Hepatitis Flashcards
Definition of viral hepatitis
- 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
Types of hepatitis
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ABCDE
Hepatitis A: source, transmission, potential for chronic infection, prevention
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- Source: feces
- Transmission: fecal-oral
- Chronic infxn: no
- Prevention: pre/post exposure IZ, handwashing
Hepatitis B: source, transmission, potential for chronic infection, prevention
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- Source: blood/blood derived body fluids
- Transmission: percutaneous per mucosal
- Chronic: yes (6-10%)
- Prevention: pre/post exposure IZ, behavior
Hepatitis C: source, transmission, potential for chronic infection, prevention
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- Source: blood/blood derived body fluids
- Transmission: percutaneous per mucosal
- Chronic: yes (85%)
- Prevention: blood donor screening, risk behavior modification
Hepatitis D: source, transmission, potential for chronic infection, prevention
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- 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
Hepatitis E: source, transmission, potential for chronic infection, prevention
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- Source: feces
- Transmission: fecal-oral
- Chronic infxn: no
- Prevention: ensure safe drinking water
Clinical course of acute viral hepatitis
not always progress to icteric (jaundice)
pruritis(itchy): if viral infxn then intense itching, consider
Acute Viral Hepatitis:
- Prodrome: Malaise (dec apeptite), anorexia, nausea, low grade fever, right upper quad pain, headache = 2-10 days
- 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
Expected PE findings in acute viral hepatitis
- Jaundice (±)
- Hepatomegaly
- Right upper quadrant tenderness
- Splenomegaly (20%)
- No lymphadenopathy
Expected lab findings in acute viral hepatitis
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- Increased aminotransferases
- Variable bilirubin levels
- Alkaline phosphatase normal or only mildly elevated
- Albumin and globulins normal
- Leukopenia
- Prothrombin time usually normal
Labs: best markers of severity of acute hepatitis?
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- NOT aminotransferases (ALT/AST) - these are not liver function tests, they are markers of cell necrosis
- Best marker of severity: PT/INR
- biopsy unnecessary
What is fulminant hepatitis and how is it diagnosed?
- 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
Definition chronic viral hepatitis: labs, symptoms
- 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)
How is chronic hepatitis classified?
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
Fibrosis Progression in Chronic Hepatitis - what do you tell patients for education? what are the stages
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
CDC Updated
HCV Testing Guidelines
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- 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.
Groups Recommended for HCV Testing by AASLD and USPHS
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- 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
Should acute HCV be treated?
Only if HCV RNA detectable 2-3 mo after onset of infection
How can HCV infection be prevented?
- 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
How is HCV diagnosed?
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HCV Ab+ then confirmed via HCV RNA (if viral load not detected, + Ab represents past infection)
Once HCV infection confirmed, what are initial mgmt steps?
- 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
How is a liver biopsy evaluated?
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
What are some Noninvasive Alternatives to Biopsy
for Monitoring Fibrosis?
- 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
Describe the expected timeline for progression of HCV virus
