Hepatitis (GI) Flashcards
What are two types of hepatitis (non-viral)?
- autoimmune hepatitis - these flashcards focus on AIH
- ischaemic hepatitis
Define autoimmune hepatitis.
Chronic inflammatory disease of the liver of unknown aetiology
Who does autoimmune hepatitis tend to affect more?
Young females (4:1)
What are the three types of autoimmune hepatitis?
- type 1 AIH (classic, 80% of cases) - children and adults
- type 2 AIH - children only
- type 3 AIH
What are the most common antibodies present in type 1 autoimmune hepatitis? (2 + 2)
- antinuclear antibodies (ANA)
- anti-smooth muscle antibodies (ASMA)
- (anti-actin antibodies - AAA)
- (anti-soluble liver antigen - anti-SLA)
What antibodies are present in type 2 autoimmune hepatitis? (1 + 1)
- anti-liver kidney microsomal-1 (anti-LKM-1)
- (anti-liver cytosol - ALC-1)
What antigen is targeted in type 3 autoimmune hepatitis?
Anti-soluble liver antigen (anti-SLA)
What is the aetiology of autoimmune hepatitis?
Idiopathic
What are some examples of autoimmune diseases that autoimmune hepatitis is commonly associated with? (4)
- Hashimoto’s thyroiditis
- Graves disease
- ulcerative colitis
- Coeliac disease
What gene plays a role in autoimmune hepatitis?
HLA gene (HLA-DR3/4)
Genetically predisposed individual –> environment e.g. viruses/drugs may lead to hepatocyte expression of HLA-DR3/4 –> T-cell mediated autoimmune attack against hepatocytes
What is autoimmune hepatitis characterised by?
Presence of circulating autoantibodies with a high serum globulin concentration (hyperglobulinaemia), inflammatory changes on liver histology (chronic inflammation) and a favourable response to immunosuppressive treatment
When can ischaemic hepatitis occur?
Following acute hepatic hypoperfusion e.g. after sepsis or cardiac arrest
What is ischaemic hepatitis characterised by? (2)
- marked elevation of AST and ALT 1-3 days after insult
- significant rise in LDH (very sensitive for ischaemic hepatitis)
What are the clinical features of hepatitis? (13)
- fatigue
- malaise
- anorexia
- abdominal discomfort
- hepatomegaly
- splenomegaly
- jaundice
- encephalopathy
- pruritus
- arthralgia
- nausea
- amenorrhoea
- spider naevi
What might you see on examination of hepatitis?
- ascites
- hepatomegaly
- splenomegaly
- jaundice
- spider naevi
- GI bleeding
What are some risk factors for hepatitis? (4)
- female
- genetics
- viral triggers
- drug triggers
What are the first-line investigations in hepatitis? (2)
- LFTs - AST, ALT, BR, GGT
- prothrombin time
What do we see in bloods/LFTs in hepatitis?
- high AST and ALT
- BR, GGT and ALP - mild to moderately increased
- low serum albumin (when synthetic function affected)
- high globulins (hypergammaglobulinaemia)
What do we suspect instead of hepatitis if ALP was raised a lot (rather than mild-moderate)?
Bile duct pathology
What serum autoantibodies can be found in type 1 and type 2 autoimmune hepatitis?
- type 1 AIH: ANA & ASMA
- type 2 AIH: anti-LKM-1
What is characteristic of type 1 autoimmune hepatitis?
Decreased albumin, increased prothrombin time
What is prothrombin time like in hepatitis?
Prolonged PT
What would serum protein electrophoresis show in hepatitis?
Hypergammaglobulinaemia (increased IgG)
Why would a liver biopsy be done in hepatitis and what would it show?
Confirms diagnosis - inflammation and bridging necrosis seen
What LFTs are markedly raised in hepatitis? (2)
- aspartate aminotransferase (AST)
- alanine aminotransferase (ALT)
What investigations can we do in hepatitis to rule out other causes? (6)
- viral serology (hepatitis B/C)
- urinary copper/caeruloplasmin (Wilson’s disease)
- ferritin and transferrin saturation (haemochromatosis)
- alpha-1-antitrypsin (deficiency)
- anti-mitochondrial antibodies (PBC)
- ERCP (PSC)
What are some differential diagnoses for hepatitis? (13)
- primary biliary cirrhosis (PBC)
- primary sclerosing cholangitis (PSC)
- chronic hepatitis
- drug-induced hepatitis
- granulomatous hepatitis
- genetic haemochromatosis
- alpha-1-antitrypsin deficiency
- Wilson’s disease
- cholangiopathy related to AIDS
- non-alcoholic steatohepatitis (NASH) - presence of 1+ components of metabolic syndrome
- alcoholic liver disease
- SLE
- Graft vs Host disease
What are the indications for management of hepatitis? (3 + 3)
- aminotransferases >10x upper limit of normal
- symptomatic
- histology:
- significant interface hepatitis
- bridging necrosis
- multiacinar necrosis
How do we manage hepatitis?
- corticosteroid - prednisolone followed by maintenance treatment with gradual reduction in dose
- immunosuppressant - azathioprine
- maintenance phase: steroid-sparing agents, frequent LFT and FBC monitoring
- often long term treatment
- definitive Rx: liver transplant
What do we test for before starting azathioprine in hepatitis?
Test for TPMT1
Thiopurine methyltransferase deficiency
What is the definitive treatment for hepatitis?
Liver transplant (if refractory/intolerant/end-stage)
How do we monitor disease progression in hepatitis? (3)
- ultrasound and alpha-feroprotein level every 6-12 months if cirrhosis present - to detect hepatocellular carcinoma
- repeat liver biopsies to check disease progression
- frequent FBC+LFTs
What vaccinations could we give in hepatitis?
Hepatitis A and B vaccinations
What are some complications of hepatitis? (7)
- fulminant hepatic failure (severe impairment in absence of pre-existing liver disease)
- cirrhosis
- portal hypertension (ascites, varices)
- hepatocellular carcinoma
- corticosteroid side effects
- azathioprine side effects (malignancy, BM suppression, cholestatic hepatitis, pancreatitis, teratogenic)
- infections due to immunosuppression
Describe the prognosis of hepatitis.
- majority of patients with moderate/severe AIH respond to treatment within 2 weeks
- achieve remission with serum aminotransferases falling into normal range after 12+ months of treatment
