Viral Hepatitis Flashcards
What causes hepatitis
Presentation
- Asymptomatic
- Abdo pain
- Fatigue
- Arthralgia
- N+V
- Fever
- Jaundice if high bilirubin
- Fever
- Higher ALT / AST than ALP
Can lead to cholestasis which differentiates from normal flu
- HSM - painful
- Dark urine / pale stools
- Pruritus
Hep ABCDE Autoimmune Drug induced Alcohol and NAFLD CMV, EBV, HIV Herpes Enterovirus VZV Rubella Q-fever, Yellow fever, Psittacosis, Leptospirosis Ischaemia
How is hep A spread
Foecal oral
Contaminated food or drink
Most common travel
What are the symptoms of hep A
Short incubation - 28 days Benign and self limiting Mild flu Period of fever / malaise Anorexia N+V Abdominal pain Jaundice Pruritus
Can lead to cholestasis
Dark urine / pale stool
HSM – painful
Who is at high risk and offered immunisation
Travellers CHronic liver Occupational exposure Haemophiliac Homosexual PWID
How do you Dx Hep A
Abnormal LFT
IgM HAV
IgG shows past exposure
FOB
How do you treat hep A
No treatment as self limiting 1-3 months
Relieve pain / itching / nausea
Human Ig lasts 4 months
Vaccine to prevent if high risk
What are complications of hep A
Prolonged fatigue / jaundice
No chronic damage or HCC risk
How is hep B spread (DNA virus)
Blood Sexual Vertical to babies Horizontal among children Carrier states exist but less likely to be chronic than hep C
How infective is hep B
Very 100x more than HIV
What are the symptoms of hep B
Long incubation - 6 weeks (need to wait 4 to test) Flu prodrome Fever Headache Fatigue ANorexia N+V Abdo pain Arthralgia / myalgia DIarrhoea Skin lesion / urticaria
CHolestasis
Pruritus / dark urine / pale stool
Jaundice + HSM develop which DDX from other flu
What is suggestive of hep B
Non-specific Hx
Jaundice
ABnormal LFT
What is the risk of neonates / adults developing chronic infection
90% neonate if infected mother
70% children
Adults = 5-10%
Who is at risk of hep B
Chronic liver Travellers MSM Haemophiilac / dialysis IVDU Healthcare
What is fulminant hepatic encephalopathy
DIC
Encephalopathy
Hypoglycaemia
Prolonged PT
Hep B serology
HBsAg = surface antigen (first to appear in acute infection)
HBcAg = core antigen
HBeAg = released by core when active
HBV DNA = viral DNA
If antigen detect then you have infection
e = current and highly infectious
s = acute or chronic
What suggests highly infectious
HBeAg + HBV DNA
Consider infectious even if e antigen is -ve due to risk of mutation
What suggests chronic hep B
HBeAg or surface antigen >6 months
How do you interpret serology
Anti-HBs
- Implies immunity, develop as lose surface antigen and infection clears
- Either exposure or immunisation
- -ve in chronic as not cleared
Anti-HBc
- C = caught (previous or current)
- -ve if vaccine
IgM HBc
- Acute and lasts 6 months
IgG HBc
- Persists forever and shows past infection NOT vaccine
Anti-IBe
- Inactive virus
What suggests previous immunisation
Anti-Hbs
All other -ve
What suggests hep B 6 months ago
Anti-Hbs
Anti-HBc
IgG HBc
HBsAg -ve
What suggest previous hep B but now carrier / chronic
HbsAg +ve = chronic
Anti-HBc
How do you dx hep B
Serology
Liver enzymes
What should you do if testing for hep B
Test for HIV and hep D
Who gets tested for hep B
High endemic IVDU MSM At risk heterosexual HIV / HCV Anti-TB / immunosuppressed / chemo Persistent abnormal LFT - no cause Pregnant Babies born to +ve mother Needle stick Household contact Prisoners = BBV Blood transfusion / long term dialysis
How do you Rx acute hep B
No Rx
Self limiting
Prevent with vaccine
Can give Ig if needle stick
What do you advice someone with hep B
Public health <5% become chronic NO alcohol / sex Household precaution Vaccinate contacts
When do you test for HIV / HBV / HCV
6 months
What are complications of HBV
10% chronic Cirrhosis HCC Liver failure Membranous GN Polyarteritis nodosa Cyroglobulinuria Vasculitis rash
When do you consider treatment of chronic
2+ of Abnormal LFT High viral load Abnormal fibroscan / cirrhosis HbeAg +ve (DNA / ALT raised)
What do you do otherwise
Monitor
Some stages of chronic are highly infectious
How would you treat
Anti-viral (nucleoside analogue) = 1st line
Pegylated interferon (anti-viral + immune)
Liver transplant if cirrhotic
Monitor renal function
Interferon less successful in chronic
What is prophylaxis in hep B if exposed
Vaccine to newborn at birth, 4 weeks and 12 months as well as normal 3
HBIG if HbeAg at birth
If on chemo / immunosuppressed / contact = vaccine and Ig
What do you do after vaccine
Check Anti-Hbs levels at 3 months
If chronic liver / healthcare
How do you monitor and follow up hep B
Clinic
LFT
Fibroscan
Advise if become immunocompromised
When can you not perform invasive procedure
HbeAg or HbsAg +Ve
High HBV DNA
Hep C
Who is at risk of no response to vaccine
Obesity Alcohol SMoking >40 Immunocompromsie
How do you treat hep B in pregnancy
Tenofavir safe Obstetric team Advise delivery Passive and active to newborn Can breast feed Test baby at 1 year
How is hep C. spread (RNA)
Blood - IVDU / snort - more common hep C
Little sexual / placental
Can breast feed
Can you become immune to hep C
No so can get reinfected
No vaccine
What are the symptoms of hep C
Short incubation Flu like symptoms Malaise Anorexia Fatigue Arthralgia 10% jaundice
What are complications of hep C
85% = chronic Cirrhosis HCC Sjogren Cryoglobulinuria Membranous GN
What is chronic defined as
HCV RNA >6 months
Who is more likely to het fulminant hepatitis
Pregnancy
Elderly
Immunocompromised
What suggests cirrhosis
ALT up
Platelet down
Test other BBV
HCC surveillance
Who is at risk of hep C
Alcohol accelerates HIV accelerates IVDU Haemophiliac Transfusion pre screen Dialysis Tattoo / piercing
How do you Dx hep C
Increased LFT No IgM IgG not detected for months HCV antigen detection or HCV RNA - PCR HCV Ab if chronic or previous exposure If Ab +ve but RNA -ve = cleared or treated
When do you retest for hep C
3-6 months to make sure
When do you treat hep C
If Ab and antigen +ve
How do you treat hep C
Now curable Anti-viral 3 months Protease inhibitor - interferon and ribavirin = 1st line Interferon no longer NO PEP or VACCINE
How do you prevent hep C
Don’t share needles
Donor screen
Cover wounds
Do monthly PCR if on PEP and Rx if seroconversion
What are SE of ribavirin
Teratogenic so don’t get pregnant 6 months
Haemolytic anaemia
Cough
What are the SE of interferon
Thrombocytopenia Leukapenia Fatigue Depression Flu
What does response to Rx of hep C depend on
Age
Gender
Liver disease
Amount of virus
What are types of response to hep C Rx
Non Responder
Viral Breakthrough
Relapse - when Rx stopped
Sustained viral after 6 months = 95%
How is hep D transmitted
Same as hep B
But requires hep B surface antigen
What are the symptoms of hep D
More severe hep B and rapid progression if co-infection
Suspect if acute flare up
How do you Dx hep D
IgM and IgG
PCR = Dx
How do you treat hep D
NO vaccine
Pegylated interferon
Transplant
Prevent hep B
What are the complications of hep D
Chronic B
Cirrhosis
HCC
Fulimant hepatitis
How is hep E spread
Foecal oral
What is the most common hepatitis
E
Screen in any acute liver injury
What are the symptoms of hep E
Short incubation = 40 days
Mild
Like HAV
Jaundice <1%
When is hep E dangerous
Pregnancy = high infant mortality (diff hep A) due to fulminant
Elderly men
What are extra hepatic complications of hep E
AKI - think if no cause Pancreatitis Bell's Palsy GBS Neuralgic arthropathy - brachial plexus pain Arthtiris Anaemia
Who is at risk of hep E
Occupational - farm
Blood transfusion due to short viraemia phase
When do you suspect hep E
Deranged LFT for alcohol consumption
How do you Dx hep E
IgG and IgM
HEV PCR serology
Abnormal LFT
What is chronic hep E
> 3 months
No dip in HEV RNA 6 months
How do you treat hep E
No specific Rx or vaccine
Clean water and avoid undercooked meat
What are complications of hep E
Persistent in immunocompromsied
Liver failure if CLD
Do you notify government
YES
What vaccines do chronic liver patients get
Pneumococcal one off
Influenza annual
What is the window period
Point in infection where surface antigen and antibody = zero
Not actually zero just in equilibrium
Core Ab only thing that is +Ve
