Hepatitis: Pathophysiology

Question 1

Hepatitis A & E transmission

Answer 1

-contaminated

Question 2

Acute Hepatitis

Answer 2

A & E, B too

Question 3

Chronic Hepatitis

Answer 3

C, D & B

Question 4

Clinical Picture of Acute Hepatitis

Answer 4

• Hep A, B, E
• fever, fatigue, abdominal pain
• Enlarged, tender liver
• Labs: high AST/ALT(1,000-5,000), bilirubin, Prothrombin time
• HVC rarely acute

Question 5

Clinical Outcome of Acute Hepatitis

Answer 5

most common: spontaneous resolution (no treatment needed), 95% hep B resolves
-progression to chronic infection
Hep C (80%), 5% of HBV, not Hep A or Hep E
-Fulminant liver failure, rare but most life-threatening complication, <1% HBV less common in HAC

Question 6

Acute Hepatitis Diagnosis

Answer 6

-IgM antibody
hep A: IgM anti HAV ab
hep E: IgM anti HEV ab
Acute HBV: IgM anti HBcore ab

Question 7

What does IgG antibody indicate?

Answer 7

-previous infection (resolved or active chronic infection)

Question 8

What does viral RNA or DNA indicate?

Answer 8

-active infection (does not differentiate chronic vs acute)

Question 9

Fulminant Hepatic Failure

Answer 9

-most serious complication of acute viral hepatitis
Presentation: altered mental status in patient with acute hepatitis (hepatic encephalopathy due to cerebral edema)
-90% mortality (brain herniation, infection)
-urgen liver transplant is the only cure

Question 10

Chronic Viral Hepatitis

Answer 10

• persistent infection >6 months
• asymptomatic (most cases found incidentally)
• mild elevations in AST & ALT (<5x normal)
• some patient can have normal LFT
• almost all cases caused by Hep C & Hep B

Question 11

Accelerated Fibrosis

Answer 11

-progression to cirrhosis in 15-20 yrs
-obesity (fatty liver)
-HIV
-Post Liver Transplant
-Alcohol consumption
(normal to fibrosis to cirrhosis to HCC liver cancer)

Question 12

Alcohol drinking in patients with chronic HCV?

Answer 12

2 beers/day
2 wind/day
30 cc rum/twice week
60cc whisky/week

Question 13

When do you treat chronic HBV?

Answer 13

1. when evidence of liver injury (high ALT)

2. liver biopsy showing advanced fibrosis

Question 14

Goals of HBV Treatment

Answer 14

-chronic cannot be cured in most patients
(only 5-10%)
-decreased replication: lower DNA
minimize liver injury & prevent progression
-decrease risk of hepatocellular carcinoma

Question 15

Hep B: Immunocompromised Host Reactivation of Latent (occult) Infection

Answer 15

• all should be tested for HBV
• natural history is likely to be worse and chance of spontaneous clearance is low
• presents as acute inc. in LFT due to reactivation of “inactive infection”
• pharmacologic prophylaxis is indicated in all patients with HBV surface antigen positivity

Question 16

Hep B in HIV

Answer 16

• all HIV patients should be tested
• likely worse and chance of spon. clearance is low
• many anti HIV drugs have anti HBV activity also
• Tenofovir

Question 17

Hep Delta

Answer 17

-not complete virus
-needs Hep B surface antigen to infect
-seen only in paitents who have HBV
-parenterally transmitted
Super Infection: infect patient with chronic HBV
CO-Infection: along with HBV

Question 18

Hepatitis Delta: Implication in HBV & Diagnosis

Answer 18

-inc. severity of HBC
-large # of patients develop cirrhosis
-Disgnosis: by delta ab or RNA
all patients have HepB Surface Antigen (HBsAG)

Question 19

Hep. C

Answer 19

most common chronic viral hepatitis in US

Question 20

Screening for HCV

Answer 20

-anyone born b/w 1945-1965 irrespective of risk factors

Question 21

Hep C Clinical Presentation

Answer 21

• incidental
• screening risk population
• testing for abnormal ALT/AST
• asymptomatic
• extra hepatic manifestations

Question 22

Hep C Treatment

Answer 22

-curable with treatment
-goal to eradicate
Duration: typically 6 months to 1 year

Question 23

Hep B & C: Hepatocellular Carcinoma

Answer 23

• most common cancer worldwide
• inc. in US
• HCV causes HCC only with cirrhosis
• HBV can cause HCC even without cirrhosis

Question 24

Liver Transplantation in Viral Hepatitis

Answer 24

1. Cirrhosis with liver failure
2. Hepatocellular carcinoma
3. Fulminant hepatic failure

Question 25

CMV Hepatitis in Immunocompromised Patients

Answer 25

- fever, diarrhea (GI tract involve) - acute increase in ALT & AST - Diagnosis: CMV DNA, CMV antigen - gold standard is tissue biopsy: liver of GI tract - Treatment: Ganciclovir, prophylaxis is recommended with valcyclovir