Hepatitis Flashcards
What is hepatitis?
Causes
Hepatitis describes inflammation in the liver.
Causes
- Alcoholic hepatitis
- Non alcoholic fatty liver disease
- Viral hepatitis
- Autoimmune hepatitis
- Drug induced hepatitis (e.g. paracetamol overdose)
Clinical features of hepatitis
Hepatitis may be asymptomatic or could present with non-specific symptoms:
Abdominal pain Fatigue Pruritis (itching) Muscle and joint aches Nausea and vomiting Jaundice Fever (viral hepatitis)
What are biochemical findings that demonstrate a “hepatitic picture”?
high transaminases (AST / ALT) with proportionally less of a rise in ALP
Bilirubin can also rise as a result of inflammation of the liver cells. High bilirubin causes jaundice.
Hepatitis A
Type of virus?
Transmission
Clinical features
Hepatitis A is the most common viral hepatitis
It is an RNA virus
It is transmitted via the faecal-oral route usually by contaminated water or food.
Clinical Features
- nausea, vomiting, anorexia and jaundice
- cholestasis (slowing of bile flow through the biliary system) with dark urine and pale stools
- moderate hepatomegaly.
Management
- resolves without treatment in around 1-3 months.
- basic analgesia
- Vaccination is available to reduce the chance of developing the infection
It is a notifiable disease and Public Health need to be notified of all cases.
Hepatitis B
Type of virus?
Transmission
Hepatitis B is a DNA virus
TRANSMISSION via direct contact with blood or bodily fluids:
- during sexual intercourse or sharing needles (i.e. IV drug users or tattoos)
- sharing contaminated household products such as toothbrushes or contact between minor cuts or abrasions
- vertical transmission
Hepatitis B
Progression
Management
PROGRESSION
- 90% are acute infections resolving within months
- 10% go on to become chronic hepatitis B carriers: In these patients the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins
MANAGEMENT
- Conservative:
+ Screen for other blood born viruses (hepatitis A and C and HIV) and other sexually transmitted diseases
+ Notify Public Health (it is a notifiable disease)
+ Stop smoking and alcohol
+ Education about reducing transmission and informing potential at risk contacts
+ Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
- Medical: Refer to gastroenterology, hepatology or infectious diseases for specialist management
+ Antiviral medication can be used to slow the progression of the disease and reduce infectivity (pegylated interferon) - Surgical:
+ Liver transplantation for end-stage liver disease
Hepatitis B viral markers
HBsAg
HBeAg
HBcAB
HBsAB
HBV DNA
IgM and IgG
Surface antigen (HBsAg) – active infection
E antigen (HBeAg) – marker of viral replication and implies high infectivity
Core antibodies (HBcAb) – implies past or current infection [Caught from infection]
Surface antibody (HBsAb) – implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
Antibodies:
- IgM implies an active infection and will give a high titre with an acute infection and a low titre with a chronic infection
- IgG indicates a past infection where the HBsAg is negative.
Hepatitis C
Type of virus
Transmission
Hepatitis C is an RNA virus
It is spread by blood and body fluids (but not vertical transmission)
No vaccine is available. It is now curable with direct acting antiviral medications.
Hepatitis C
MANAGEMENT
Have a low threshold for screening patients that are at risk of hepatitis C
CONSERVATIVE
- Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases
- Notify Public Health (it is a notifiable disease)
- Stop smoking and alcohol
- Education about reducing transmission and informing potential at risk contacts
- Testing for complications: FibroScan for cirrhosis and ultrasound for hepatocellular carcinoma
MEDICAL
- Refer to gastroenterology, hepatology or infectious diseases for specialist management
- Antiviral treatment with direct acting antivirals (DAAs) is tailored to the specific viral genotype (e.g. ribavarin). They successfully cure the infection in over 90% of patients. They are typically taken for 8 to 12 weeks
SURGICAL
- Liver transplantation for end-stage liver disease
Hepatitis D
Virus type
Transmission
Complications
Management
Hepatitis D is an RNA virus
It can only survive in patients who also have a hepatitis B infection. It attaches itself to the HBsAg to survive and cannot survive without this protein.
Hepatitis D increases the complications and disease severity of hepatitis B.
There is no specific treatment for hepatitis D. It is a notifiable disease and Public Health need to be notified of all cases.
Hepatitis E
Virus Type
Transmitted
Prognosis
Hepatitis E is a RNA virus
It is transmitted by the faecal oral route.
Normally it produces only a mild illness, the virus is cleared within a month and no treatment is required.
Rarely it can progress to chronic hepatitis and liver failure, more so in patients that are immunocompromised.
There is no vaccination. It is a notifiable disease and Public Health need to be notified of all cases.
Autoimmune Hepatitis
Types
Type 1: occurs in adults + affects women in their late forties or fifties. It presents around or after the menopause with fatigue and features of liver disease on examination
Type 2: occurs in children: patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
Autoimmune Hepatitis Investigations
Diagnosis confirmation
Bloods will show raised transaminases (ALT and AST), IgG levels and it is associated with many autoantibodies.
- Type 1 Autoantibodies:
Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)
Anti-soluble liver antigen (anti-SLA/LP) - Type 2 Autoantibodies:
Anti-liver kidney microsomes-1 (anti-LKM1)
Anti-liver cytosol antigen type 1 (anti-LC1)
Diagnosis can be confirmed using a liver biopsy.
Autoimmune Hepatitis
Management
Treatment is with high dose steroids (prednisolone) that are tapered over time as other immunosuppressants, particularly azathioprine, are introduced.
Liver transplant may be required in end stage liver disease, however the autoimmune hepatitis can recur in transplanted livers.
Hepatitis Associations
Hepatocellular Carcinoma
Chronicity
Cryglobulinaemia (can present as painful multifocal polyneuropathy / mononeuritis multiplex)
