Hepatitis

Question 1

Define acute viral hepatitis

Answer 1

Acute hepatitis caused by virus

Question 2

Clinical features

Answer 2

1. May be subclinical
2. Flu-like prodrome preceeding icteric phase by 1-2 weeks ƒƒnausea, vomiting, anorexia, taste/smell disturbance, headaches, fatigue, myalgia, low-grade fever ƒƒarthralgia and urticaria (especially HBV)
3. Pale stools, dark urine 1-5 days before jaundice
4. Hepatomegaly, RUQ pain
5. May have splenomegaly, cervical lymphadenopathy

Question 3

Investigations

Answer 3

1. AST and ALT (10-20X normal)
2. ALP and bilirubin minimally elevated
3. Viral serology

Question 4

Management

Answer 4

1. Supportive:

Hydration

Diet

Analgesia

2. Avoid alcohol, drugs

Question 5

Indications for admission

Answer 5

1. Encephalopathy
2. Coagulopathy
3. Severe vomiting
4. Hypoglycemia

Question 6

Complications

Answer 6

1. Hepatocellular necrosis (+LFTs)
2. Cholestasis (pale stools, jaundice)
3. Encephalopathy
4. Coagulopathy
5. Hypoglycemia

Question 7

Prognostic indicators poor

Answer 7

1. comorbidities
2. persistently high bilirubin (>340 mmol; 20 mg/dL)
3. increased INR
4. decreased albumin
5. hypoglycemia
6. Cholestasis

Question 8

In which viral hepatitis is cholestasis more common

Answer 8

Hepatitis A

Question 9

Hepatitis A: type of virus, transmission, common age group, incubation

Answer 9

1. RNA
2. Fecal-oral
3. Common in children, in adults more common to be fulminant disease
4. Incubation 2-6 weeks

Question 10

When does AST/ALT rise in hep A and return to normal

Answer 10

Rise within 1 month, returns to normal 5-20 weeks

Question 11

Clinical features in hepatitis A

Answer 11

Key factors

1. presence of risk factors
2. fever
3. malaise
4. nausea and vomiting
5. jaundice
6. hepatomegaly
7. RUQ pain
8. clay-coloured stools

Question 12

Investigations in hepatitis A and results

Answer 12

1. 1st tests to order serum transaminases->elevated serum bilirubin->?elevated blood urea->+if renal failure serum creatinine->+if renal failure
2. prothrombin time
3. IgM anti-hepatitis A virus (HAV)->elevated in acute

Question 13

Management hepatitis A unvaccinated people with recent exposure to hepatitis A

Answer 13

IM immunoglobulin for prevention

1. Supportive

Analgesia

Fluids

Nutrition

2. Avoid alcohol

Question 14

Hepatitis B: virus type, transmission (4), incubation

Answer 14

1. DNA
2. Blood products, sexual, IVDU, vertical, direct
3. 6 months

Question 15

Risk factors for hepatitis B

Answer 15

Strong

1. perinatal exposure in an infant born to an HBV-infected mother
2. multiple sexual partners
3. men who have sex with men (MSM)
4. injection drug use
5. Asian, eastern European, or African ancestry
6. FHx of HBV and/or chronic liver disease
7. FHx of hepatocellular carcinoma (HCC)
8. household contact with HBV

Weak

1. male sex history of STDs
2. infected with HIV infected with hepatitis C virus (HCV)
3. blood or blood product transfusion
4. health care worker (HCW)
5. history of incarceration haemodialysis

Question 16

Interpreting hepatitis B serology for acute, chronic, resolved and immunised->HBsAg, Anti-HBS, HBeAg, Anti-HBe, Anti-HBc

Answer 16

Hepatitis B

Serology HBsAg Anti-HBs HBeAg Anti-HBe Anti-HBc Liver Enzymes

Acute HBV + – + – IgM

Chronic HBV (high HBV DNA) + – + – IgG ALT, AST elevated

Chronic HBV (low HBV DNA) + – – + IgG ALT, AST normal

Resolved infection – ± – ± IgG

Immunization – + – – –

Question 17

Clinical features of hepatitis B

Answer 17

1. Key factors presence of risk factors
2. May have normal physical examination
3. jaundice
4. hepatomegaly
5. ascites
6. fever/chill malaise
7. maculopapular or urticarial rash
8. RUQ pain
9. fatigue nausea/vomiting
10. arthralgia/arthritis
11. palmar erythema
12. spider angiomata
13. splenomegaly
14. asterixis

Question 18

Phases of chronic hepatitis B overview

Answer 18

1) immune tolerance
2) immune clearance
3) immune control
4) immune escape

Question 19

Immune tolerance in hepatitis B

Answer 19

1. extremely high HBV-DNA (>20,000 IU/mL), HBeAg positive, but normal ALT/AST; due to little immune control and minimal immune-mediated liver damage; characteristic of perinatal infection (or ‘incubation period’ in adult with newly acquired HBV

Question 20

Immune clearance

Answer 20

1. falling but still elevated HBV-DNA levels (>20,000 IU/mL),
2. HBeAg positive; due to immune attack on the virus and immune mediated liver damage; characterized by progressive disease without treatment and increasing liver fibrosis (sometimes progressing to cirrhosis and/or hepatocellular carcinoma); likely to benefit from treatment

Question 21

Immune control

Answer 21

1. lower HBV-DNA immune response suppresses viral replication to low or undetectable levels. Inflammation reduces and serum alanine aminotransferase normalises. The establishment of immune control is associated with HBeAg seroconversion, and these patients are thought not to have ongoing damage. Once seroconversion occurs, patients may stay in this phase indefinitely

Question 22

Immune escape

Answer 22

1. (“core or precore mutant”): elevated HBV-DNA (>2,000 IU/mL), HBeAg negative because of pre-core or core promoter gene mutation, anti-HBe positive, ALT/AST high; characterized by progressive disease without treatment and increasing liver fibrosis (sometimes progressing to cirrhosis and/or hepatocellular carcinoma); likely to benefit from treatment

Question 23

Investigations

Answer 23

1st tests to order

1. hepatic panel->+ALT/AST, +bilirubin, +ALP
2. FBC->microcytic anemia, thrombocytopenia (portal HTN)
3. basic metabolic panel (BMP)->hyponatremia (fluid overload, diuretics to treat), urea (+in pre-renal azootemia) coagulation profile (PT/INR)
4. serum HBsAg, serum HBsAb, serum HBcAb (IgM) serum HBcAb (IgM + IgG), serum HBeAg HBV DNA

Question 24

What does HbeAg suggest

Answer 24

high infectivity

Question 25

What serology defines carrier status in hepatitis B

Answer 25

+HbsAg \>6 months after exposure.

Question 26

In what phase of chronic hepatitis B is antiviral therapy targeted

Answer 26

Antiviral treatment of chronic hepatitis B is directed at patients in the immune clearance phase (phase 2) and the immune escape phase (phase 4).

Question 27

Antiviral therapy options for hepatitis B chronic

Answer 27

1. entecavir 0.5 mg orally, once daily, continued for 12 months after HBeAg seroconversion or long term if no seroconversion OR 1. tenofovir 300 mg orally, once daily, continued for 12 months after HBeAg seroconversion or long term if no seroconversion OR 1. peginterferon alfa-2a 180 micrograms SC, once weekly for 48 weeks.

Question 28

Complications in hepatitis B

Answer 28

1. Fulminant liver failure 2. Cirrhosis 3. Hep B glomerulonephritis 4. Cholestasis 5. Hepatocellular carcinoma

Question 29

Interferon side effects

Answer 29

1. influenza-like illness, fever, chills, headache, malaise, myalgia, fatigue, anorexia, weight loss, and mild hair loss. They may also have a myelosuppressive effect

Question 30

Patient instructions with hepatitis B

Answer 30

1. Barrier protection 2. Do not share razors, toothbrushes 3. Cover open wounds/scratches 4. Clean blood spills with bleach/detergent 5. Do not donate blood, semen, organ 6. Avoid heavy alcohol use 7. Sexual partners and all household contacts of HBsAg-positive people should be vaccinated for HBV if they test negative for HBV serological markers.

Question 31

Starting antiviral treatment early in acute hepatitis C- options

Answer 31

1. Starting antiviral treatment within 12 weeks of onset of hepatitis maximises the chance of viral clearance, without reducing the chance of response. 2. peginterferon alfa-2a 180 micrograms SC, once weekly for 24 weeks or peginterferon alfa-2b 1.5 micrograms/kg SC, once weekly for 24 weeks.

Question 32

Transmission in hep C

Answer 32

Blood transfusion, sexual

Question 33

Number developing chronic in hepatitis C, cirrhosis

Answer 33

85% chronic, 20-30% cirrhotic

Question 34

Why is genotyping in hepatitis C important

Answer 34

Peginterferon therapy is less effective in G1, 4, 5, 6

Question 35

Contraindications for PEG

Answer 35

1. Allergy 2. Autoimmune hepatitis 3. Severe liver dysfunction 4. Decompensated liver cirrhosis

Question 36

Investigations in hepatitis C

Answer 36

1. LFTs normal until cirrhosis develops 2. anti-HCV antibodies 3. Recombinant immunoblot assay HCV-PCR 4. Liver biopsy 5. HCV genotyping

Question 37

How is diagnosis established in hep C infection

Answer 37

Presence of HCV-RNA

Question 38

Is chronic hepatitis B more likely in infants or adults

Answer 38

More in infants

Question 39

Differential for acute hepatitis

Answer 39

1. Alcohol 2. Drugs 3. Toxins 4. EBV/CMV 5. Leptospirosis 6. Malaria 7. Q fever 8. Syphillis 9. Yellow fever 10. Chronic hepatitis

Question 40

Hepatitis D co-infection vs superinfection

Answer 40

co-infection: acquire HDV and HBV at the same time ƒƒbetter prognosis than superinfection (acute HDV infection on pre-existing HBV infection