Liver Symposium Flashcards by Sophie Pitcairn

Describe hepatitis A and E

Enteric viruses
Cause self limiting acute infections

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Describe hepatitis B,C and D

Parental viruses
Cause chronic disease

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How is hepatitis diagnosed?

IgM antibodies
5-14 commonest group
Asymptomatic is common

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Describe hepatitis A (HAV)

Occurs sporadically or in epidemic form
Transmission is faecal, sexual or blood

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Who is immunised for HAV?

Travellers
Patients with chronic liver disease
Haemophiliacs
Occupational exposure
Men who have sex with men

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What are some HBV antigens the presence of virus?

Hep surface antigen - HBsAg

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What are some HBV antigens which show active replication?

Hep e antigen - HBeAg
Hep core antigen - HBcAg
HBV DNA

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What are some HBV antibodies?

Anti-HB
IgM anti-HB
IgG anti-HBc
Anti-HBe - inactive virus

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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)

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What are the treatment options for HBV?

Pegylated interferon
Oral antiviral drugs - Tenofovir is mostly used

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Describe hepatitis C

Rarely acute, 85% chronic
Most asymptomatic until cirrhotic
May have normal LFTs
RNA virus

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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

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What is used to treat HCV?

IFN-free combination of direct acting anti-viral drugs

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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

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Describe Hepatitis E

Commonest cause of acute hep in Grampian
Self limiting and no specific treatment or vaccine

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What are some other viruses?

Hep F, G, GB
EBV, CMV and herpes simplex

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What can herpes simplex cause?

Rare severe acute hepatitis

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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