Hepatitis

Question 1

DDx for hepatitis

Answer 1

Infectious:

• Viral: Hep A-E viruses, EBV, CMV, adenovirus
• Bacterial: Coxiella Burnetii (Q fever), Treponema pallidum (Syphllis)

Autoimmune hepatitis

Drugs - Alcoholic hepatitis, drug-induced e.g. paracetamol OD

Metabolic
NASH, Wilson’s disease, alpha-1 anti-trypsin deficiency , haemochromatosis

Malignancy
Primary HCC or secondary metastatic disease

Question 2

Risk factors on history

Answer 2

Sexual history 
Travel history 
Drugs history - IVDU, needlestick contact / exposure 
Family history of hepatobiliary disease 
Medications history

Question 3

Name a few peripheral stigmata of (chronic) liver disease

Answer 3

Pruritic scratch marks 
Ecchymosis 
Spider naevi 
Sclera icterus / jaundice 
Altered mental state / Wernicky-Korsakoff Syndrome 
Asterixis / Hepatic flap 
Gynaecomastia 
Hepatosplenomegaly 
Ascites 
Caput medusae

Question 4

Features of fulminant hepatitis (3)

Answer 4

Altered mental state
Ecchymosis
Asterixis

Question 5

Investigations to rule in viral hepatitis

Name a few ancillary tests as well :)

Answer 5

LFTs - AST:ALT <1 = viral, AST, ALT 10x normal = viral
PCR + Serology- Hep A-E antibodies (IgM - acute)

Bedside: urine toxicology screen
Bloods: FBC, EUCs, coags, ceruloplasmin
Imaging: abdominal ultrasound

Question 6

What is the clinical progression of (viral) hepatitis

Answer 6

1. Inoculation: direct contact or through intestinal transmission
2. Incubation: asymptomatic
3. Pre-icteric: non-specific symptoms
4. Icteric: jaundice, potentially hepatomegaly on examination, dark urine, pale stool (3-10days)
5. Recovery: jaundice is subsiding (2-4 weeks)

Question 7

Identify features of Hep A - Hep E that differentiate them + concerns over time to address

Answer 7

Mode of transmission: Hep A and E are fecal-oral; others are through sexual transmission

Prevention: Hep A and Hep B have vaccinations

Probability to chronicity: Hep B, C ; Hep E is concerning for pregnant women

Question 8

Interpret:

HBsAg (-), Total anti-HBc (-), anti-HBs (-)

Answer 8

Susceptible

Question 9

Interpret: HBsAg (-), Total anti-HBc (+), anti-HBs (+)

Answer 9

Immunity due to natural infection/ exposure

Question 10

Interpret: HBsAg (-), Total anti-HBc (-), anti-HBs (+)

Answer 10

Immunity due to vaccination

Question 11

Interpret: HBsAg (+), Total anti-HBc (+), IgM anti-HBc (+), anti-HBs (neg)

Answer 11

Acute infection

Question 12

Interpret: HBsAg (+), Total anti-HBc (+), IgM anti-HBc (+), anti-HBs (-)

Answer 12

Chronic infection

Question 13

Interpret: HBsAg (-), Total anti-HBc (+), anti-HBs (-)

Answer 13

A couple possibilities;

• False positive
• Recovering from an acute infection
• Distant immunity with slow mounting immune response
• Chronic HBV infection

Question 14

Management

Answer 14

Prevention is possible! - patient education (vaccines for HAV and HBV)

Supportive management
Anti-virals
Liver transplant if fulminant hepatitis :O zomg!