Hepatitis (GI)

Question 1

What are two types of hepatitis (non-viral)?

Answer 1

• autoimmune hepatitis - these flashcards focus on AIH
• ischaemic hepatitis

Question 2

Define autoimmune hepatitis.

Answer 2

Chronic inflammatory disease of the liver of unknown aetiology

Question 3

Who does autoimmune hepatitis tend to affect more?

Answer 3

Young females (4:1)

Question 4

What are the three types of autoimmune hepatitis?

Answer 4

• type 1 AIH (classic, 80% of cases) - children and adults
• type 2 AIH - children only
• type 3 AIH

Question 5

What are the most common antibodies present in type 1 autoimmune hepatitis? (2 + 2)

Answer 5

• antinuclear antibodies (ANA)
• anti-smooth muscle antibodies (ASMA)
• (anti-actin antibodies - AAA)
• (anti-soluble liver antigen - anti-SLA)

Question 6

What antibodies are present in type 2 autoimmune hepatitis? (1 + 1)

Answer 6

• anti-liver kidney microsomal-1 (anti-LKM-1)
• (anti-liver cytosol - ALC-1)

Question 7

What antigen is targeted in type 3 autoimmune hepatitis?

Answer 7

Anti-soluble liver antigen (anti-SLA)

Question 8

What is the aetiology of autoimmune hepatitis?

Answer 8

Idiopathic

Question 9

What are some examples of autoimmune diseases that autoimmune hepatitis is commonly associated with? (4)

Answer 9

• Hashimoto’s thyroiditis
• Graves disease
• ulcerative colitis
• Coeliac disease

Question 10

What gene plays a role in autoimmune hepatitis?

Answer 10

HLA gene (HLA-DR3/4)

Genetically predisposed individual –> environment e.g. viruses/drugs may lead to hepatocyte expression of HLA-DR3/4 –> T-cell mediated autoimmune attack against hepatocytes

Question 11

What is autoimmune hepatitis characterised by?

Answer 11

Presence of circulating autoantibodies with a high serum globulin concentration (hyperglobulinaemia), inflammatory changes on liver histology (chronic inflammation) and a favourable response to immunosuppressive treatment

Question 12

When can ischaemic hepatitis occur?

Answer 12

Following acute hepatic hypoperfusion e.g. after sepsis or cardiac arrest

Question 13

What is ischaemic hepatitis characterised by? (2)

Answer 13

• marked elevation of AST and ALT 1-3 days after insult
• significant rise in LDH (very sensitive for ischaemic hepatitis)

Question 14

What are the clinical features of hepatitis? (13)

Answer 14

• fatigue
• malaise
• anorexia
• abdominal discomfort
• hepatomegaly
• splenomegaly
• jaundice
• encephalopathy
• pruritus
• arthralgia
• nausea
• amenorrhoea
• spider naevi

Question 15

What might you see on examination of hepatitis?

Answer 15

• ascites
• hepatomegaly
• splenomegaly
• jaundice
• spider naevi
• GI bleeding

Question 16

What are some risk factors for hepatitis? (4)

Answer 16

• female
• genetics
• viral triggers
• drug triggers

Question 17

What are the first-line investigations in hepatitis? (2)

Answer 17

• LFTs - AST, ALT, BR, GGT
• prothrombin time

Question 18

What do we see in bloods/LFTs in hepatitis?

Answer 18

• high AST and ALT
• BR, GGT and ALP - mild to moderately increased
• low serum albumin (when synthetic function affected)
• high globulins (hypergammaglobulinaemia)

Question 19

What do we suspect instead of hepatitis if ALP was raised a lot (rather than mild-moderate)?

Answer 19

Bile duct pathology

Question 20

What serum autoantibodies can be found in type 1 and type 2 autoimmune hepatitis?

Answer 20

• type 1 AIH: ANA & ASMA
• type 2 AIH: anti-LKM-1

Question 21

What is characteristic of type 1 autoimmune hepatitis?

Answer 21

Decreased albumin, increased prothrombin time

Question 22

What is prothrombin time like in hepatitis?

Answer 22

Prolonged PT

Question 23

What would serum protein electrophoresis show in hepatitis?

Answer 23

Hypergammaglobulinaemia (increased IgG)

Question 24

Why would a liver biopsy be done in hepatitis and what would it show?

Answer 24

Confirms diagnosis - inflammation and bridging necrosis seen

Question 25

What LFTs are markedly raised in hepatitis? (2)

Answer 25

- aspartate aminotransferase (AST) - alanine aminotransferase (ALT)

Question 26

What investigations can we do in hepatitis to rule out other causes? (6)

Answer 26

- viral serology (hepatitis B/C) - urinary copper/caeruloplasmin (Wilson's disease) - ferritin and transferrin saturation (haemochromatosis) - alpha-1-antitrypsin (deficiency) - anti-mitochondrial antibodies (PBC) - ERCP (PSC)

Question 27

What are some differential diagnoses for hepatitis? (13)

Answer 27

- primary biliary cirrhosis (PBC) - primary sclerosing cholangitis (PSC) - chronic hepatitis - drug-induced hepatitis - granulomatous hepatitis - genetic haemochromatosis - alpha-1-antitrypsin deficiency - Wilson's disease - cholangiopathy related to AIDS - non-alcoholic steatohepatitis (NASH) - presence of 1+ components of metabolic syndrome - alcoholic liver disease - SLE - Graft vs Host disease

Question 28

What are the indications for management of hepatitis? (3 + 3)

Answer 28

- aminotransferases >10x upper limit of normal - symptomatic - histology: - significant interface hepatitis - bridging necrosis - multiacinar necrosis

Question 29

How do we manage hepatitis?

Answer 29

- corticosteroid - **prednisolone** followed by maintenance treatment with gradual reduction in dose - immunosuppressant - **azathioprine** - maintenance phase: steroid-sparing agents, frequent LFT and FBC monitoring - often long term treatment - definitive Rx: liver transplant

Question 30

What do we test for before starting azathioprine in hepatitis?

Answer 30

Test for TPMT1 | Thiopurine methyltransferase deficiency

Question 31

What is the definitive treatment for hepatitis?

Answer 31

Liver transplant (if refractory/intolerant/end-stage)

Question 32

How do we monitor disease progression in hepatitis? (3)

Answer 32

- ultrasound and alpha-feroprotein level every 6-12 months if cirrhosis present - to detect hepatocellular carcinoma - repeat liver biopsies to check disease progression - frequent FBC+LFTs

Question 33

What vaccinations could we give in hepatitis?

Answer 33

Hepatitis A and B vaccinations

Question 34

What are some complications of hepatitis? (7)

Answer 34

- fulminant hepatic failure (severe impairment in absence of pre-existing liver disease) - cirrhosis - portal hypertension (ascites, varices) - hepatocellular carcinoma - corticosteroid side effects - azathioprine side effects (malignancy, BM suppression, cholestatic hepatitis, pancreatitis, teratogenic) - infections due to immunosuppression

Question 35

Describe the prognosis of hepatitis.

Answer 35

- majority of patients with moderate/severe AIH respond to treatment within 2 weeks - achieve remission with serum aminotransferases falling into normal range after 12+ months of treatment