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Year 3 > Viral hepatitides (I) > Flashcards

Viral hepatitides (I) Flashcards

1
Q

What type of viruses cause hepatitis A&E?

A

RNA viruses that follow an acute course

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2
Q

What virus causes hepatitis A?

A

RNA picornavirus

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3
Q

What virus causes hepatitis E?

A

Calcivirus

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4
Q

What is the route of transmission and incubation period for hepatitis A&E?

A

Faecal oral route, 3-6 weeks incubation period

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5
Q

When is hepatitis A&E considered non-infectious?

A

Patients considered non-infectious 1 week after onset of jaundice

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6
Q

What is a common cause of hepatitis A?

A

Shellfish

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7
Q

What is hepatitis E most commonly spread by?

A

Undercooked pork

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8
Q

Where is hepatitis A endemic?

A
  • developing world - infection often occurs sub-clinically
  • better sanitisation in developed world = less common
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9
Q

Where is hepatitis E endemic?

A

Asia, Africa, Central America

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10
Q

Which group is hepatitis A associated with?

A

Travellers

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11
Q

Which type of hepatitis is more common in pregnant women?

A

Severe hepatitis in pregnant women - hepatitis E

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12
Q

What types of antibodies are involved in hepatitis A&E?

A

IgM produced, then IgG, then immunity

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13
Q

Who is chronic hepatitis E limited to?

A

Almost exclusively limited to immunosuppressed patients

(Chronic HEV = >3mth)

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14
Q

What kind of virus is hepatitis B?

A

Double-stranded DNA hepadnavirus

Enveloped, partially double-stranded DNA virus

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15
Q

What viral proteins does hepatitis B contain? (3)

A
  • core antigen (HBcAg)
  • surface antigen (HBsAg)
  • e antigen (HBeAg) - marker of high infectivity
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16
Q

What kind of virus is hepatitis D?

A
  • single-stranded RNA virus coated with HBsAg
  • defective virus - requires hepatitis B surface antigen to complete its replication and transmission cycle
  • only co-infects those with HBV or superinfects those who are already carriers of HBV
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17
Q

Who can hepatitis D affect? (2)

A
  • co-infect with hepatitis B
  • superinfect those who are already carriers of hepatitis B - we suspect hepatitis D superinfection in chronic Hep B patients who have flare-ups
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18
Q

How is hepatitis B&D transmitted? (3)

A
  • sexual contact
  • blood
  • vertical transmission (mother to child)
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19
Q

What is the incubation period for hepatitis B&D?

A

3-6 months

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20
Q

What are there no antibodies to in hepatitis B&D vaccination?

A

HBcAg (core antigen)

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21
Q

What do carriers of hepatitis B/D never make antibodies to?

A

HBsAg (surface antigen)

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22
Q

Where is hepatitis B/D common?

A

Southeast Asia, Africa and Mediterranean countries

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23
Q

What kind of virus is hepatitis C?

A

Small, enveloped, single-stranded RNA virus

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24
Q

What is classed as acute vs chronic hepatitis C?

A
  • acute <6 months
  • chronic >6 months - most common type of hepatitis to become chronic
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25
Q

How is hepatitis C transmitted? (3)

A
  • sexual contact
  • blood
  • vertical transmission (mother to child)
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26
Q

What is the incubation period for hepatitis C?

A

2 weeks to 6 months

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27
Q

Is there a vaccine for hepatitis C?

A

No

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28
Q

What is the most common liver infection globally?

A

Hepatitis B

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29
Q

Why do we generally get jaundice and pruritus in viral hepatitis?

A

Liver inflammation and hepatocyte necrosis caused by immune response = bilirubin with bile salts released into bloodstream –> jaundice + pruritus

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30
Q

Why do we generally get dark urine and pale stool in viral hepatitis?

A

Bilirubin from blood is filtered by kidneys and ends up in urine instead of stool

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31
Q

What does histology show in viral hepatitis?

A
  • inflammatory cell infiltration of portal tracts (neutrophils, macrophages, eosinophils, lymphocytes)
  • zone 3 necrosis
  • bile duct proliferation
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32
Q

How often is hepatitis E asymptomatic?

A

Approximately 95% of patients with acute hepatitis E infection are asymptomatic

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33
Q

When is hepatitis A/E more likely to be asymptomatic?

A

Children

34
Q

What are the clinical features of hepatitis A&E? (6 + 4)

A
  • acute
  • prodromal period - malaise, anorexia, fever, N&V, headache (before jaundice)
  • hepatitis:
    • dark urine
    • pale stools
    • jaundice
    • pruritus/itching
  • RUQ pain
  • pyrexia
  • hepatomegaly
35
Q

How many recover from hepatitis A/E?

A

85% make full recovery within 3 months

36
Q

What are the clinical features of hepatitis B/D? (8)

A
  • asymptomatic
  • incubation period 3-6 months
  • prodromal features - malaise, headache, anorexia, N&V, diarrhoea, RUQ pain
  • jaundice
  • dark urine - increased conjugated BR in urine
  • hepatomegaly
  • ascites
  • maculopapular or urticarial rash (part of serum sickness-like syndrome)
37
Q

What might you see on examination of hepatitis B/D? (2)

A
  • cervical lymphadenopathy
  • chronic liver disease/cirrhosis symptoms
38
Q

How does hepatitis C usually present?

A

90% of acute infections are asymptomatic

39
Q

What are the clinical features of hepatitis C? (6)

A
  • asymptomatic
  • constitutional Sx - fatigue, myalgia, arthralgia
  • jaundice
  • ascites
  • signs of hepatic encephalopathy (confusion, altered consciousness, coma)
  • extrahepatic manifestations
40
Q

What other diseases can hepatitis C lead to? (7)

A
  • arthritis
  • arthralgia
  • eye problems (Sjogren’s syndrome)
  • cirrhosis
  • hepatocellular cancer
  • cryoglobulinaemia
  • membranoproliferative glomerulonephritis (–> renal dysfunction)
41
Q

What might you see on examination in hepatitis C? (2)

A
  • skin rash caused by mixed cryoglobulinaemia –> small vessel vasculitis
  • renal dysfunction (due to glomerulonephritis)
42
Q

What are the risk factors for hepatitis A&E? (8)

A
  • living in/travel to endemic region
  • close personal contact with infected person
  • MSM
  • known foodborne outbreak
  • illegal drug use
  • homelessness
  • immunosuppression
  • infected mother (for foetus)
43
Q

What are some risk factors for hepatitis B&D? (6)

A
  • IV drug use
  • unscreened blood/products (including haemodialysis)
  • infants of HBeAg/HBsAg-positive mothers
  • sexual contact with Hep B carriers
  • born in endemic region
  • Fx of HBV, hepatocellular carcinoma and/or chronic liver disease
44
Q

What are some risk factors for hepatitis C? (6)

A
  • IV drug users
  • needlestick injury - healthcare workers
  • blood transfusions (especially before 1992)
  • non-sterile acupuncture
  • tattooing
  • haemodialysis
45
Q

What are the general first-line investigations for viral hepatitis? (4)

A
  • LFTs + bilirubin
  • urinalysis
  • viral serology (diagnostic)
  • U&Es
46
Q

In general, what do LFTs show in viral hepatitis? (5)

A

Raised:

  • AST
  • ALT
  • ALP (generally not as elevated as AST&ALT)
  • bilirubin
  • GGT
47
Q

What would we see in bloods in viral hepatitis? (4)

A
  • high ESR
  • low albumin
  • high platelets
  • high PT in severe liver disease
48
Q

What might uranalysis show in viral hepatitis? (2)

A
  • positive for bilirubin
  • raised urobilinogen
49
Q

What is the test of choice for diagnosis of hepatitis A?

A

IgM anti-hepatitis A virus serology

50
Q

What serology does hepatitis A have? (2)

A
  • anti-hepatitis A IgM present during acute illness, disappears after 3-5 months
  • anti-hepatitis A IgG persists indefinitely after infection/vaccination
51
Q

What serology does hepatitis E have? (2)

A
  • anti-hepatitis E IgM for active infection
  • anti-hepatitis E IgG for past infection
52
Q

What test is generally positive in hepatitis B?

A

HBsAg positive (surface antigen)

53
Q

What would you find in acute hepatitis B?

A

HBsAg positive & IgM anti-HBcAg positive

54
Q

What would you find in chronic hepatitis B?

A

HBsAg positive & IgG anti-HBcAg positive

May be HBeAg positive or negative (correlates with severity)

55
Q

What would you find in hepatitis B cleared?

A

Anti-HB antibody positive & IgG anti-HBcAg positive

56
Q

What would you find in hepatitis B vaccinated?

A

Anti-HB antibody positive and everything else negative (no IgG anti-HBcAg like in hep B cleared)

57
Q

What is HBeAg in hepatitis B?

A

Marker of infectivity - higher means more infectious and so more likely to transmit

58
Q

How do we detect hepatitis D?

A

IgM or IgG against hepatitis D virus with PCR

59
Q

What is high in severe cases of hepatitis B/D?

A

PT = sensitive marker for significant liver damage

60
Q

How do we detect hepatitis C?

A

Anti-hepatitis C antibodies + RT-PCR

  • IgM = acute
  • IgG = past exposure or chronic
61
Q

What more invasive investigation can be done for viral hepatitis?

A
  • liver biopsy - assess degree of inflammation and liver damage
  • percutaneous/transjugular if clotting deranged or ascites present (hepatitis B/D)
  • useful for diagnosing cirrhosis (hepatitis C)
62
Q

What marker can we test for in viral hepatitis?

A

Alpha-fetoprotein (AFP) for those with hepatitis B/C as high risk of cancer

63
Q

What are some differential diagnoses for viral hepatitis? (11)

A
  • EBV infection - lymphadenopathy and splenomegaly
  • Coxsackie virus - buccal/pharyngeal lesions, hand-foot-and-mouth disease
  • CMV infection
  • HSV infection - cutaneous ulceration
  • biliary atresia - jaundice 0-8wk of age
  • autoimmune hepatitis
  • alcoholic hepatitis
  • ischaemic hepatitis
  • drug-induced hepatitis
  • A1AT disease
  • Wilson’s disease
64
Q

How do we manage acute viral hepatitis?

A

Bed rest and supportive, symptomatic treatment (e.g. antipyretics, antiemetics or cholestyramine for severe pruritus)

65
Q

What can we give for chronic hepatitis B/C? (3)

A
  • interferon alpha (antiviral) - standard or pegylated (increased half-life) - cytokine which augments natural antiviral responses
  • hepatitis C: ribavirin (guanosine nucleotide analogue)
  • nucleoside/nucleotide analogues (entecavir, adefovir, telbivudine, tenofovir)
66
Q

What should we screen for in viral hepatitis patients?

A

HIV

67
Q

How can we prevent hepatitis A? (4)

A
  • hepatitis A vaccine (no vaccine for hepatitis E)
  • safe water
  • sanitation
  • food hygiene
68
Q

What are the main principles for treatment of hepatitis A? (2)

A
  • symptomatic management
  • avoid alcohol and excess paracetamol
69
Q

What are indications for antiviral treatment in hepatitis B (low yield)?

A
  • chronic hepatitis (ALT and hepatitis B DNA levels)
  • compensated cirrhosis and HBV DNA>2000iu/ml
  • decompensated cirrhosis and detectable HBV DNA by PCR
70
Q

What do we give for chronic hepatitis B?

A

Interferon alpha (antiviral - cytokine that increases natural antiviral responses)

71
Q

How do we prevent hepatitis B/D? (4)

A
  • hepatitis B vaccine
  • blood screening
  • safe sex
  • instrument sterilisation
72
Q

What antivirals can we give for hepatitis C? (2)

A
  • interferon alpha
  • ribavirin
73
Q

How can we prevent hepatitis C? (2 + 1)

A
  • blood screening
  • instrument sterilisation
  • no vaccine available for hepatitis C
74
Q

What type of disease is viral hepatitis (A-E)?

A

Notifiable disease

75
Q

What types of viral hepatitis is there a vaccine for?

A

Only hepatitis A&B

  • active immunisation with attenuated hepatitis A vaccine offers safe and effective immunity for those travelling to endemic areas and high-risk individuals
  • passive immunisation with IM human immunoglobulin effective for short time
76
Q

What are some complications of viral hepatitis? (7)

A
  • fulminant hepatic failure (especially in pregnant women) - mortality 80%
  • cholestatic hepatitis
  • post-hepatic syndrome (malaise for months)
  • cirrhosis
  • hepatocellular carcinoma (NOT hepatitis A/E)
  • chronic hepatitis
  • extra-hepatic manifestations (rare, hepatitis C): cryoglobulinaemia, AIHA, glomerulonephritis (also in Hep B), leukocytoclastic vasculitis, diabetes, hypothyroidism, skin conditions
77
Q

What is an extra-hepatic manifestation ONLY seen in hepatitis B?

A

Polyarteritis nodosa - systemic upset, nodular and ulcerating skin lesions and mononeuritis complex, skin biopsy –> non-granulomatous necrotising vasculitis

78
Q

What are the most common causes of hepatocellular carcinoma (complication of hepatitis B&C)?

A
  • most common cause worldwide = chronic Hep B
  • most common cause in Europe = chronic Hep C
79
Q

What are some risk factors for hepatocellular carcinoma (complication of hepatitis B&C)? (5)

A
  • liver cirrhosis secondary to Hep B&C
  • alcohol
  • NAFLD
  • A1AT deficiency
  • haemochromatosis
80
Q

How do we investigate hepatocellular carcinoma (complication of hepatitis B&C)? (2)

A
  • raised alpha-fetoprotein (AFP) - useful diagnostic marker
  • screening with US and AFP - for people with cirrhosis secondary to Hep B/C, haemochromatosis or alcohol
81
Q

Describe the prognoses of viral hepatitis. (3)

A
  • hepatitis A&E: usually recover within 3-6 weeks
  • hepatitis B&D: 10% become chronic, of these 20-30% develop cirrhosis
  • hepatitis C: 80% become chronic, of these 20-30% develop cirrhosis

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