Acute and Chronic Hepatitis... the sequel

Question 1

What’s one of the few things that can get liver enzymes over 10,000 (units)?

Answer 1

Acetominophen

Question 2

Review: What’s the liver enzyme ratio to remember for alcoholic hepatitis?

Answer 2

> 3:1 AST:ALT

he says 3:1, Krok said 2:1…

Question 3

What are the absolute levels of liver enzymes like in alcoholic hepatitis compared to other types of hepatitis?

Answer 3

They tend to be low, due to the nutritional deficiencies that go with alcoholism.

Question 4

Non-hepatic causes of AST and ALT elevation?

Answer 4

Celiac, hypothyroidism, muscle problems

Question 5

If you see elevated Alk Phos, you should think…

Answer 5

Cholestasis

Question 6

Places other than liver that Alk Phos can come from?

Answer 6

bone, placenta, kidney

Question 7

Which hepatitis viruses are spread enterically?

Answer 7

HAV and HEV

they’re non-enveloped

Question 8

Trivia?: What’s the only hepatitis virus that’s a DNA virus?

Answer 8

HBV

Question 9

What’s the post-exposure prophylaxis for HAV?

Answer 9

Immune globulin

Vaccination

Question 10

What can a positive anti-HBc alone mean? (no HBs-Ag, no anti-HBs-Ab, no anti-HBc IgM)

Answer 10

Past infection, but immunity has waned.
False positive.
Very rarely - chronic infection.

Question 11

What’s the significance of HBe-Ag?

Answer 11

It’s present when HBV is actively replicating - associated with high viral loads and contagiousness.
(can get a false negatives in some HBV strains with mutated pre-core Ag)

Question 12

If a patient has high HBe-Ag, but normal liver enzymes, what’s going on?

Answer 12

They’re immune tolerant - the virus is there replicating a lot, but the immune system isn’t napalming the liver.

Question 13

Review: What 3 drugs are the first-line therapy for chronic HBV?

Answer 13

Peginterferon alfa-2a
Tenofovir
Entecavir

Question 14

What’s a good endpoint for treatment of HBV?

Answer 14

Loss of HBe-Ag.

Cure (loss of HBs-Ag and gain of anti-HBs IgG) only happens 5% of time.

Question 15

What’s the leading cause of liver cancer in the US / world?

Answer 15

HCV

Question 16

Does HCV have a lot of extrahepatic manifestations?

Answer 16

Yep… including necrotizing vasculitis, cryoglobulinemia, others.

Question 17

Is HCV curable?

Answer 17

Yes, it seems so, and will be moreso soon.

Question 18

What’s the old treatment for HCV?

Answer 18

PEGylated interferon + ribavirin.

Question 19

How do you distinguish steatosis from steatohepatitis?

Answer 19

Biopsy

Question 20

Best treatment for NAFLD?

Answer 20

Weight loss.

forget pioglitazone

Question 21

Review: 2 drugs notorious for intrinsic drug-induced liver injury (DILI)?

Answer 21

Acetominophen

Methotrexate

Question 22

Are people with existing liver disease more likely to get idiosyncratic DILI?

Answer 22

No.

Take-home point: Don’t be afraid to use statins if people need them.

Question 23

What formula is used to evaluate biochemical patterns of DILI?

Answer 23

R value: Which is ( ALT / upper limit of normal) / (Alk Phos / upper limit of normal).
Different values suggest hepatocellular, cholestatic, or mixed patterns of injury.

Question 24

Review: What’s Hy’s law?

Not-review: What’s quantitative version of this?

Answer 24

Hepaptocellular injury + jaundice from DILI predict at least 10% mortality.
Quantitative: ALT > 3x upper limit of normal and Total Bili > 2x upper limit of normal leads to at least 10% risk of mortality.

Question 25

If you see AMA (fatigue, pruritis, and xanthomas), think…

Answer 25

PBC