Clin Med - Hepatitis Flashcards
1
Q
Hepatitis
- define
A
- diffuse or patchy cell necrosis
- pan lobar infiltration with WBCs
- hyperplasia of Kupffer cells
- variable degrees of cholestasis and resulting jaundice
2
Q
How does the hepatitis virus affect hepatocytes?
A
- not directly cytopathic
- clinical manifestations are due to immunologic response of the host
3
Q
Hepatitis
- presentation
A
- low-grade fever
- v/d anorexia
- dehydration (tachycardia, dry mucous, loss skin turgor, delayed cap refill)
- scleral icterus, icterus of mucous membranes and TM
- jaundice, urticaria
- RUQ pain
- hepatomegaly with smooth edge
4
Q
chronic hepatitis presentation
A
Feel fine
5
Q
Acute hepatitis
- common causes
A
- hepatitis virus
- alcohol
- drugs (high doses of acetaminophen, isoniazid)
6
Q
Acute hepatitis
- uncommon causes
A
- cytomegalovirus
- Epstein-barr virus
- autoimmune (sarcoidosis, UC)
- leptospirosis infection
7
Q
Hep A
- nucleic acid
- major transmission
- incubation
- epidemics?
- chronicity?
A
- RNA
- fecal-oral
- 15-45 days
- Yes
- No
8
Q
Hep B
- nucleic acid
- major transmission
- incubation
- epidemics?
- chronicity?
A
- DNA
- blood, percutaneous
- 40-180 days
- No
- Yes
9
Q
Hep C
- nucleic acid
- major transmission
- incubation
- epidemics?
- chronicity?
A
- RNA
- Blood (IVDU, share needles in IV injection)
- 20-120 days
- No
- Yes
10
Q
Hep D
- nucleic acid
- major transmission
- incubation
- epidemics?
- chronicity?
A
- incomplete RNA
- needle (blood)
- 30-180 days
- No
- Yes
11
Q
Hep E
- nucleic acid
- major transmission
- incubation
- epidemics?
- chronicity?
A
- RNA
- Water (dirty), fecal-oral
- 14-60 days
- Yes
- No
12
Q
hepatitis differential
A
long list in slide :)
13
Q
Acute viral hepatitis
A
- infection of the liver by one of the hep virus (A-E) OR
- other less common viruses (Epstein-Barr, cytomegalovirus, etc..)
14
Q
Of Hepatitis A, B, and C, which commonly cause acute hepatitis
A
A and B
15
Q
Acute viral hepatitis
- presentation
A
- nonspecific viral prodrome followed by - anorexia - fever - RUQ pain
16
Q
Acute viral hepatitis
- when does jaundice appear
A
- as other sx begin to resolve
17
Q
Acute viral hepatitis
- resolution?
A
- most resolve spontaneously
- some progress to chronic
- rarely progress to fulminant hepatitis (acute liver failure) which is very bad
18
Q
What are the four phases of acute viral hepatitis?
A
- Incubation
- Prodromal (pre-icteric) phase: majority of sx
- Icteric phase: dark urine and jaundice
- Recovery
19
Q
Anicteric hepatitis
A
- no jaundice/icterus
- common in HCV or children with HAV
- manifests as minor flu-like symptoms
20
Q
Recrudescent hepatitis
A
rare, recurrent relapses during recovery phase
21
Q
What is the first step in dx hepatitis?
A
obtain liver enzyme levels
22
Q
Decision tree for hep dx:
- marked elevation of AST and ALT
- no elevation of Alk phos
A
check viral serologic tests to determine which virus is the cause
- if negative, look for other causes such as alcohol or drugs
23
Q
Decision tree for hep dx:
- elevation of AST, ALT, and Alk phos
A
look for biliary tree obstruction
24
Q
Decision tree for hep dx:
no elevation of liver enzymes
A
NOT hepatitis!
25
What 4 tests does an acute hepatitis panel include?
1. IgM anti-HAV
2. HBsAG
3. IgM anti-HBc
4. anti-HCV OR HCV-RNA
26
alcoholic hepatitis
- hx of excessive drinking
- more gradual sx onset
- vascular spiders, other sx of chronic alcohol abuse
- AST/ALT rarely >300 IU/L
- AST gen higher than ALT
27
how distinguish alcoholic hepatitis from viral?
liver biopsy
28
Acute hepatitis
| - which viruses symptomatic which not
- HAV and HBV symptomatic
| - HCV may be asymptomatic
29
Which two hepatitis viruses never become chronic
HAV
| HEV (less severe)
30
Fulminant Hepatic Failure (FHF)
acute liver failure complicated by hepatic encephalopathy
31
Chronic hepatitis
- length of time
- which two viruses most common
- common co-morbidity
- >6 months
- clinical illness may take months or years to evolve
- HBC and HCV
- 20% develop cirrhosis
* some may remain asymptomatic for life
32
Chronic hepatitis
| - four common causes
```
- HBV, HCV
non-viral:
- autoimmune hepatitis, primary biliary cirrhosis
- fatty liver (NASH)
- alcoholic hepatitis
```
33
How is chronic hep often found?
- routine labs bc asymptomatic
| - can present first as cirrhosis
34
Liver biopsy as dx
| - acute vs. chronic
- not needed in acute
| - chronic may need to determine etiology
35
Hepatitis A
| - major points overview
- No carrier state-
- No chronic state
- Shed a TON in feces before patient knows have an infection
36
HAV Sx
several weeks of:
- malaise
- anorexia
- nausea
- vomiting
- elevated aminotransferase levels
- jaundice in severe cases
37
Acute HAV
- adults vs. children
- relapse?
- lifelong experience?
- higher mortality in adults
- young children can be asymptomatic
- can relapse for up to a year
- infected once = lifelong immunity
38
how likely is it HAV acute infection will lead to FHF?
< 1%
39
Acute HAV Chart
Review in slides
40
Acute HAV
| - serum testing
1. IgM anti-HAV: appears quickly, disappears months after initial infection
2. IgG anti-HAV: takes longer to develop but lasts for a lifetime, confers immunity to future HAV infections
41
HAV tx
- supportive
- no antiviral available
- hosp for those at risk of dehydration due to n/v
- hosp if suspect hepatic failure
42
How to prevent HAV infection
- sanitation
- hand washing, personal hygiene
- bleach or 85C for 1 minute kills virus
- vaccination: routine age 1 and second dose 6-18 months later
43
Who should receive HAV vaccine
- occupational risk (lab, daycare)
- chronic liver disease (increased FHF risk)
- travelers (>1 month prior)
- immunocompromised
- MSM
- illicit drug use
- receive clotting factor concentrates
- close contact with international adoptee from endemic country
44
Post exposure prophylaxis for HAV
- single dose HAV vaccination
- If >75 yo, chronic liver dz, immunocompromised: immune globine dose
* can give up to 2 weeks after exposure but earlier is better
45
HBV
- onset of sx
- endemic where?
- increased risk of waht
- symptomatic at onset
- endemic in Asia
- sig increase of hepatocellular carcinoma
46
HBV
| - non-percutaneous routes of transmission
- intimate/sexual contact
| - perinatal transmission
47
How contagious is HBV vs. HAV?
HAV much more contagious
48
Chronic Hep B
- How does age affect chances of chronic infection
- what co-morbidity is more likely
- younger age at acute infection, high risk for chronic infection
- increased risk of cirrhosis
* much less likely to become chronic than HCV
49
Hep B carrier state
- what does it mean for pathophysiology of virus?
- what type of patient more likely to remain chronically infected?
- the existence of inactive HBV carriers suggests the virus is not directly hepatotoxic, it's the body's immune response that is damaging...
- patients with immune problems at greater risk for chronic infection
50
People at high risk HBV
SO MANY, highlighted in class:
- people born in or who have parents who emigrated from endemic areas of the world
- IVDU
- high risk sex
- inmates
51
What is the first step to diagnosing hepatitis
AST, ALT, Alk phos!
ALT will be predominantly high unless alcoholic hepatitis which will have higher AST
52
What three serum markers are positive in acute HBV
- HBsAG
- IgM anti-HBc
- HBV-DNA
53
What 5 serum markers are positive in chronic HBV
- HBsAG (same as acute)
- IgG anti-HBc
- HBV-DNA
- +/- HBeAG
- +/- Anti-HBe
54
What three serum markers are positive if have had prior HBV infection
- Anti- HBs
- +/- IgG anti-HBc
- +/- Anti-HBe
55
what one serum marker indicates prior HBV vaccination, prior infection, and immunity
Anti-HBs
56
HBsAg
surface antigen
- Appears before sx
- implies infection (acute or chronic)
- disappears after recovery
57
what is HBV carrier state
- in 5-10% of people who are infected, HBsAG lasts but no antibody is developed
- Anti-HBc is also present. Never mount antibody response to the surface antigen...
- called carrier state, chronic infection
58
Anti-HBs
surface antibody
- appears weeks or months after the HBsAg, after recovery
- persists for life and confers immunity.
- indicates either past infection or vaccine
* * Need >10mIU/mL for immunity
59
Where is HBcAg found
NOT in serum, in liver cells only
60
IgM anti-HBc vs. IgG anti-HBc
IgM - elevates early and then falls off. Indicator of acute infection
IgG - elevates slowly, indicates chronic infection
61
HBeAg and Anti-HBe are useful for what
e markers are more helpful for prognosis, not used so much for diagnosis
62
HBeAG
- protein from the viral core
- present only in HBsAG positive serum
- suggests more active viral replication = greater infectivity
* not all pts with HBV need treatment, e markers help decide who needs tx and who does not
63
If have HBeAG, what does the presence of anti-HBe indicate?
lower infectivity
64
HBeAG and anti-HBe and the risk for liver disease?
- HBeAG indicates greater chance of liver dz
| - Anti-HBe indicates less risk
65
HBV-DNA
- fail-proof if you are confused :)
- in serum if active infection (acute or chronic)
- PCR to detect virus
- qualitative or quantitative
- can use quantitative count to check for suppression in pts being treated
66
Chronic HBV treatment
- antiviral therapy
| - refer to GI or hepatologist
67
Goals for HBV tx
- suppress viral replication (no cure)
- lower morbidity and mortality related to chronic infection (cirrhosis and hepatocellular carcinoma)
- NOT to cure
68
What is a major cause of worldwide hepatocellular carcinoma?
HBV
| - maybe >80% of primary hepatocellular carcinoma causes worldwide!
69
what serum marker in HBV indicates a higher risk of hepatocellular carcinoma?
HBeAG
70
How to prevent HBV
Vaccinations!!
- all infants, children <19
- healthcare and first responders
- sexual workers
- high risk sex
- dialysis, DM, CLD, chronic HCV, HIV
- IVDU
- incarcerated ppl
- travelers to endemic areas
71
how to treat infant born to HBV infected mom
- treat with hepatitis B immune globulin (HBIG)
- vaccinate immediately after delivery
* generally transmitted at birth; trans-placental transmission can occur but is rare.
72
Hepatitis C
| - pearls from Roark
- almost always becomes chronic
- lots of genotypes
- increased cancer risk
73
Hep C
- # of genotypes
- what is diff between genotypes
- one exception
- 6 genotypes
- each responds differently to tx but same pathogenesis and progress
- exception is #3, more likely steatosis and progression
74
Hep C immunity
no immunity against future reinfection:
- high mutation rate
- genotypic diversity
- no effective humoral immunity
75
when did the US start screening blood for Hep B? Hep C
Hep B: 1969
| Hep C: 1990
76
who is at risk for hep C
- blood transfusion/organ transplantation before 1992
- IVDU (current or former)
- tattoos
- hemodialysis
- HIV
- born to HCV+ mom
77
Who should be screened for HCV?
- current/former IVDU
- born 1945-1965
- other high risk
(list on slide but it's pretty obvious)
78
HCV serology - what are the two tests, what is the best option
- Anti-HCV antibody
- HCV RNA PCR
* best is HCV RNA, antibody test just tells you there is an antibody, RNA positive tells you active infection and RNA negative tells you no infection
79
HCV RNA PCR vs. HCV RNA PCR titer
- PCR: qualitative test to detect presense or absence of virus
- PCR titer: quantitative test to detect amt of virus or "viral load", usually in millions
80
If do Anti-HCV test and get negative but know pt has exposure what is next?
test HCV RNA (this is why you should go straight to RNA test, this was a dumb waste of time and money)
81
If do Anti-HCV test and get positive, what net?
test HCV RNA to determine if have current infection or if antibodies are from past infection
(again, this is why you should go straight to RNA test, this was a dumb waste of time and money)
82
Hep D
- requires what
- how common
- nickname
- acute or chronic?
- requires co-infection with hep B to replicate
- uncommon in US
- "delta hepatitis"
- acute or chronic
83
How prevent Hep D
no vaccine avail, can be prevented via HBV vaccine
84
worldwide, where are two patterns of Hep D?
- mediterranean region: non-percutaneous transmission
| - US/Northern Europe: IVDU and hemophiliacs
85
Hep E
- how common in US
- vaccine?
- rare in use, more in countries with poor sanitation :(
| - no vaccine
