Viral hepatitis Flashcards
Hepatitis: presentation
a) Acute symptoms
b) Acute signs
c) Blood results
d) Chronic hepatitis
e) Decompensated liver disease: clinical and biochemical findings
a) - May be asymptomatic
- General malaise, Myalgia, GI upset, Abdominal pain
- Jaundice (+/- pale stools, dark urine)
b) Tender hepatomegaly, jaundice
c) Raised AST, ALT (+ GGT, ALP) +/- Bilirubin,
- Positive serology
d) - Clubbing, palmar erythema, gynaecomastia, spider naevi, Dupuytren’s contracture, etc.
- May cause cirrhosis and HCC
e) - Clinical: jaundice, ascites, encephalopathy, portal hypertension and bleeding varices (haematemesis, malaena)
- Biochemical: low albumin, coagulopathy (raised PT)
Hepatitis: causes
a) Viral
b) Non-viral infective
c) Drug causes
d) Non-infective
a) - Hepatitis A to E
- Herpes viruses (e.g. EBV, CMV, VZV)
b) Leptospirosis, Toxoplasmosis, Coxiella (Q fever)
c) Acute hepatitis.
- Anti-TB drugs
- Anticonvulsants
- Methotrexate
- Azathioprine
- Amiodarone
- Paracetamol poisoning
- Antibiotics (eg. co-amoxiclav)
Chronic liver disease (cirrhosis).
- Methotrexate
- Amiodarone
Cholestasis.
- Steroids (anabolic)
- Oestrogens
- Erythromycin
d) Alcohol, Toxins / Poisoning, Pregnancy, Autoimmune, Hereditary metabolic (eg. haemochromatosis, Wilson’s)
Hep A virus.
a) Transmission
b) At risk groups; prevention
c) Clinical
d) Investigations
e) Management
a) Faeco-oral transmission from Contaminated food or water, shellfish
b) Travellers, food handlers
- Prevention: Hep A vaccine, handwashing, washing and cooking food properly, avoid tap water in endemic areas
c) Acute hepatitis only, usually self-limiting - Fulminant hepatic failure risk very low (< 1%)
d) - Hep A antibody test (appears ~ 3 - 4 weeks post-exposure): IgM indicates acute infection and IgG indicates past infection or immunisation
- LFTs - raised ALT and bilirubin
- Clotting - usually normal; raised PT in acute liver failure
e) Supportive:
- Monitor liver function
- Management of close contacts (HNIG, vaccine)
- Primary prevention: vaccination (travel)
- Notify PHE
Hep E virus.
a) Transmission
b) Main reservoir
c) Differences to Hep A infection (3)
a) Faecal-oral
b) Pigs
c) - No vaccine
- can cause chronic hepatitis
- more serious in pregnancy (mortality ~ 20%)
Hep B virus.
a) Transmission, incubation and risk factors
b) Investigations and diagnosis
c) Management: acute
d) Prevention
e) Chronic infection: risk, diagnosis and management
f) Hep B is the only of the hepatitis viruses with what structure?
a) - Contact with infected blood/fluids
- Incubation ~ 1 - 3 months
- RFs: IVDU, needle stick (6-20%), Tattoos, Sexual, Vertical (90% of pregnancies of Hep B+ women)
b) Hep B serology.
- Acute infection: surface ANTIGEN (HBsAg) - high IgM - detectable ~ 30 days post-exposure
- Past infection: core antibody (HBcAb) - low IgM
- Immunised: surface ANTIBODY (HBsAb) - low IgM
- Chronic infection: HBsAg in serum for > 6 months
Other Ix.
- LFTs, clotting, FBC;
- if chronic - antibody tests for Hep C and HIV; USS liver
c) - Supportive: fluids, rest, antiemetics, avoid alcohol
- Stop any non-essential hepatotoxic medication
- Monitor liver function (hepatology support)
- Management of contacts (vaccine +/- HBIG)
- If decompensated: Interferon antiviral treatment
- Partner notification and contact tracing (note: infectious for as long as HBsAG is present)
- Notify PHE
d) Vaccine at 0, 1, and 6 months (or 0, 7 and 21 days)
e) - Around 5% chronic (risk of cirrhosis and HCC)
- Confirmed by presence of Hep B surface antigen (HBsAg) in the blood or serum for > 6 months
- Supportive as above + tenofovir
f) DNA virus (the others are RNA viruses)
Hep D virus
a) Requires what other virus to infect? (can cause superinfection)
a) Hep B virus
Hep C virus
a) Risk of chronic disease
b) Transmission and risk factors
c) Clinical features
d) Who should be screened for Hep C?
e) Investigations
f) Management
g) Prevention
h) People with Hep C more likely to get which diseases?
a) 70% (of these, around 10 - 40% develop cirrhosis)
- Risk of ESLD and hepatocellular carcinoma
b) Blood-borne;
- RFs: IVDU, sex with affected person, needlestick injury, transfusion pre-1991, vertical transmission, HIV
c) - Acute: mostly asymptomatic; may have jaundice or deranged LFTs
- Chronic: persistently deranged LFTs
d) - Anyone with unexplained abnormal LFTs
- Anyone in an at-risk group
e) - Acute: serum HCV RNA
- Chronic: serum HCV antibody (takes ~ 3 months to appear)
- Other hepatitis serology: Hep A IgM, HBsAg (active Hep B), HBcAb (past Hep B)
- Other bloods: FBC, U+Es/creatinine, LFTs, clotting, etc.
- Other STIs: HIV +/- chlamydia/gonorrhoea
- Imaging (in chronic Hep C): USS liver +/- transient elastography or biopsy to diagnose cirrhosis
f) Conservative.
- Supportive treatment
- Avoidance of alcohol and maintenance of healthy diet and weight
- Avoidance of hepatotoxic medication
- Sexual contacts/IVDU contact notification
- Safe sex and safe needle practice
Medical.
- Antiviral therapy: Peginterferon alfa + ribavirin (all patients with chronic Hep C or decompensation)
Surgical.
- Liver transplantation
g) - No vaccine
- Target risk factors (condoms, needle exchange, etc.)
- Avoid needlestick injuries
h) - Diabetes
- Autoimmune (eg. Sjogren’s, autoimmune hepatitis, thyroiditis)
Viral hepatitis: summary
A is Acquired by mouth from Anus, is Always cleared Acutely and only ever Appears once
E is Even in England and can be Eaten, if not always beaten
B is Blood-Borne and if not Beaten can Be Bad
B and D is DastarDly
C is usually Chronic but Can be Cured – at a Cost
Antibody/antigen tests for hepatitis.
a) Hep A - acute? - past infection/immunity?
b) Hep B - acute? - chronic? - past infection? - vaccination?
c) Hep C - acute? - chronic?
a) - Acute - IgM Hep A antibody (from ~ 3 weeks)
- Immunity/past infection - IgG Hep A antibody
b) - Acute - Hep B surface ANTIGEN (HBsAg)
- Chronic - HBsAg > 6 months
- Past infection - Hep B CORE ANTIBODY
- Vaccination - Hep B SURFACE ANTIBODY
c) - Acute - serum HCV RNA
- Chronic: serum HCV antibody (takes ~ 3 months to appear)
