Hepatitis Flashcards
What is hepatitis?
inflammation in the liver.
This can vary from a chronic low level inflammation to acute and severe inflammation that leads to large areas of necrosis and liver failure.
Causes of hepatitis
Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)
Presentation of hepatitis
Hepatitis may be asymptomatic or could present with non-specific symptoms:
Abdominal pain
Fatigue
Pruritis (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever (viral hepatitis)
Typical biochemical findings with hepatitis?
liver function tests become deranged with high transaminases (AST / ALT) with proportionally less of a rise in ALP.
This is referred to as a “hepatitic picture”.
Transaminases are liver enzymes that are released into the blood as a result of inflammation of the liver cells.
Bilirubin can also rise as a result of inflammation of the liver cells.
High bilirubin causes jaundice.
Hepatitis A: About?
Hepatitis A is the most common viral hepatitis worldwide but it is relatively rare in the UK with under 1000 cases in England and Wales in 2017.
It is an RNA virus. It is transmitted via the faecal-oral route usually by contaminated water or food.
It presents with nausea, vomiting, anorexia and jaundice.
It can cause cholestasis (slowing of bile flow through the biliary system) with dark urine and pale stools and moderate hepatomegaly.
It resolves without treatment in around 1-3 months.
Management is with basic analgesia.
Vaccination is available to reduce the chance of developing the infection. It is a notifiable disease and Public Health need to be notified of all cases.
Hepatitis B: About?
Hepatitis B is a DNA virus. It is transmitted by direct contact with blood or bodily fluids, such as during sexual intercourse or sharing needles (i.e. IV drug users or tattoos). It can also be passed through sharing contaminated household products such as toothbrushes or contact between minor cuts or abrasions. It can also be passed from mother to child during pregnancy and delivery (known as “vertical transmission”).
Most people fully recover from the infection within 2 months, however 10% go on to become chronic hepatitis B carriers. In these patients the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins
Viral markers of HepB
Surface antigen (HBsAg) – active infection
E antigen (HBeAg) – marker of viral replication and implies high infectivity
Core antibodies (HBcAb) – implies past or current infection
Surface antibody (HBsAb) – implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
Vaccination and HepB infection
Vaccination is available and involves injecting the hepatitis B surface antigen. Vaccinated patients are tested for HBsAb to confirm their response to the vaccine.
The vaccine requires 3 doses at different intervals. Vaccination to hep B is now included as part of the UK routine vaccination schedule (as part of the 6 in 1 vaccine).
Management: Hepatitis B
Have a low threshold for screening patients that are at risk of hepatitis B.
Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
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 medication can be used to slow the progression of the disease and reduce infectivity
Liver transplantation for end-stage liver disease
Hepatitis C: About?
Hepatitis C is an RNA virus. It is spread by blood and body fluids. No vaccine is available. It is now curable with direct acting antiviral medications.
Disease course HepC?
1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic
Complications: liver cirrhosis and associated complications and hepatocellular carcinoma
Testing of HepC
Hepatitis C antibody is the screening test
Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype
Management of HepC infection
Have a low threshold for screening patients that are at risk of hepatitis C
Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
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
Hepatitis D: About?
Hepatitis D is an RNA virus. It can only survive in patients who also have a hepatitis B infection. It attaches itself to the HBsAg to survive and cannot survive without this protein. There are very low rates in the UK. Hepatitis D increases the complications and disease severity of hepatitis B.
There is no specific treatment for hepatitis D. It is a notifiable disease and Public Health need to be notified of all cases.
Hepatitis E: About?
Hepatitis E is an RNA virus. It is transmitted by the faecal oral route. It is very rare in the UK. Normally it produces only a mild illness, the virus is cleared within a month and no treatment is required.
Rarely it can progress to chronic hepatitis and liver failure, more so in patients that are immunocompromised. There is no vaccination. It is a notifiable disease and Public Health need to be notified of all cases.
What is Autoimmune hepatitis?
Autoimmune hepatitis is a rare cause of chronic hepatitis. We are not sure of the exact cause, however it could be associated with a genetic predisposition and triggered by environmental factors such as a viral infection that causes a T cell-mediated response against the liver cells.
This is where the T cells of the immune system recognise the liver cells as being harmful and alert the rest of the immune system to attack these cells.
There are two types that have different ages of onset and autoantibodies: Autoimmune Hepatitis?
Type 1: occurs in adults
Type 2: occurs in children
Type 1 typically affects women in their late forties or fifties. It presents around or after the menopause with fatigue and features of liver disease on examination. It takes a less acute course than type 2.
In type 2, patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
Investigations for autotimmune hepatitis?
Investigations will show raised transaminases (ALT and AST), IgG levels and it is associated with many autoantibodies.
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)
Diagnosis of autoimmune hepatitis can be confirmed using a ?
liver biopsy
Treatment of autoimmune hepatitis?
with high dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine, are introduced.
Immunosuppressant treatment is usually successful in inducing remission however it is usually required life long.
Liver transplant may be required in end stage liver disease, however the autoimmune hepatitis can recur in transplanted livers.
