Hepatitis

Question 1

Viral causes of hepatitis

Answer 1

• Hepatitis viruses (A, B, C, D, E)
• EBV + CMV (severe in immunocompromised)
• Yellow fever (flavivirus, transmitted by mosquitos)

Question 2

Bacterial causes of hepatitis

Answer 2

• Leptospirosis
• Brucella
• Coxiella (Q fever)
• Mycobacteria

Question 3

Parasite causes of hepatitis

Answer 3

• Schistosoma
• Hydatids
• Fluke

Question 4

Stages of acute hepatitis

Answer 4

INCUBATION: 2 - 9 weeks depending on pathogen
PRE-ICTERIC/PRODROME - malaise, anorexia, nausea, fever
ICTERIC - jaundice, dark urine, pale stools, RUQ pain, may be hepatomegaly, splenomegaly, lymphadenopathy

Question 5

Hepatitis A: type, transmission, incubation, prevalence

Answer 5

• RNA virus
• Faecal-oral
• Incubation period 2-5 weeks
• Endemic in developing world
• More common in crowded places and areas of poor sanitation
• UK 30% seropositive (70% susceptible)
• Outbreaks from food, water and sometimes contaminated blood products

Question 6

Hepatitis A presentation

Answer 6

• Acute hepatitis - no chronic/carrier state
• Patients may be asymptomatic (esp <5yo)
• Fulminant hepatitis rare (0.01%), more common in older adults or those with existing chronic liver disease

Question 7

Hepatitis A investigations

Answer 7

BLOODS
• Liver enzymes (ALT, AST) dramatically raises (>1000)
• bilirubin may be raised
• prolonged INR rare and suggests hepatic necrosis
SEROLOGY
• IgM acute infection, IgG immune
• Viral hep screen to exclude acute hepatitis B or C infection
OTHER
• Liver US usually normal
• Biopsy only in cases of diagnostic uncertainty

Question 8

Hepatitis A serology

Answer 8

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/hepatitis-A/images/hep-a-figure-1.jpg

Question 9

Hepatitis A management

Answer 9

• Usually self limiting
• Supportive, advise to avoid paracetamol and alcohol
• Fulminant liver failure needs specialist liver unit care and may require transplant
• Notify HPA
• Consider vaccination of contacts in outbreaks
• Immunoglobulin can give immediate passive immunity lasting up to 3 months

Question 10

Hepatitis A vaccination info

Answer 10

• Purified, inactivated Hep A
• Creates active immunity, give at least 2 weeks, preferably a month before travel/exposure
• Repeat at 6-12 months

Question 11

Indications for hep A vaccine

Answer 11

• Travel to intermediate or high prevalence of Hep A
• MSM
• Haemophiliacs or people who will receive blood products
• IVDUs
• Occupational hazards (sewers, primates)

Question 12

Hepatitis E: type, transmission, incubation, prevalence

Answer 12

• Faecal-oral
• Usually waterborne, also food
• Hosts include pigs, monkeys, rodents and sheep
• Incubation 2 - 9 weeks
• Less prevalent and less easily spread than A
• Endemic in Central and South East Asia, North and West Africa and the Middle East
• No vaccine

Question 13

Hepatitis E: presentation and control

Answer 13

• Acute, may be asymptomatic or fulminant

* Ensure good sanitation, make sure pork properly cooked

Question 14

Hepatitis B: type, transmission, incubation, prevalence

Answer 14

• DNA virus, uses host hepatocytes for replication
• Transmission: Perinatal (most common worldwide); IVDU, sexual contact, infected blood products, needlestick
• Incubation period 6 weeks to 6 months
• Most common serious liver infection world-wide
• Worldwide 400 million people have; >500 000 deaths/year

Question 15

Hepatitis B: illness

Answer 15

• Can be acute or chronic

* 5-10% become chronic, in children who acquire through vertical transmission, up to 80%

Question 16

Complications of chronic hepatitis infection

Answer 16

• Cirrhosis (25%)
• End stage liver disease
• Hepatocellular carcinoma

Question 17

Stigmata of chronic liver disease

Answer 17

These come from problems with either metabolic or synthetic function
• Jaundice (bilirubin metabolism)
• Bruising (impaired synthesis of vitamin K dependent clotting factors)
• Leukonychia - hypoalbuminaemia
• Portal hypertension:
      - Splenomegaly
      - Caput medusa
      - Ascites
     (- Varices and haemorrhoids)
• Hepatic encephalopathy
      - flap
      - confusion/drowsiness
• Altered oestrogen metabolism
      - gyneacomastia
      - testicular atrophy
      - loss of axillary hair
• Palmer Erythema
• Dupytren's
• Clubbing

Question 18

Hepatitis B investigations

Answer 18

BLOODS
• LFTs, clotting factors
• Hepatitis B core DNA
• Liver US
• Fibroscan (US that measures 'stiffness' of liver
• Liver biopsy

Question 19

Things to screen for in those with cirrhosis

Answer 19

• Alpha fetoprotein (for HCC)
• Abdominal US
• OGD to assess for varices

Question 20

Hepatitis B serology
http://www.bio-rad.com/webroot/web/images/cdg/products/blood_virus/product_overlay_content/global/bvd_monolisa_antihbc_01b_overlay.jpg

Answer 20

http://depts.washington.edu/hepstudy/images/hepB/HBV_Serologic_d02.png
HBsAg (antigen) = acute infection with HBV (if present more than 6 months = chronic)
Anti-HBs (antibody) = immunity following infection or vaccine
HBeAg = may be present in acute or chronic, signifies high-infectivity
NEEDS MORE

Question 21

Advice in Hep B

Answer 21

• Avoid alcohol

* Have Hep A vaccine if not immune

Question 22

Prevention of Hep B

Answer 22

• Protected sex
• Don’t share razors
• Careful treatment of cuts
• Vaccination of household contacts
• Screening of blood products
• Pre-exposure vaccination in at risk groups (children in endemic areas; healthcare staff; partners of patients)
• Post exposure vaccine/Ig for sexual contacts, needlestick injuries or babies born to infected mothers

Question 23

Treatment of Hepatitis B

Answer 23

Acute: Supportive
Chronic:
• Inactive HBsAg carriers or normal ALT just monitor
• Deranged LFTs or cirrhosis give antivirals (tenofovir; entecavir; pegylated interferon; [lamivudine])
Patients with decompensated cirrhosis may be eligible for transplant

Question 24

Hepatitis D

Answer 24

• Requires co-infection with hepatitis B to replicate
• Simultaneous hepatitis B and D infections increase the risk of fulminant hepatitis
• Exacerbations of hepatitis may occur in patients with hepatitis B who acquire hepatitis D
• Common in Southern Italy, North Africa and Middle East
• Check hepatitis D serology in all hepatitis B patients

Question 25

Hepatitis C: type, transmission, incubation, prevalence

Answer 25

* RNA virus * Transmitted through blood and sexual contact * Incubation period 2 weeks to six months * 170 million people worldwide * Common in IVDU * Common in Egypt, Taiwan and Japan * No vaccine available

Question 26

Hepatitis C: presentation

Answer 26

* May give acute infection, but usually less severe than hepatitis A or B * 80% infections become chronic * Of these, 20% develop cirrhosis * Of these, 1/3 develop HCC

Question 27

Hepatitis C investigations

Answer 27

* AST and ALT not as markedly raised as in B or C * Serology detects antibody to hepatitis C but can't distinguish if active or passive infection * Hepatitis C RNA detects virus in blood (shows active infection) * Viral genotyping to guide treatment (6 genotypes, of which 1a is most difficult to treat) * Serology for other hepatitis viruses (and vaccinate against A and B if not immune) * Liver US; alpha fetoprotein; fibroscan; liver biopsy (more accurate, although more invasive assessment of cirrhosis)

Question 28

Hepatitis C prevention

Answer 28

* Screening of blood products * Needle exchange programs and education for IVDU * Universal infection control procedures

Question 29

Hepatitis C treatment

Answer 29

Supportive for acute infections CHRONIC Standard: • Pegylated Interferon (flu-like, neurological, psychiatric symptoms; bone marrow suppression) • Ribavirin (in conjunction with interferon; haemolytic anaemia) New treatments: • Addition of protease or polymerase inhibitors increase response rate but also side effects Transplant may be indicated in cirrhosis or end stage liver disease. Transplant or resection may be indicated in HCC.