Liver & Biliary system conditions Flashcards
Transmission of viral hepatitis A (2)
Food/water: faecal-oral
Body fluids - sexual fluids, blood to blood
Which hepatitis viruses are associated with chronic liver disease (3)
B,C,D
Hepatitis A risk factors (4)
Age 5-14
Sex between men
Living in endemic region
Contact with infected person
Hepatitis A symptoms (4) /signs (4)
Symptoms: Nausea/vomiting - ABRUPT ONSET RUQ pain - ABRUPT ONSET Malaise - ABRUPT ONET Jaundice - typically 2 wks after infection/other symptoms
Signs: Fever - ABRUPT ONSET Hepatomegaly Steatorrhoea Dark urine
JAUNDICE APPEARS IN HEP A MUCH QUICKER THAN ALL THE OTHER TYPES
Hepatitis A investigations (2)
Diagnostic - IgM anti-hepatitis A antibodies
LFTs - elevated serum transaminases, elevated bilirubin
Hepatitis A treatment (2)
NO SPECIFIC TREATMENT; ONLY SUPPORTIVE; body will clear virus itself
If not vaccinated for hep A:
-hep A vaccine or normal immunoglobulin
If confirmed hepatitis A:
-Supportive care - rest, analgesia
Who is the hepatitis A immunisation targeted at (5)
Travellers to endemic regions Patients with chronic liver disease Haemophiliacs (have impaired clotting ability) Occupational exposure Men who have sex with men
How is hepatitis B transmitted
Through body fluids - blood to blood or sexual fluid
Hepatitis B infection pathophysiology
Virus doesn’t actually kill hepatocytes
Host immune response (particularly cellular) to the viral antigens causes the liver injury
Hepatitis B risk factors (5)
HBV infected mother passing onto baby IV drug use Sex between men Multiple sexual partners Family history of HBV/chronic liver disease
Antigens of HBV + what do they indicate if detected (4)
Hepatitis B surface antigen (HBsAg) - indicates active replication; disappears after acute infection
Hepatitis B early antigen (HBeAg) - indicates active replication of HBV; in early acute stage then disappears
Hepatitis B core antigen (HBcAg) - indicates active replication of HBV, not detected in blood
HBV DNA - indicates active replication of HBV
Hepatitis B symptoms (5)/ signs (5)
*but what’s the important thing to remember
*MAJORITY ASYMPTOMATIC until cirrhotic
Symptoms: Fever/chills Fatigue Arthralgia RUQ pain Nausea/vomiting
Signs: Hepatomegaly Jaundice Dark urine Ascites Spider naevi
Hepatitis B investigations
- bloods (3)
- specific serology (antigen, PCR, 4 antibodies)
- LFTs (elevated aminotransferases (ALT/AST), alk phos)
- FBC
- U+Es - hyponatraemia, high urea
- Serum HBsAg (surface antigen) - FIRST TEST; disappears after acute infection
- HBV DNA
- Serum anti-HBs (anti hep B surface antigen antibody) - appears wks after surface antigen disappears; suggests resolved acute infection
- Serum IgM anti-HBc (IgM anti hep B core antigen antibody) - appears during acute infection
- Serum IgG anti-HBc - develops after IgM
- Serum anti-HBe (hepatitis B envelope antibody)
4 antibodies produced against HBV + do they indicate acute or chronic infection
Anti-HBs (hep B surface antigen antibody) - suggest resolved infection, lifelong immunity
IgM anti-HBc (IgM hep B core antigen antibody) - indicate acute infection
IgG anti-HBc - indicate resolved acute or chronic infection
Anti-HBe (hepatitis B envelope antibody) - indicate inactive infection if HBeAg negative
Hepatitis B treatment (5)
- acute infection (2)
- chronic infection (3)
Acute infection
-supportive care (rest, analgesia)
+/- oral antivirals - if progresses to very SEVERE or liver failure
Hepatitis B vaccine (only works to prevent or in very recent exposure before person has been infected)
Chronic infection:
- Oral antivirals (entacovir) OR pegylated interferon
- Liver transplant - if decompensating cirrhosis
Complications of hepatitis B, C + D infection (3)
Chronic hepatitis –> liver cirrhosis –> HCC/ESLD
Transmission of hepatitis C
Body fluids - blood, sexual
Which hepatitis viruses are RNA (4) /DNA (1) viruses
RNA virus - A,C,D,E
DNA virus - B
What enzyme do RNA viruses need to replicate
Reverse transcriptase
Hepatitis C risk factors (5)
IV DRUG USE BLOOD TRANSFUSIONS Unsafe medical practices Heavy alcohol use HIV
Hepatitis C symptoms (3) /signs (4) + do they appear in acute or chronic HCV
Asymptomatic until cirrhotic
Symptoms -
fatigue (acute + chronic hep C),
arthralgia/myalgia (chronic hep C)
Signs - fever (acute hep C), jaundice (chronic), ascites (chronic), HE (chronic)
Hep C investigations (3)
- serology (antibody, antigen)
- bloods
ELISA for serum anti-HCV antibody
PCR for HCV RNA
LFTs - elevated aminotransferases, esp ALT (alanine aminotransferase)
Hep C treatment (2)
Oral antiviral combo x2
Liver transplant - if liver failure
Transmission of hepatitis D
Transmitted by body fluids - blood or sexual contact
What is special about hepatitis D infection
Only infects those that are already infected with HBV as it needs HBV to be able to survive inside body
Surface antigen of HDV (hint: HDV can only exist with HBV infection as well)
Same as surface antigen of HBV:
HBsAg
Hepatitis D risk factors (3)
Carrying HBV
IV drug use
Sex between men
Hepatitis D symptoms/signs
Same as HBV
Hepatitis D investigations (3)
-serology (2 antibodies, 1 antigen)
Serum IgM anti-HDV
Serum IgG anti-HDV
HDV RNA - by doing PCR
Hepatitis D treatment
- prevention
- medical
INCURABLE
Prevented by HBV vaccine
Pegylated interferon alpha (slows spreading but doesn’t cure)
Transmission of hepatitis E
Food/water: faecal-orcal transmission
What is the commonest hepatitis infection in grampian
Hep E
Hepatitis E risk factors (3)
Poor sanitation areas
Undercooked meat/contaminated meat
Pregnant women/infected mother to child
What is fulminant hepatitis + when is it likely to occur
Acute liver failure
Occurs more frequently when hepatitis E occurs during pregnancy
Hepatitis E symptoms (5) /signs (4)
Symptoms - Fever, nausea/vomiting, anorexia, fatigue, RUQ pain
Signs- Jaundice --> dark urine -->steatorrhoea Hepatomegaly
Hepatitis E investigations (2)
-serology (antibody, antigen)
Serum IgM anti-HEV
HEV RNA
Hepatitis E treatment (3)
No specific treatment
Very resistant to treatment
Maintain good hygiene
Complications of hepatitis E
Acute liver failure (fulminant hepatitis)
What is alcoholic liver disease + 3 stages of alcoholic liver disease
Direct alcohol toxicity causing fatty change of liver
- Steatosis –> alcoholic hepatitis –> cirrhosis
- STILL REVERSIBLE AT THIS STAGE
Cause of alcoholic liver disease
CHRONIC ALCOHOL
Alcoholic liver disease pathophysiology
Abnormal lipid retention in hepatocytes (steatosis) –> large triglyceride fat vacuoles accumulate –> fatty liver
May be accompanied by progressive inflammation –> steatohepatitis
Alcoholic liver disease risk factors (4)
Chronic alcohol
Female
Hepatitis C
Obesity
Alcoholic liver disease symptoms (3) /signs (4)
Symptoms:
Abdominal pain - RUQ
Fatigue/malaise
Anorexia
Signs: Hepatomegaly Ascites Weight loss OR gain Dupuytren's contracture - in advanced disease
Alcoholic liver disease investigations
- LFTs (5)
- imaging (1)
LFTs
- AST, ALT (AST: ALT = >2:1)
- gamma GT - high
- bilirubin - high
- albumin - low as synthetic liver function decreased
Liver ultrasound
What is the AST:ALT ratio in alcoholic liver disease/ alcoholic hepatitis
AST: ALT = >2:1
Alcoholic liver disease treatment (5)
-lifestyle - most important one of all
-medical (3)
+/- medical
ALCOHOL ABSTINENCE - 1st line
Treat alcohol withdrawal - benzodiazepine
Nutritional supplements (thiamine)
Immunisations - for flu, hep A/B
+/- Steroids (prednisolone) if:
- Glasgow alcoholic hepatitis score >9
- Maddrey’s discrimination function >32
What is the criteria for giving steroids in ALD (2)
Glasgow alcoholic hepatitis score >9
Maddrey’s discrimination function >32
Complications of ALD (3)
Hepatic encephalopathy
Portal hypertension
GI bleed
What is autoimmune hepatitis
Chronic inflammatory disease caused by auto-antibodies attacking hepatocytes
Cause of autoimmune hepatitis
Idiopathic
Pathophysiology of autoimmune hepatitis
-combination of what factors
Interaction between genetics, environmental trigger, and immune dysregulation
In the genetically predisposed, environmental agent can trigger a pathogenic process leading to liver necrosis and fibrosis
Autoimmune hepatitis risk factors (2)
Female
Genetic predisposition
Autoimmune hepatitis symptoms (4) /signs (4)
Symptoms: Fatigue/malaise Anorexia RUQ pain Pruritus - MILD
Signs: Jaundice Fever Hepatomegaly Spider naevi
Autoimmune hepatitis investigations
- LFTs (4)
- autoantibodies (2)
- definitive diagnosis
LFTs
- ALT - high
- AST - high
- albumin - low
- bilirubin - high
Anti nuclear antibodies
Smooth muscle antibodies
LIVER BIOPSY
What liver function test is more specific for alcohol related liver injury
Gamma GT - raised
Autoimmune hepatitis treatment (1 +/- 1)
Steroids - prednisone
+/- other immunosuppressant (azathioprine)
Complications of autoimmune hepatitis
- of long term corticosteroids
- of the disease itself
Osteoporosis, diabetes, hypertension due to corticosteroids
Acute/chronic liver failure
End stage liver disease and HCC are unlikely
What is non-alcoholic fatty liver disease + the 3 stages of NAFLD
Fatty change of the liver not due to alcohol
Steatosis –> non-alcoholic steatohepatitis (NASH) –> fibrosis + cirrhosis
Hypothesised cause of NAFLD, although not 100% clear
Insulin resistance
Pathophysiology of NAFLD (5)
Insulin resistance –> fatty accumulation in liver (steatosis) –> inflammation (NASH) –> healing of inflammation by fibrosis –> cirrhosis
NAFLD risk factors (4)
Obesity
Diabetes
Hypercholesterolaemia
Hypertension
NAFLD/hepatic steatosis (3)/ signs (2)
Symptoms:
Fatigue
Malaise
RUQ pain
Signs:
Hepatosplenomegaly
Truncal/central obesity
ASYMPTOMATIC until advanced