Hepatitis

Question 1

What is the epidemiology of hepatitis A?

Answer 1

Picorna
Most common type 
Autumn, affects children and young adults 
Faeco-oral route
Contaminated food or water (shellfish)
Overcrowding and poor sanitation facilitate spread
No carrier state
In UK it's a notifiable disease

Question 2

What are the clinical features of hep A?

Answer 2

Nausea and anorexia
After 1-2 weeks jaundice
liver and spleen enlarged
Lymphadenopathy sometimes
Extrahepatic complications (arthritis, vasculitis, myocarditis, renal failure)

Question 3

What are the investigations for hep A?

Answer 3

Raised AST or ALT precede jaundice (remain raised even after)
Leucopenia with relative lymphocytosis
Rarely- combo’s positive haemolytic anaemia or aplastic anaemia
PT prolonged in severe
ESR is raised
Anti-HAV IgM

Question 4

What is the course and prognosis for hep A?

Answer 4

Excellent prognosis
Cholestatic viral hepatitis if prolonged jaundice
Post hepatic syndrome
Never progresses to chronic liver disease

Question 5

When are people immunised for hep A?

Answer 5

Those travelling frequently to endemic areas
Patients with chronic liver disease
Patients with haemophilia 
Community outbreaks
IV drug users
HIV patients
Men who have sex with men 
Passive immunisation gives protection for 3-4 months

Question 6

What is the epidemiology of hep B?

Answer 6

Hepadna
Carrier state
Spread by IV, close personal contact, sex (esp homosexual)
Found in semen and saliva
Vertical transmission from mother to child

Question 7

What are the clinical features of hep B?

Answer 7

Similar to Hep A but more severe
Immunological syndrome may be seen- rashes (urticaria/maculopapular) and polyarthritis
Fever
Extrahepatic occasionally- arteritis or glomerulonephritis

Question 8

What are specific tests for hep B?

Answer 8

HBsAG is looked for initially
HBsAG cleared rapidly in acute infection
Anti-HBs-IgM is dianostic
HBV DNA is the most sensitive index of viral replication, found without e antigen due to mutants

Question 9

What is the time course of the serological changes seen when infected with hep B (acute infection)?

Answer 9

HBsAG- 6 weeks-3 months after acute infection then disappears
HBeAG- rises early and declines rapidly
Anti-HBs- appears late and indicates immunity
Anti-HBc- first antibody to appear, persists for many months
Anti-HBe- appears after Anti-HBc, decreased infectivity

Question 10

What is the time course of the serological changes seen when infected with hep B (acute infection leading to chronic hep B)?

Answer 10

HBsAG- persists and indicates a chronic infection (or carrier state)
HBeAG- increased severity and infectivity and development of chronic liver disease. Ag disappears and rise in ALT
HBV DNA- continual viral replication

Question 11

What is the course of hep B?

Answer 11

Majority of patients recover
Some develop chronic hepatitis to hepatocellular carcinoma
Some become asymptomatic carriers

Question 12

Which groups are vaccinated for hep B in the UK?

Answer 12

All healthcare personnel
members of emergency and rescue teams
Children born in the UK at 2, 3 and 4 months of age
Morticians and embalmers
Children in high risk areas
people with haemophilia
Patients in some psychiatric units
Patients with chronic renal failure/on dialysis units
Long-term travellers
Homosexual, bisexual and prostitute (men)
IV drug users

Question 13

Who should be given combine prophylaxis (vaccination and immunoglobulin) for hep B?

Answer 13

Staff with accidental needle stick injury
All newborn babies with of HBsAg positive mothers
Regular sexual partners of HBsAg- positive patients who have found to be HBV negative

Question 14

What are the characteristics of carriers of hep B?

Answer 14

Carriers of HBsAg
Occurs more readily with neonatal or childhood infection
Asymptomatic carriers are HBe-Ag negative, HBe antibody positive with no HBV DNA- no acute liver disease, not highly infective
Some carriers have the e antigen and HBV DNA in their serum- liver disease develops when the immune balance changes and lymphocytes recognise infected hepatocytes causing hepatitis

Question 15

What are the characteristics of hep D?

Answer 15

Incomplete RNA particle enclosed in a shell of HBsAg
Activated by presence of Hep B
Seen particularly in IV drug users, can affect all risk groups of Hep B
Coinfection or superinfection
Fulminant hepatitis is more common with coinfection

Question 16

What is the epidemiology of Hep C?

Answer 16

Flavi 
Transmitted by blood and blood products
High rate in patients with haemophilia
Low sexual transmission
Rare vertical transmission

Question 17

What are the clinic features of Hep C?

Answer 17

Most acute infections are asymptomatic- mild flu, jaundice, rise in aminotransferases
Most won’t be diagnosed until years later when they present with chronic liver disease or abnormal transferase values
Extrahepatic- arthritis, glomerulonephritis, porphyria cutanea tarda

Question 18

How is hep C diagnosed?

Answer 18

Exclusion in a high risk individual with negative markers for HAV, HBV
Drug cause should be excluded
HCV RNA can be detected 1 or 2 weeks after
Anti-HCV is usually positive 6 weeks from infection

Question 19

What is the course of Hep C?

Answer 19

85% go on to develop chronic liver disease
Cirrhosis and hepatocellular carcinoma can develop
Alcohol consumption should be discouraged

Question 20

What are the characteristics of hep E?

Answer 20

Calici
Clinically very similar to hep A
Mortality rate 1-2% fulminant hepatic failure and 20% in pregnancy
No carrier state
Does not progress to chronic liver disease
Faecal-oral route