8.1 Viral hepatitis Flashcards
Liver = …1… organ positioned in the ..2.. of the abdomen
- peritoneal
- right upper quadrant (RUQ)
List some functions of liver
- Production of bile
- Filtering of toxins
- Excretion of bilirubin cholesterol/hormones/drugs
- Breakdown of carbohydrates, fats, protein
- Activation of enzymes
- Storing glycogen, minerals, ADEK
- Synthesise blood proteins
- Synthesise clotting factors
hepatitis means ?
inflammation of liver
5 main types of hepatitis viruses ?
- A
- B
- C
- D
- E
all viral hepatitis infections are ..1.. diseases
notifiable
Who would need to be notified about notifiable diseases apart from partner of an infected patient ?
- Local health protection board member
- CDC
- health protection agency
- UKHSA
Name some different strains that are included in enteroviruses
- group A and group B coxsackieviruses
- the echoviruses
- the plioviruses
- hepatitis A virus
Normal site of replication for hepatitis
GI tract
When viral infection damages the liver what can be damaged ?
all of the liver’s essential functions
When may the symptoms of viral hepatitis occur ?
- instant
- or occur months or years after the infection itself
list symptoms of viral hepatitis
- jaundice - yellowing of skins & eyes
- abdominal pain & distention
- dark urine
- light coloured stool
- vomiting
- fatigue
- weight loss
- coma brought on by accumulation of waste products
When the host immune system responds to the infection within the liver cells the response ..1.. liver cells ands causes ..2..
- kills
- the liver damage
What can chronic hepatitis infection cause ?
- permanent liver damage
- liver failure
- cancer
Virus type of hepatitis A virus ?
non-enveloped ss RNA virus
Hepatitis A infection replicates in ..1.. interfering with ..2… and causing ..3..
- hepatocytes
- cell function
- inflammation
transmission of hepatitis A ?
faecal-oral route
Hepatitis A transmission happens via …1…. often occurs in ….2… to places where the virus is ..3….
- contaminated food or water
- travellers
- highly endemic
Where are the highest risk areas for UK travellers for Hepatitis A ?
- Indian sub-continent
- sub-saharan africa
- middle east
- south east
- east asia
Why is infection uncommon among adults living in countries which are the highest risk areas for UK travellers for Hepatitis A ?
most people are exposed at a young age and acquire lifelong immunity
Although HAV is uncommon in the UK, list some of the risk groups :
- travel - those travelling to endemic areas
- sexual - high risk activities, multiple partners, MSM, analingus
- haematological disorders - factor 8 & 9 concentrates have been implicated in transmission
- occupational risks - for example lab or sewage workers
- IVDU - known to be at INC risk
clinical features of hepatitis A infection ?
- most children and 1/2 adults = asymptomatic
- symptoms common to all acute viral hepatitis
Illness type of hepatitis A infection is usually…?
self-limiting
4 clinical phases of hepatitis A infection ?
- Incubation
- prodromal
- icteric
- convalescent
Incubation phase of Hep A
1. days
2. symptoms
- ~ 30
- no symptoms
prodromal phase of Hep A
1. days
2. symptoms
- 3-10
- flu-like symptoms, general fatigue, joint pain , low grade fever, GI symptoms e.g. nausea, vomiting , RUQ discomfort
Icteric phase of Hep A
1. days
2. symptoms
- 1-3 weeks (can persist < 12 weeks)
- jaundice, pale stools, dark urine, pruritus (itching), hepatomegaly
convalescent phase of Hep A
1. days
2. symptoms
- (up to 6 months)
- malaise, anorexia, muscle weakness, hepatic tenderness
Investigations for Hep A ?
1. … testing
2. IgM during … , IgG ….
3. Acute infection - IgM … , IgG ….
4. vaccination / past infection - IgM …. , IgG ….
- antibody testing - HAV IgM , HAV IgG
- IgM detectable during acute infection (and slightly after), IgG persists
- IgM positive, IgG positive
- IgM negative, IgG positive
Investigations for hepatitis A that isn’t antibody testing
- liver function test - ALT (raised)
- bilirubin (elevated)
- ALP (elevated)
- prothrombin time, clotting function tests (prolonged)
management of hepatitis A ?
- notify HPU
- paracetamol / analgesia (not liver impairment)
- anti emetics
- provide information to patient e.g …
- follow up: repeat LFTs & admit to hospital if seriously unwell
management of hepatitis A involves providing information such as what ?
- avoid alcohol
- avoid work
- school until no longer infectious
- ensure proper hygiene
- avoid handling food
Hepatitis A vaccine is recommended to who ?
- those at risk of infection
- at risk of complications of infection
List individuals who should be offered vaccination for Hep A
- travel (to endemic areas)
- chronic liver disease
- sexual (MSM, high risk activities)
- occupational risks
- IVDU
HBV is an infection of the ..1.. caused by ..2..
- liver
- HBV
What is the most common liver infection globally ?
Hepatitis B infection
HBV is a …1… partially double-stranded ..2… virus
- circular
- DNA
What are the 3 surface antigens that are commonly tested for in clinical practice ?
- surface antigen
- E antigen
- core antigen
Transmission of HBV ?
- blood - direct blood to blood contact
- sex - direct contact with sexual fluids
- mother to child during birth
- tattoos, piercings, barbers
- sharing needles
- household contact, sharing hygiene equipment
- unsterile healthcare practices
Where is the highest burden of HBV infection ?
- western pacific
- african regions
Risk factors for HBV ?
- perinatal exposure
- sexual transmission (MSM, multiple sexual partners)
- IVDU
- living in or travel to highly endemic region
- incarceration
- family history of HBV
- diagnosis of chronic liver disease / HCC
Typical symptoms of acute HBV infection include ?
- weight loss, fever, fatigue
- nausea
- anorexia
- RUQ pain
- jaundice
- skin rash
Chronic clinical features of HBV ?
- no physical signs
- can present with symptoms if they develop HCC, cirrhosis or liver failure
Due to HCC: distended abdomen, well-circumscribed, solid and relatively homogenous HCC tumour nodule
What groups are considered high-risk for hepatitis B in the UK?
people who are at a high risk of exposure to hepatitis B virus (HBV) or who are at risk of complications from HBV infection.
can include healthcare workers, people with multiple sexual partners, IVDU, individuals with certain chronic conditions
What antigen does the hepatitis B vaccine contain?
inactivated hepatitis B surface antigen (HBsAg)
What type of immune response is generated by the hepatitis B vaccine?
induces the production of antibodies against the hepatitis B surface antigen (HBsAb)
Why must serology be considered in context with clinical features and liver function test (LFT) results?
to accurately diagnose and assess the stage and severity of HBV infection
providing a comprehensive understanding of the patient’s condition
Can patients with acute HBV infection have no jaundice?
Yes, some patients with acute HBV infection may experience subclinical hepatitis, which means they have no associated jaundice and may have minimal or no symptoms.
What might elevated LFTs indicate in the context of HBV infection?
may indicate:
* acute HBV infection
* chronic HBV infection
* observed after infection has been resolved
Is it possible for LFTs to be normal in a patient with chronic HBV infection?
Yes, LFTs may be normal in a patient with chronic HBV infection, especially if they have a low viral load.
What is the typical outcome for most adults with acute HBV infection?
will achieve seroconversion, developing HBsAb (antibodies to the hepatitis B surface antigen), without the need for antiviral treatment.
What type of treatment is generally recommended for immunocompetent patients with acute HBV infection?
Supportive treatment
What does supportive treatment for acute HBV infection involve?
managing symptoms and ensuring the patient’s comfort, hydration, and nutritional needs are met while monitoring liver function.
In what scenarios might antiviral therapy be required for acute HBV infection?
patients with acute HBV infection who develop acute liver failure
or have a severe course of infection, such as presenting with ascites (accumulation of fluid in the abdomen) or encephalopathy (brain dysfunction due to liver failure).
- What is the ultimate goal of treatment for chronic HBV infection?
- how is this marked by ?
- ameliorate hepatic dysfunction and achieve a disease-free state
- seroconversion from HBsAg-positive to HBsAg-negative and the production of anti-HBs (HBsAb).
Overall eradication of HBV is rare so primarily goal is what ?
suppression of HBV DNA to undetectable levels
Antivirals are often used in patients with chronic HBV infection in patients with what ?
- cirrhosis
- elevated ALT levels / evidence of histological disease
- positive HBeAg or elevated HBV DNA levels
In management of chronic HBV infection, what are antivirals considered to reduce risk of ?
perinatal transmission
Hepatitis C what type of virus ?
single stranded, enveloped RNA
Hep B virus transmitted by ?
blood exposure
Hep C transmitted by blood exposure: situations ?
- IVDU
- sexual activity
- perinatal
- intranasal drug use
- blood products
- injection
Hep C risk factors ?
- IVDU
- blood transfusion recipients
- country with high prevalence of HCV e.g. Africa, Asia, Pacific islands
- Babies born to mothers with HCV
- prisoners
- HIV-positive
- MSM
- healthcare workers e.g. needlestick injuries
Acute clinical presentaiton of Hep C ?
- maj patients are asymptomatic ~ 30% have fatigue, jaundice > ALT
- some patients spontaneously clear virus within 12 months
- maj of patients develop chronic infection
Chronic hep C infection is generally defined as … ?
persistence of HCV RNA in blood for at least 6 months
Chronic clinical presentation of Hep C ?
patients usually ..1.. but may present with features of …2.. or …3… carcinoma
occasionally patients may present with ..4.. manifestations
- asymptomatic
- decompensated cirrhosis
- hepatocellular
- extrahepatic
Examples of features of decompensated cirrhosis involves ?
- jaundice
- ascites
- signs of hepatic encephalopathy
HCV screenign antibody test positive result indicates what ?
current infection (either acute/ chronic) or past resolved infection
If antibody test for HCV is positive then what confirms current HCV infection ?
positive HCV RNA testing
Why is HCV RNA testing important after a positive HCV antibody test?
it differentiates between a current active infection and a past resolved infection, helping to determine if the virus is actively replicating
Which liver function test (LFT) is particularly important in the context of HCV infection?
ALT (Alanine Aminotransferase) test
What can elevated ALT levels indicate in a patient with HCV infection?
inflammation or damage, which may be due to an active HCV infection
When is treatment initiated for HCV infection?
Initiated in all patients with active HIV infection
Are the treatment regimens different for chronic and acute HCV infection?
no, the same regimens are used for both chronic and acute HCV infection
What type of treatment is given to patients with HCV infection?
antiviral treatment is given to all patients
What type of antivirals are used in the treatment of HCV infection ?
direct-acting oral agents (DAAs)
What is considered equivalent to a ‘cure’ for HCV infection ?
undetectable HCV levels in the blood after treatment
What type of virus is hepatitis D ?
enveloped RNA virus
Can hepatitis D infect individuals on its own ?
No, Hep D can only survive in patients who also have a Hep B infection
It attaches itself to the HBsAg and cannot survive without this protein
What are the two ways Hepatitis D can infect an individual?
co-infection or superinfection
what is co-infection in relation to Hep D ?
where a person is infected simultaneously with both HDV and HBV
What is superinfection in relation to Hep D ?
occurs when a person already infected with Hep B contract Hep D
Co-infection with HBV leads to ….1… which is usually a ….2… illness
- acute HDV and HBV infection
- self-limited
Hep D effct on Hep B ?
Hep D increases the complications and disease severity of Hep B
how is Hep D virus transmitted ?
via contaminated blood or blood products through precutaneous per mucosal and sexual transmission
What is HDV more likely than acute HBV infection alone to do ?
lead to severe illness and acute liver failure
HDV progression to chronic ifnection mirrors that of ….1… infection with ..2.. age at infection predicting higher risk of …3…. (~2%)
- chronic
- younger
- chronicity
How does superinfection HBV and HDV present ?
- as severe hepatitis - either in someone not known to have chronic HBV infection or as a flare of disease in someone with chronic HBV infection
Clinical presentation of hep D virus infection ranges from what ?
- asymptomatic to acute liver failure
- cirrhosis
- chronic liver disease
- hepatic decompensation
- hepatocellular carcinoma
Why are patients with risk factors for HBV infection also at risk for HDV infection ?
since HDV infection occurs in the setting of HBV infection
What do Anti-HDV IgG and IgM tests indicate?
Anti-HDV IgG and IgM antibodies appear 3-4 weeks after HDV infection.
They may persist even after the clearance of the infection, indicating past exposure or ongoing immunity.
When is HDV-RNA testing recommended?
In cases of suspected ongoing HDV infection. A positive result indicates active viral replication.
What does HDV antigen testing indicate?
Detects presence of HDV antigens , indicative of current HDV infection
Why is it important to perform HDV serology tests alongside HBV serology?
HDV requires HBV for its life cycle and replication.
Therefore, HDV serology tests should always be done alongside HBV serology tests to assess co-infection or superinfection.
What is the significance of persistent Anti-HDV antibodies after clearance of infection?
Persistent Anti-HDV antibodies suggest prior exposure to HDV or ongoing immunity against the virus, even if the infection has been cleared.
How is Hepatitis E transmitted?
primarily by the faecal-oral route, often through contaminated water or food
Where is Hepatitis E most commonly found?
Southeast Asia, Africa, Mexico, Hong Kong, and China
- What is the typical course of Hepatitis E infection?
- what do most patients not require ?
- usually causes a mild illness that resolves on its own within about a month.
- specific treatment.
What is the likelihood of Hepatitis E progressing to chronic hepatitis and liver failure?
rare , occuring in less than 5% of cases
typically in immunocompromised individuals
Is there a vaccine available for hepatitis E ?
no
