Hepatitis

Question 1

Causes of hepatitis

Answer 1

Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)

Question 2

Presentation of hepatitis

Answer 2

Abdominal pain
Fatigue
Pruritis (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever (viral hepatitis)

Question 3

Typical LFT findings in hepatitis

Answer 3

Hepatitic picturre

AST and ALT proportionally higher than ALP

Bilirubin may also be high - due to inflammation of the liver cells. High bilirubin causes jaundice.

Question 4

How are the different viral hepatitis spread?

Answer 4

Hep A and E - faecal-oral route

Hep B and C - Contact with blood or bodily fluids e.g. IVDU, sex

Hep D - only occurs as a co-infection in Hep B

Question 5

What is Hep B?

Answer 5

A double stranded DNA virus spread often through blood borne route

Can also be spread by vertical transmission

Question 6

Hep B serology

Answer 6

HbsAg - Hep B surface antigen:
- Positive in active infection (acute or chronic)

Anti-HBc (HBcAb) (antibody against Hep B core antigen)

• Implies past or current infection
• Not positive after vaccination
• Can be used to distinguish between acute and chronic infection
• IgM in acute, IgG in chronic

Anti-HBs (HBsAb) (antibody to Hep B surface antigen)
- Positive in both past infection and vaccination

HBeAg:

• Determines infectivity
• If this is negative and anti-HBe is positive - implies they have been through phase where virus was replicating and are less infectious
• If this is positive = higher infectivity

Question 7

Management of Hep B

Answer 7

Screen for other blood born viruses e.g. Hep C, HIV and other STIs

Refer to gastroenterology, hepatology or infectious diseases for specialist management

Notify public health England

Advice on reducing transmission

• Avoid unprotected sex (including oral sex)
• Avoid sharing needles
• Avoid sharing toothbrushes

Testing for complications - FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Stop smoking and alcohol

Interferon-alpha for chronic hepatitis B (an antiviral)
- Tenofovir is second line

Question 8

HbsAg negative

Anti-HBs - positive

Anti-HBc - negative

Answer 8

Vaccinated against Hep B

Question 9

HbsAg negative

Anti-HBs - positive

Anti-HBc - positive

Answer 9

Previous hepatitis B infection

Question 10

HbsAg - positive

Anti-HBs - negative

Anti-HBc - negative or positive IgM

Answer 10

Acute Hep B

Anti-HBc is positive for IgM in later infection

Question 11

HbsAg - positive

Anti-HBs - negative

Anti-HBc - positive IgG

HBe-Ag - negative

Anti-HBe - positive

Answer 11

Chronic Hep B with low infectivity

Question 12

HbsAg - positive

Anti-HBs - negative

Anti-HBc - positive IgG

HBe-Ag - positive

Anti-HBe - positive

Answer 12

Chronic Hep B with high infectivity

Question 13

What is Hepatitis C?

Answer 13

An RNA virus spread through blood borne route

Question 14

What is the disease prognosis and possible complications of Hep C?

Answer 14

1/4 make full recovery

3/4 get chronic Hep C

Complications are liver cirrhosis and its associated complications and hepatocellular carcinoma

Question 15

Hepatitis C serology

Answer 15

HCV RNA - positive in active infection

Anti-HCV - positive in previous infection and chronic infection usually

Question 16

Hepatitis C management

Answer 16

Screen for other blood born viruses (hepatitis A and B and HIV) and other STIs

Refer to gastroenterology, hepatology or infectious diseases for specialist management
Notify Public Health (it is a notifiable disease)

Stop smoking and alcohol

Education about reducing transmission and informing potential at risk contacts

Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma

Antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype. They successfully cure the infection in over 90% of patients. They are typically taken for 8 to 12 weeks

Liver transplantation for end-stage liver disease

Question 17

Who needs to be informed in viral hepatitis cases?

Answer 17

Public Health

A notifiable disease

Question 18

What is autoimmune hepatitis?

Answer 18

May be due to environmental factors such as a viral infection that causes a T cell-mediated response against the liver cells

Two types:

• Type 1 - adults
• Type 2 - children (more acute course)

Question 19

What are the autoantibodies seen in autoimmune hepatitis?

Answer 19

Type 1 Autoantibodies:

• Anti-nuclear antibodies (ANA)
• Anti-smooth muscle antibodies (anti-actin)
• Anti-soluble liver antigen (anti-SLA/LP)

Type 2 Autoantibodies:

• Anti-liver kidney microsomes-1 (anti-LKM1)
• Anti-liver cytosol antigen type 1 (anti-LC1)

Question 20

Investigations in suspected autoimmune hepatitis?

Answer 20

LFTs - raised ALT and AST
Autoantibody screen
Clotting/INR - liver function

Liver biopsy to confirm diagnosis

Question 21

Treatment of autoimmune hepatitis?

Answer 21

Treatment is with high dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine are started

Treatment usually needed lifelong

Liver transplant may be needed in end-stage liver disease