3. Viral Hepatitis & abdo pain

Question 1

Tell me about Hepatitis A :

• how is it spread
• where is it prevalent
• what age is it most common in
• does it go on to develop into chronic hepatitis

Answer 1

• Never goes on to develop chronic hepatitis
• faecal oral spread
• endemic in the developing world
• Common in childhood

Question 2

Tell me about Hep A:

• what is the duration of the disease
• does it need treated
• is there an immunisation for it

Answer 2

• typically 12 weeks (note will be detectable in stools week 1-2 but won’t get ill till end of week 2 and then ALT will rise and so will IgM)
• treatment not needed as it is self-limiting
• immunisation possible for travel and other liver disease

Question 3

Tell me how Hep B is spread

Answer 3

Blood (IVDU, medical equipment)
sex (prevalent in the gay community
vertical transmission (from mother to baby but not from breast milk)

Question 4

Tell me about Hep B:

• can you be immunised again it
• can it cause cancer

Answer 4

yes you can be immunised

yes it can cause cancer as its a DNA virus

Question 5

Tell me about Hep B:

- what determines. the progression of acute hep B to chronic hep B

Answer 5

the young you are the more likely it will become chronic
if your immunosuppesed
if you have a certain genotype

Question 6

tell me about Hep B:

- what is the prognosis determined by

Answer 6

rate of fibrosis progression and the vial load

Question 7

In early acute Hep B what biochemical make is there an early rise in

Answer 7

anti-core IgM

Question 8

What biochemical make shows that the Hep B is chronic and what is the difference in being;

a) HbeAg +ve
b) HbeAb +ve

Answer 8

chronic is when you have persistent HbsAg for 6/12 months

a) if you have the eAg then it means you are immunotolerant 
	High viral levels = infectious
	Normal LFTs
	Few liver problems 
b) if you have the eAb then it means you are immune reactive 
	Low viral levels = less infectious
	ALT raised
	Often fibrotic/cirrhotic

(note the eAg or eAb is a sign of active infection )

Question 9

What is the treatment for hep B

Answer 9

o Acute infection then none is usually needed
o Chronic: can’t cure it but can manage it with antiviral medication or interferon which causes immune stimulation (would give this to e antigen positive)

Question 10

How is Hep C transmitted

Answer 10

blood borne
medical (from unsterilised needs)
IVDU
however in 10-20% of cases there is genuinely no risk factor
note that thee is very low sexual and vertical transmission

(If one partner had it then would advise not to share toothbrushes or razor blades )

Question 11

Tell me about Hep C:

• is there a vaccine
• what is the treatment

Answer 11

not vaccinne
treatment is;
- interferon based on genotype 
- ribavirin (antiviral)
- protease inhibitor

Question 12

tell me about Hep C:

• what percentage of people will recover and be RNA negative
• What percentage will develop chronic hepatitis which leads to increasing fibrosis and cirrhosis

Answer 12

• 25%

- 75%

Question 13

Tell me about Hep E;

• which other Hep class is it identical to
• how is it spread
• in which group of people can it cause severe disease

Answer 13

• identical to Hep A
• spread via pork meat
• may cause severe disease in pregnancy

Question 14

Tell me about hepatitis delta
- which Hep class must you have to be infected with sin order to get hep delta

Answer 14

Hep B

Question 15

Name some hereditary causes of hepatitis

Answer 15

• Wilson’s (rare genetic disorder > causes copper poisoning in the body > healthy liver normally excretes copper in urine)
• haemochromatosis (iron deposits in tissue)

Question 16

Name some drug induced causes of hepatitis

Answer 16

medication
paracetamol
alcohol

Question 17

name some causes of hepatitis

Answer 17

hereditary
drug induced
infection
autoimmune

Question 18

If someone has biliary colic (pain) what would they present with and what happens if it associated with jaundice and fever

Answer 18

RUQ pain

- indicates cholangitis (eg sepsis in biliary duct)

Question 19

IF someone has pancreatitis what would they present with

Answer 19

severe epigastric pain radiating to the back

Question 20

if someone has no abdo pain with obstructive jaundice what are you most concerned about

Answer 20

cancer of liver or pancreas

Question 21

What are the risk factors for presenting with jaundice

Answer 21

• Alcohol intake
• Drug use including non-prescription drugs
• Travel
• Blood transfusions
• Tattoos
• Unprotected sexual activity

Question 22

In someone with abdo pain and/or jaundice what liver function tests do you want to look at

Answer 22

• clotting factors especially prothrombin time (PT) or INR

* Albumin - useful to mon tor the degree of liver damage and prognosis as it goes down in liver disease

Question 23

In someone with abdo pain and/or jaundice what liver enzymes do you want to look at

Answer 23

o	Transaminases (AST, ALT)
o	Alkaline phosphatase (most useful to aid diagnosis)

Question 24

What things would make you suspect cancer in someone who had jaundice

Answer 24

unintentional weight loss
if they look cachectic on examination
if they have a hard “craggy” liver edge
do they have risk factors predisposing them to cancer

Question 25

what is the most common primary cancer in the liver, gallbladder and pancreas and in what group of person must this be actively excluded

Answer 25

• carcinoma of the head of the pancreas

- patients over 40 who have painless, obstructive jaundice

Question 26

What cancer is usually caused by metastases from other primary cancers such as lung cancer

Answer 26

liver cancer

Question 27

Primary hepatocellular cancer is more common in patients with liver cirrhosis and so what levels in the blood should you check and why

Answer 27

serum alpha-fetoprotein levels

this is made by regenerating hepatocytes and also produced by a tumour

Question 28

If you can palpate the gallbladder then what cancer could this be

Answer 28

cholangiocarcinoma

Question 29

How does someone with Hep A present and what is the management

Answer 29

• nausea, vomiting, anorexia and jaundice
• can cause cholestasis (slowing of bile flowing through the biliary system) with dark urine, pale stools and moderate hepatomegaly
• management is basic analgesic as resolves in around 1-3 months

Question 30

In Hep B serology what does the following mean if detected;

• surface antigen (HBsAg)
• E antigen (HBeAg)
• Core antibodies (HBcAb)
• Surface antibody (HBsAb)
• Hep B virus DNA (HBV DNA)

Answer 30

• surface antigen is active infection
• E antigen is a marker of viral replication and implies high infectivity
• Core antibody implies past or current infection
• Surface antibody implies vaccination or past or current infection
• Hep B DNA is a direct count of the viral load

Question 31

In Hep B serology which two things should you first measure

Answer 31

Core antibody for previous infection
Surface antigen for active infection
if these are positive can then do further testing for E antigen and viral load