Non viral hepatitis Flashcards
In what patients should you suspect fulminant wilson’s disease?
In patient who has Neuro + Liver Involvement 🡪 must always suspect Wilson
Eg: Cachexia/tremor with depression/hallucination 🡪 suspect Wilson
What do you treat Wilson’s disease with?
Treatment with penicillamine, then Zinc
Penicillamine is a chelating agent that binds to excess Cu & removes it from bloodstream
What is a screening test for Wilson’s?
Ceruloplasmin
- A slightly low Ceruloplasmin 🡪 not v specific for Wilson
- But an almost undetectable level of Ceruloplasmin 🡪 V specific for Wilson
Ceruloplasmin is the major copper-carrying protein in the blood, and in addition plays a role in iron metabolism
What are the clinical features of ischaemic hepatitis?
- AST and ALT increases >1000
- Increased LDH (sign of cell death)
- Delayed increased in Total BR
- A/W hypoxia, decreased MAP
Autoimmune hepatitis is thought to be caused by an environmental trigger in a genetically susceptible individual.
There is increased frequency of ___________. Familial clustering has been reported and there is a strong family history of extra-hepatic autoimmune diseases e.g. ________________.
Target of injury in AIH is the _______________.
Majority of patients with AIH are identified in a bimodal age distribution
- Either in their late teenage years to early 20s or in the range of 40-50 years
- Strong ___________
HLA-DR3 and DR4
Hashimoto’s thyroiditis, RA, celiac disease, Sjogren’s;
periportal hepatocyte (zone I);
female predisposition
In what groups of patients are you suspicious of AI hepatitis?
A female patient p/w cirrhosis / deranged LFTs.
With FHx or PMHx of AI Dz eg: UC, Thyroiditis, Sjogren’s, Arthritis, Haemolytic anemia
Autoimmune hepatitis
Type 1 AIH
- Most common
- Finding of ________________ in about 80% of individuals
Type II AIH
- Uncommon, disproportionately affects ______________
- Negative ANA, ASMA
- Positive ______________
If no positive antibodies (10-20% of patients) 🡪 liver biopsy (will see _____________)
ANA and anti-smooth muscle antibodies (ASMA IgG4);
children and young adults (teens to 20s);
anti LKM (liver kidney microsome), anti-LC1;
interface hepatitis
What are the clinical features of autoimmune hepatitis?
*Note: Autoimmune liver disease is a diagnosis of exclusion. Viruses, drugs/alcohol, metabolic causes and genetics causes should be ruled out before a diagnosis of AILD is made
- Acute severe hepatitis associated with systemic symptoms and jaundice
- Malaise, rash, arthralgias
- Hepatomegaly
- Ascites, jaundice, encephalopathy - Elevation in liver enzymes which are incidentally discovered in an asymptomatic patient on routine laboratory testing
- Acute flare on background autoimmune hepatitis
What is the management of autoimmune hepatitis?
Immunosuppression therapy
- Prednisolone (induction)
- Azathioprine (maintenance)
- Other agents: Cyclosporin, MM, Tracolimus
Other agents: ciclosporin, mycophenolate mofetil and tacrolimus
Screen for other autoimmune diseases: TFT (Hashimoto), RF (RA)
[Alcoholic hepatitis]
Lies on a spectrum of alcoholic liver diseases, ranging from:
- _________ (all alcoholics): always reversible if alcohol stopped
- ______________ (~30% alcoholics): inflammation; usually reversible if EtOH stopped
- _________ (10-15% of alcoholics): potentially reversible
Pathophysiology
- Ethanol oxidation to acetaldehyde reduces NAD+ to NADH. Increased NADH decreases __________ to the liver, impairing __________ and leading to accumulation of fatty acids in triglycerides in the liver
- Alcohol metabolism: Relative hypoxia in liver zone __________ > zone____________
- Hepatocyte necrosis and hepatic vein sclerosis
Fatty liver;
Alcoholic hepatitis;
Cirrhosis;
ATP supply;
lipolysis;
III (near central veins; poorly oxygenated) ;
I (around portal tracts, where oxygenated blood enters)
What are the histological features of alcoholic hepatitis?
Ballooned hepatocytes often containing Mallory bodies (intracellular eosinophilic aggregates of cytokeratins), characteristically surrounded by neutrophils.
Chicken-wire fibrosis: network of intralobular connective tissue surround venules
What are the clinical features of alcoholic hepatitis?
History of recent alcohol binge on a background of chronic alcoholism
Severity can vary from mild liver impairment to acute liver failure
- Jaundice & coagulopathy
- Hepatomegaly, RUQ pain, low-grade fever (severe)
What are the investigations to be conducted for alcoholic hepatitis?
AST/ALT (both usually 100-300 )
Classically AST:ALT > 2:1, normal ALP, raised GGT
Raised TW
What is the management of alcoholic hepatitis?
Supportive management
- Glucose and thiamine supplementation
- Glucose b/c patient usually malnutritioned
- Thiamine to prevent development of WE & KP
Caution with drugs metabolized by the liver
Alcohol cessation and abstinence
Maddrey Discriminant Factor for prognosis
- Discriminant function = (4.6 x [prothrombin time- control pt]) + serum bilirubin
- > 32 = Poor prognosis 🡪 give prednisolone / pentoxifylline
Mortality at 1 month: 50%
NFALD
- Largely benign course of disease
- ____________ on liver biopsy
- _______________ on fibroscan
- Commonly a/w: __________________
Minimal or no inflammation ;
No fibrosis, not cirrhotic (since no inflammation to trigger fibrosis);
T2DM, obesity, metabolic syndrome, insulin resistance, HTN
