conditions
- Psychosocial factors that preclude recovery
- brain death
- Technical/anatomical barriers
We have different protocol for deciding transplants in those with acute liver failure and chronic cirrhosis.
How do we assess someone with chronic cirrhosis for a tansplant?
MELD Score - Model for End-Stage Liver Disease
The higher these scores the more likely you are to die without a transplant
Liver TRansplant is an orthotopic transplant, what does this mean?
It means it occurs at the same spot.
I.e. the original liver must be removed and the new one implanted in its place
What post op care is there for a liver transplant?
ICU care with a MDT
Prophylactic antibiotics & antifungals
Anti-rejection meds for life:
- Azathioprine (steroid-sparing immunosuppresant)
LFT results of NAFLD?
- RAised ALT, AST, ALKP, GGT
- Low AST/ALT ratio