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DipGUM 🤦‍♀️ > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

HBsAg neg
Anti HBc neg
Anti HBs neg

A

Susceptible

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2
Q

HBsAg neg
Anti HBc pos
Anti HBs pos

A

Immune due to natural infection

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3
Q

HBsAg neg
Anti HBc neg
Anti HBs pos

A

Immune as vaccinated

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4
Q

HBsAg pos
Anti HBc pos
Anti HBc IgM pos
Anti HBs neg

A

Acutely infected

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5
Q

HBsAg pos
Anti HBc pos
Anti HBc IgM neg
Anti HBs neg

A

Chronic infection

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6
Q

HBsAg neg
Anti HBc pos
Anti HBs neg

A

1) recovering acute infection or
2) distantly immune and low level of anti HBs not detected
3) false positive anti HBc
4) chronic infection with rare circumstance of not detectable HBsAg

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7
Q

Infectious period for people with hep a

A

2 weeks before (prodrome) and 1 week of the jaundice phase

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8
Q

Hep A incubation period

A

15-45 days

Average 28 days

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9
Q

Percentage of adults that asymp with hep A or v mild non specific Sx with little or no jaundice

A

50%

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10
Q

Symptom phases of hep A

A

Pro dome phrase - flu like illness (malaise, fatigue, myalgia) often with RUQ pain. Lasts 3-10 days
Icteric phase - jaundice with anorexia, nausea and fatigue. Usually 1-3 weeks. Fever rare in this phase

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11
Q

Signs in the icteric phase of hep A

A

Jaundice with pale stools, dark urine, liver enlargement and signs of dehydration

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12
Q

Complications of hep A

A

Pregnancy - miscarriage and preterm but nil teratogenic
Mortality v low (<0.1%) except if ALFailure (40%)
Chronic infection >6/12 but small nos
0.4% acute liver failure
15% need hosp care (25% severe hepatitis) PT >3 secs and Bili >170nanomols/l

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13
Q

General Mx Hepa A

A

PHE inform avoid food handling until non infectious

Employment hx

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14
Q

PN for Hep A

A

At risk MSM within infectious period (oroanal, anal or digital rectal)
House hold contacts, those at risk from food or water contamination will be contacted by PHE

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15
Q

Rx for Hep A contacts
When to give vaccine up until?
Who to give HNIG to ans when up until?

A

Can give Hep A vaccine up to 14 days after exposure providing the exposure was within the infectious period of the source case
Human normal immunoglobulins (HNIG) 250-500mg IM to high risk contacts (hep b or c also, hiv, chronic liver disease or >50yo) only from PHE. Best when first few days post first contact, unlikely to work after 2 weeks, can use up to 28 days to reduce severity of disease

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16
Q

Hep A vaccine schedule

A

0 and then 6-12 months

95% protection for at least 10 years

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17
Q

If vaccinating Hep A an HIV positive patient with CD4< 300 at time?

A

Give further vaccine when CD4 over 500 if IgG still remains neg on testing

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18
Q

Active Hep A follow up plan

A

See every 1-2 weeks until ALT normal (usually 4-12 weeks)

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19
Q

Who to offer Hep A vaccine to routinely?

A

MSM visiting GUM - one off due to vaccine shortages
PWID
Chronic hep B and C
GP vaccinate those going to developing countries
Can check Hep A antibodies prior but can give dose whilst await results

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20
Q

Countries where Hep B common

A 
South east Asia
Africa
South and Central America
Southern Europe
Western Europe
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21
Q

Routes of transmission for Hep B

A

Sexual contacts - MSM (multiple partners, anal sex, oro- anal sex. Heterosexuals also.
Sex workers
Vertical
Parenteral (blood products, needle sharing. Tattoo

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22
Q

Incubation period of Hep B

A

40-160 days

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23
Q

Symptoms of Hep B

A

Kids asymp
Adults 10-50% asymp
Chronic carriers - asymp but might have fatigue or loss of appetite
Prodromal and icteric phases similar to Hep A but more prolonged and severe

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24
Q

Signs of Hep B

A

Acute phase - as for Hep A
After many years of chronic - spider naevi, clubbing, jaundice, hepatospenomegaly
Ascites, liver flap, encephalopathy

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25
Q

Complications of Hep B

A

Acute -
Pregnancy- preterm del and miscarriage
ALF less than 1% but worse risk than Hep a

Chronic infection -
>6/12
5-10% of sumtpomayics but higher if HIV
Almost all infants born to infectious mother (e antigen pos) will be chronic carriers unless immunise at birth

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26
Q

5 phases of chronic Hep B infection

A

1) immune tolerant - HBeAg pos chronic HBV- HBeAg pos, HBV DNA high, normal ALT, no liver necro on biopsy
2) immune active - HSeAg pos, high but falling HBV DNA, raised ALT, significant necro inflam and fibrosis
3) inactive Hep B carrier - HBeAg neg, HBV DNA low and normal ALT
4) HBeAg neg chronic active hepatitis - HBeAg neg, fluctuate HBV DNA, inform and progressive fibrosis, ?genetic mutations
5) occult HBV infection - HBsAg neg, positive Anti HBc +/- Anti HBs, normal ALT no DNA

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27
Q

Chronic infection in Hep B - outcomes

A

Phases 2 and 4 may give progression to cirrhosis
Concurrent Hep C infection - more aggressivejnfevtion with higher risk of cirrhosis and liver Ca
Concurrent HIV infection - increased risk of death and cirrhosis
Acute Hep A infection with Hep B can be severe
Can go concurrent Hep D which can be severe
10-50% chronic carriers develop cirrhosis leading to pre death in 50%

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28
Q

General Mx of Hep B

A

Public health
No sex until not infectious (loss of HBsAg or partner successfully vaccinated)
Don’t donate blood/ semen/ organs
If chronic infection - liver USS and fibroscan or liver biopsy if needed

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29
Q

Management of Hep B

A

Acute icteric - supportive Mx
If severe acute infection - antivirals can prevent ALF
Refer all HBsAg pos to hepatology
Usually Rx adults with HBV DNA >2000i.u/ml with evidence of necro inflam and or fibrosis

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30
Q

Hep B drug options

A 
(Nucleostide analogues)
Tenofovir disoproxil fumarate (TDF)
Tenofovir alafenamine (TAF)
Entecavir (these three antivirals would risk ARV resistance if used as mono therapy)
Pegylated interferon
31
Q

Decision to Rx Hep B with drugs depends on…

A

Pattern of disease
HBV dna level
Prescense or abscence of necro inflam and fibrosis

32
Q

What can you use to suppress HBV replication during HIV therapy?

A

Lamivudine
Emtricitabine
TDF (tenofovir disproxil fumatate)
TAF (tenofovir alafenamide)
Prevent liver damage if used as part of triple therapy
Lamivudine and Emtricitabine high resistance on own to HIV
Entecavir - do not use for HIV unless HIV suppressed

33
Q

HBV follow up

A

6-12 monthly for those with significant fibrosis or cirrhosis to check for HCC with USS and alpha feta protein

34
Q

Which patients are at high risk of HCC development regardless of cirrhosis status in HBV?

A 
Africans over 20
Asian men over 40
Asian women over 50
Over 50
FHx HCC
Give screening despite no cirrhosis
35
Q

Hep B and vertical transmission perfectanges depending on e antigen positivity

A

E antigen pos - 90%

E antigen neg but surface antigen pos - 10%

36
Q

What can be given to pregnant woman if highly infectious in acute HEp B?

A

Hep B specific immunoglobulin 200i.u IM

Reduces vertical transmission by 90%

37
Q

When would you give tenofovir mono therapy to a pregnant woman with Hep B?

A

In third trimester if HBV DNA > 10 to power of 7 iu/ml

Reduces vertical transmission

38
Q

Partner notification for Hep B

A

Sex or needle share partner during infectious time ( 2 weeks pre jaundice and until surface antigen neg)
Chronic infection - as far back as jaundice or when thought to acquired
Screen kids if needed
Public health

39
Q

What can be given to a non immune contact of Hep B after a single UPSI or parenteral exposure and when does it work?

A 
Hep B immunoglobulin 500i.u IM
Works within 12 and ideally 48hours
Won’t work after 7/7
From public health
Give rapid vaccination also to all sexual and household contacts
40
Q

Ultra rapid Hep B vaccination

A

0, 7 and 21 days

Booster at 12 months

41
Q

Rapid Hep B vaccine course

A

0, 1, 2 months and booster at 12/12

42
Q

Vaccination post exposure to Hep B

A

All sexual and household contacts
Rapid schedule
Theoretically protection when started within 6 weeks from first exposure
Single booster for those prev vaccinated with proven immunity

43
Q

Post ultra rapid vaccine schedule - when to test and boost?

A

Test anti Hbs at 4-12 weeks post last dose
If >10i.u but ideally >100 - ok
If low risk then booster 12/12
If inadequate antibody response or high risk - repeat course

44
Q

How long does Hep B vaccination last?

A

20 years at least

45
Q

Hep B follow up schedule

A

Acute hep B - serology after 6/12 even if LFTs normal
Chronic - if untreated then yearly review
Immunity after recover i.e surface antigen neg - life long in over 90%

46
Q

Who to test for Hep B?

A 
MSM
Sex workers
PWID
Hiv pos
Sex assault
Endemic countries 
Needle stick
Heterosexuals with > 10 partners per year and pos or high risk partners
47
Q

If positive Hep b from screening how to manage?

A

If not immune - vaccinate
Chronic carrier - ref to Hep
If anti HBc neg - vaccinate
If anti HBc pos - test HBsAg - if pos acute or chronic Hep B so check IgM anti HBc/ HBeAg/ HBeAb/HBV DNA

If anti HBc pos and HBsAg neg - naturally immune to Hep B. Check anti- HBs and if neg give booster

48
Q

Standard Hep B vaccine schedule

A

0,1and 6/12

49
Q

Hep B Vaccination regime for HIV pos patients

A

Reduced response
Loss of antibodies quicker post vaccine
Give high dose vaccine 50nanograms Engerix or HBVaxPro or use Fendrix 20mcg at 0,1,2 and 6/12
Only use single dose ultra rapid if CD4 > 500
Measure levels at 4-8 weeks post last dose ans give booster if >10 but less than 100
Boosters when <100

50
Q

What to do if HB vaccine course not completed?

A

Can give outstanding doses at 4 or more years later without needing to restart

51
Q

Hep D overview

A 
RNA
Only those HBV HBsAg positive 
Risk - infection from abroad, PWID, sex workers
If Hep b acute phase severe or chronic carrier has further acute attack or rapidly progressive liver disease - suspect hep D
High rate of cirrhosis and fulminant
Check anti HDV antibody and HDV RNA
Poor response to antiviral
Ref to Hep
52
Q

Hep E brief overview

A 
Pigs
Slaughterhouse and vets 
High mortality in pregnancy
Faecal oral route
Contaminated water
Incubation 2-9 weeks
Self limiting
No chronic illness
Serology, good hand sanitation, avoid high risk water
53
Q

Hep C transmission

A 
Parenteral - shared needles
Transfusions
Renal dialysis
Needle stick
Sharing razors
Snorting kit
Sexual 
Vertical
54
Q

Risk of sexual transmission of Hep C

A

V low risk in heterosexuals
Increased risk if HIV pos also
MSM rising incidence of Hep C largely with HIV coinfection
Association with other STIs - sts/ LGV, traumatic anal sex, fisting, sharing sex toys, group sex
Sex workers
Former prisoners

55
Q

Hep C transmission risk correlates with…

A

HCV RNA

Vertical transmission 5% but higher with HIV

56
Q

HCV incubation

A

4-20 weeks
HCV serology positive for 3 months post exposure but can take 9 months
HCV antibodies often delayed in HIV pos

57
Q

Percentage of Hep C that become chronic carriers

A

50-85%

Usually asymp

58
Q

Chronic Hep C risk of liver disease

A

Increased risk liver ca
35% significant liver disease but normal ALT
30% severe liver disease 14-30 years post infection

59
Q

Hep C seeology in acute infection

A

HCV RNA - pos after 2 weeks
HCV RNA pos but anti HCV antibody neg or they seroconvert to antibody pos
HCV core antigen marker of replication activity

60
Q

Hep C serology if chronic infection.

A

HCV RNA pos after 6/12
Do EIA screening antibody/ antigen test
Do viral RNA and identify HCV genotype

61
Q

General Mx hep C

A 
Curable
Public health 
Don’t donate blood/ semen/ organs
Written info
Ref to hepatology
Sti screen
Fibroscan
62
Q

Definition of HCV cure?

A

Negative HCV RNA in blood at 12 weeks post Rx competed

63
Q

Treating HCV during acute phase

A

Most asymp
Reduces progression
Spont resolution if RNA cleared in 6/12
4 weekly RNA - if less than 2 log 10 decline at week 4 give Rx
Or if greater than 2 log ten - check RNA 12 weeks. If remains pos at week 12 - Rx
If neg then monitor for 48 weeks

64
Q

Treating Hep C with what drugs?

A 
Direct acting antiviral agents
Target HCV non structural proteins to prevent viral replication 
Target NS3/4A protease inhibitors 
Simiprevir 
Ritonavir boosted ombitasvir
Grazoprevir
Glecaprevir
Can give DAAs to HIV pos
Depends on viral load of HCV, liver disease stage 
Vaccinate against hep B and C
65
Q

Hep c and breastfeeding and preggers

A

Breastfeed ok

Can’t rx in pregnancy - small vertical risk

66
Q

PN for Hep C

A

Any needle share partners
Screen contacts for HCV
Avoid sex in acute infection
Chronic infection - condoms with partner but low risk transmission through sex (except HIV coinfect)
MSM and HIV - gloves fisting, no group set, single use sex toys

67
Q

Hep C follow up

A

Chronic untreated - 6-12 monthly assessment
Cirrhosis fibrosis - 6/12 alpha and uss for HCC screen
Prev HCV doesn’t prevent future infection

68
Q

Who screen for HCV?

A 
PWID
Hiv pos annual screen 
Blood pre 1990
Needle stick
Annual test MSM at high risk
Group sex
Annual HCV RNA for those cleared HCV
Other STI
Traumatic sex hx - fisting etc
69
Q

Hep B and HIV - peginterferon risks

A

Low response rate
Depression and myelotoxicity
Risk of CD4 decline

70
Q

Hiv positive and Rx Hep B

A

Truvada good

If egfr <60 use TAF plus Emtricitabine

71
Q

Protease inhibitors for treating Hep C (DAAs)

A

Ritonavir boosted:
Ombitasvir
Dasabuvir
Paritaprevir

72
Q

NS5A inhibitors for treating Hep C

A

Daclatasvir
Elbasvir
Ledipasvir
Ombitasvir

73
Q

NS5B polymerase inhibitor for treating Hep C:

A

Non nucleoside dasabuvir

Nucleotide sofosbuvir

74
Q

Post exposure to Hep B when is the latest can give ultra rapid vaccine

A

6 weeks

DipGUM 🤦‍♀️ (29 decks)

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