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Gastro > Hep B > Flashcards

Hep B Flashcards

1
Q

Does HBV suppression reduce risk of HCC?

A

Yes but not enough to stop surveillance. Reduces risk by about 50-60 percent

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2
Q

What are the four phases of HBV infection?

A

Immune tolerance (whilst a kid- if horizontal transmission skip this often)
Immune clearance
Immune control
Immune escape

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3
Q

Which phases of HBV infection are amenable to treatment?

A

Immune clearance and immune escape- ALT will be elevated or fluctuating

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4
Q

Hep B - who should you treat?

A

Immune clearance phase- eAg positive, VL over log 5 or 20 000, abnormal ALT

immune escape- eAg neg, VL over log 3 or 2000 and abnormal ALT

NO POINT in interfering if immune system has it under control

advanced fibrosis - biopsy if fibroscan over 7 kPA

Cirrhotics (but if DNA less than 2000 may treat or observe)
In decompensated cirrhosis and any detectable level DNA- always treat - NOT with IFN!
HCC
Pregnancy

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5
Q

What are the pitfalls of the fibroscan ?

A 
Operator dependent 
Obesity 
Narrow rib space 
Ascites 
Falsely elevated readings with increased ALT, acute liver injury, liver congestion, cholestasis
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6
Q

Side effects PEG interferon

A

Flulike
Marrow suppression
Depression and anxiety
Autoimmune disorders especially autoimmune thyroiditis

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7
Q

Does resistance emerge during interferon peg therapy?

A

No

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8
Q

What factors predict a response to antiviral treatment?

A

High ALT
low HBV DNA
mild to mod histological activity and stage
More likely to e or s seroconvert if a>b>c>d with peg interferon alpha2B

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9
Q

HBV rna or DNA virus

A

DNA

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10
Q

What part of the virus is eAg?

A

Soluble nucleocapsid protein

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11
Q

cvc DNA

A

covalently closed circular

Becomes established in hepatocyte nuclei so eradication of virus is difficult

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12
Q

Clinical significance of pre-core or core promoter gene mutation

A

HBeAg neg in chronic HBV
More likely to have progressive liver injury, fluctuating ALT, lower HBV DNA, cannot have tenement induced HBeAg seroconversion.

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13
Q

Benefits of fibroscan

A

Non invasive
Fast
Well validated in HCV and HBV

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14
Q

Interpretation results fibroscan in HBV

A

If elevated ALT 1-5 times ULN

Less than 7.5 kPA 96% sensitivity to exclude bridging fibrosis

Over 12- 98% specific for bridging fibrosis

7.5 to 12 consider biopsy

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15
Q

Who should get PEG interferon

A

Stimulates immune system to clear virus
20-30 percent remission rate
Usually young eAg pos patients to try and prevent long term Tx with nucleoside or nucleotide analogues
Cannot give in cirrhosis
STOP (treatment fertility) if -
eAg positive - if sAg over 20 thousand at week 12
eAg negative- if no drop in sAg and less than 2log

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16
Q

How do you manage lamivudine resistance?

A

Either-
Add adefovir
Or
Change to tenofovir- current standard

(Likely 20-50% to be resistant to entecavir)

17
Q

Which nucleos(t)ide analogues are ok in preg?

A

Lamivudine

Tenofovir

18
Q

Upside and downside of tenofovir?

A 
Low resistance 
Hypophosphataemia +/- Fanconi syndrome in 10%
-acidosis
-low K
-glycosuria
-rhabdo

Also causes decreased bone density

19
Q

Maternal factors- highest transmission risk

A

EAg positive over log 8

20
Q

Preventing HBV transmission in preg

A

Passive immunisation at deleted delivery HBIGuf sAg pos
Mode delivery does not matter
HBV immunisation as per national schedule
Antivirus in last trimester if VL over log7- tenofovir cat B. Entecavir not used. Lamivudine cat C.
Cease antiviral a if wish to breast feed
Otherwise continue until week 4 to 12
Post partum flares usually within 4 weeks
Check status child 9 months
Breast feeding does not appear to increase transmission risk - don’t do it if nipples bleeding

21
Q

Agents that cause HBV reactivation

A 
Steroids EXCEPT asthma or gout
Chemo
Methotrexate
Rituximab
Omfatumomab 
6MP
HIV after immune reconstitution
22
Q

When is prophylaxis indicated prior to immunosuppressive?

A

HBsAg or DNA positive: prophylactic analogue to prevent reactivation. Tenofovir good expecially if long term therapy needed. Avoid IFN because bone marrow supression.

HbSAg neg but ant HBc positive, sAb =/- consider if rituximab.

23
Q

If prophylaxis needs to be given for immunosupression, how do you do it?

A

Lamivudine if DNA neg and short treatment duration eg standard chemo
entecavir or tenofovir if long duration

HBV DNA less than 2000 then continue 6 months post completion of treatment
Over 2000 continue until end points as if immunocompetent

24
Q

Strongest predictor of progression to cirrhosis in HBV

A

HBV DNA load

25
Q

For someone infected at birth and after the age of 10 years, what is the lifetime risk of HCC?

A

Birth- 15-40%

Horizontal after age 10- 15-25%

26
Q

What impact does the HBeAg status of mother have on child?

A

eAg + lower risk of acute icteric hepatitis but much higher risk of chronic HBV infection

eAg - higher risk of acute icteric hepatitis and lower risk of chronic infection HBV

27
Q

If find someone in the immune clearance phase, what do you do?

A

Give immune system time to try and sort it out for themselves. Don’t want going on for years or will cause cirrhosis. If immune system cannot get on top of it may intervene.

28
Q

Which HBV genotype is associated with more rapid disease progression?

A

HBV genotype C

Core promoter mutation

29
Q

What are the three main antivirals for HBV infection?

A

Tenofovir - nucleotide analogue- no reported resistance

Entecavir- don’t give if lamivudine resistant- purine based nucleoside analogue

pegIFN

30
Q

How often do you screen for ECC in compensated cirrhosis?

A

US and AFP every 6-12 months

31
Q

What does Fanconi syndrome look like? Which is the worst one for it?

A

Worst is adefovir, sometimes tenofovir.
PRofound prox myopathy, metabolic acidosis, hypophosphataemia, hypokalaemia, glucosuria but normal serum glucose and CHRONIC BONE PAIN! Hobble in.

32
Q

Which virus does not cause fulminant hepatic failure?

A

Hepatitis C!

33
Q

What kind of anaemia do you see in Wilson’s disease?

A

Coombs negative HA
Also AST:ALT >2 (in alcoholic hepatitis approx 2)
Normal or LOW ALP
LOW uric acid

34
Q

Who needs USS surveillance in hep B?

A 
Cirrhosis
FH of HCC
African over 20
Asian men over 40
Asian women over 50

Not it is ultrasound plus/minus AFP

35
Q

First serology to appear as positive in acute infection?

A

surface antigen (HBsAg) is the first marker to appear

36
Q

Who do you screen for HBV related HCC

A 
all cirrhotics
white over 40 if high ALT or viral load over 2000
african over 20
asian male over 40
asian woman over 50

Gastro (12 decks)

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