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Gastroenterology > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

How many Hepatitis C genotypes are there and which is most common in Canada? (PBSG)

A
  • 6 major genotypes
  • Genotype 1 >60% of cases in Canada
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2
Q

What is more infectious by blood, HCV or HIV? (PBSG)

A
  • HCV 10x more infectious than HIV
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3
Q

How is Hepatitis C most commonly transmitted? (PBSG)

A
  • Parenterally (IVDU)
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4
Q

In which years were blood transfusions a known risk factor for HCV? (PBSG)

A
  • Before 1992
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5
Q

What are 3 questions to ask patients with abnormal liver function tests?

A
  • New Prescription Drugs
  • Alcohol
  • Travel history
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6
Q

What are 6 risk factors for viral hepatitis B? (USPSTF)

A
  • Persons born in countries and regions with a high prevalence of HBV infection (≥2%)
    • Asia, Africa, Middle East, Eastern Europe
  • HIV positive
  • IVDU
  • Household contacts or sexual partners of persons with HBV infection
  • MSM
  • Persons receiving hemodialysis or cytotoxic or immunosuppressive therapy (e.g. chemotherapy for malignant diseases and immunosuppression related to organ transplantation and for rheumatologic and gastroenterologic disorders
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7
Q

What are 8 risk factors for viral hepatitis C? (USPSTF)

A
  • Blood-borne exposure and Transfusions and Organ Transplant (before 1992 in Canada)
  • High-risk sexual activity (e.g. sex with IVDU)
  • Incarceration/Imprisonment
  • IV drug use
  • Snorting cocaine with shared equipment
  • Tattoos or body piercing
  • Long-term hemodialysis
  • Being born to a mother with HCV infection
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8
Q

What are 8 symptoms of liver disease? (DFCM Open)

A
  • Fatigue (most characteristic symptom)
  • Pruritus
  • Nausea (more severe liver disease)
  • Poor appetite with weight loss (common in acute, rare in chronic disease)
  • Diarrhea (with severe jaundice)
  • Jaundice
  • Dark urine
  • Light stools (severe cholestasis)
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9
Q

What are 7 signs that can be seen with liver disease? (DFCM Open)

A
  • Icterus
  • Hepatomegaly
  • Hepatic tenderness
  • Splenomegaly
  • Spider angiomata
  • Palmar erythema
  • Excoriations
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10
Q

What are 13 signs associated with severe or advanced liver disease? (DFCM Open)

A
  • Muscle wasting
  • Ascites
  • Edema
  • Dilated abdominal veins
  • Hepatic fetor
  • Asterixis
  • Loss of male-pattern hair distribution
  • Enlarged Virchow’s (left supraclavicular) or Sister Mary Joseph’s (umbilical) nodes
  • JVD or Rt pleural effusion
  • Mental confusion
  • Stupor/coma
  • Gynecomastia
  • Testicular atrophy
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11
Q

Where are ALT and AST found in and which is more specific for hepatocellular damage? (AFP)

A
  • ALT primarily in the liver
  • AST also found in skeletal muscles and erythrocytes
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12
Q

Which blood tests are markers of liver damage? (TN)

A
  • AST
  • ALT
  • ALP
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13
Q

Which blood tests are markers of liver function? (TN)

A
  • PT or INR
  • Albumin
  • Bilirubin
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14
Q

Which clotting factors are not synthesized in the liver? (TN)

A
  • Factor VIII
  • VWF
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15
Q

Does liver dysfunction cause elevated direct (conjugated) or indirect (unconjugated) bilirubin? (TN)

A
  • Direct bilirubin
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16
Q

IF the ALP is elevated out of proportion to the ALT/AST elevation, what are 4 diagnoses to consider? (TN)

A
  • Obstruction of CBD
    • Extraluminal = pancreatic cancer, lymphoma
    • Intraluminal = stones, cholangiocarcinoma, sclerosing cholangitis, helminths
  • Destruction of microscopic ducts
    • PBC
  • Bile acid transporter defects
    • Drugs
    • Intrahepatic cholestasis of pregnancy
  • Infiltration of the liver
    • Liver metastases
    • Lymphoma
    • Granulomas
    • Amyloid
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17
Q

What are the 3 different abnormal Liver Lab patterns?

A
  • Pre-Hepatic
    • Elevated UNconjugated (indirect) bilirubin
    • AST & ALT normal
  • Hepatocellular – Increased AST and ALT
    • Alcohol = 2:1 AST:ALT (Shots, Shots, Shots)
    • Viral = 2:1 ALT:AST
    • Elevated CONjugated bilirubin
  • Biliary/Obstructive – Increase ALP and GGT
    • Elevated CONjugated bilirubin
    • ALP found in bone, liver and placenta
      • If elevated, check Anti-Mitochondrial Antibody and get Abdo U/S
      • Refer for surgery if obstruction found
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18
Q

What is the differential diagnosis for acute or chronic liver disease with either a hepatocellular or cholestatic pattern? (DFCM Open)

A

Hepatocellular

Cholestatic

Acute (<6 months)

  • Hepatitis A/B/C
  • Autoimmune hepatitis
  • Mononucleosis associated hepatitis
  • Wilson’s disease
  • EtOH/drug use
  • Primary Biliary Cirrhosis
  • Drug abuse
  • Gallstone
  • Biliary duct dilation
  • Fatty liver
  • Masses
  • Ampullary lesions
  • Primary sclerosing cholangitis

Chronic

  • Hepatitis B/C
  • Hemochromatosis
  • Wilson’s disease
  • Autoimmune hepatitis
  • Alcohol abuse
  • Drug abuse
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
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19
Q

What does jaundice without dark urine indicate and what are 3 possible diagnoses? (DFCM Open)

A
  • Unconjugated Hyperbilirubinemia
    • Hemolytic anemia
    • Genetic disorders
      • Gilbert’s syndrome
      • Crigler-Najjar syndrome
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20
Q

What does a normal and low albumin (measure of protein synthesis) indicate in the context of liver disease? (DFCM Open)

A
  • Low albumin = chronic process
    • Cirrhosis
    • Cancer
  • Normal albumin = acute process
    • Viral hepatitis
    • Choledocholithiasis
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21
Q

What does the INR (measure of protein synthesis) indicate in the context of liver disease? (DFCM Open)

A
  • Elevated INR = vitamin K deficiency due to prolonged jaundice and malabsorption or significant hepatocellular dysfunction
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22
Q

What does the failure to correct a prolonged INR with IV vitamin K indicate? (DFCM Open)

A
  • Severe hepatocellular injury
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23
Q

What is the differential diagnosis (10) for elevated liver enzymes?

A
  • Infectious
    • Hepatitis A, B or C (ALT>AST)
    • Liver abscess
  • Toxic
    • Tylenol, Statins, INH
    • Alcohol (AST>ALT)
  • Cirrhosis (AST>ALT)
  • Biliary obstruction
  • Nonalcoholic fatty liver disease or NASH
  • Autoimmune – Hepatitis or Primary Biliary Cirrhosis
  • Metabolic
    • Hemochromatosis
    • Wilson’s
  • Right-sided CHF
  • Neoplastic – Hepatocellular or Metastatic
  • Extra-Hepatic – Heart or Skeletal Muscle injury
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24
Q

What is the differential diagnosis (5) for when the AST or ALT is > 500 to 1000?

A
  • Tylenol overdose or other toxin ingestion
  • Viral Hepatitis – particularly Hepatitis A
  • Liver shock or Hepatic ischemia
  • Budd-Chiari syndrome
  • Right-sided CHF
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25
Q

How does alcoholic hepatitis typically present? (TN)

A
  • History of recent alcohol
  • RUQ abdominal pain
  • AST:ALT >2
    • AST usually <300
  • Low grade fever
  • Mildly elevated WBC
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26
Q

In an asymptomatic patient with elevated LFTs, what would be your approach?

A
  • I wouldn’t wait 6 months, probably 1 month
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27
Q

In an asymptomatic patient with an elevated ALP, what would be your approach?

A
  • Antimitochondrial Ab positive in Primary Biliary Cirrhosis
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28
Q

If an elevated ALT returns to the normal range on repeat testing, what still needs to be screened for? (AFP)

A
  • Hepatitis C
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29
Q

What is the most common cause of mild elevations of LFTs? (AFP)

A
  • Nonalcoholic fatty liver disease
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30
Q

What % of the population is affected by NAFLD? (AFP)

A
  • 30%
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31
Q

Combined, what % of mildly elevated liver transaminase levels were hepatitis B, hepatitis C and hemochromatosis in NHANES? (AFP)

A
  • 31%
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32
Q

What AST:ALT ratio is usually found in NAFLD? (AFP)

A
  • 1:1
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33
Q

What could an AST:ALT ratio >4 suggest? (AFP)

A
  • Wilson’s disease
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34
Q

In addition to an AST:ALT ratio >2, what other blood test supports a diagnosis of alcoholic liver disease in this setting? (AFP)

A
  • Elevated GGT
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35
Q

What % of the population has NASH? (AFP)

A
  • 3-6%
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36
Q

What % of healthy nondrinkers can have elevated liver transaminase levels after dosages of 4g per day of acetaminophen for 5-10 days? (AFP)

A
  • 58%
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37
Q

What % of elevated transaminase levels spontaneously resolve in persons taking statins? (AFP)

A
  • 70%
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38
Q

In which persons is autoimmune hepatitis more common? (AFP)

A
  • Women
  • History of thyroid disease or other autoimmune conditions
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39
Q

What tests can be done to diagnose autoimmune hepatitis? (AFP)

A
  • SPEP
  • ANA
  • Smooth muscle antibody
  • Liver/kidney microsomal antibody type 1 testing
40
Q

What are the key clinical clues that may suggest Wilson disease? (AFP)

A
  • Kayser-Fleischer rings (copper deposition around the cornea)
  • Neuropsychiatric symptoms
41
Q

What is Wilson disease, how is it inherited and how common is it? (AFP)

A
  • Autosomal recessive genetic disease related to ineffective copper metabolism
  • 1 in 30,000 persons
  • More common in Eastern Europeans
42
Q

When does Wilson disease generally present? (AFP)

A
  • Before 40 years of age
43
Q

What test can be done for Wilson disease? (AFP)

A
  • Serum ceruloplasmin
44
Q

What is the difference between NAFLD and NASH? (AFP)

A
  • NAFLD = hepatic steatosis (excessive fat accumulation in the liver)
  • NASH = steatohepatitis (steatosis, liver cell injury and inflammation)
45
Q

How can NAFLD and NASH be differentiated? (AFP)

A
  • Liver biopsy and histology
46
Q

What is NAFLD strongly associated with? (AFP)

A
  • Physical inactivity
  • Obesity
  • Metabolic syndrome (3+)
    • BP ≥130 SBP or ≥80 DBP or on antihypertensive therapy
    • Triglycerides ≥ 1.7 mmol/L or pharmacotherapy
    • HDL < 1.29 mmol/L in women or < 1.04 mmol/L in men
    • Waist circumference ≥ 35” in women or ≥ 40” in men
    • Glucose intolerance ≥ 5.6 mmol/L
47
Q

What is 1st line management for the treatment of NAFLD? (AFP)

A
  • Reduce insulin resistance
    • Healthy diet
    • Weight loss
    • Exercise
  • Hepatitis A and B vaccination
  • Limit alcohol use
48
Q

What should be treated, if present, in patients with NAFLD? (AFP)

A
  • Diabetes
  • Hyperlipidemia
  • Hypertension
  • OSA
49
Q

Are statins contraindicated in NAFLD? (AFP)

A
  • No – risk of hepatotoxicity is not increased compared to the general population
50
Q

What antihypertensive should be 1st line in patients with NAFLD? (AFP)

A
  • ARBs
51
Q

What medication has been shown to be effective for weight loss and to improve liver tests in NAFLD? (AFP)

A
  • Orlistat (Xenical)
    • Effective for short-term weight loss
    • Improves AST, ALT and liver histology
52
Q

What is the sensitivity and specificity of HBsAg for detecting HBV? (USPSTF)

A
  • >98%
53
Q

What serology findings would you expect for Hepatitis B in acute infection, chronic infection, chronic carrier, recovery and when immunized?

A

Serology

sAg

Anti-sAg

eAg

Anti-eAg

Anti-cAg

Acute

+

+

IgM

Chronic (infectious)

+

+

IgG

Chronic (carrier)

+

+

IgG

Resolved infection

+

+

IgG

Immunized

+

  • sAg present when virus present –infectious
  • Anti-sAg antibody present when clear infection or immunized
  • IgM-cAb present during window period, eventually becoming IgG-cAb
  • eAg a marker of high viral replication – very infectious
  • IgG-eAb present only if exposed to virus (vaccine is recombinant sAg)
54
Q

What is necessary for the diagnosis of chronic HBV infection? (USPSTF)

A
  • Persistence of HBsAg for at least 6 months
55
Q

In acute HBV infection, what is the appearance of HBsAg followed by? (USPSTF)

A
  • IgM anti-HBc
56
Q

What is found in serology when HBV infection resolves and a patient has natural immunity? (USPSTF)

A
  • Disappearance of HBsAg
  • Anti-HBs and Anti-HBc
57
Q

How long after exposure can HCV be detected? (PBSG)

A
  • 6-8 weeks (anti-HCV)
58
Q

What does a positive HCV antibody result but negative HCV RNA result indicate and what should be done? (PBSG)

A
  • Usually indicates a past HCV infection that has cleared (i.e. immune)
  • Repeat HCV RNA in 6 months
  • No further management if positive HCV antibody test and repeatedly negative HCV RNA
59
Q

In patients with Hepatitis B, what and when would you consider screening them with?

A
  • Screen with Ultrasound q6months to 1year for Cirrhosis or Cancer
    • Females >50
    • High-risk
      • Males >40
      • Africans >20
      • HBV DNA > 105
60
Q

What % of patients with chronic HBV infections die of cirrhosis or HCC? (USPSTF)

A
  • 15-25%
61
Q

When do patients with Hepatitis B require treatment?

A
  • HBV DNA >20,000 or >2,000 with early fibrosis
62
Q

What should patients with Hepatitis B be tested for?

A
  • HIV
63
Q

What should patients with Hepatitis B be vaccinated for?

A
  • Hepatitis A
64
Q

What is the post-exposure prophylaxis regimen after possible exposure to Hepatitis B?

A
  • If needed, begin treatment within 24h and seek consultation

Vaccination Status

Source HBsAg Positive

Source Unknown

Source HBsAg Negative

Unvaccinated

HBIG

HBV Vaccination

HBV Vaccination

HBV Vaccination

Previously Vaccinated

Good Titers

No Treatment

No Treatment

No Treatment

Poor Titers

HBIG

HBV Vaccination

If high risk individual, treat as HBsAg Positive

No Treatment

Consider re-vaccination

Unknown Titers

Test Anti-HBsAg titers

  • If Poor, treat as such
  • If Good, no treatment

Test Anti-HBsAg titers

  • If Poor, treat as such
  • If Good, no treatment

No Treatment

65
Q

If a patient tests positive for Anti-HCV, what should they best tested for?

A
  • HCV RNA
66
Q

If a patient tests negative for Anti-HCV but may have been exposed to HCV within the previous 6 months, what should be done? (AFP)

A
  • HCV RNA every 4 to 8 weeks for at least 6 months OR repeat Anti-HCV 12 weeks later
67
Q

If a patient tests positive for Anti-HCV but are negative for HCV RNA, what should be done?

A
  • Repeat HCV RNA in 6 months
68
Q

What is the infectiousness of Hepatitis C based on?

A
  • HCV-RNA levels
69
Q

What % of Hepatitis C becomes chronic and what % of these patients develop cirrhosis? (AFP)

A
  • 80% of Hepatitis C becomes Chronic
    • 20% of Chronic Hepatitis C develop Cirrhosis
      • 75% will die (cirrhosis or HCC)
70
Q

What does the USPSTF recommend in regards to screening for Hepatitis C? (USPSTF)

A
  • Recommend screening in high risk individuals (Grade B)
    • Past or present IVDU
    • Sex with an IVDU
    • Blood transfusion before 1992
    • Long-term hemodialysis
    • Being born to a mother with HCV
    • Incarceration
    • Intranasal drug use (e.g. cocaine)
    • Getting an unregulated tattoo
    • Other percutaneous exposure (e.g. healthcare workers)
  • Recommend 1-time screening in adults born between 1945-1965 (Grade B)
    • Due to increased risk factors and high likelihood of contaminated blood transfusions
71
Q

According to the USPSTF, what is the sensitivity and NNS for HCV screening? (USPSTF/AFP)

A
  • Sensitivity >90% (95% sensitivity, 99% specificity in AFP)
  • NNS = <20
72
Q

What factor determines the severity of Hepatitis C?

A
  • Severity depends on Genotype
  • Can have cirrhosis and normal transaminases
73
Q

In patients testing positive for Hepatitis C, what should they be tested for?

A
  • HIV
74
Q

What should patients with Hepatitis B and C be educated about?

A
  • Warn about transmission both sexually or with IVDU
  • No blood donation
  • Do NOT breastfeed with cracked nipples
  • No shared razors
  • Decreased Alcohol intake (<2 drinks/week)
  • Vaccination – Hepatitis A/B and Annual Influenzae vaccine
75
Q

What is the post-exposure prophylaxis regimen after possible exposure to Hepatitis C?

A
  • There is NO effective PEP
  • If seroconvert, then begin Interferon
  • Must counsel, test and follow-up
76
Q

What screening test should be considered in patients with Hepatitis C?

A
  • Screening U/S q6months – 1year for cirrhosis or cancer
77
Q

Is pregnancy contraindicated in patients with HCV and what is the risk of vertical transmission? (PBSG)

A
  • NOT contraindicated
  • 4-7% risk of vertical transmission if HCV-RNA positive mother
78
Q

What treatment for HCV is available in Canada for the Genotype 1 and can potentially cure HCV?

A
  • Harvoni (Ledipasvir + Sofosbuvir) for 12 weeks (Cost $93,000)
79
Q

What score is used to grade cirrhosis? (DFCM Open)

A
  • Modified Child-Turcotte-Pugh (CTP) score
    • Estimates the likelihood of survival and complications of cirrhosis
    • Used to determine candidacy for liver transplant
80
Q

How does liver dysfunction progress based on LFTs in cirrhosis? (TN)

A
  • “W” = decrease Platelets à increase INR à decrease Albumin à increase Bilirubin
81
Q

What is the most common inherited disorder among Caucasian populations and what is the prevalence? (TOP)

A
  • Hemochromatosis
  • Prevalence between 1 in 200 to 1 in 400 in western countries (north European descent)
82
Q

What genetic mutation causes hemochromatosis and how? (TOP)

A
  • HFE gene mutation on chromosome 6
    • Three common alleles: normal, C282Y, H63D
  • Controls the rate of absorption of iron from the small bowel
83
Q

How is hemochromatosis inherited? (TOP)

A
  • Autosomal recessive
84
Q

Which type of HFE gene mutation in hemochromatosis is the most severe? (TOP)

A
  • C282Y >>> H63D
85
Q

What is hemochromatosis a disorder of? (TOP)

A
  • Excessive iron stores
86
Q

What are 4 factors that can affect the development of iron stores in hemochromatosis? (TOP)

A
  • Menses and Childbearing in women
  • Vegetarians
  • Iron supplements in multivitamins
  • Blood donations
87
Q

At what age do the clinical manifestations of hereditary hemochromatosis present? (TOP)

A
  • 30 to 50 years of age
88
Q

What are 8 potential early clinical signs of hereditary hemochromatosis? (TOP)

A
  • Elevated LFTs
  • Recurrent RUQ pain and hepatomegaly
  • Arthropathy (occasionally acute episodes of inflammatory arthritis)
  • Impotence
  • Amenorrhea
  • Irritability
  • Depression
  • Fatigue
89
Q

What are 7 organs that can be damaged by hemochromatosis? (TOP)

A
  • Liver – Cirrhosis and the potential for Hepatocellular Carcinoma if cirrhosis diagnosed
  • Heart – CHF
  • Pancreas – Diabetes (loss of Islet cells)
  • Joints – arthritis
  • Skin – abnormal pigmentation (bronze or grey)
  • Pituitary – hypothyroidism, hypogonadism
  • Testis – impotence
90
Q

How should hemochromatosis be screened? (TOP)

A
  • % transferrin saturation + serum ferritin (FASTING)
  • Iron saturation > 45% + elevated ferritin (>300 ng/mL in men and >200 ng/mL in women)
  • Elevated ferritin BY ITSELF is not diagnostic of hemochromatosis as it is an acute phase reactant
91
Q

Below what ferritin level is significant end-organ damage unlikely? (TOP)

A
  • <1000 ng/mL
92
Q

Can hemochromatosis cause polycythemia? (TOP)

A
  • No
93
Q

Which patients require genetic testing for hemochromatosis? (TOP)

A
  • 1st degree relatives of individuals with definitely diagnosed HFE hemochromatosis
  • Those with persistently elevated transferrin saturation level at or above levels suspicion, particularly in the presence of elevated ferritin
94
Q

What is a risk of genetic testing for HFE hemochromatosis? (TOP)

A
  • Risks of discrimination in regards to insurance
95
Q

What are the target levels for ferritin and hemoglobin in patients with HFE hemochromatosis? (TOP)

A
  • End-organ damage
    • Ferritin 50-100 ng/mL
    • Hemoglobin >110 g/L
  • No end-organ damage
    • Ferritin <300 ng/mL in males and <200 ng/mL in females
    • Hemoglobin >110 g/L
96
Q

What are 3 lifestyle recommendations for patients with hemochromatosis? (TOP)

A
  • Regular blood donations at Canadian Blood Services
  • Reduce exogenous iron (supplements)
  • Reduce alcohol intake

Gastroenterology (1 decks)

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