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Tim CP3 @ UoN - Medicine & Surgery > Acute & Chronic Hepatitis > Flashcards

Acute & Chronic Hepatitis Flashcards

1
Q

What is hepatitis?

A

Inflammatory disease of the liver

-can be acute or chronic

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2
Q

What are the acute causes of hepatitis?

A

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

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3
Q

What are the chronic causes of hepatitis?

A 
Hep B +/- Hep D
Hep C
AI hepatitis
Alcohol
NAFLD
Drugs (methyldopa/nitrofurantoin)
Metabolic disorders
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4
Q

What are the metabolic disorders that cause chronic hepatitis?

A

Wilson’s disease
a-1-antitrypsin deficiency
Haemachromatosis

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5
Q

What investigations make up a liver screen?

A

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

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6
Q

What are they key features of Hepatitis A?

A 
RNA virus
Faeco-oral transmission
Incubation period 2-6wks
80% asymptomatic
Acute liver disease only
Affects children/young adults
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7
Q

What are the key features of Hepatitis E?

A

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

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8
Q

What are the key features of Hepatitis B?

A 
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
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9
Q

What are the key features of Hepatitis D?

A

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

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10
Q

What are the key features of Hepatitis C?

A 
RNA virus
Transmitted via bodily fluids
Common in IVDUs
Vertical/sexual transmission rare
85% chronic
30% cirrhosed
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11
Q

For which hepatitis viruses are there vaccines?

A

Hep A

Hep B

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12
Q

What are the non A-E infections?

A

10-15% hepatotrophic viral infections cannot be typed

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13
Q

What other viruses can cause acute hepatitis?

A

CMV
Yellow fever
HSV (immunocompromised pts)

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14
Q

What is the underlying pathophysiology of acute hepatitis?

A

Hepatocytes undergo degenerative changes

  • swelling & vacuolation THEN
  • necrosis & rapid removal
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15
Q

What is the pattern of necrosis in acute hepatitis?

A

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

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16
Q

What is the underlying pathophysiology of chronic hepatitis?

A

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

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17
Q

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

A

Child-Pugh Score

  • degree of inflammation (grading)
  • extent of fibrosis/cirrhosis (staging)
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18
Q

What are the serological markers of Hep B infection?

A

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

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19
Q

What serological markers of Hep B infection suggest immune tolerance?

A

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

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20
Q

What serological markers of Hep B infection suggest acute hepatitis?

A

HBsAb (-ve)

All other markers (+ve)

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21
Q

What serological markers of Hep B infection suggest chronic hepatitis?

A

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

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22
Q

What serological markers of Hep B infection suggest natural immunity?

A 
HBsAg (-ve)
HBsAb (+ve)
HBcAb IgG (+ve)
HBcAb IgM (-ve)
HBeAg (-ve)
HBeAb (+ve)
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23
Q

What serological markers of Hep B infection suggest vaccination?

A 
HBsAg (-ve)
HBsAb (+ve)
HBcAb IgG (-ve)
HBcAb IgM (-ve)
HBeAg (-ve)
HBeAb (-ve)
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24
Q

What are the two stages of acute hepatitis?

A

Pre-ictal

Ictal

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25
Q

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

A

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

26
Q

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

A 
Icterus (jaundiced)
Intrahepatic cholestatic jaundice (pale stools/dark urine)
Pruritis
Skin rash
Lymphadenoapthy & hepatosplenomegaly
27
Q

What sx do Hep A/C cause?

A

Very mild/no sx

28
Q

In which Hep virus are extrahepatic features more common?

A

Hep B

29
Q

How does acute alcoholic hepatitis present?

A 
Post-binge
Jaundice
RUQ pain
Systemic upset
Signs of chronic liver disease
30
Q

What clinical values are combined to form the discriminant function?

A

Bilirubin
Prothrombin time
Hepatic encephalopathy

31
Q

What is the discriminant function?

A

Combination of clinical values that predict survival

-DF >32 = severe, 50% mortality

32
Q

What value on LFTs suggests alcoholic liver disease?

A

AST:ALT >2

33
Q

How does autoimmune hepatitis present?

A

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

34
Q

What conditions is autoimmune hepatitis associated with?

A

1o biliary sclerosis
1o sclerosing cholangitis
IBD

35
Q

What investigations are appropriate in suspected autoimmune hepatitis?

A

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

36
Q

How does chronic hepatitis present?

A

Asymptomatic unless complications develop

37
Q

How is chronic hepatitis diagnosed?

A

Serum ALT raised for >6mo

38
Q

What are the management options for autoimmune hepatitis?

A 
Prednisolone 30mg OD
Azathioprine 1mg/kg/day (after TPMT assays)
Long term therapy
   -low dose pred (5-10mg)
   -azathioprine
39
Q

What are the management options for Hepatitis B?

A 
Acute 
   -supportive therapy
   -alcohol avoidance
Chronic 
   -s.c. peginterferon-alfa-2a for 48wks
40
Q

What are the management options for Hepatitis C?

A

Specialist decision

41
Q

What options are available for taking a liver biopsy?

A

Needle
USS/CT guided
Laparoscopic

42
Q

What are the indications for a liver biopsy?

A 
Chronic hepatitis
Cirrhosis
Suspected neoplastic disease
Storage diseases
Unexplained hepatomegaly
43
Q

What are the contraindications to a liver biopsy?

A

Prolonged PT
Platelet count <80
Ascites
Extra-hepatic cholestasis

44
Q

What are the potential complications of a liver biopsy?

A 
W/I 2HRS
   -abdo/shoulder pain
   -minor intraperitoneal bleeding
W/I 3/7
   -haemothorax
   -pleurisy
   -haemobilia (biliary colic &amp; jaundice)
   -biliary peritonitis
45
Q

What alternative are available to a liver biopsy?

A

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

46
Q

What sort of reaction do intrinsic hepatotoxins cause?

A

Type A (dose dependant, predictable)

47
Q

What sort of reaction do extrinsic hepatotoxins cause?

A

Type B (idiosyncractic)

48
Q

What drugs are likely to cause chronic hepatitis?

A 
Methyldopa
Nitrofurantoin
Minocycline
Lisinopril
Diclofenac
49
Q

What sort of hepatotoxin is paracetamol?

A

Intrinsic

50
Q

How is paracetamol metabolised?

A

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

51
Q

How does a paracetamol overdose cause it’s hepatotoxicity?

A

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

52
Q

How does paracetamol overdose present?

A 
<24hrs
   -asymptomatic
   -anorexia
   -nausea/vomiting
>24hrs
   -RUQ pain
   -metabolic acidosis, hypoglycaemia
   -hypotension, arrhythmias
   -pancreatitis
53
Q

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

A

18hrs after ingestion

54
Q

When does liver damage due to paracetamol overdose peak?

A

72-96hrs post ingestion

  • may develop fulminant liver failure
  • may develop renal failure (ATN)
55
Q

What are the management options for paracetamol overdose?

A

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

56
Q

What blood tests must be taken when managing paracetamol overdose?

A 
INR
ABG
LFTs
U&amp;Es
Glucose
Blood salicylate &amp; paracetamol level
57
Q

How does N-acetylcysteine work?

A

Replenishes glutathione level

Repairs oxidative damage

58
Q

What are the potential side effects of N-acetylcysteine?

A

In 5% causes

  • rash
  • oedema
  • hypotension
  • bronchospasm
59
Q

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

A

IV chlorphenamine

Stop if true anaphylaxis

60
Q

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

A

Oral methionine

  • can be used 12hrs post ingestion
  • unreliable if vomiting/activated charcoal been used

Tim CP3 @ UoN - Medicine & Surgery (136 decks)

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