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Viral Hepatitis & Interpretation of Liver function tests Flashcards

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1
Q

What causes hepatitis [13]

A

Hep ABCDE
CMV
EBV
HIV
Herpes
Enterovirus
VZV
Rubella
Q-fever
Yellow fever
Psittacosis
Leptospirosis
Ischaemia

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2
Q

How is hep A spread [2]

A

Foecal oral eg ano-oral sex

Contaminated food or drink

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3
Q 
Hep A
Incubation period
Prognosis
Presentation in <5yo
Presentation in adult &amp; adolescent [4]
A

Short incubation - 28 days
Prog: Benign and self limiting

<5yo: subclinical, no jaundice
Adult, adolescent: 
- fever, malaise, anorexia
- N&amp;V, abdominal pain
- intrahepatic jaundice 
- hepatosplenomegaly 10-14d later (dark urine, pale stool)
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4
Q

Who is at high risk and offered immunisation [6]

A 
Travellers
CLD
Occupational exposure
Haemophiliac
Homosexual 
PWID
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5
Q

How do you Dx Hep A [3]

A

LFT increased

o Anti-HAV IgM: present at onset of symptoms; falls to non-detectable levels by 3-6m
o Anti-HAV IgG: indicates previous infection

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6
Q

How do you treat Hep A [5]

A

No treatment as self limiting
Relieve pain / itching / nausea

Prevention

  • General: good personal hygiene, sanitation
  • Patients should avoid work or school for 7 days after symptom onset.
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7
Q

What are complications of Hep A

Compare the protection that active versus passive immunization confers

A

Prolonged fatigue / jaundice
No chronic damage or HCC risk

  • Passive immunisation: HNIG provides immediate passive protection for 4m for close contacts
  • Active immunisation: inactivated vaccine gives single dose protection by 2w followed by a booster at 6-12m for 20y protection
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8
Q

How is Hep B spread [5]

Describe epidemiology of Hep B [2]

A 
Blood
Sexual 
Vertical (mother to baby)
Horizontal (households)
Carrier states exist

Ep: sub-Saharan Africa and SEA

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9
Q

How infective is Hep B?
Incubation

What are 2 rare complications of Hep B?

A

Very 100x more than HIV
Long incubation - 6 weeks (need to wait 4 to test)

Complications

  • intrahepatic jaundice
  • fulminating hepatitis
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10
Q

What are the symptoms of Hep B?
Acute [4]
Chronic [5]

A

Acute

  • Onset: within few weeks or 6m
  • Anorexia, lethargy, fever
  • N+V+D, abdominal discomfort
  • Pruritus, dark urine, pale stool

Chronic:

  • Hepatitis
  • Fulminant liver failure
  • HCC
  • GN
  • Cryoglobulinemia
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11
Q

Who is at risk of hep B [7]

A 
MSM, Travellers, 
Haemophiilac, dialysis
IVDU, Tattoo / piercing
Blood transfusion pre-screen
Healthcare workers
Chronic liver
Babies born to infected mothers
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12
Q

What is fulminant hepatic encephalopathy [4]

A

DIC
Encephalopathy
Hypoglycaemia
Prolonged PT

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13
Q

Hep B serology [6]

A

HBsAg = surface antigen (first to appear in acute infection)
HBcAg = core antigen
- IgM
- IgG
HBeAg = breakdown of core antigen in infection liver cells
HBV DNA = viral DNA

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14
Q

What suggests highly infectious

A

HBeAg + HBV DNA

Consider infectious even if e antigen is -ve due to risk of mutation

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15
Q

What suggests chronic hep B

A

HBeAg >6 months
Anti-HBc IgG

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16
Q

How do you interpret serology

A

Anti-HBs

  • Implies immunity, develop as lose surface antigen and infection clears
  • Either exposure or immunisation
  • -ve in chronic as not cleared

Anti-HBc

  • C = caught (previous or current)
  • -ve if vaccine

IgM HBc
- Acute and lasts 6 months

IgG HBc
- Persists forever and shows past infection NOT vaccine

Anti-IBe
- Inactive virus

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17
Q

What suggests previous immunisation [2]

A

Anti-Hbs

All other -ve

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18
Q

What suggests hep B 6 months ago [4]

A

Anti-Hbs
Anti-HBc
IgG HBc
HBsAg -ve

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19
Q

What suggest previous hep B but now carrier [2]

A

HbsAg +ve = chronic

Anti-HBc

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20
Q

How do you dx hep B [2]

A

Serology

Liver enzymes

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21
Q

What should you do if testing for hep B and why?

A

Test for HIV and hep D

Hep D because it requires HBV surface particle to complete replication and transmission cycle

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22
Q

Who gets tested for hep B [5]

A 
All demographics with risk factors +
Anti-TB tx
Immunosuppressed
Persistent abnormal LFT with no cause
Pregnant
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23
Q

How do you Rx acute hep B

A

No Rx

Self limiting

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24
Q

What do you advice someone with hep B [5]

A 
Public health
<5% become chronic
NO alcohol / sex
Household precaution
Vaccinate contacts
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25
When do you test for HIV / HBV / HCV
6 months
26
What are complications of HBV [7]
``` 10% chronic Cirrhosis, Liver failure HCC Membranous GN Polyarteritis nodosa Cyroglobulinuria Vasculitis rash ```
27
When do you consider treatment of chronic [5]
2+ of: - Abnormal LFT - High viral load - Abnormal fibroscan / cirrhosis - HbeAg +ve (DNA / ALT raised)
28
What do you do otherwise
Monitor | Some stages of chronic are highly infectious
29
How would you treat Hep B [3]
1. Anti-viral (nucleoside analogue) = 1st line Pegylated interferon (anti-viral + immune) 2. Liver transplant if cirrhotic 3. Monitor renal function Interferon less successful in chronic
30
What is prophylaxis in hep B [2]
Vaccine to newborn and human Ig | If on chemo / immunosuppressed / contact = vaccine and Ig
31
What do you do after vaccine
Check Anti-Hbs levels
32
How do you monitor and follow up hep B [3]
In clinic: - ALT / LFT - Fibroscan - Advise if become immunocompromised
33
Who is at risk of no response to vaccine [5]
``` Obesity Alcohol Smoking >40 Immunocompromsie ```
34
How do you treat hep B in pregnancy [5]
- Tenofavir - Obstetric team to advise delivery - Passive and active immunisation - newborn - Can breast feed - Test baby at 1 year
35
How is hep C. spread [3]
Blood/tissue donation IVDU Vertical and breastfeeding transmission is rare
36
Can you become immune to hep C | Incubation period
No so can get reinfected Short incubation 6-9w
37
What are the symptoms of hep C [6]
``` Flu like symptoms - Malaise - Anorexia - Fatigue - Arthralgia 10% jaundice ```
38
What are complications of hep C [6]
``` 85% = chronic hepatitis Cirrhosis HCC Sjogren Cryoglobulinuria Membranous GN ```
39
Who is more likely to het fulminant hepatitis [2]
Pregnancy | Immunocompromised
40
What suggests cirrhosis [2]
ALT up | Platelet down
41
Who is at risk of hep C [4]
Alcohol accelerates IVDU Haemophiliac, Dialysis Tattoo / piercing
42
How do you Dx hep C [4]
Increased LFTs | HCV RNA - PCR * detectable 1-2m Anti-HCV IgG - detectable 3m No IgM test
43
When do you retest for hep C If Ab +ve but RNA -ve? What is the likely diagnosis?
3-6 months to make sure If Ab +ve but RNA -ve = cleared or treated
44
When do you treat hep C
If Ab and antigen +ve
45
How do you treat hep C [5]
General: - Avoid alcohol - Test for other BBV - Offer immunisation Antivirals - protease inhibitor combination e.g. DACLATASVIR + SOFOSBUVIR +/- RIBAVARIN - 3 months
46
What are SE of ribavirin [3]
Teratogenic Haemolytic anaemia Cough
47
What are the SE of interferon [5]
``` Thrombocytopenia Leukapenia Fatigue Depression Flu ```
48
What does response to Rx of hep C depend on [4]
Age Gender Liver disease Amount of virus
49
What are types of response to hep C Rx
Non Responder Viral Breakthrough Relapse - when Rx stopped Sustained viral after 6 months = 95%
50
How is hep D transmitted
Same routes as hep B | But requires HBV surface particle to complete replication and transmission cycle
51
What are the symptoms of hep D
More severe hep B and rapid progression if co-infection
52
How do you Dx hep D [2]
IgM and IgG | Reverse PCR = Dx
53
How do you treat hep D [4]
NO vaccine Pegylated interferon Transplant Prevent hep B
54
What are the complications of hep D [4]
Chronic B Cirrhosis HCC Fulminant hepatitis
55
How is hep E spread
Foecal oral
56
What is the most common hepatitis Incubation period
Hep E Screen in any acute liver injury Short incubation = 40 days
57
Clinical presentation Hep E [3]
- Presentation resembles HAV - Subclinical/mild in women, more severe in elderly men - Extra-hepatic features Jaundice <1%
58
When is hep E dangerous [2]
Pregnancy = high infant mortality (diff hep A) due to tendency to progress to fulminant Elderly men
59
What are extra hepatic complications of hep E [6]
``` AKI - think if no cause Pancreatitis Bell's Palsy, GBS Neuralgic arthropathy - brachial plexus pain Arthritis Anaemia ```
60
Who is at risk of hep E
Occupational - farm | Blood transfusion due to short viraemia phase
61
When do you suspect hep E
Deranged LFT for alcohol consumption
62
How do you Dx hep E [3]
IgG and IgM HEV PCR serology Abnormal LFT
63
What is chronic hep E [2]
>3 months | No dip in HEV RNA 6 months
64
How do you treat hep E [2]
No specific Rx or vaccine | Clean water and avoid undercooked meat
65
What are complications of hep E [2]
Persistent in immunocompromsied | Liver failure if CLD
66
Interpretation of liver function tests: source Bilirubin ALT and AST ALP and GGT Albumin PT or INR
Bilirubin: Hb breakdown ALT and AST: hepatocytes ALP and GGT: biliary epithelium Albumin: synthesised by hepatocytes PT or INR: synthesised by livers
67
Different patterns of liver biochemistry suggesting different causes: Hepatocellular Cholestatic Isolated hyperbilirubinemia
1. Hepatocellular: ALT and aspartate transaminase (AST) raised in excess of other liver enzymes. 2. Cholestatic: ALP and gamma-glutamyl transferase (GGT) raised in excess of other liver enzymes. 3. Isolated hyperbilirubinaemia (other liver biochemistry normal): conjugated (e.g. Gilbert’s) or unconjugated (e.g. haemolysis).
68
Mechanisms of jaundice
1. Overproduction of bilirubin: predominantly unconjugated, rarely >70 μmol/L, caused by increased red cell breakdown (i.e. haemolysis, haematoma dissolution). 2. Failure of bilirubin conjugation: either impaired delivery of bilirubin to the liver (e.g. congestive cardiac failure, portosystemic shunting) or enzymatic defects (e.g. Gilberts disease, Crigler–Najjar syndrome). 3. Failure to export bilirubin across the canalicular membrane: conjugated. Divided into intrahepatic (e.g. viral or alcoholic hepatitis, MRP2 mutation in Dubin–Johnson syndrome) and extrahepatic (e.g. bil- iary obstruction). May also occur in non-hepatic conditions (e.g. sepsis).
69
Liver screen [7]
FBC Ferritin Copper studies BBV screen Ig Anti-mitochondrial, anti-smooth muscle or anti-nuclear antibodies Alpha-1 antitrypsin
70
Liver screen - expected abnormalities and what they suggest? FBC, ferritin, Immunoglobulins
FBC- macrocytosis, thrombocytopenia, may indicate alcohol excess, hypersplenism relation to portal hypertension Ferritin - elevated ferritin, associated with haematochromatosis, non-alcoholic and alcoholic fatty liver disease Immunoglobulins - elevated IgG and IgM suggesting PBC, autoimmune liver disease.
71
Patterns of abnormal LFT (raised more than 5x the upper limit of normal) ALT>AST AST>ALT
ALT>AST - Autoimmune hepatitis - Coeliac disease - Drug induced liver injury - Haemachromatosis - NAFLD - Viral hepatitis - Wilsons disease AST>ALT - Alcoholic liver disease - Cirrhosis
72

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