Hepato-biliary disease

Question 1

List the common causes of acute hepatits

Answer 1

• Viral infection (Hepatitis A-E/Non A-E infections)
  
  • Hep A may cause infection in childhood, though 80% of those infections are asymptomatic
  • Hep D & E are rare in UK
  • Hep B and C infection is usually astmptomatic except in IV drug users, in whom 30% develop jaundice
• Autoimmune
• Drug reactions
• Alcohol

Question 2

What are risk factors for acute hepatitis?

Answer 2

• Use of needles
• Risky sexual behaviour
• Poor hygeine
• Blood transfusion
• Travel

Question 3

Describe the types of liver damage that may be caused by drug therapy

Answer 3

• Intrinsic hepatotoxins cause type A reactions
  
  • Augmented pharmacologic effects - Dose dependant & predictable
• Extrinsic hepatoxins cause idiosyncratic type B reactions
  
  • Unpredictable
  • Appear not to be concentration dependent

Question 4

Describe the common causes of chronic hepatitis

Answer 4

• Hepatitis B +/- Hepatitis D virus - most common
  
  • Hep B: Hepa-DNA virus, transmitted in the blood, semen and saliva via skin breaks or mucous membranes
  • Hep D: can only cause infection in presence of Hep B as it is an incomplete RNA virus so needs Hep B for its own assembly
• Hepatitis C virus - most common
  
  • RNA flavivirus, transmitted via bodily fluids, and is particuarly common in IV drug users
• Autoimmune hepatitis
  
  • It is a cell-mediated auto-immunity and may be triggered by infection
• Alcohol
• Hyperlipidaemia (Non-acholic fatty liver disease - NAFLD)
• Drugs (methyldopa/nitrofuranroin)
• Metabolic disorders (Wilson’s disease, alpha-1-antitrypsin deficiency, haemochromatosis)

NOT HEPATITIS A & E!! (ONLY ACUTE)

Question 5

Describe the morphology and pathological consequences of acute hepatitis

Answer 5

• Patholigical changes are the same regardless of the cause
• Hepatocytes undergo degenerative changes (swelling & vaculoation) before necrosis and rapid removal
• Necrosis is usually maximal in zone 3, as this is centrilobular and thus receives the least oxygenated blood
• Extent can vary from scattered necrosis to multiacinal necrosis leading to fulminant hepatic failure

Question 6

Describe the morphology and pathological consequences of chronic hepatitis

Answer 6

• Defined as any hepatitis lasting more than 6 months, and is the principle cause of chronic liver disease, cirrhosis and hepatocellular carcinoma
• Chronic inflammatory cell infiltrates are present in the portal tracts
• They may also be loss of definition of the portal/periportal limiting plate, confluent necrosis and fibrosis
• This eventually leads to cirrhosis
• The overall severity is judged by the degree of inflammation (grading), and the extent of fibrosis/cirrhosis (staging), using various scoring systems such as the Child Pugh score

Question 7

Discuss the diagnosis of a patient with jaundice including relevant history, blood tests and radiological investigations

Answer 7

Full history

• Risk factors for viral hepatitis
• Acholol intake
• Nutrional status
• Establish extra-jaundice features

Blood tests

• FBC
• Reticulocytes
• LFTs
• U&Es
• bilirubin levels
• Albumin and clotting
• Toxins (paracetamol)
• Viral load
• Immunogloblin - paraproteinaemia (identify what virus)

​Urinalysis

• Urobilinogen in urine –> gives dark urine

Imaging

• An ultrasound of the liver may exclude alternative diagnoses.
• MRCP and ERCP may display abnormalities of the biliary system.

Biopsy is able to histologically confirm diagnoses of intra-hepatic pathology.

Question 8

How will LFTs, virology, immunology and radiology help for a patient with jaundice?

Answer 8

Help find if the jaundice is: Pre-hepatic, Hepatic, Post-hepatic…

• LFTs – will show a hepatodestructive or obstructive pattern
• Virology – will guide to diagnosis of viral cause
• Immunology – will guide to diagnosis of autoimmune cause
• Radiology – USS and MRCP may exclude pancreaticobiliary cause.