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Phase 2 1. Gastroenterology > Viral hepatitis > Flashcards

Viral hepatitis Flashcards

1
Q

What is hepatitis?

A

inflammation of the liver

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2
Q

What changes are seen in acute hepatitis?

A

o Inflammation of the liver
o Raised ALT / AST
o Jaundice
o Clotting Derangement

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3
Q

What changes have been seen in chronic hepatitis

A

o Hepatitis virus present for more than 6 months
o Jaundice has normally settled by this point
o Variable changes in Liver Function

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4
Q

What can cause acute hepatitis?

A
  • infections
  • toxins
  • drugs
  • alcohol
  • autoimmune
  • Wilsons
  • Haemochromatosis
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5
Q

What infections can lead to acute hepatitis?

A 
o Hep A, B, C, D, E
o EBV, CMV, Toxoplasmosis
o Leptospirosis
o Q Fever
o Syphilis
o Malaria
o viral haemorrhagic fever
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6
Q

Describe the transmission of the hepatitis A virus

A

o Faeco-oral transmission
o Contaminated water and food
o Person-person
o Humans are the only reservoir

Virus shed via biliary tree into gut and faeces

Virus can survive for months in contaminated water

No chronic carriage

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7
Q

Describe the epidemiology of hepatitis A

A

 Highly prevalent in areas of poor public health
infrastructure
o Poor water and sanitation
 In UK, mostly seen in travellers

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8
Q

What is the incubation period for hepatitis A?

A

~30 days

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9
Q

What symptoms are associated with hepatitis A infection?

A

Fever, abdominal pain, diarrhoea, jaundice, itch,
muscle pains

o Flu-like symptoms + jaundice

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10
Q

What is the outcome of hepatitis A infection?

A

 Usually self-limiting illness
o Very low death rates

 Age is main determinant of severity
o Mostly asymptomatic in children 50 year – but rare in this age group

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11
Q

How is hepatitis A managed?

A

 No specific treatments
 Maintain hydration, avoid alcohol
 No role for vaccine or IgG
o Preventative vaccine exists but no vaccine for treatment

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12
Q

What are the test results of hepatitis A patients

A

 Acute Hep A: IgM Positive or RNA in blood or stool (using PCR – tests for the viral nucleic acid)

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13
Q

What are the test results of a patient who has been vaccinated against hepatitis A

A

IgG Positive

IgM suggests a new infection, whereas IgG (mature antibody) suggests secondary response/immunity

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14
Q

Describe the hepatitis A vaccine

A
  • inactivated virus
  • protection 4 weeks after dose
  • 2nd dose gives life protection
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15
Q

When is the hepatitis A vaccine given?

A

Pre-exposure:

  • travellers
  • homosexual men
  • IVDU
  • chronic liver disease patients

Post-exposure:
- outbreak control

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16
Q

What is the hepatitis A immune globulin and when is it given?

A
  • pooled immunoglobulin
  • confers 3-6 months immunity

Pre-exposure:

  • if vaccine allergic
  • <4weeks to travel

post-exposure:
- outbreak control

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17
Q

Summarise hepatitis A

A 
 RNA virus
 Faeco-oral spread
 1 month incubation
 Diagnosed by IgM to Hep A, and deranged Liver Tests
 Very low death rate
 No specific treatment
 No chronic carriage
 Travel related, rare in UK
 Excellent vaccine
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18
Q

Describe the hepatitis E virus

A

 RNA virus
 More common now than Hep A in the UK
 Incubation period 40 days
 4 Genotypes

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19
Q

How is hepatitis E transmitted?

A

o Faeco-oral
o Pork products
o Minimal person-to- person transmission

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20
Q

What is the epidemiology of hepatitis E

A

 Much more common now in the UK than it used to be
o Appears to be related to contact with contaminated pork
o More common than Hepatitis A
 Between 1996 and 2003, only 9% of cases were acquired in the UK
 71% of 2012 cases were acquired in the UK

Chronic Hep E is seen in very immunosuppressed patients, e.g. bone marrow transplants.
o Hazard for the patient and the wards they visit (lots of immunosuppressed patients)

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21
Q

What are the clinical symptoms of hepatitis E

A

Fever, abdominal pain, diarrhoea, jaundice, itch,
muscle pains
o Flu-like symptoms + jaundice

(Similar to Hepatitis A plus rare reports of neurological effects)

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22
Q

What is the neurological manifestation of hepatitis E

A 
 May be genotype (GT) 3 associated
 5% patients affected in one series
o Guillaine Barre syndrome
o Encephalitis
o Ataxia
o Myopathy
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23
Q

What is the fatality rate of Hepatitis E

A

Case-fatality rate: 1 - 3%

o Fatality rate is higher in Pregnant women for some genotypes (especially GT 1)

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24
Q

How is hepatitis E managed?

A

Treatment: Supportive

No Vaccine

Treatment with ribavirin

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25
Q

Summarise Hep E

A

 High mortality, esp. in Pregnancy with GT 1
 No Vaccine
 No Immunity
 Increasingly recognised as a cause of hepatitis in UK
 Neurological complications described
 Chronic carriage in some

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26
Q

What is the link between hepatitis B and mortality?

A

o Causes chronic liver inflammation, ALT remains elevated
o Results in liver scarring and eventual cirrhosis
o Liver decompensation/upper GI haemorrhage (due to varices) can result
o High risk of hepatocellular carcinoma

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27
Q

How is hepatitis B transmitted?

A
  • transfusion (blood, blood products)
  • fluids (blood, semen)
  • organs and tissue transplant
  • child to child
  • mother to child (vertical transmission at birth)
  • contaminated needles and syringes
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28
Q

What are the common modes of transmission in the tropics?

A

 Majority of infections occur vertically or during childhood by horizontal transmission between children
and infected persons
o Child to child transmission – children fighting/playing
 Contact with open sores, scarification, circumcision, bedbugs
 Not transmitted by Mosquitoes
 Sexual
 Iatrogenic

29
Q

What are the common modes of transmission in the UK?

A

 95% of new diagnoses in the UK are immigrants infected elsewhere moving to the UK
 Many are picked up on antenatal screening of pregnant women
 New sexual infections in UK are rare

30
Q

Describe acute hep B infection

A

 Incubation: 2 - 6 months
 Fever, fatigue, jaundice, myalgia, joint pains
 Acute case-fatality rate: 0.5% - 1%
 Age at the time of infection determines:
1. Severity of acute illness
2. Risk of Chronic HBV Infection (CHB)

31
Q

How can age affect the chronicity of hep B?

A

 Infection at birth / young child is usually asymptomatic but leads to chronic infection
o Baby has very little independent immune system and cannot fight the infection  becomes
chronically established
o Lack of symptoms (clinical illness) is also because of the lack of immune response
o Newborn babies should be vaccinated to prevent lifelong infection
 Infection as an adult is usually symptomatic but cleared

32
Q

What symptoms are associated with Hep B infection?

A 
 Weight loss, abdominal pain, fever
 Cachexia
 Mass in abdomen s
 Bloody ascites (malignant ascites)
o Suggests hepatoma
 HB sAg +ve
33
Q

What are the complications associated with chronic hepatitis B infection?

A 
 Development of chronic liver disease in 25%, particularly those infected as babies
o Cirrhosis
o Decompensation
o Hepatocellular Carcinoma (HCC)
o Death
34
Q

How do we test for Hepatitis B Serology?

A 
sAg - Surface antigen
sAb – Surface antibody
cAb – Core antibody
eAg – e antigen
eAb – e antibody
HBV DNA
35
Q

What is the surface antigen?

A

marker of infection
o blood test to check for infection
o sAg present = infected

36
Q

what is the surface antibody?

A

marker of immunity
o Only seen in people who have been infected in the past
but have cleared the virus
o Seen in vaccinated individuals

37
Q

What is the core antibody?

A

o Definitely been infected (currently or in the past)

o Check surface antigen to determine if infection is active

38
Q

What is the significance of the e antigen?

A

suggests high infectivity

39
Q

What is the significance of the e antibody?

A

– suggests low infectivity

40
Q

What is the purpose of testing for HBV DNA?

A

Measures how much of the virus is in the blood

41
Q

How is hepatitis B diagnosed?

A

HBV infection is diagnosed if sAg or DNA are detectable

HBV cAb + only, means past infection but now cleared

42
Q

What should you test for alongside hepatitis B and C?

A

always test patient for HIV (also with Hep C) because they have the same transmission route

43
Q

How does liver damage occur in hepatitis b

A

Liver damage occurs when the body tries to fight the virus

 The damage increase the risk of liver cirrhosis and hepatocellular cancer

44
Q

How are chronic hepatitis B patients classified?

A

sAg detectable for >6/12

  • eAg +ve (early disease)
  • eAg –ve (late disease)
45
Q

What are the features of chronic hep b (early disease)?

A

o High Viral Load
o High risk of chronic liver disease and hepatocellular carcinoma
o Highly infectious

46
Q

What are the features of chronic hep b (late disease)?

A

o Low viral load
o Lower risk of CLD and HCC
o Less infectious

47
Q

How is acute HBV treated?

A

o No treatments

48
Q

How is chronic hbv treated?

A

 Chronic HBV
o Treat those with liver inflammation (LFT and Biopsy)
o Small number, <5%, will clear sAg spontaneously
o Aim of treatment is NOT to cure, but to suppress viral replication +/- to convert from eAg+ to eAb+

49
Q

What two types of therapy can be used in chronic Hep b?

A
  • immunological (Pegylated interferon alpha)

- antiviral (Tenofovir/Entecavir)

50
Q

Describe the use of immunological therapies in chronic hep b

A

Pegylated interferon alpha
 Increases cellular immune responses, boosts immune system to prevent further damage
 Lots of side-effects – flu-like symptoms for entire duration of treatment
 Injection in the stomach once a week
 1 year course of medication

51
Q

Describe the use of antiviral therapies in chronic hep b

A

(nucleoside/tides) to suppress viral replication
o Tenofovir
o Entecavir
o NB: no major side effects, but once started, treatment continues for life

52
Q

How can hep b be prevented?

A 
 Education (safe sex, injecting etc.)
 Screening of pregnancy women / doctors
 Protect blood supply &amp; hospital supplies
 Immunisation:
o Active (HBV sAg Vaccine)
 High risk groups in UK
 All in USA, most African / Asian countries
o Passive (HBIG)
 Babies born to some HBV+ mothers
 Post exposure in non-immune
53
Q

What is the risk of hbv transmission from mother to baby dependent on

A

depends on mother’s viral load

54
Q

What interventions are in place to prevent hbv transmission from mother to baby

A
  1. HBV vaccination
    => given to all newborns
  2. HBV Immunoglobulin
    => given if mother is eAg+ or has high viral load
  3. Tenofovir
    => given during the last trimester if high VL (>10 6 IU/mL)
    - Aims to reduce mother’s viral load to try and prevent transmission
55
Q

Describe hepatitis D

A

 ss RNA virus
 Requires HBV to replicate (unable to replicate on its own)
o Can only be present with Hepatitis B

56
Q

How is hepatitis D transmitted?

A

 Transmission same as Hep B, but vertical transmission is rare
 Acquired by:
o Co-infection with HBV
 Infection at the same time
o Super-infection of chronic HBV carriers
 Patient is infected with hep B and then catches Hep D

57
Q

What complications are associated with hepatitis d

A

Increases risk of chronic liver disease

58
Q

How is hep d treated?

A

Peg IFN only

59
Q

Summarise hep B and D

A

 Blood / Sex / Needle Transmission
 Hep D requires Hep B to survive
 Chronic Carriers have risk of Cirrhosis and Cancer
 Hep B is most common Hepatitis Virus worldwide
 Preventable by excellent vaccine
 Vaccine used only in high risk groups in UK
 Treatments for Hep B are not curative, but reduce risk of complications and reduce infectivity

60
Q

How is hepatitis c transmitted?

A

Transmission:
o Injecting drugs
o Transfusion + Transplant
o Sexual/vertical transmission are rare

61
Q

How is hep c prevented?

A

No vaccine, no post exposure prophylaxis

62
Q

Describe hepatitis c in scotland

A

 Most common hepatitis virus in Glasgow (0.7% Scottish population)
 Most commonly seen in drug users (> 50% of Injecting Drug Users are
hep C infected)

63
Q

What is the incubation period for hepatitis c

A

Incubation period average 6-7 weeks

64
Q

How does hepatitis c present?

A

 Mostly asymptomatic

 Most diagnosed by screening of high risk groups

65
Q

How is hepatitis c diagnosed?

A

 Test for antibodies (IgG) first
o Anti HCV IgG positive = chronic infection or cleared infection
 Then test for virus itself (antigen test or PCR test)
o PCR or Antigen positive = current infection / viraemia

66
Q

What is the aim of hep c treatment?

A

“Sustained Virological Response”

= Cure
= PCR negative 12 weeks after
treatment

67
Q

How is hep c treated?

A

Direct Acting Antivirals (DAAs) have substantially increased the chance of cure
 Sofosbuvir
 Simeprevir
 Ledipasvir

Highly effective but very expensive SMC approved drugs for HCV

Different drugs target
different aspects - Can be used in combination

68
Q

How is Direct-Acting Antivirals regimen decided?

A

according to Genotype and degree of fibrosis / cirrhosis

69
Q

Summarise hep c

A

 Hep C is most common Hepatitis Virus in UK
 Needle / Blood Transmission
 Infection is usually asymptomatic and not noticed
 70% develop Chronic infection and at risk of cirrhosis
 Treatment aim is to cure
 Newer antiviral drugs cure nearly all
 No Vaccine and no reliable immunity after infection

Phase 2 1. Gastroenterology (20 decks)

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