Chapter 38: Liver Diseases

Question 1

Acute Viral Hepatitis

Answer 1

• Inflammation of the liver parenchyma
• caused by many viruses (cytomegalovirus, Epstein-Barr)
• “viral hepatitis” (Hepatitis A, B, C, D, & E)

Question 2

Hepatitis A (HAV)

Answer 2

• RNA virus spread by fecal-oral route
• Also called enteric hepatitis
• 2- to 7-week incubation period
• Prodromal period (Jaundice, RUQ pain. malaise, anorexia, nausea, low-grade fever, children may not experience jaundice)
• Followed by jaundice lasting approx 2 weeks
• Self-limited course
• Serologic Testing (Anti-HAV IgG (previous infection), IgM (acute infection))
• Treatment is supportive (rest, nutritious diet) and includes avoiding ETOH, acetaminophen, and hepatotoxins
• Prevention includes careful hand washing, segregation, cleaning of laundry and personal items, and immunization with y-globulin

Question 3

Hepatitis B (HBV)

Answer 3

• Partially double-stranded DNA virus
• Spread by parenteral contact with infected blood or blood products (Includes contaminated needles and sexual contact)
• Also called serum hepatitis
• 300 million (5%) of world population have chronic infection
• 1 to 1.25 million in United States
• Risk factors include Perinatal, health care settings (3%); transfusions and dialysis (1%); acupuncture, tattooing, extended overseas travel, residence in an institution
• Incubation period of 2 to 6 months
• Prodromal period that includes Asymptomatic or rashes, arthralgia, arthritis, angioedema, serum sickness, glomerulonephritis, jaundice (lasting 2 weeks on average)

Question 4

Serologic Testing of Hepatitis B (HBV)

Answer 4

• Surface antigen (HBsAg): early/active and chronic infection
• Surface antibody (HbsAb): resolution and immunity
• Core antigen (HBcAg): appears first in active infection
• Core antibody (HBcAb): seroconversion
• Hepatitis B e antigen (HBeAg): viral replication and infectivity

Question 5

Treatment of Hepatitis B (HBV)

Answer 5

• Persons with detectable virus and HBeAg positive readily transmit virus to their contacts, and should be counseled
• Supportive: Most nonfulminant infections resolve spontaneously. about 5% progress to chronic infection
• Liver transplant
• Interferon-alpha (24 to 48 weeks of therapy, Response rate of 33%)
• Lamivudine, Telbivudine
• Adefovir, Tenofovir
• Entecavir (TREATMENT OF CHOICE) (Response rate of 67%, Extremely expensive)

Question 6

Prevention of Hepatitis B (HBV)

Answer 6

• Immunizations (Doses given at 0, 1, and 6 months, 95% response rate, recommended as part of the childhood vaccination regimen and for high-risk individuals, and after exposure)
• Administration of HBIG postinoculation
• ^ Contains high levels of hepatitis B surface antibody
• ^ Given within 7 days of exposure
• ^ Indications include Neonates born to HBsAg-positive mothers, Prophylaxis after needlestick or sexual exposure in nonimmune persons, and After liver transplantation in patients who are HBsAg+ prior to transplantation

Question 7

Hepatitis C (HCV)

Answer 7

• Single-stranded RNA virus (Flavivirus)
• Spread through IV drug use or blood transfusions prior to 1990
• Also called non-A, non-B hepatitis
• 3% worldwide infected
• Have 6 types (Type 1: most common in the United States but has a lower response rate to treatment; Types 2 and 3: common in N. America; Types 4 to 6: common overseas)

Question 8

Acute and Chronic Hepatitis C (HCV)

Answer 8

• Acute HCV infection (Usually asymptomatic; Course is erratic with wide fluctuations on liver enzymes)
• Chronic HCV infection (Usually asymptomatic until advanced liver disease intervenes; Most common cause of end-stage liver disease with cirrhosis)

Question 9

Treatment for Acute Hepatitis C (HCV)

Answer 9

• Supportive and expectant
• Early treatment not recommended (20% to 40% of acute seropositive patients will convert to seronegativity and an undetectable viral load during 1st 6 months after infection; Immune globulin is not helpful in preventing infection

Question 10

Treatment for Chronic Hepatitis C (HCV)

Answer 10

• Assessed by a viral load and viral genotype
• Liver biopsy to stage disease activity
• Pegylated interferon-alpha with ribavirin and protease inhibitor (5% to 10% drop out of treatment because of side effects and cost (expensive); Type 1: 48 weeks; Other types: 24 weeks)
• Vaccinate against hepatitis A and B
• Counsel regarding blood-borne precautions
• Centers for Disease Control and Prevention does not currently recommend barrier methods for patients with long-term sexual partners because of the apparent low risk of infection

Question 11

Hepatitis D (Delta)

Answer 11

• Defective RNA virus that requires the helper function of
  HBV to replicate
• Infection appears to accelerate and worsen HBV infection symptoms
• Prevention of HBV infection also prevents HDV infection
• Transmitted parenterally and intimate contact

Question 12

Diagnosis and Prevention of Hepatitis D

Answer 12

• Diagnoisis: Anti-HDV IgM and IgG enzyme linked immunosorbent assay (ELISA)
• Prevention: Safe sexual practices, Avoidance of IV drug use, Vaccination of susceptible persons with HBV vaccine
• No specific treatment

Question 13

Hepatitis E (HEV)

Answer 13

• RNA virus spread via fecal-oral route (Contaminated H2O and
  Parenteral transmission)
• Most common in developing countries or recent travel to these areas
• Relatively high mortality rate in pregnant women
• Incubation period is 2 to 9 weeks
• Prodromal and icteric illness (Usually last only 2 weeks;
  Similar to HAV infection)
• Supportive treatment
• Prevention Includes Careful hand washing, Avoidance of undercooked foods, and Drinking safe H2O and beverages

Question 14

Chronic Hepatitis

Answer 14

• Group of diseases characterized by inflammation of the liver that lasts 6 months or longer
• Causes include Autoimmune disease, Viral hepatitis (B and C), Toxins, Metabolic diseases
• Pathogenesis includes Chronic low-grade liver inflammation of any cause (also called “triaditis” or “transaminitis”) and Inflammation confined to portal triads without destruction of normal liver structures
• Clinical Manifestations are Asymptomatic or mild, nonspecific symptoms
• Treatment: No drug treatment needed; excellent prognosis

Question 15

Chronic Active Hepatitis

Answer 15

• Progressive, destructive inflammatory disease of the liver lasting >6 months (Extends beyond the portal triad to hepatic lobule (piecemeal necrosis)
• May progress to cirrhosis
• clinical manifestations include Fatigue, malaise, nausea, anorexia, ascites, hepatomegaly, abdominal pain, and jaundice
• Laboratory diagnosis looks for abnormal liver enzymes and serologic studies
• Liver Biopsy confirms diagnosis, and grading and staging
• treatment depends on cause