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Adult Adult > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

Definition of viral hepatitis

A
  • Systemic viral infection in which the liver is the predominant and often the sole target of injury
  • hepatitis = inflammation of liver
  • also hepatocyte necrosis = diagnostic hallmark is an increase in aminotransferases
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2
Q

Types of hepatitis

***exam

A

ABCDE

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3
Q

Hepatitis A: source, transmission, potential for chronic infection, prevention

***exam

A
  • Source: feces
  • Transmission: fecal-oral
  • Chronic infxn: no
  • Prevention: pre/post exposure IZ, handwashing
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4
Q

Hepatitis B: source, transmission, potential for chronic infection, prevention

***exam

A
  • Source: blood/blood derived body fluids
  • Transmission: percutaneous per mucosal
  • Chronic: yes (6-10%)
  • Prevention: pre/post exposure IZ, behavior
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5
Q

Hepatitis C: source, transmission, potential for chronic infection, prevention

***exam

A
  • Source: blood/blood derived body fluids
  • Transmission: percutaneous per mucosal
  • Chronic: yes (85%)
  • Prevention: blood donor screening, risk behavior modification
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6
Q

Hepatitis D: source, transmission, potential for chronic infection, prevention

***exam

A
  • Source: blood/blood derived body fluids
  • Transmission: percutaneous per mucosal (infects only HBV pts)
  • Chronic: yes (45%)
  • Prevention: pre/post-exposure IZ, risk behavior modification
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7
Q

Hepatitis E: source, transmission, potential for chronic infection, prevention

***exam

A
  • Source: feces
  • Transmission: fecal-oral
  • Chronic infxn: no
  • Prevention: ensure safe drinking water
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8
Q

Clinical course of acute viral hepatitis

A

not always progress to icteric (jaundice)

pruritis(itchy): if viral infxn then intense itching, consider

Acute Viral Hepatitis:

  1. Prodrome: Malaise (dec apeptite), anorexia, nausea, low grade fever, right upper quad pain, headache = 2-10 days
  2. Anicteric and resolve OR become Icteric phase and resolve

Icteric phase: darkening urine, jaundice, lightening of feces, amelioration of general symptoms, pruitrus = 7-28 days

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9
Q

Expected PE findings in acute viral hepatitis

A
  • Jaundice (±)
  • Hepatomegaly
  • Right upper quadrant tenderness
  • Splenomegaly (20%)
  • No lymphadenopathy
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10
Q

Expected lab findings in acute viral hepatitis

***exam

A
  • Increased aminotransferases
  • Variable bilirubin levels
  • Alkaline phosphatase normal or only mildly elevated
  • Albumin and globulins normal
  • Leukopenia
  • Prothrombin time usually normal
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11
Q

Labs: best markers of severity of acute hepatitis?

***exam

A
  • NOT aminotransferases (ALT/AST) - these are not liver function tests, they are markers of cell necrosis
  • Best marker of severity: PT/INR
  • biopsy unnecessary
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12
Q

What is fulminant hepatitis and how is it diagnosed?

A
  • Hepatic failure w/in 8 weeks of onset of acute hepatitis (ABCDE)
  • Diagnosed by presence of hepatic encephalopathy and prolonged PT
  • Histologically: massive hepatic necrosis
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13
Q

Definition chronic viral hepatitis: labs, symptoms

A
  • Elevated aminotransferases and/or viral markers present for > 6 months
  • Non-specific symptoms
  • May progress to liver fibrosis, cirrhosis and hepatocellular carcinoma
  • Caused by hepatitis viruses B, C, D or as yet unknown virus(es)
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14
Q

How is chronic hepatitis classified?

A

Grade = inflammation and necrosis

0 (none) to 4+ (severe)

Stage = pattern of fibrosis

None = 0

Portal = 1

Peri-portal to early bridging = 2

Extensive bridging = 3

Cirrhosis = 4

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15
Q

Fibrosis Progression in Chronic Hepatitis - what do you tell patients for education? what are the stages

A

pt education: can use nose - end is spongier, as you move up gets harder

Stage 1 - Mild fibrosis

Stage 3- Severe fibrosis

Stage 4 - cirrohosis

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16
Q

CDC Updated
HCV Testing Guidelines

***exam

A
  • Baby boomers (born 1945-1965) who have never been tested should receive at least a one-time HCV test
  • Augments (does not replace) previous recommendations
  • All HIV-infected adolescents and adults should be routinely tested for HCV infection.
17
Q

Groups Recommended for HCV Testing by AASLD and USPHS

***exam

A
  • Recent/past injection drug users—even if only used once
  • Groups with high HCV prevalence
    • HIV-infected individuals
    • Hemophiliacs treated with clotting factor concentrates before 1987
    • Hemodialysis recipients
    • Patients with unexplained aminotransferase abnormalities
  • Recipients of transfusion or transplantation before July 1992
  • Children born to women infected with HCV
  • Healthcare, public safety, and emergency medical personnel following
  • needle injury or mucosal exposure to HCV-infected blood
  • Current sexual partners of individuals infected with HCV
  • Persons who have used illicit drugs by noninjection routes
18
Q

Should acute HCV be treated?

A

Only if HCV RNA detectable 2-3 mo after onset of infection

19
Q

How can HCV infection be prevented?

A
  • no means to prevent hepatitis C
  • Avoid high-risk behaviors and appropriate use of universal precautions
  • Needle exchange programs and education regarding the risks of drug use
  • Prevent accidental needle stick exposure
    • Neither immune globulin nor preemptive antiviral therapy is recommended
    • Monitor AST, HCV RNA, and anti-HCV (at baseline and 1 and 6 months after exposure) . This allows for early intervention and treatment
20
Q

How is HCV diagnosed?

***exam

A

HCV Ab+ then confirmed via HCV RNA (if viral load not detected, + Ab represents past infection)

21
Q

Once HCV infection confirmed, what are initial mgmt steps?

A
  • Characterize HCV infection – genotype, viral load
  • Assessment of fibrosis – liver biopsy vs. fibroscan
  • Screen for HAV, HBV, HIV >> immunize
  • Counseling regarding alcohol and HCV transmission
  • Assess readiness and motivation for antiviral therapy
  • Modify pre-treatment factors predicting response to antiviral therapy (e.g., SAD, fatty liver)
  • Careful patient selection for antiviral therapy
22
Q

How is a liver biopsy evaluated?

A

Two components: inflammation grade, which is the redness that forms around a cut in the skin, and fibrosis stage, which is scar tissue

Inflammation Grade

  • Measure of severity and ongoing disease activity
  • 0-4 (METAVIR)
  • Inflammation leads to scarring/fibrosis

Fibrosis Stage

  • Amount of fibrous scar tissue
  • 0-4 (METAVIR)
  • Stage 4 = cirrhosis
  • Indicates long-term disease progression
23
Q

What are some Noninvasive Alternatives to Biopsy
for Monitoring Fibrosis?

A
  • Not FDA approved or standard of care
  • Serum indices
    • Forns fibrosis index, APRI, FIB-4
  • Serological markers
    • FibroTest, FibroSure, FibroSpect II
  • Liver stiffness measurement
    • Ultrasound elastography (FibroScan)
    • MRI elastography
24
Q

Describe the expected timeline for progression of HCV virus

A
25
Q

Elements of an Ideal HCV Regimen

A
  • ¨Simple schedule – shorter duration, easy stopping rules
  • ¨Easy dosing – once daily, low pill burden
  • ¨All-Oral – no interferon
  • ¨Highly effective – higher cure rates across patient groups
  • ¨Pan-genotypic – effective against GT1-6
  • ¨Low resistance – higher genetic barrier to resistance
  • ¨Safe and tolerable – few or easily managed side effects
  • ¨Affordable – accessible to all patients¨
26
Q

Targets for direct acting antivirals

A
  • Protease Inhibitors: NS3, NS4A
  • NS5A inhibitors
  • NS5B inhibitors: nucleoside and non-nucleoside analogs
27
Q

Recommended treatments in HCV

***exam

A
  • Dependent on several factors: genotype, past treatment, resistance, kidney function, cirrhosis
  • In the past: pegylated interferon + ribavirin: long tx duration, many side effects, and relatively low cure rates
  • NOW: DAAs with very high cure rates.
  1. Harvoni (Ledipasvir/Sofobuvir)
  2. Sovaldi (Sofobuvir)
  3. Olysio (simeprevir)
  4. Daklinza (daclatsvir)
  5. Technivie (PrO)
  6. Viekira Pak (PrOD)
28
Q

Resistance testing for HCV Tx: targets of resistance testing

A
29
Q

HCV treatment in ESRD

A

Previously no DAAs available, now if eligible, Zepatier (ELB/GZR)

if up for transplant, transplant first >> improved outcomes

30
Q

HCV: testing needed before tx

  • HIV testing within __
  • HCV Viral load within __
  • HCV Genotype within __
  • Chem 7, Liver profile, Albumin , PT/INR and CBC (__ days)
  • What imaging
A
  • HIV testing within one year
  • HCV Viral load within 6 months
  • HCV Genotype within 5 years
  • Chem 7, Liver profile, Albumin (not included in the liver profile), PT/INR and CBC (30-60 days)
  • Baseline abdominal ultrasound – including spleen size – not RUQ limited
  • ¨Fibroscan and Hep C Education
31
Q

Lab results that indicate under stage 3 HCV

A
  • Normal platelets, albumin, ALT > AST
  • Liver imaging:
  • may be fatty
  • no mention of lobular or nodular morphology
  • No splenomegaly
32
Q

Lab results that indicate above stage 3 HCV

A
    • PLts under 150
  • Albumin under 3.7
  • AST > ALT
  • Liver imaging demonstrates nodularity/lobular contour, enlarged caudate lobe and splenomegaly

Adult Adult (7 decks)

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