Liver Infection

Question 1

Clinical spectrum of viral hepatitis

Answer 1

Acute hepatitis
Resolves without long term effects for 6 months
May be asymptomatic or mild/ moderate / severe disease state

Acute fulminant hepatitis
Rapid,severe inflammation and necrosis of hepatocytes
Rare and life threatening complication of acute hepatitis

Chronic hepatitis
Ongoing liver inflammation >6 months

Carrier state
Harbour virus but asymptomatic

Question 2

Acute hepatitis - signs

Answer 2

Early stage. Flu like symptoms - general fatigue , malaise, joint and muscle pain , low grade fever uo to 38

GI symptoms - anorexia , naseua , vomiting , upper right quadrant discomfort

May be accompanying headache , cough , sore throat , constipation , diarrhoea or itch or urticaria

Icteric/ jaundice phase
 Jaundice, pale stools and dark urine 
Itchy skin 
Fatigue, anorexia , nausea , vomiting 
Possible enlarged liver, spleen and lymph nodes 
Hepatic tenderness

Recovery stage 
Malaise 
Anorexia 
Muscle weakens 
Hepatic tenderness

Question 3

What is hepatitis A

Answer 3

Non- enveloped single stranded RNA virus

Usually self limiting virus with good prognosis
Severity tends to increase with age

Transmission by faecal- oral route

Incubation period 2-7 weeks

Question 4

Diagnosis of Hep a

Answer 4

Acute illness with discrete onset of Illness
Jaundice or elevated serum amino transferase levels
Laboratory confirmed igM and igG antibodies to HAV

Question 5

Management of Hep A

Answer 5

Hospital admission if severally merl
Rest
Supportive symptomatic care

Question 6

Supportive symptomatic care for HAV

Answer 6

Pain- paracetamol , ibuprofen , weak opioid if mild liver impairment. Avoid codeine if sever liver impairment.

Nausea
Anti sickness like cyclizine at Normal doses . Seek specialist advice if severe liver impairment.

Itch
Cool, well ventilated environment , loose clothing , avoid hot baths
Chlorophenamime at night
Corticosteroid ? Seek specialist advice

Question 7

HAV Vaccination indicated

Answer 7

Traveller to moderate or high risk area
Chronic liver disease, clotting factor disorders , injecting drug users
Those at high risk due to their sexual Behaviir

Question 8

Hep B

Answer 8

Enveloped DNA virus

Acute HBV long incubation period -3-6 months

Chronic HBV - persistence of HBsAG > 6 months

Transmission blood to blood , sexually or mother to baby

Outcome depend on age , host genetic factors and virus characteristics

Question 9

Hep B hugh risk groups

Answer 9

Injecting drug users
People who change sexual partners frequently
Travelling to / from hugh Risk area
Sex workers and clients
Household contacts if those with HBV
people receiving regular blood or blood products
Those with chronic renal failure or chronic liver disease
Those with an occcuoational risk
Prison inmates and staff
Infants born to mothers with HBV

Question 10

HBV acute infection

Answer 10

Symptoms and jaundice usually last 1-3 months
HBsAG cleared in 95% of immunocompetent adults
Fulminant Hep is a rare complication - less than 1%

Question 11

Chronic infection HBV

Answer 11

Most are inactive carries of HBVags - asymptomatic and healthy
15-20% develop cirrhosis
May take up to 20 years to manifest
Alcohol consumption , co infection with HCV, HDV, HIV can lead to faster progression of liver damage
May lead to increased risk of cancer

Question 12

HBV diagnosis

Answer 12

CLINICAL FEATURES 
Early symptoms such as fever , joint stiffness or rash 
Malaise , fatigue , Naseau, poor appetite 
Right upper quadrant abdominal pain 
Jaundice 
Spider naevi 
Finger clubbing 
Signs of severe liver disease 

LIVER FUNCTION TESTS
increase bilirubin

HBsAg
IgM antibody to Hep core antigen

Question 13

HBV management

Answer 13

Hospital admission if severely unwell

Rest , hydrate , symptomatic supportive care for pain, naseua , itch

Acute HBV is a notifies level disease

Chronic HBV Treatemnt options
Peginterferron alpha or interferon alpha
Antivirals - entacavir is option for initial treatment

Question 14

Patient advice of HBV

Answer 14

AVOID ALCOHOL
increased risk of cirrhosis and cancer

MINIMISING RISK OF TRANSMISSIOM 
avoid sharing items contaminating with blood
Use of condoms 
Avoid sharing needles 
Do not donate blood or semen 

IF PREGNANT
90% chance of infant contracting HBV unless immunised at birth
Increase risk of preterm delivery and low infant birth weight
Breastfeeding safe provided infant is immunised

Question 15

HBV prevention

Answer 15

IMMUNISATION

IMMUNOGLOBIN PROPHYLAXIS

Question 16

HCV

Answer 16

Blood borne , causing slow , progressive , liver disease

Acute infection - presence of HBV immediately following incubation (2-6 weeks)
Most asymptotic
Chronic infection follows in 50-85%

Use of injected drugs most common route of transmission

Long term impact highly variable and unpredictable

Question 17

HCV complications and proGNOSISN

Answer 17

25-50% spontaneously clear virus

Acute HCV rarely lead to fulminant Hep

Chronic can lead to
Liver cirrhosis and liver failure if left untreated

Common comorbidities
Diabetes , chronic kidney disease

Question 18

HCV - diagnosis

Answer 18

Antibody test and HCV RNA test

Clinical features indicative of Hep
Only 20-35% experience symbol symptoms in the early stages

Abnormal LFTs

The following are routinely screened
Those who intend to donate blood or organs
Ppl with end stage chronic kidney disease requiring replacement therapy
Health care workers eg surgeons

Question 19

HCV MANAGEMENT

Answer 19

Signposting

Lifestyle advice and measures to stop spreading
Alcohol , smoking cessation , maintaining ideal body weight

Immunisations
Hep a&b
Pneumococcal

DIRECT ACTING ANTIVIRALS (DAA) are first line treatment eg sofosbuvir
Successful for >90%
Usually once daily for 8-12 weeks

Asses state of infection and progression of liver disease
Blood tests
Ultrasound
Biopsy