5 - Liver disease and Hep B

Question 1

Structure of the hepatitis B virus

Answer 1

Double stranded DNA virus

Question 2

Epidemiology of hep B

Answer 2

most common cause of hepatitis

350million worldwide affected

Question 3

HbeAg antigen

Answer 3

Secreted by infected cells (marker for active infection)

Question 4

HBsAg antigen

Answer 4

First marker to appear and causes the production of anti-HBs

Question 5

HbsAg 1-6months

Answer 5

Acute disease

Question 6

HbeAg 1-3 months

Answer 6

Results from breakdown of infected liver cells

Marker for infectivity

Question 7

Anti-HBc

Answer 7

Core antibody
implies previous or current infection
o IgM anti-HBc appears during acute or recent infection (6 months)
o IgG anti-HBc persists for life

Question 8

Anti-Hbs (surface antibody) implies

Answer 8

Immunity
due to exposure or immunisation
negative in chronic disease as no immunity in this case

Question 9

Transmission of hep b

Answer 9

Sexual intercourse
Blood
Bites from an infected person
Vertical - mother to infant

Question 10

Clinical presentation of hep b

Answer 10

Acutely presents as flu-like
Anorexia, loss of appetite
Nausea
RUQ pain
Fever
Malaise
Jaundice

Question 11

Signs of decompensated liver disease

Answer 11

Ascites
Encephalopathy
GI bleeding (varices)

Question 12

Chronic hep B

Answer 12

> 6 months
if inactive - no significant harm
Carriers present with nausea, fatigue, RUQ pain
May progress to liver fibrosis, cirrhosis and HCC

Question 13

Acute hep b symptoms

Answer 13

weight loss
anorexia
Nausea
fatigue
muscle or joint pain

Question 14

Chronic hep b symptoms

Answer 14

Weight loss, anorexia, fatigue, bleeding easily, dark coloured urine, itchy skin, confusion, drowsiness, ascites, oedema, jaundice, spider naevi, hepatosplenomegaly.

Question 15

Hep b specific investigations

Answer 15

 HBsAg, HBeAg, anti-HBe, anti-HBs, anti-HB core
 HBV genotype
 HBV DNA quantification
 Quantitative HCV RNA polymerase chain reaction (1 or 2 weeks post infection)
 HCV antibody enzyme immunoassay (ELISA)

Question 16

General liver test

Answer 16

FBC
Liver Enzymes (ALT, AST, GGT), Bilirubin, Albumin, Clotting, autoantibody screen

Question 17

Biomarkers of liver injury

Answer 17

 Alanine transaminase (ALT) and Aspartate aminotransferase (AST)

Question 18

Alkaline phosphate

Answer 18

Biomarker for biliary tree pathology

Question 19

Gamma-glutamyl transferase

Answer 19

Alcohol involvement

Question 20

Hep B treatment

Answer 20

Avoid unprotected sex
Avoid alcohol
Support- analgesia, antiemetics, fluids

Question 21

Treatment of hep b if chronic infection

Answer 21

lifelong treatment
Antivirals - pegylated inferferon alfa-2a for 48 weeks
or
NtRTI - nucleotide analog reverse-transcriptase inhibitor
 e.g. tenofovir, entecavir, sofosbuvir, grazoprevir

Question 22

Complications of HepB

Answer 22

Hepatocellular carcinoma
Cirrhosis
Fulminant liver failure

Question 23

What is cirrhosis

Answer 23

Irreversible liver damage

end stage of liver disease

Question 24

Causes of cirrhosis

Answer 24

Alcohol abuse
HBV (most common), HVC
Genetics - wilsons, haemochromatosis 
Autoimmune - Primary Biliary Cholangitis, Primary Sclerosing Cholangitis
Drugs - Amidarone, methotrexate

Question 25

Pathogenesis of cirrhosis

Answer 25

o 1) alcohol/virus  2) constant stress on liver  3) inflammation and destruction of hepatocytes 4) liver cell necrosis  5a) stellate cell activation  production of fibrogenic mediators ( TGF-B)  increased collagen  fibrosis  5b) remaining liver cells that are damaged form colonies (regeneration nodule formation)  6a) macronodular -chronic hep b 6b) micronodular <3mm caused by alcohol.

Question 26

Compensated liver

Answer 26

 Liver can still undergo its function, may be asymptomatic or have non-specific symptoms such as weight loss, fatigue, weakness

Question 27

What is decompensated liver

Answer 27

 Liver can’t function and do its normal jobs (jaundice, pruritus, ascites, hepatic encephalopathy, easy bruising