Viral Hepatitis

Question 1

What is viral hepatitis?

Answer 1

Liver inflammation due to a viral infection

Question 2

What are the causes of acute hepatitis?

Answer 2

Hepatitis infection, alcohol, drugs, EBV, CMV, toxoplasmosis, haemochromatosis, toxins, autoimmune

Question 3

What is the pattern of infection of acute hepatitis?

Answer 3

1. Prodromal: flu-like symptoms: fatigue, nausea, vomiting, pain; liver symptoms: clay-coloured stools
2. Jaundice: 1-2 weeks later, spleno/hepatomegaly
3. Recovery: resolution of symptoms but elevation of LFTS

Question 4

What is chronic hepatitis?

Answer 4

Hepatitis present for > 6 months, with variable changes in liver function.

Question 5

What clinical symptoms are there in acute hepatitis?

Answer 5

Raised ALT/AST, jaundice, clotting derangements.

Question 6

What types of hepatitis cause only acute hepatitis?

Answer 6

Hepatitis A

Question 7

How are the hepatic acinar zones affected in hepatitis?

Answer 7

Zone 1: sees oxygenated blood first, so most susceptible to hepatitis
Zone 3: more susceptible to ischaemia

Question 8

What is the pathophysiology of chronic hepatitis?

Answer 8

Hepatocytes degenerate: swelling, cytoplasmic granularity and vacuolation.
Multiacinar necrosis occurs as inflammatory lymphocytes infiltrate into lobules and portal tracts.

Question 9

What kind of virus is hepatitis A?

What is the epidemiology of hepatitis A?

Answer 9

Single-stranded RNA virus, with a single serotype.

Travel-related, most common acute viral hepatitis.

Question 10

How is hepatitis A transmitted?

Answer 10

Faecal-oral route vie food and water.

Question 11

What is the lifecyle of hepatitis A?

Answer 11

Replicates in the liver, is excreted in bile and then in faeces 2 weeks before onset of clinical symptoms with 1 month incubation.
No chronic carriage and good immunity.

Question 12

What are the clinical features of hep A?

Answer 12

Flu symptoms.
Jaundice due to intrahepatic cholestasis
Age determinant of severity,

Question 13

Investigations/diagnosis of hep A?

Answer 13

IgM positive or RNA in the blood or stool in acute hep A.

If previously infected or vaccinated, IgG positive

Question 14

What vaccinations are there for hep A?

Answer 14

Active:
- inactivated virus, 95% efficacy. MSM, IVDV, travellers, outbreak control.

Passive:
- pooled immunoglobulins, if allergic to vaccine or before 4 weeks of travel; 3-6 month efficacy

Question 15

What kind of virus is hepatitis E?

Answer 15

RNA virus

Question 16

How is hep E transmitted?

Answer 16

Faecal-oral route; pork, water

Incubation period 40 days

Question 17

How many genotypes does hep E have?

Answer 17

4. 3rd is linked to neurological problem e.g. GB syndrome, encephalopathy, alaxia, myopathyin 5% patients

Question 18

What are the symptoms of hep E?

Answer 18

General flu-like symptoms

Question 19

What is treatment of hep E?

Answer 19

Supportive treatment, since there is no vaccine.

Chronic can be seen (rarely) in immunocompromised patients e.g. bone marrow transplants

Question 20

How is hep E diagnosed?

Answer 20

IgG and IgM and antiHEV

Question 21

What are the complications of hep E?

Answer 21

High mortality rates, especially in pregnancy with the GT 1 serotype

Question 22

What kind of virus in hepatitis B?

Answer 22

Hepadnavirus DNA virus

Question 23

Hep B epidemiology?

Answer 23

300 million cases worldwide, 2 million deaths a year

Question 24

What is the difference between the surface antigen and the e-antigen in HBV?

What does the core antibody indicate?

What is the difference between the surface antibody and the core antibody?

Answer 24

Surface antigen: present in all carriers. If present for over 6 months, chronic.
E-antigen: reflects high infectivity

Core antibody: previous infection

Surface antibody: marker of immunity
E-antibody: reflects low infectivity

Question 25

How is hep B transmitted?

Answer 25

Vertically from mother to child in womb. | Horizontally via transfusion, needles, blood, semen etc.

Question 26

What are the symptoms of hep B?

Answer 26

Fever symptoms: myalgia, joint pain; jaundice, weight loss, abdominal pain, bloody ascites Incubation period: 2-6 months

Question 27

How does the age of infection affect the severity of the acute illness and the severity of chronic infection with hep B?

Answer 27

Babies are less likely to get an acute infection but they are also more likely to become carriers (70-90%) and have the chronic disease later in life, since they have no immune system to attack the virus when they're young.

Question 28

What complications can chronic hep B cause?

Answer 28

Liver cirrhosis in 25%. Hepatocellular carcinoma Chronic active HBV Upper GI haemorrhage and varices

Question 29

What is the main route of hep B transmission in UK?

Answer 29

Sex

Question 30

How is HBV diagnosed?

Answer 30

Surface antigen (marker of infection) present, or if DNA is detectable

Question 31

Which aminotransferase increases in chronic HBV infection?

Answer 31

ALT: increases during immune clearance, and decreases at reactivation

Question 32

What 2 groups are hep B carriers divided into?

Answer 32

eAG positive: early disease. High risk of chronic liver disease and hepatocellular carcinoma. eAG negative: late disease. Low risk.

Question 33

What is the treatment for acute and chronic hep B?

Answer 33

Acute: none Chronic: treat liver inflammation; aim is to suppress viral replication and convert eAg +ve to -ve (less infectious) Immunological: pegylated interferon alpha weekly for 1 year to increase cellular immune responses; side effect of constant flu. Antiviral drugs: suppress viral replication. - Tenofovir - Entecavir

Question 34

How can hepatitis B be prevented?

Answer 34

- Education: condoms and needle awareness. | - Screening in pregnancy.

Question 35

What immunisation is available for hep B?

Answer 35

Active: HBV sAg antigen in high risk groups. Passive: babies to HBV+ve mums

Question 36

What interventions can be made in pregnancy to prevent hep B?

Answer 36

1. HBV vaccination to newborn 2. HBV Ig, if eAg+ve 3. Tenofovir in last trimester for mum

Question 37

What kind of virus is hep D?

Answer 37

ss RNA virus

Question 38

What other hepatitis is hep D always present with?

Answer 38

Hep B: needs it to replicate

Question 39

How is hep D transmitted?

Answer 39

Same as hep B. Can be coinfected with hep B (coinfection) or infect someone already with HBV (superinfection) vertical is rare

Question 40

What treatment is there for hep D?

Answer 40

Pegylated interferon alpha injections only.

Question 41

What kind of virus is hep C, and how many genotypes?

Answer 41

RNA flavirus with 6 genotypes

Question 42

What type of hepatitis is most common in IV drugs users in Glasgow?

Answer 42

Hepatitis C: 0.7% Scottish population

Question 43

How is hep C transmitted?

Answer 43

Parenteral transmission (same as hep B/D) >50% IV drug users have HCV Vertical: mother to baby

Question 44

What is the incubation period of hep C?

Answer 44

6-8 weeks

Question 45

What are the symptoms of hep C?

Answer 45

Asymptomatic in 90% of cases and 35-40% is undiagnosed.

Question 46

What are the complications for HCV carriers?

Answer 46

60-90% have risk of developing chronic active hepatitis, liver cirrhosis and hepatocellular carcinoma.

Question 47

Do those that have been infected with HCV become immune? Is there a vaccine?

Answer 47

No reliable immunity after infection | No vaccine

Question 48

How is HCV diagnosed?

Answer 48

Anti HCG Ig +ve = chronic OR cleared infection | PCR/antigen +ve = current infection/viraemia

Question 49

How can HCV be treated?

Answer 49

Pegylated interferon alpha Ribavicin - cures 40-60% after 24-48 weeks Also: direct acting antiviral to increase chance of a cure.