Hepatitis Fredenburg Flashcards
What herbal substances increase risk of hepatitis?
- St. John’s wort
- Comfrey
- Chaparral
- Ephedra
- Kava
What social history aspects increase the risk of hepatitis?
- ETOH, illicit substances
- Sexual history
- Transfusions
- Occupational
- Travel
- Surgery
What meds can increase risk of hepatitis?
- Vit A
- Statins
- Acetaminophen
- NSAIDs
- Penicillin derivatives
Where is the first place to notice jaundice?
Sclera (icterus)
What are nonhepatic sources of bilirubin?
RBCs
What are nonhepatic sources of AST?
Skeletal and cardiac muscle
What are nonhepatic sources of LDH?
Heart, RBCs
What are nonhepatic sources of ALP?
Bone, 1st trimester placenta, kidneys, intestines
How do statins affect the liver?
- Rare reports of fatal hepatic failure
- Increases aminotransferase levels
- Guidelines do not restrict use
How do penicillins affect the liver?
- Rare instances of liver injury
- High IV and IM doses
- BUT many case reports were before serologic testing was available for hepatitis
How are AST/ALT levels in chronic liver disease?
May or may NOT be elevated
What can cause minimal ALT elevations (less than 1.5x normal)?
- Race/gender
- Obesity
- Muscle injury
Mildly elevated AST and ALT is normally caused by:
- Fatty infiltration
- ETOH
- HLD
- Obesity
- T2DM
What causes elevated AST?
- Common bile duct obstruction
- Cholangitis
- Alcoholic hepatitis
AST should make you think of:
Alcohol
ALT should make you think of:
Virus
What does AST:ALT ratio of 2+ suggest?
ETOH liver disease
AST:ALT ratio of less than 2 suggests?
- Acute or chronic viral hepatitis
- Cholestatic disease
- NASH (non-alcoholic steatohepatitis)
When should elevated aminotransferases cause concern?
- More than one liver enzyme abnormal
- Clinical s/s of liver disease
- Greater than 5 fold elevation of an enzyme
- Persistence of abnormal levels for 6+ months
How is Hep A transmitted?
Fecal to oral
What is the most likely period of someone spreading Hep A virus?
2 weeks before onset of jaundice
Can Hep A be spread through blood?
- Occasionally
- There is a short period of viremia once infected
Does Hep A cause a chronic infection?
No
Treatment of Hep A virus?
Immunoglobulin (IG)
-Must be given within 14 days of exposure
How long does IG pre-exposure prophylaxis protect travelers?
3-5 months
How does IG work in treating HAV?
- Passive transfer of neutralizing antibodies
- Prevents infection or clinical expression of disease
Describe the HAV vaccine
- Used for PREP
- Given as 2 dose series
- Licensed for use in 12+ months old
- Protects for at least 20 yrs if not more
What are the unresolved issues surrounding HAV vaccine?
- Should it be used as PEP
- Should it be used in community-wide outbreaks
Who should receive HAV vaccine?
- All children 12-18 months old regardless of residence
- Travelers to HAV endemic countries
- Homosexual and bisexual men
- Drug users
- Chronic liver disease patients
Which hepatitis virus is MC caused by IV drug use?
HCV
Which hepatitis virus is MC caused by sexual exposure?
HBV
Which hepatitis virus is MC caused by perinatal exposure?
HBV
Which hepatitis virus is MC caused by occupational exposure?
HBV
What are the MC transmission methods of HBV?
- Percutaneous and permucosal (e.g. IV drug use, needle sticks)
- Sexual (both homo and hetero)
- Perinatal (mother to child during labor and delivery)
What do you look at to see if someone is chronically infected with HBV?
HBsAg (Hep B surface antigen)
What does HBeAg indicate?
Active HBV replicating
What is given for post-exposure prophylaxis of HBV?
HBIG
How is the HBV vaccine used?
For both pre and post exposure
Current strategy of HBV vaccine
- Routine for infants
- Routine of adolescents who didn’t get it in infancy
- High risk children, adolescents and adults
Describe HBIG
- Used for post exposure
- Prepared from plasma containing high titers anti-HBs
- Does NOT protect against future exposures
What is the primary component of HBV vaccine?
HBsAg
Describe the HBV vaccine
- Worldwide plasma-derived and recombinant formulations available
- Only recombinant available in US
- 3 dose series
- Highly immunogenic (seroconversion approx 95%)
- Long lasting protection (no booster recommendation)
Which hepatitis virus has no vaccine available?
HCV
Which populations are MC affected by HCV?
Males, middle aged
Risk factors for HCV
- Transfusions (more of a problem in the past due to lack of screening blood products)
- IV drug use (bigger problem now)
- Sexual
What is the risk for HCV involved with tattooing, body piercing, acupuncture?
No or insufficient data showing increased risk
When is HCV testing routinely recommended?
- Hx of injected illegal drugs
- Received clotting factors made before 1987
- Received blood/organs before July 1992
- Chronic hemodialysis
- Evidence of liver disease
- HC workers
- Children born to HCV positive women
In areas where there is high/moderate endemicity of HCV, what is the MC cause?
HC related
In areas where there is low endemicity of HCV, what is the MC cause?
IV drug use
How is HCV diagnosed?
- IgG assays for anti-HCV (false negatives possible in 1st 15 wks)
- Nucleic acid amplification testing to detect HCV RNA in blood (viremia in 80% with acute infection)
What is important to know about IgG assays for anti-HCV?
False negative can occur in first 15 weeks after exposure
When is HCV treatment recommended?
-Elevated ALT levels
-Age over 18 yo
-Positive HCV antibody and serum HCV RNA tests
etc etc
What is a sustained viral response?
Considered a “cure” of HCV (levels we can’t detect, so it could come back theoretically)
HCV med regimens
- Pegylated interferon and ribavirin for 24-48 weeks
- New oral agents added are increasing “cure rates” on initial treatment attempts
Describe Hepatitis D
- “Delta hepatitis”
- RNA virus structurally unrelated to A, B, C viruses
- Acute or chronic
- Uncommon in US
- Only occurs WITH HBV
Why does HDV only occur with HBV?
Incomplete virus that requires helper function of HBV to replicate
What population is affected by HDV?
Those infected with HBV
Vaccination for HDV?
- None available
- BUT is prevented by HBV vaccine in pts NOT already HBV infected
Describe coinfection of HDV
- Simultaneous infection with HBV and HDV
- Presents similar to HBV alone
- MC outcome is complete clinical recovery and clearance of HBV and HDV
Describe superinfection of HDV
- HDV infection in pt already positive for HBsAg
- Progresses more rapidly to develop cirrhosis and possible hepatocellular carcinoma
Does fulminant liver failure occur more often in coinfection or superinfection of HDV?
Superinfection!
Describe HEV
- RNA virus, Hepeviridae family
- Fecal oral route
- Japan and Europe MC areas
- Mainly zoonotic and foodborne
- Perinatal transmission is common
Which hepatitis virus affects pregnant women most?
HEV
When are US residents most at risk for HEV?
- Traveling to epidemic areas
- Eating raw or undercooked venison, boar, pig liver
How does HEV present?
Prodromal phase
Icteric phase
How is HEV diagnosed?
- Anti-HEV IgM and IgG
- HEV RNA in serum or stool
- No diagnostic test approved by FDA
What is the treatment of HEV?
Supportive
What is the prevention of HEV?
- No vaccine or drugs available
- Avoid drinking contaminated water
- Avoid eating undercooked or raw animal products
Describe HGV
- Prevalence in general population is high
- Linked to HCV
- Tx limited to rest, avoiding ETOH
Describe HFV
“Hypothetical” virus linked to hepatitis - not a major player
Describe TTV
- Detected in many people including those with fulminant hepatic failure or chronic hepatitis of unknown etiology
- No current evidence that chronic TT viremia is responsible for hepatic inflammation, cirrhosis, or hepatocellular carcinoma
Prognosis of HAV?
- Usually mild and self limited
- Infection confers lifelong immunity
- 3 rare complications (relapsing hepatitis, cholestatic hepatitis, FHF)
Prognosis of HBV?
FHF develops in 0.5-1% of HBV infected pts
Prognosis of HCV?
- Chronic infection develops in 50-60%
- Leading indication for liver transplant in US
What is the leading indication for liver transplant in the US?
HCV
Prognosis of HDV with coinfection of HBV?
- BETTER than superinfection
- Tend to develop chronic HDV
- Often leads to rapidly progressive subacute or chronic hepatitis
Prognosis of HEV?
- Usually mild and self limited
- A problem in pregnant women though!
