Hepatitis Flashcards
Which types of Hep can be come chronic?
B, C, D
Hepatitis that is only acute
A and E
Fulminant Hepatitis means…
Acute Liver failure in the setting of Hepatitis
Encephalopathy, Coagulopathy, Hepatomegaly, Jaundice, edema, ascites, asterixis, hyperreflexia
AST and ALT values of Acute and Chronic Hep
Acute: >500
Chronic: <500
What can cause Fulminant Hepatitis? (Acute liver failure)
Acetaminophen toxicity (tylenol)
Viral hep
Reye syndrome- kids given ASA after viral infection
Reye syndrome
when you give ASA to a child after viral infection
Tx of Fulminant Hepatitis
IVF
Mannitol (if ICP elevation)
Blood products of platelets
Definitive: liver transplant
Hep A- acute always
Fecal-oral, International travel
May be A-sx, or SPIKING FEVER
Tx: none, self limiting
Prevent: Sanitation and handwashing
If you’ve been exposed: HAV vaccine. If you are immunocomp or have chronic liver dz, get HAV and HAV immunoglobulin
Hep E is always acute, but what is the worry?
Highest mortality due to Fulminant Hep during pregnancy
(esp during 3rd trimester)
Transmission: mother to child, fecal-oral, blood transfusion
What does Hep D need in order to be present?
Hep B!
Hep D details
Transmission: blood
Tx: none FDA approved, but can try Interferon alpha if chronic, and Liver transplant as definitive
Prevention: get the Hep B vaccine!
Hep C is known for
becoming CHRONIC "C for Chronic" Most common infectious cause of: -Chronic liver dz -Cirrhosis -Liver transplant
Transmission of Hep C is usually
IVDU
or needlestick injury
How long does it take for Hep C antibodies to become positive?
within 6 weeks
Is Hep C curable?
thankfully, YES
> 95% cure rate within 12 weeks of oral therapy
The type of Hep with all the crazy antibodies
Hep B
Tx for Hep B
Supportive is mainstay, most pts will not advance to Chronic
Tx for Chronic hep B
If pt has persistent or severe sx, marked jaundice, etc
Antiviral therapy: Entecavir, Tenofovir
Hep B vaccine
Infant: birth, 2 mo, 6-18 mo (3 doses)
Adult if not previously vaccinated: 0, 1, and 6 mo (3 doses)
How many doses of Hep B vaccine do you normally get?
3 doses
Contra to Hep B vaccine
Baker’s yeast
Remember the order of antibody initiation
“My Grandma…..”
M, then G
Hep B antibodies
if IgM= acute
if IgG= chronic
If the surface antigen is present,
either have positive Acute or Chronic Hep
3 step approach to interpreting Heb B antibodies:
Surface antigen
Core ANTIBODY
Surface ANTIBODY
1) look at Surface antigen- if it’s positive, then you have Hep B
2) look at Core antibody- if its IgM: acute. if it’s IgG: chronic.
3) if Surface antigen is negative- then you either have resolved infection OR immunity from vaccination. the anti-hBs will be positive.
If you have negative HBsAg (meaning no active infection) but positive anti-HBs, how can you tell if the immunity is from a Vaccination or past Infection that’s healed?
look at the core igG antibody (the 2nd one to come into play)
if IgG is positive: recovery from past infection
if IgG is negative and surface anti-HBs was the only thing positive: Vaccination was given
Steps of antibodies to look at with Hep B
Surface ANTIGEN (HBsAg) Core antiBODY (anti-HBc) Surface antiBODY (anti-HBs)
If liver CA is due to hepatitis, what types is it going to be from?
Hep B or Hep C
Tx of Liver CA
Surgical resection if confined to a lobe and not assoc w/ Cirrhosis
Most common cause of Portal HTN in children
Hepatic Vein Obstruction (Budd-Chiari syndrome)
primary: liver vein clot
secondary: liver vein or inferior vena cava occlusion
Cirrhosis
Irreversible fibrosis
Most common cause: Hep C!! and then Alcohol
PE sign of Hepatic Encephalopathy
Confusion and Lethargy (inc ammonia levels in the brain)
Asterixis- flapping wrist tremor
Tx of Liver Cirrhosis
Avoid alc and Hepatotoxic meds, weight reduction
Hep A and Hep B vaccine
Liver transplant- definitive
Tx of Encephalopathy
Lactulose or Rifamixin
Tx of Ascites
Spironolactone
Furosemide (lasix)
Tx of Pruritis associated with Cirrhosis
Cholestyramine- a bile acid sequestrant, reduces bile salts in the skin, leading to less irritation from the bile salts
If you have Liver cirrhosis, what screening do you need to have?
LIVER CA surveillance-
UltraSound every 6 months
Why can Cirrhosis cause itching of the skin?
Bile salts in the skin
tx: cholestyramine
Spontaneous Bacterial Peritonitis
a serious complication of Liver Cirrhosis
Infection of the Ascitic fluid E.Coli PE: Shifting dullness, Fluid wave Dx: Paracentesis Tx: Cefotaxime or Ceftriaxone (Rocephin)
Proph: need lifelong Bactrim
Shifting dullness, Fluid wave
Tx: Ceftriaxone
Proph: Bactrim
what is this condition
Spontaneous Bacterial Peritonitis
(a complication of Liver Cirrhosis)
Sx: Fever, chills, abd pain, diarrhea. NOT LOOKIN SO HOT
Primary Biliary Cholangitis
Autoimmune
Intraliver small bile ducts disorder, leading to decreased bile salt excretion, Cirrhosis, and ESRD
Older women (30-60) \+ AMA
Fatigue is often first symptom
Women like to watch PBC channel
Women, autoimmune
age 30-60
Fatigue, pruritis
+ AMA
Tx: Ursodeoxycholic acid
Primary Sclerosing Cholangitis -PSC
younger men
associated with ULCERATIVE COLITIS
Fibrosis of intra AND extra hepatic biliary ducts
+ P-ANCA
Beaded appearance of biliary ducts on MRCP,ERCP
Beaded appearance of biliary ducts (bc of fibrosis and narrowing)
younger men
+P-ANCA
PSC- Primary Sclerosing Cholangitis
pay attention to middle word- SCLEROSING tells us about fibrosis aspect of dz
Copper accumulation
Keyser Fischer rings on eye exam
Wilson disease!!!
Other sx of Wilson disease- can affect many parts of the body
Dysarthria, Psychosis, Hallucinations, Arthralgias
What causes Wilson dz?
GENETIC DISORDER- Rare autosomal recessive
copper accumulates in the brain, liver, kidney, joints, cornea
EVERYWHERE
Tx for Wilson dz
Copper chelating agents- Trientine or D- Penicallime and B6
Most common type of hernia
Indirect Hernia
protrusion at the internal inguinal ring, into the tunnel
Hesselbach’s triangle “RIP”
Rectus abdominis
Inferior epigastric vessels
Inguinal ligament
Femoral hernias are more commonly seen in Men or Women?
Women
Diet recommended for diarrhea
Bland low residue
Crackers, boiled veggies, yogurt, soup
B: banana
R: rice
A: applesauce
T: toast
Noravirus
“Nora is in her 20s and she is a bish”
Fecal-oral, contaminated food/water
CRUISESHIP and restaurants
lasts 2-3 days
Vomiting is the most dominant sx
Rotavirus
Kiddos
Most common in unimmunized kids b/w 6 mo-2 yo
fecal- oral transmission
Vomiting, diarrhea, and fever
Two most common types of Non-infectious diarrha
Noravirus (adults)
Rotavirus (kiddos)
Staph Aureus gastroenteritis
short incubation within 6 hours
Food is the cause: dairy, mayo, meat, eggs, salad
Bacillus cereus
short incubation within 6 hours
source: Fried rice
Traveler’s diarrhea
Enterotoxigenic E. Coli
contaminated food and water
Copious watery diarrhea “Rice water stools”
“fishy odor”
Vibrio cholerae
Tx: oral rehydration and electrolyte.
Abx: Tetracyclines if needed
Most common cause of death from seafood consumption in the US
V. Vulnificus
can cause necrotizing fasciitis, cellulitis, and gastroenteritis
C-Diff is non-invasive, non bloody diarrhea
BUT the complications of it are:
Pseudomembranous colitis
Bowel perforation
TOXIC MEGACOLON
what type of bacteria is C-Diff
Spore forming
Gram (+) anaerobic
Types of Invasive diarrhea
Yersinea Campylobacter enteritis Enterohemorrhagic E. Coli Typhoid Nontyphoidal Salmonella Shigellosis
Most common cause of bacterial enteritis in the US
Campylobacter Enteritis
C. Jejuni, associated with Guillian Barre syndrome
C. Jejuni
Raw/undercooked CHICKEN
Fever, crampy periumbilical abd pain
Tx: Azithromycin
Enterohemorrhagic E. Coli
most common in CHILDREN and eldery
Do we treat with abx?
NOT IN CHILDREN
d/t increased incidence of HUS- Hemolytic Uremic Syndrome
Typhoid fever YIKES
Tx: FluoroQ (Ciprofloxacin, Ofloxacin)
Travel to areas w poor sanitation
HA, intractable fever, chills, abd pain
“pea soup” green diarrhea
Fever w bradycardia
Rose spot rash
Hepatosplenomegaly!!, GI bleeding, dehydration, delirium
Non typhoidal salmonella
most common cause of foodborne disease in US- chicken, eggs, REPTILES
Tx is supportive unless severe, then give FluroQ
Explosive watery diarrhea that progresses to Mucoid and blood
Highly virulent
Leukemoid reaction >50,000
Shigellosis!!!
highest risk: children at daycare <5 yo
In general, what class of Abx are often used in treating Invasive diarrhea if the diarrhea is severe enough?
FluoroQuinolones
“Backpacker’s diarrhea” / Beaver fever
Greasy, foul smelling diarrhea
Will see trophozoites or cysts on stool exam
Giardia Lamblia
Tx: Metronidazole
Amebiasis - E. Histolytic is associated with what complication
Liver abscess- fever, RUQ pain, anorexia
Tx: Metronizadole + Tinidazole + intraluminal antiparasitic –> then Chloroquine
may need drainage also if no response to meds
Most common cause of SBO
post surgical adhesions
Most common cause of LBO
CA
4 clinical sx associated with SBO
Crampy abd pain, Distention, Vomiting, Obstipation (no gas)
Bowel sounds indicative of SBO on physical exam
High pitched tinkles
Visible peristalsis on early obstruction
Tx for SBO (as long as non-strangulated)
NPO, bowel rest
IVF
Bowel decompression with NG suction
Acute Cholecystitis
obstruction of CYSTIC DUCT by gallstones
RUQ pain, worse w fatty foods/large meals
Fever, Murphys sign, Boas sign (R shoulder, subscap)
US test of choice, but HIDA scan most accurate
Tx for Acute Cholecystitis
obstruction of cystic ducts
NPO, IVF, Abx- Ceftriaxone and Metro
Then Removal of gallbladder!
Acute Acalculous Cholecystisi
cause is NOT gallstones, but rather Neco-inflammatory disease
Gallbladder stasis and ischemia
Risk Factor: critically ill patients
Sx: Fever, jaundice, sepsis, vague abd pain
Acute Ascending CHOLANGITIS
Obstruction of the WHOLE COMMON BILE DUCT
Charcot’s triad: Fever, RUQ pain, Jaundice
Tx for Acute Asc Cholangitis
IV abx, make pt stable
ERCP to remove stone
Then, ultimately remove the Gallbladder
What is the diff b/w Cholelithiasis and Choledocholithiasis?
Cholelithiasis: stone in the gallbladder without inflammation
Docholithiasis: stone in the COMMON BILE DUCT (more serious bc can lead to cholestasis and blockage) Jaundice.
Why is a baby jaundice?
elevated plasma bilirubin
Jaundice is considered physiologic on days
3-5, but if it persists beyond that, can lead to –> Kernicterus (cerebral dysfx and encephalopathy)
Kernicterus occurs bc there is bilirubin deposition in
the brain tissue, leading to:
- seizures
- lethargy
- irritable
- hearing loss
- mental developmental delay
Bilirubin >20
Constipation is considered how many stools per week?
<2 per week
