Hepatitis Flashcards
What is hepatitis?
inflammation in the liver
- this can be a chronic low level inflammation
- or an acute, severe inflammation that results in large areas of necrosis + liver failure
What are the possible causes of hepatitis?
- alcoholic hepatitis
- non-alcoholic fatty liver disease
- viral hepatitis
- autoimmune hepatitis
- drug-induced hepatitis (e.g. paracetamol overdose)
What is the presentation of hepatitis typically like?
- it can be asymptomatic
- or present with non-specific symptoms:
- fever (viral)
- jaundice
- abdominal pain
- pruritis
- fatigue
- muscle / joint aches
- N&V
What are the typical LFT findings in hepatitis?
- there are high transaminases (AST / ALT)
- there is a proportionally smaller raise in ALP
- this is called a “hepatitic picture”
- bilirubin may also be raised as a result of inflammation
- high bilirubin causes jaundice
transaminases are liver cell enzymes that are released into the blood as a result of inflammation of the liver cells
How is hepatitis A transmitted?
- it is a RNA virus
- it is transmitted via the faecal-oral route through contaminated food / water
it is the most common viral hepatitis worldwide but relatively rare in the UK
What are the symptoms associated with hepatitis A?
- N&V
- anorexia
- jaundice
- it can cause cholestasis with dark urine and pale stools
- moderate hepatomegaly
cholestasis = slowing of bile through the biliary system
What is involved in the management of Hepatitis A?
- it will resolve without treatment in 1-3 months
- basic analgesia is given
- vaccination is available to reduce the chance of developing an infection
- it is a notifiable disease so Public Health must be notified in all cases
In what ways can Hepatitis B be transmitted?
- it is a DNA virus
- transmitted through direct contact with blood or bodily fluids (sexual intercourse, sharing needles - IVDU / tattoos)
- can be passed through sharing contaminated household products - e.g. toothbrushes
- or between minor cuts / abrasions
- can be passed from mother to child during pregnancy / delivery (vertical transmission)
What is the prognosis like following hepatitis B infection?
- most people fully recover within 2 months
- 10% will become chronic hepatitis B carriers
- the viral DNA has integrated into their own DNA so they continue to produce viral proteins
What is meant by chronic hepatitis B?
- hepatitis B that lasts for 6 months or more
- it can potentially lead to cirrhosis or hepatocellular carcinoma
- it may be asymptomatic
What are the 5 different viral markers that can be tested for in hep B?
surface antigen (HBsAg):
- a marker of active infection
E antigen (HBeAg):
- a marker of viral replication that implies high infectivity
core antibodies (HBcAb):
- implies past or current infection
surface antibodies (HBsAb):
- implies vaccination, past or current infection
Hep B virus DNA (HBV DNA):
- direct count of the viral load
What does the presence of HBsAg indicate?
there is an active infection with Hep B
What does the presence of HBeAg indicate?
- this indicates the patient is in the acute phase of the infection
- the virus is actively replicating
- a high level of HBeAg correlates with high infectivity
What does the presence of HBcAb indicate?
either a past or current Hep B infection
How can HBcAb be used to distinguish between an acute, chronic and past infection?
through measuring IgM and IgG versions of the HBcAb
- IgM implies active infection
- a high titre of IgM indicates acute infection
- a low titre of IgM indicates chronic infection
- IgG indicates a past infection when HBsAg is negative
What does the presence of HBsAb imply?
- there has been an immune response to HBsAg
- this could be due to vaccination, current or past infection
How can you tell if HBsAb is due to vaccination or infection?
- HBsAg is given in the vaccine
- a positive HBsAb could indicate an immune response to the vaccine
- other viral markers are needed to distinguish between vaccination or infection
What is the order of tests when screening for Hep B?
- test for HBcAb for evidence of previous infection
AND
- test for HBsAg for evidence of active infection
- if these are positive, then test for HBeAg and viral load
What does it mean if HBeAg is negative but HBeAb is positive?
- the patient has been through a phase where the virus was replicating
- now the virus has stopped replicating and they are less infectious
What is involved in the vaccination for hep B?
- it involves injection of HBsAg
- individuals are then tested for HBsAb to confirm response to the vaccine
- there are 3 doses at different intervals
it is part of the UK routine vaccination schedule
Who should be screened for Hep B?
- there should be a low threshold for screening patients at risk of Hep B
- other bloodborne viruses (hep A / HIV) and other STDs should also be screened for
What advice is given to a patient with hepatitis B?
- stop smoking and drinking alcohol
- education about reducing transmission and informing potential at risk contacts
What is involved in the management of hepatitis B?
- PHE must be informed as it is a notifiable disease
- FibroScan to check for cirrhosis
- USS to check for hepatocellular carcinoma
- antiviral medication can be given to slow progression of disease + reduce infectivity
- liver transplantation for end-stage liver disease
the patient is referred to gastroenterology, hepatology or infectious diseases for specialist management
What is hepatitis C and how is it spread?
- it is an RNA virus
- it is spread via blood and bodily fluids
What is the prognosis of Hepatitis C like?
- 1 in 4 will make a full recovery
- 3 in 4 will develop chronic Hep C infection
- chronic infection is associated with liver cirrhosis + hepatocellular carcinoma
How can Hepatitis C be tested for?
- the screening test looks for Hepatitis C antibody
- if this is positive, Hepatitis C RNA testing is used to confirm the diagnosis, calculate viral load and assess individual genotype
What is involved in the management of Hep C?
- it is the SAME as hepatitis B except for:
- no vaccine is available
- direct acting antivirals (DAAs) tailored to the specific viral genotype can cure the infection in 90% patients when taken for 8-12 weeks
What is Hepatitis D and which individuals can contract this infection?
- it is an RNA virus
- it can only survive in patients with a concurrent Hep B infection
- it attaches to the HBsAg to survive and cannot survive without this protein
there are very low rates in the UK
What are the consequences of hepatitis D?
How is it managed?
- it increases the complications and severity of hep B infection
- there is no specific treatment for hep D
- PHE must be notified as it is a notifiable disease
What is hepatitis E and how is it transmitted?
- it is an RNA virus
- it is transmitted via the faecal-oral route
it is very rare in the UK
What type of illness is typically produced by Hep E?
- it usually produces a mild illness
- this clears within 1 month and no treatment is required
- rarely it can progress to chronic hepatitis and liver failure in immunocompromised patients
it is a notifiable disease + no vaccine is available
What is thought to be the cause of autoimmune hepatitis?
- there is a genetic predisposition and it is triggered by environmental factors
- a viral infection causes a T-cell mediated response against liver cells
- the T cells recognise the liver cells as being harmful
- they alert the rest of the immune system to attack these cells
the exact cause is unknown
What are the 2 different types of autoimmune hepatitis?
- Type 1 tends to occur in adults
- Type 2 tends to occur in children
Who tends to be affected by Type 1 autoimmune hepatitis?
- women in their late 40s or 50s
- it presents around or after the menopause
- it presents with fatigue and features of liver disease on examination
- the course is less acute than T2
Who is typically affected by Type 2 autoimmune hepatitis?
- it typically affects teenagers / individuals in their early 20s
- they have an acute picture with high transaminases and jaundice
What will investigations for autoimmune hepatitis show?
- raised transaminases (ALT / AST)
- raised IgG
- it is associated with many autoantibodies
What autoantibodies are associated with Type 1 autoimmune hepatitis?
- anti-nuclear antibodies (ANA)
- anti-smooth muscle antibodies (anti-actin)
- anti-soluble liver antigen (anti-SLA/LP)
What autoantibodies are associated with Type 2 autoimmune hepatitis?
- anti-liver kidney microsomes-1 (anti-LKM1)
- anti-liver cytosol antigen type 1 (anti-LC1)
How is autoimmune hepatitis diagnosed?
liver biopsy
What is involved in the treatment for autoimmune hepatitis?
- high dose steroids - typically prednisolone
- prednisolone is tapered over time as other immunosuppressants (typically azathioprine) are introduced
- immunosuppressant treatment induces remission but is usually required life-long
- liver transplant may be required in end-stage disease but autoimmune hepatitis can recur in transplanted livers
