Liver Symposium Flashcards
Describe hepatitis A and E
Enteric viruses
Cause self limiting acute infections
Describe hepatitis B,C and D
Parental viruses
Cause chronic disease
How is hepatitis diagnosed?
IgM antibodies
5-14 commonest group
Asymptomatic is common
Describe hepatitis A (HAV)
Occurs sporadically or in epidemic form
Transmission is faecal, sexual or blood
Who is immunised for HAV?
Travellers
Patients with chronic liver disease
Haemophiliacs
Occupational exposure
Men who have sex with men
What are some HBV antigens the presence of virus?
Hep surface antigen - HBsAg
What are some HBV antigens which show active replication?
Hep e antigen - HBeAg
Hep core antigen - HBcAg
HBV DNA
What are some HBV antibodies?
Anti-HB
IgM anti-HB
IgG anti-HBc
Anti-HBe - inactive virus
Describe the natural history of chronic hepatitis B
Can lead to cirrhosis or no further progression
Cirrhosis then can lead to hepatocellular carcinoma (HCC) and end stage liver disease (ESLD)
What are the treatment options for HBV?
Pegylated interferon
Oral antiviral drugs - Tenofovir is mostly used
Describe hepatitis C
Rarely acute, 85% chronic
Most asymptomatic until cirrhotic
May have normal LFTs
RNA virus
Describe the natural history of HCV
85% become chronic instead of resolving
Then 20% of them move onto cirrhosis instead of stabilising
Then 25% of them develop HCC and need transplant
What is used to treat HCV?
IFN-free combination of direct acting anti-viral drugs
Describe Hepatitis D
Small RNA virus which does not code for own protein code and enveloped by HBsAg
Co-infection or super infection with HBV
Very resistant to treatment
Describe Hepatitis E
Commonest cause of acute hep in Grampian
Self limiting and no specific treatment or vaccine
What are some other viruses?
Hep F, G, GB
EBV, CMV and herpes simplex
What can herpes simplex cause?
Rare severe acute hepatitis
What are some mechanisms of injury for drug induced liver disease (DILI)?
Toxic necrosis, acute hep, cholestasis, chronic hep, hepatic vein thrombosis, veno-occlusive disease, steatosis, granulomatous hep
Describe the treatment for paracetamol induced liver failure
N-Acetyl cysteine (NAC) infusion
Follow graph on paracetamol and hours of ingestion
What does non alcoholic fatty liver disease include?
Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis
What are some associated components of NAFLD?
Diabetes mellitus
Obesity
Hypertriglyceridemia
Hypertension
Age, ethnicity and genetics
What is the natural history of NAFLD?
Normal - steatosis - NASH with possible fibrosis - cirrhosis
Increasing CV risk
What is used for diagnosis of NAFLD?
Liver biopsy is gold standard
Enhanced liver fibrosis panel
Cytokeratin-18
Fibro scan
MR spectroscopy
Describe NAFLD score
Patients are classed as high risk if 3 or more categories
Includes age, diabetes, BMI, Platelet count, albumin and more
Describe the Fib-4 score
If less than 1.45 then no advanced fibrosis
If more than 3.25 then cirrhosis
Takes in age, AST, platelet count and ALT
What is the non-pharmacological treatment for NAFLD?
Diet and weight reduction
Exercise
Weight reduction surgeries
What is the pharmacological treatment for NAFLD?
Insulin sensitizers - metformin, pioglitazone
Glucagon like peptide-1 (GLP-1) analogues
Farnesoid X nuclear receptor ligand
Vitamin E
What are some autoimmune liver diseases?
Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis
Describe autoimmune hepatitis
Female predominant
Elevated IgG
Liver biopsy diagnosed
What are the 3 antibodies in autoimmune hepatitis?
Type 1 - ANA, SMA
Type 2 - LKM1
Type 3 - SLA
What is the treatment for autoimmune hepatitis?
Responds well to steroids
Long term azathioprine
Describe primary biliary cholangitis
Female predominant
IgM elevation
Intrahepatic bile duct involved
Anti-mitochondrial antibody positive
What are the symptoms of primary biliary cholangitis?
Pruritus - itching
Fatigue
What is the treatment for primary biliary cholangitis?
UDCA - helps bile flow
Describe primary sclerosing cholangitis
Male predominant
pANCA positive
Intra and extra hepatic ducts are involved
Stricturing disease
What is the presentations of primary sclerosing cholangitis?
Recurrent cholangitis
Jaundice
What is the treatment for primary sclerosing cholangitis?
Liver transplant
Biliary stents if only one major stricture
Who can get a liver transplant?
Chronic liver disease with poor predicted survival or poor QoL
Hepatocellular carcinoma
Genetic diseases - primary oxaluria, tyrosemia
What are some contraindications for transplant?
Active extrahepatic malignancy
Tumour invasion or macrovascular involvement
Active substance or alcohol abuse
Active and uncontrolled infection
How do we prioritize liver transplants in cirrhosis?
Child’s Pugh scoring A B and C
MELD score - bilirubin, creatine, INR
UKELD- same as above and sodium
What is orthotopic surgery?
Whole organ taken out and new one put in same place
What is the post operative treatment for liver transplant?
ICU care, prophylactic antibiotics, anti-fungal drugs, anti-rejection drugs
What are some anti-rejection drugs?
Steroids
Azathioprine
Tacrolimus/Cyclosporine
