Hepatitis

Question 1

Hepatitis C screen

Answer 1

Indications: IV drug use, tattoos, piercings, transfusions, high risk sex

Anti HCV
HCV RNA NAAT

Question 2

Hepatitis B screen

Answer 2

Indications: Endemic area, MSM, IV drug use, dialysis, HIV, pregnancy, contacts of HBV infected person

HBsAg, HBsAb, HBcAB

Question 3

Hepatitis A screen

Answer 3

Indication: hepatitis plus possible faecal oral exposure

IgM HAV

Question 4

Hepatitis E screen

Answer 4

Indication: hepatitis plus return from endemic area or negative hepatitis A,B,C screen

IgM HEV

Question 5

Alcoholic liver disease screen

Answer 5

High risk alcohol consumption:
Women: 14 STD/week
Men: 21 STD/week

Transaminitis pattern:
Mild elevation (<300)
AST:ALT >2
Elevated GGT

Ultrasound

Question 6

Haemochromatosis screen

Answer 6

Indication: abnormal liver test without acute hepatitis

Iron studies, HFE gene mutation analysis if Tsat >45% or high ferritin

Question 7

Autoimmune hepatitis screen

Answer 7

Indication: Abnormal AST/ALT, particularly with autoimmune diseases

ANA, ASMA, IgG/globulins (+/- anti liver kidney microsomal antibody, anti soluble liver antigen antibody)

Question 8

Wilson’s disease screen

Answer 8

Indication: Persistently high AST/ALT, particularly <55yrs old

Serum ceruloplasmin

Question 9

Αlpha 1 anti trypsin deficiency screen

Answer 9

Indication: Persistently elevated AST/ALT

Question 10

Primary biliary cholangitis screen

Answer 10

Indication: elevated ALP +/- bilirubin

Anti-mitochondrial antibody

Question 11

Primary sclerosing cholangitis screen

Answer 11

Indication: Elevated ALP +/- bilirubin

IgG4 + MRCP or ERCP

Question 12

NAFLD screen

Answer 12

Indication: Mild transaminitis + metabolic syndrome (diabetes, overweight, dyslipidaemia, hypertension)

Ultrasound

Question 13

Liver chemistry patterns

Answer 13

Cholestatic: raised ALP to ALT/AST +/-bilirubin
Hepatocellular: raised ALT/AST +/- bilirubin
Mixed
Isolated hyperbilirubinaemia

R ratio: (ALT/ALT ULN) / (ALP/ALP ULN)
>5 = hepatocellular, <2 = cholestatic, 2-5 = mixed

AST>ALT:
Alcohol
Cirrhosis
Ischaemic hepatitis
Congestive hepatopathy
Rare things

ALT>AST: everything else

Question 14

Non hepatic transaminitis

Answer 14

Rhabdo
Strenuous exercise
Heat stroke
Cardiac muscle damage
Thyroid disease
Haemolytic
Adrenal insufficiency

Question 15

Mild transaminitis (<5x ULN) pathway

Answer 15

Discontinue hepatotoxic meds and alcohol
Fatty liver and viral risk factors

FBC, LFT, Albumin, Coags, HBsAg/HBsAb/HBcAb, HCV Ab, Iron studies

Ultrasound

If persistent consider:
ANA, ASMA, IgG, ceruloplasmin, alpha 1 antitrypsin

Question 16

Moderate transaminitis (5-15x ULN) pathway

Answer 16

Discontinue hepatotoxic meds and alcohol
Consider acute liver failure

FBC, LFT, Albumin, Coags, HAV IgM/HAV IgG, HBsAg/HBsAb/HBcAb, HCV Ab, Iron studies, ceruloplasmin, ANA, SMA, IgG

Ultrasound

Question 17

Severe transaminitis (>15x ULN) pathway

Answer 17

Discontinue hepatotoxic medications and alcohol
Consider liver failure, ischaemia, rhabdo
Consider NAC if paracetamol ongestion

FBC, LFT, Coags, Albumin, HBsAg/HBsAb/HBcAb, HCV Ab, HSV, EBV, CMV, ceruloplasmin, ANA, ASMA, Anti LKM, IgG, paracetamol

Doppler ultrasound

Question 18

Elevated ALP pathway

Answer 18

Normal transaminases and bili:
Normal GGT: consider non hepatobiliary cause
Abnormal GGT: ultrasound, consider AMA, ANA, SMA

Abnormal transaminases or bili:
Ultrasound: duct dilation -> ERCP/MRCP
Ultrasound: no dilation -> AMA, ANA, SMA

Question 19

Elevated bilirubin causes

Answer 19

Unconjugated (>75/80%)
Gilbert’s
Crigler Najar
Haemolysis
Ineffective erythropoiesis
Hyperthyroid
Medications
Fasting

Conjugated (>50%)
Every other liver disease
Sepsis
TPN
Cholestasis of pregnancy