Acute & Chronic Hepatitis Flashcards by Tim Resch

What is hepatitis?

Inflammatory disease of the liver

-can be acute or chronic

How well did you know this?

Not at all

Perfectly

What are the acute causes of hepatitis?

Viral Infections (Hep A-E/Non A-E infections)
Autoimmune
Drug reactions
Alcohol

How well did you know this?

Not at all

Perfectly

What are the chronic causes of hepatitis?

Hep B +/- Hep D
Hep C
AI hepatitis
Alcohol
NAFLD
Drugs (methyldopa/nitrofurantoin)
Metabolic disorders

How well did you know this?

Not at all

Perfectly

What are the metabolic disorders that cause chronic hepatitis?

Wilson’s disease
a-1-antitrypsin deficiency
Haemachromatosis

How well did you know this?

Not at all

Perfectly

What investigations make up a liver screen?

Microbiology - viral screen
Clinical chemistry - ferritin/transferrin, lipids, caeruloplasmin, AFP, a-1-antitrypsin
Immunology - autoantibodies
Abdominal USS

How well did you know this?

Not at all

Perfectly

What are they key features of Hepatitis A?

RNA virus
Faeco-oral transmission
Incubation period 2-6wks
80% asymptomatic
Acute liver disease only
Affects children/young adults

How well did you know this?

Not at all

Perfectly

What are the key features of Hepatitis E?

RNA virus
Faeco-oral transmission
Acute, self-limiting hepatitis
Can cause severe disease in pregnant women

How well did you know this?

Not at all

Perfectly

What are the key features of Hepatitis B?

DNA virus
Transmitted via blood/semen/saliva
Vertical transmission most common
Incubation period 1-6mo
Virus has inner HBcAg core surrounded by HBsAg
10% chronic
1% fulminant

How well did you know this?

Not at all

Perfectly

What are the key features of Hepatitis D?

Incomplete RNA virus
-can only cause infection in presence of Hep B
Transmitted by bodily fluids
Acute OR chronic
Likely to develop fulminant liver disease

How well did you know this?

Not at all

Perfectly

What are the key features of Hepatitis C?

RNA virus
Transmitted via bodily fluids
Common in IVDUs
Vertical/sexual transmission rare
85% chronic
30% cirrhosed

How well did you know this?

Not at all

Perfectly

For which hepatitis viruses are there vaccines?

Hep A

Hep B

How well did you know this?

Not at all

Perfectly

What are the non A-E infections?

10-15% hepatotrophic viral infections cannot be typed

How well did you know this?

Not at all

Perfectly

What other viruses can cause acute hepatitis?

CMV
Yellow fever
HSV (immunocompromised pts)

How well did you know this?

Not at all

Perfectly

What is the underlying pathophysiology of acute hepatitis?

Hepatocytes undergo degenerative changes

swelling & vacuolation THEN
necrosis & rapid removal

How well did you know this?

Not at all

Perfectly

What is the pattern of necrosis in acute hepatitis?

Maximal in zone 3 (centrilobular)
Varying extent (scattered to multiacinal necrosis)
Leads to fulminant hepatic failur

How well did you know this?

Not at all

Perfectly

What is the underlying pathophysiology of chronic hepatitis?

Any hepatitis lasting >6mo
Main cause of chronic liver disease/cirrhosis/hepatocellular carcinoma
Chronic inflammatory cells present in portal tracts
-loss of definition of portal/periportal limiting plate
-confluent necrosis
-fibrosis
Leads to cirrhosis

How well did you know this?

Not at all

Perfectly

What features are used to judge the severity of chronic hepatitis?

Child-Pugh Score

degree of inflammation (grading)
extent of fibrosis/cirrhosis (staging)

How well did you know this?

Not at all

Perfectly

What are the serological markers of Hep B infection?

HBsAG - marker of viral rep, active infec (6w-3mo)
HBsAb - marker of prev infec
HBeAg - marker of infectivity
HBcAb IgG - non-specific marker of current/prev infec
HBcAb IgM - infec w/i 6mo
HBV PCR - viraemia

How well did you know this?

Not at all

Perfectly

What serological markers of Hep B infection suggest immune tolerance?

HBsAg (+ve)
HBeAg (+ve)
PCR (+ve)
Transaminases (-ve)

How well did you know this?

Not at all

Perfectly

What serological markers of Hep B infection suggest acute hepatitis?

HBsAb (-ve)

All other markers (+ve)

How well did you know this?

Not at all

Perfectly

What serological markers of Hep B infection suggest chronic hepatitis?

HBsAb (-ve)
all other makers (+ve)
HBeAg (+ve)
HBeAb (-ve)

How well did you know this?

Not at all

Perfectly

What serological markers of Hep B infection suggest natural immunity?

HBsAg (-ve)
HBsAb (+ve)
HBcAb IgG (+ve)
HBcAb IgM (-ve)
HBeAg (-ve)
HBeAb (+ve)

How well did you know this?

Not at all

Perfectly

What serological markers of Hep B infection suggest vaccination?

HBsAg (-ve)
HBsAb (+ve)
HBcAb IgG (-ve)
HBcAb IgM (-ve)
HBeAg (-ve)
HBeAb (-ve)

How well did you know this?

Not at all

Perfectly

What are the two stages of acute hepatitis?

Pre-ictal

Ictal

How well did you know this?

Not at all

Perfectly

What are the features of the pre-ictal phase of acute hepatitis?

1-2wk prodrome (malaise, arthralgia, headache, anorexia) Aversion to cigarette smoke RUQ pain

What are the features of the ictal phase of acute hepatitis?

``` Icterus (jaundiced) Intrahepatic cholestatic jaundice (pale stools/dark urine) Pruritis Skin rash Lymphadenoapthy & hepatosplenomegaly ```

What sx do Hep A/C cause?

Very mild/no sx

In which Hep virus are extrahepatic features more common?

Hep B

How does acute alcoholic hepatitis present?

``` Post-binge Jaundice RUQ pain Systemic upset Signs of chronic liver disease ```

What clinical values are combined to form the discriminant function?

Bilirubin Prothrombin time Hepatic encephalopathy

What is the discriminant function?

Combination of clinical values that predict survival | -DF >32 = severe, 50% mortality

What value on LFTs suggests alcoholic liver disease?

AST:ALT >2

How does autoimmune hepatitis present?

As chronic hepatitis -40% as acute w/ jaundice Non-specific sx (fatigue, arthralgia, fever, wt loss) Women (peaks at 15-25 & perimenopausal)

What conditions is autoimmune hepatitis associated with?

1o biliary sclerosis 1o sclerosing cholangitis IBD

What investigations are appropriate in suspected autoimmune hepatitis?

Transaminases/IgG (high) Viral seorlogy (-ve) High titres of autoantibodies (ANA, ASMA) Liver biopsy

How does chronic hepatitis present?

Asymptomatic unless complications develop

How is chronic hepatitis diagnosed?

Serum ALT raised for >6mo

What are the management options for autoimmune hepatitis?

``` Prednisolone 30mg OD Azathioprine 1mg/kg/day (after TPMT assays) Long term therapy -low dose pred (5-10mg) -azathioprine ```

What are the management options for Hepatitis B?

``` Acute -supportive therapy -alcohol avoidance Chronic -s.c. peginterferon-alfa-2a for 48wks ```

What are the management options for Hepatitis C?

Specialist decision

What options are available for taking a liver biopsy?

Needle USS/CT guided Laparoscopic

What are the indications for a liver biopsy?

``` Chronic hepatitis Cirrhosis Suspected neoplastic disease Storage diseases Unexplained hepatomegaly ```

What are the contraindications to a liver biopsy?

Prolonged PT Platelet count <80 Ascites Extra-hepatic cholestasis

What are the potential complications of a liver biopsy?

``` W/I 2HRS -abdo/shoulder pain -minor intraperitoneal bleeding W/I 3/7 -haemothorax -pleurisy -haemobilia (biliary colic & jaundice) -biliary peritonitis ```

What alternative are available to a liver biopsy?

Fibroscan (transient elastography) -liver stiffness measured non-invasively MR elastography Serum biomarker

What sort of reaction do intrinsic hepatotoxins cause?

Type A (dose dependant, predictable)

What sort of reaction do extrinsic hepatotoxins cause?

Type B (idiosyncractic)

What drugs are likely to cause chronic hepatitis?

``` Methyldopa Nitrofurantoin Minocycline Lisinopril Diclofenac ```

What sort of hepatotoxin is paracetamol?

Intrinsic

How is paracetamol metabolised?

Conjugated w/ glucuronide & sulphate (at therapeutic doses) Small amount metabolised --> NAPQI -conjugated w/ glutathione (due to toxicity)

How does a paracetamol overdose cause it's hepatotoxicity?

Overwhelms glutathione stores Excess NAPQI formed Causes cellular damage -severity dose related

How does paracetamol overdose present?

``` <24hrs -asymptomatic -anorexia -nausea/vomiting >24hrs -RUQ pain -metabolic acidosis, hypoglycaemia -hypotension, arrhythmias -pancreatitis ```

At what point is liver damage due to paracetamol overdose detectable on blood tests?

18hrs after ingestion

When does liver damage due to paracetamol overdose peak?

72-96hrs post ingestion - may develop fulminant liver failure - may develop renal failure (ATN)

What are the management options for paracetamol overdose?

A-E resus Lavage if >12g (<150mg/kg in children) w/i 1hr Activated charcoal if <1hr since ingestion Bloods taken at 4hrs N-acetyl cysteine if: -<8hrs AND blood levels above treatment line ->8hrs AND >150mg/kg ingested Discuss w/ liver team if deteriorating Mental health review

What blood tests must be taken when managing paracetamol overdose?

``` INR ABG LFTs U&Es Glucose Blood salicylate & paracetamol level ```

How does N-acetylcysteine work?

Replenishes glutathione level | Repairs oxidative damage

What are the potential side effects of N-acetylcysteine?

In 5% causes - rash - oedema - hypotension - bronchospasm

How should the side effects of N-acetylcysteine be managed?

IV chlorphenamine | Stop if true anaphylaxis

What drug is available as an alternative to N-acetylcysteine in paracetamol overdose?

Oral methionine - can be used 12hrs post ingestion - unreliable if vomiting/activated charcoal been used

Brainscape's Knowledge GenomeTM

Acute & Chronic Hepatitis Flashcards

Brainscape's Knowledge Genome^TM