Liver symposium Flashcards
What tests are done for Hep. A?
- IgM (acute disease)
- ALT
- IgG
What tests are done for Hep. B?
• Antibodies - Anti-HBs (protection) - IgM anti-HBc (acute) - IgG anti-HBc (chronic) - Anti-HBe (inactive virus) • Antigens - HBeAg (active reproduction - HBsAg (presence) - HBcAg (active reproduction not in blood) - HBV DNA (active replication)
What tests are done for Hep. C?
- ALT
- Anti HVC
- LFTs may be normal
What tests are done for Hep. D?
HBsAg
What tests are done for Non-alcohol fatty liver?
• Biochemical: AST/ALT ratio • Enhanced liver fibrosis panel (ELF) - Hyaluronic acid - TIMP1 - PIINP • Cytokeratin-18 • Ultrasound • Fibroscan • MR/CT • MR spectroscopy (quantify fat) • Liver biopsy
What tests are done for autoimmune hepatitis?
• Liver biopsy • Type 1 - ANA - SMA • Type 2 - LKM1 • Type 3 - SLA
What tests are done for biliary cholangitis?
- IgM elevated
* Anti-mitochondrial antibody positive
What tests are done for Primary sclerosing cholangitis
pANCA positive
How is Hep. A treated?
- Self limiting
* Vaccines to prevent Hep. A
How is Hep. B treated?
• Oral anti-viral drugs - Lamivudine - Adefovir - Entecavir - Telbivudine - Tenofovir • PEGylated interferons
How is Hep. C treated?
- PEG-IFN λ
* INF-free combo of direct acting antiviral drugs
How is Hep. D treated?
Very resistant to treatment
How is Hep. E treated
- No specific treatment
* No effective vaccine
How is Non-alcohol fatty liver disease treated?
• Diet and weight reduction • Exercise • Insulin sensitizers - Metformin - Pioglitazone • Glucagon: like peptide 1 (GLP-1) analogues e.g. Liraglutide • Fernasoid X nuclear receptor ligand e.g. obeticholic acid • Vitamin E • Weight reduction surgeries
How is autoimmune hepatitis treated?
- Steroids (responds well)
* Long term azathioprine
How is biliary cholangitis treated?
UDCA
How is primary sclerosing cholangitis treated?
• Liver transplant
- Orthopaedic surgeon
- Post operative ICU care
- MDT care
- Prophylactic antibiotics and antifungal drugs
- Anti-rejection drugs: Steroids, Azathioprine, Tacrolimus, cyclosporine
• Biliary stents
What are the major causes of liver disease (medical)?
- Alcohol related liver disease
- Viral hepatitis
- Non-alcoholic fatty liver disease
- Autoimmune liver diseases
- Liver transplantation
Explain the background of viral hepatitis
- Caused by 5 main types of viruses A, B, C, D and E
- Hepatitis A and E are enteric viruses (food and water)
- Hepatitis B, C and D are parental viruses (blood or blood related products)
- Hepatitis A and E cause self limiting acute infections
- Hepatitis B, C and D cause chronic disease
What is the clinical course of Hepatitis A
People get unwell, get a bit of a fever, then get jaundice and then it goes away. It usually takes 3 months
Explain Hepatitis A
- Occurs sporadically or in epidemic form
- Transmission: faecal-oral, sexual, blood
- 5-14 years the commonest age group
- Prevalence decreasing world wide
- Asymptomatic cases very common
Who gets immunised for hepatitis A?
- Travellers
- Patients with chronic liver disease: IDU (especially withy HCV or HBV)
- Haemophiliacs
- Occupational exposure: lab workers
- Men who have sex with men (MSM)
Explain hepatitis C
- 10% of patients report jaundice
- Rarely causes acute liver failure
- 85% chronic HCV infection
- Most asymptomatic until cirrhosis
- May have normal LFT’s
- Commonest way of getting it is by sharing needles
Explain hepatitis D
- Small RNA virus: does not code for its own protein coat, enveloped by HBsAg
- Co-infection or super-infection with HBV (needs hep. B for replication)
- Transmission the same as HBV
- Very resistant to treatment
What are the other viruses?
- Hepatitis F (might be a variant of B)
- Hepatitis G/ Hepatitis GB (related to HCV, might causes liver disease)
- EBV CMV (generally causes mildly dangerous LFTs only in immunocompromised hosts
- Herpes simplex (rare severe acute hepatitis)
Non-alcoholic fatty liver is an umbrella term encompassing 3 entities, what are they?
- Simple stenosis
- Non-alcoholic steatohepatitis
- Fibrosis and cirrhosis
What is non-alcoholic fatty liver associated with?
- Diabetes mellitis
- Obesity
- Hypertriglycemia
- Hypertension
What are the risk factors (that are not a disease) that cause NAFLD?
- Age
- Ethnicity
- Genetic factors
What are the criteria for a NAFLD score?
- Age
- Diabetes or impaired fasting glucose > 6.9mmol/L
- BMI
- AST:ALT
- Platlet count
- Albumin
What are the autoimmune liver diseases?
- Autoimmune hepatitis (F)
- Primary biliary cholangitis (F)
- primary sclerosing cholangitis (M)
- Overlap syndromes
- Autoimmune cholangiopathy
- IgG 4 disease
What symptoms are common in primary biliary cholangitis?
- Pruritus
- Fatigue
What are the signs of primary sclerosing cholangitis
- Recurring cholangitis
- Jaundice
Who do we transplant?
- Chronic liver disease with poor predicted survival
- Chronic liver disease associated with poor quality of life
- Hepatocellular carcinoma
- Acute liver failure
- Genetic diseases e.f. primary oxaluria, tyrosemia
What are the contraindications for transplantation?
- Active extra hepatic malignancy
- Hepatic malignancy with macro vascular or diffuse tumour invasions
- Active or uncontrolled infection infection outside of the hepatobiliary system
- Active substance or alcohol abuse
- Severe cardiopulmonary or other co morbid conditions
- Psycho social factors that would likely preclude recovery after transplantation
- Technical and/or anatomical barriers
- Brain death
How do we prioritise transplantation for patients with cirrhosis
- Child’s Pugh scoring A,B and C
- MELD score (bilirubin, creatinine and INR)
- UKELD (bilirubin, sodium, creatinine and INR)
What is the post operative treatment for transplantation?
- Post operative ICU care
- Multidisciplinary care
- Prophylactic antibiotics and anti fungal drugs
- Anti-rejection drugs: steroids, azathioprine, tacrolimus cyclosporine
