Hepatitis Flashcards
Hepatitis A
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- transmitted fecal-oral route
- incubation period 15-50 days (average is one month)
Symptoms
- nausea/vomiting
- abdominal pain
- fever
- dark urin
- jaundice
- puritis
- pale stools
Diagnosis
- anti-HAV igM present at illness onset; IgG present as the longer term antibody & protects against future infections
Treatment
- usually a self limiting illness
- NO chronic form of the disease
vaccination is > 95% effective after 20 years of getting it & commonly given in combo with HepB
Hepatitis B - Acute Infection
Etiology
Symptoms
Diagnosis
Treatment
diagnosis = serologic studies and results
Etiology
- think babies and blood!! as routes of transmission
- vertical transmission (in endemic areas)
- exposure to blood products
Symptoms
- can range from fulminant hepatits to a subclinical (barely any symptoms) hepatitis
- anorexia
- nausea
- jaundice (can come then disappear)
- RUQ discomfort
- can become chronic
Diagnosis
- signs on serology
- positive HBsAg: surface antigen + because ACTIVE infection
- positive anti-HBc: antibodies to the CORE proteins of hep B (only core if you actually were infected) - shows body is mounting a response
-postive IgM anti-HBc: shows IgM (immegiate) antibody response to teh infection is occuring
negative anti-HBs: becuase you havent yet mount the antibod response to the surface proteins yet (once you clear it; this will be postive)
Treatment
- supportive treatment; most pts. will not progress to chronic hep B
Hepatitis B - Chronic Infection
- who will go on to develop chronic hep B from acute
- diagnostic criteria
- phases (names)
Hep B - Chronic (not everyone who gets acute Hep B will go onto Chronic)
those who were infected at a younger age -like at birth from an infected mother are at the highest risk of progressing to chronic hep B
- less than 5% of those who acqure hep b as an adult develop a chronic infection
Diagnosis
- evidence of the Hep B CORE ANTIGEN for longer than 6 months - shows your body isnt clearing the infection – the virus is still replicating
On serology
- postive HBsAg: shows you cant clear the infection
- positive anti-HBc: shows you tried to mount an infection to fight off - indicates you were infected with a virus
- negative IgM anti-HBc: already tried to mount your infection, with the IgM in the beginning, but failed
- negative ant-HBs: havent created the long term antibody yet becuase youre still fightin
Hepatitis C - Acute Infection
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- commonly from bloodborne, IVUD, tattoos, needle sticks, blood transfusiosn, sexual and perinatal (incarcarated)
- acute = first 6 months of the infection (usually 2-12 weeks)
- majority goes undetected becuase they’re typically asymptomatic
- majority of those with acute will go on to chronic infection
Symptoms
- jaundice
- dark urine
- white stool
- nausea
- abdominal pain
- fatigue
- pruritis
- low-grade fever
- fulminent hepatic failure due to Hep c is rare
Diagnosis
- labs: AST/ALT 1020x ULN, elevated bilirubin
- postie HCV RNA followed by anti-HCV antibodies within 12 weeks
Treatment
- either spontaneously cleared within 12 weeks
- chronic hep C = majortiy of pt.
- recommended to treat during acute to avoid progression to chronic –> but is expensive
- direct-acting antiviral thearpy is what you use
- DAA: sofobuvir-velpatasvir or glecaprevir-pibrentsaivr
- assess virologic response by checking viral load at 12 week mark
- treatment is good! SVR = sustained response and possible
- prior treatment does not prevent reinfection
Hep C -Acute
Transmission Reduction
when treating hep C –important to councel the pts. on reducing risky behaviors
- stopping IVDU
- using protection in high risk sexual practices
- for those who engage in risky behavior- recommnede to repeat for HCV screening every 6-12 months
- liver failure during the acute stage is rare- but still avoid alcohol and tylenol
- all adults > 18 should be screened once
Hepatitis C - Chronic Infection
Etiology
Diagnosis
Treatment
Complications
Etiology
- unfortunately; 50-85% of those with acute hep C will go on to develop chronic hep C
- these pts. at risk fo cirrhosis and HCC
Diagnosis
- a reactive postive HCV RNA and a reactive postive HCV antibody = ususally after > 6 months
Treatment
- the same as acute – we want to treat to help reduce risks
- give DAA to achieve SVR (remebr though, this will not prevent reinfection)
Complications
- increased risk of developing cirrhosis - therefore need to monitor the progression of fiberosis
How to Monitor? - signs and symptoms
- signs of liver failure (ascites, HE, bleeding from the varices)
- lab evidence of the low albumin and high bili
- then survellence for HCC (vis US) in those who progress to fiberosis and cirrhosis
Hepatitis D
Etiology
Diagnosis
two types of infection
Hep D can ONLY occur in the setting of Hep B- will NEVER exisit by itself; its a defective virus
Etiology
- high risk groups for htose getting Hep B - IVDU, transufusions, those from other countries)
- Hep D can replicate on itse onw, but need to be in the presecen of Hep B to help assemble and work properly!
Two Types of infection
1. Co-infection
- when you get Hep B and Hep D AT THE SAME TIME
- this is acute hep B and D infection
- low risk of progression to chronic
- Superinfection
- when you have a Chronic Hep B carrier (those with a seropositive HBsAg + get Hep D on top of it
- in this case: there is a higher risk of becoming severe acute hepatitis or an exacerbation of chronic hep B
- these patients also are more likely to progress to develop chronic Hep D too
Hepatits D
Treatment
no treatment for ACUTE hep D
once it progresses to chronic…. treat those with…
- elevated AST/ALT (aucte liver disease) + HDV RNA postive pt.
- those with chronic hepatitis on liver biopsy (cirrhosis)
treatment of chronic with the above conditions = 1 year of PEGylated IFN to supress the viral RNA and normalzie ALT levels
Hepatitis E
Etiology
Symptoms
Diagnosis
Treatment
acute and chronic
Etiology
- most commonly from mother to child, contaminated food/water, transfusion, or fecal contents
- a self limiting infection
Symptoms
- asymptomatic or milk
- juandice
- malaise
- anorexia
- nausea/vomiting
- abd. pain
- fever
- hepatomeagly
Diagnosis
- elevated bili and AST/ALT
- anti-HEV IgM postive
- then go ahead and test the rising antibody HEV IgG or HEV RNA
Treament
- supportive in acute
in Chronic Hep E
- HEV RNA in the serum or stool for > 6 months
- this will occur almost exculsively in the immunosupressed
Treatment for Chronic
- try to reduce immunosuppressed therapy – so they can mount own response
- anti-vral: Ribavirin
THOSE WHO ARE PREGNANT ARE ASSOCIATED WITH AN INCREASE IN MORTALITY WITH HEP E INFECTION
Viral Hepatitis
other viral causes
lab trends
Viral Causes
- EBV
- CMV
- HSV
- VZV
- adenovirus
Lab Trends
- AST/ALT levels can exceed the 1000s!!!! ( >25 xULN)
Alcoholic Hepatitis
Etiology
Symptoms
Etiology
- alcoholic fatty liver disease leading to alcoholic hepatits leading to cirrhsis
- alcoholic hepatitis is ually used in the setting of symptomatic hepatitis in the setting of alcohol use and AFLD
- the exacy amount of alcohol intake is not know; but a history for > 7 drinks/day x 2 decades
- women more succeptible and dx. between 40-50
Symptoms
- always approach from a conciencious standpoint: asking about drinknig habits (CAGE questionare)
- jaundice, pruritis
- anoerxia/malnourshment leading to muscle weakness
- ascites
- RUQ/epigastric pain
- hepatomegaly
- bruit heard
- palmar erythmea, gynecomastia & spide angimoas
Alcoholic Hepatitis
Diagnosis
Treatment
Labs
- moderate AST/ALT elevation into the 100s with an AST:ALT ratio >2
- elevated bili and GGT
- moderate leukocytosis, macrocytic anemia
- elevated INR
- maluntrtion: low albumin
Imaging
- US and MRI and CT not needed for dx. but can help r/o other causes of acute hepatitis)
Diagnosis
- clinical + lab findings in the setting of longstanding alchol use are enough to dx.
- biopsy only necessary if you are uncertian still
then determine severity of disease progress…..
- usually a MELD score
Treatment
- abstain from alcohol
- always consider risk of withdrawal symptoms and need for hospitalization for this
- alcohol withdrawal can kill you!!
- hydration, nutrition support and monitoring for complications of cirrhosis
in severe disease…
- admit to the ICU for withdrawal
- steroids or pentoxyifylline
- liver transplant
mortality is high in these pts.
Autoimmune Hepatitis
- Etiology
- Symptoms
- Labs
Etiology
- chronic inflammatory disease of the liver
- circulation auto-antibodies & elevated gamma globulins
- ability to progress to cirrhoisis from acute hepatitis
- common in women & those with previous auto-immune conditions
- usually… environment trigger in genetically predisposed individual triggers the onset of symptoms and progressino
Symptoms (looks like viral hepatitis)
- fatigue
- myalgia
- RUQ pain
- jaundice
Labs
- AST/ALT: 10-20x ULN
- elevated IgG (hypergammaglobuinemia) but the IgM and IgA are normal
- auto-immune studies: ANA, ASMA< anti-SLA/LP, AMA, anti-dsDNA, etc. dhow positivity
- no imginag necessary unless you are r/o other conditions
Autoimmune Hepatitis
Diagnosis
Treatment
Diagnosis
- this is a dx. of exclusion
minimum of 1 elevated serum AST or ALT > 2x ULN
minimum of at least 1 lab test of IgG or serology postive
exculsion of other diseae processes
LIVER BIOPSY IS TECHNICALLY THE GOLD STANDARD
Treament
- glucocorticoids: for years
- remission is when the symptoms gone, liver chemisitires normal however relapse after stopping the steroids is common
azathioprine can be add-on therapy with steroids to help taper off with success
may need liver transplant
Primary biliary cholangitis/cirrhosis (PBC)
- isolated prescence of AMA (anti-mitochondiral antibody) {this is rarely the only elvated marker in autoimmune hepatiti s= thus its a difference}
- there is an auno-attack on the INTRA-lobarbile ducts = thus destroying the ducts
- destroying the ducts results in signs and symptoms of chlestasis (no bile flowing)
- smoking increases irisk
