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Y4 Gastrointestinal > Viral hepatitis > Flashcards

Viral hepatitis Flashcards

1
Q

Define what is meant by the term hepatitis ?

A

A disease characterized by inflammation of the liver.

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2
Q

What are the LFT’s suggestive of acute viral hepatitis infection

A
  • ALT & AST significantly increased (between 500 and 10,000 IU/L).
  • Bilirubin elevated
  • ALP < 2x the upper limit of normal
  • PT time may be prolonged
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3
Q

What is the management of acute viral hepatitis infections (<6months)?

A
  • Symptomatic
  • No antivirals given
  • Monitor for encephalopathy
  • Monitor for resolution - of Hep B or Hep C, or Hep E if immunocompromised
  • Notify Public Health
  • Immunisation of contacts
  • Test for other infections if at risk
  • Vaccinate against other infections if at risk
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4
Q

How is Hep A, D & E diagnosed ? (using Hep A as an example)

A
  • Gold standard = a PCR test for hepatitis A RNA (not widley available)
  • Otherwise measure hepatitis A IgM (HAV-IgM) and IgG (HAV-IgG)

HAV-IgM antibodies are detectable from at least five days after the onset of symptoms lasting for 45—60 days but can persist for around 6 months.

HAV-IgG antibodies are detectable 5–10 days after the onset of symptoms and then persist.

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5
Q

Interpret these results stating if the person has active or previous hepatitis A infection:

Positive HAV-IgM & IgG

A high IgG reactivity and a moderate level of IgM

Positive HAV-IgM & negative IgG

Negative HAV-IgM & positive HAV-IgG

A
  • Positive HAV-IgM, and positive HAV-IgG — acute hepatitis A infection is likely.
  • A high IgG reactivity and a moderate level of IgM — suggests hepatitis A infection in the recent past rather than current acute infection.
  • Positive HAV-IgM, and negative HAV-IgG — IgM result may be a false positive.
  • Negative HAV-IgM, and positive HAV-IgG — suggests past hepatitis A infection, or immunity from previous
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6
Q

What are the 5 different hepatitis viruses ?

A

A-E

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7
Q

Describe what hepatitis A is

A

A benign, self-limiting disease, with a serious outcome being very rare.

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8
Q

What type of virus is the hepatitis A virus ?

A

RNA picornavirus

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9
Q

How is hepatitis A transmitted, where is it common and what is its incubation period ?

A
  • Faecal-oral route or shellfish. Prevelent in Africa & south america so affects travellers
  • Also MSM and IVDU
  • Incubation period is 2-4 weeks
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10
Q

What are the clinical features of a hepatitis A infection ?

A
  1. ‘flu-like’ prodrome - fever, malaise, anorexia, nausea & arthralgia
  2. Followed by jaundice, hepatosplenomegaly, RUQ pain & adenopathy
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11
Q

Who is most commonly affected by symptomatic hepatitis A infection ?

A

Older children / young adults

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12
Q

Are there any complications of hepatitis A infection ?

A

Complications are rare and there is no increased risk of hepatocellular cancer

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13
Q

What is the treatment of hepatitis A infection ?

A

Supportive

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14
Q

What can be given to prevent hepatitis A infection and who is it given to ?

A

A vaccination and is given to:

  • people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old
  • People with chronic liver disease
  • atients with haemophilia
  • MSM
  • IVDU
  • Individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates
  • People infected with HIV
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15
Q

What type of virus is the hep E virus ?

A

RNA hepevirus

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16
Q

How is hepatitis E transmitted, where is it common and what is its incubation period ?

A
  • Spread by the faecal-oral route & zoonoses associatd with pigs
  • Incubation period: 3-8 weeks
  • Common in Central and South-East Asia - Indochina, North and West Africa, and in Mexico
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17
Q

Who does Hep E cause significant mortality in ?

A

Pregnant women (20% die if infected)

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18
Q

What are the clinical features of hep E infection ?

A

The same as hep A:

  1. ‘flu-like’ prodrome - fever, malaise, anorexia, nausea & arthralgia
  2. Followed by jaundice, hepatosplenomegaly, RUQ pain & adenopathy
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19
Q

How is Hep E treated ?

A

Supportive

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20
Q

Is there a vaccine for hep E ?

A

Not yet

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21
Q

What are the potential complications of Hep E infection ?

A

Some immunocompromised humans can get chronic infection

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22
Q

What type of virus is the hep D virus ?

A

An incomplete RNA virus (needs Hep B for its assembly)

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23
Q

What does someone need to be infected with before they can then be infected with hep D?

A

Hep B (hep D can only infect someone who is already infected with hep B)

24
Q

What are the clinical features of hep D infection ?

A

It may exacerbate hep B infection - causing acute liver failure/cirrhosis

25
Q

How should be tested for hep D?

A

Poeple who are at high risk of hep B infection and those who have a hep B infection

26
Q

What is used for treatment of Hep D infection ?

A

Interferon-alpha

27
Q

What type of virus is hep B ?

A

a double-stranded DNA hepadnavirus

28
Q

How is hepatitis B transmitted and what is its incubation period ?

A

Transmission:

  • Sex
  • Mother to child
  • Blood
  • IVDU

Incubation period is 6-20 weeks.

29
Q

Who are the at risk people of getting hep B infection ?

A
  • People born in areas of intermediate / high prevalence (see next slide) - far east, africa, mediterranean
  • Multiple sexual partners
  • IVDU
  • Children of infected mothers
  • Healthcare workers or jobs with exposure to blood/body fluids
30
Q

What are the clinical features of hep B infection ?

A

Resemble hep A but arthralgia & urticaria commoner:

  1. ‘flu-like’ prodrome - fever, malaise, anorexia, nausea & arthralgia
  2. Followed by jaundice, hepatosplenomegaly, RUQ pain & adenopathy
31
Q

What complications can develop from hep B infection ?

A
  • Chronic hepatitis (5-10%).
  • Fulminant liver failure (1%)
  • Hepatocellular carcinoma
  • Glomerulonephritis
  • Polyarteritis nodosa
  • Cryoglobulinaemia
32
Q

If chronic infection of Hep B occurs what are the typical clinical features ?

A

There are often no physical signs. After many years signs of chronic liver disease may develop:

  • Spider naevi.
  • Finger clubbing.
  • Jaundice.
  • Hepatosplenomegaly.
  • In severe cases thin skin, bruising, ascites, liver flap and encephalopathy.
33
Q

What are the LFT results in someone with chronic Hep B infection ?

A
  • In most people mildly elevated AST&ALT
  • In many liver enzymes will be normal.
34
Q

How do you diagnose hep B infections ?

A

Based on serology (antigens & antibodies):

  • Hepatitis B Surface Antigen (HBsAg) — indicates presence of viral envelope, and suggests that the person is infectious. Chronic HBV infection is indicated by the persistence of serum HBsAg for more than 6 months.
  • Hepatitis B e antigen (HBeAg) — detectable in the serum during both the early phases of acute infection and some chronic infections. Suggests patient is highly infectious.
  • Antibody to HBeAg (Anti-HBe) — present following clearance of HBeAg from the plasma. Disappearance of HBeAg, development of anti-HBe, and a decline in HBV-DNA, indicate control of viral replication and predict resolution of acute hepatitis B.
  • Antibody to HBcAg (anti-HBc) — implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection within the last 6 months and is gradually replaced by IgG. IgG anti-HBc persists for life and indcates past infection
  • Antibody to HBsAg (anti-HBs) — indicates recovery from and immunity to HBV. Anti-HBs without anti-HBc is a marker of immunization. Anti-HBs is quantified to measure vaccination response.
35
Q

How is intital infection of hep B prevented ?

A

2 groups of people are vaccinated against hep B now:

Children - given at 2, 3 and 4 months of age

At risk groups; healthcare workers, IVDU, people with frequent sexual partners esp MSM and sex workers, close family of an individual with hep B, individuals receiving blood transfusions regularly, CKD patients who may soon require renal replacement therapy, prisoners, chronic liver disease patients

36
Q

What is the post-exposure prophylaxis used to prevent Hep B infection ?

A

Vaccine + HBIG (hyperimmune Hep B immunoglobulin)

37
Q

Who are screened for hep B infection?

A

Pregnant women and babies of women with Hep B

38
Q

What should babies born of a mother who has hep B be given

A

Post-exposure prophylaxis:

  • vaccination + hepatitis B immunoglobulin
39
Q

Can hep B be transmitted via breastfeeding ?

A

No

40
Q

Who should be treated for hep B infections?

A

If have Chronic infection (>6months):

  • HBsAg and Hep B DNA present

Or those at risk of complications:

  • Evidence of inflammation / fibrosis sought, especially in Hep B
  • Non-invasive tests of fibrosis e.g. fibroscan good at identifying cirrhosis, biopsy less used than it was
  • Biochemical evidence of inflammation (↑ALT)
41
Q

What is the treatment of confirmed hep B infection ?

A

You should monitor initially as spontaneous cure is common, but if chronic infection established (i.e. infeciton > 6months) then 2 treatment options:

  1. Pegylated interferon-alpha - Use in HBsAg and HBeAg pos patients with compensated disease and prediction of good chance of cure
  2. Suppressive antiviral drugs e.g. adefovir, entecavir, Tenofovir
42
Q

What are the advantages & disadvantages of pegylated interferon-alpha used to treat chronic hep B infections?

A

Advantages:

  • Sustained cure possible from a few months of therapy

Disadvantages:

  • Side effects
  • Injections
  • Only minority gain benefit
43
Q

What are the advantages & disadvantages of Suppressive antiviral therapy used to treat chronic hep B infections?

A

Advantage:

  • Safer
  • Increasing range available

Disadvantage:

  • Suppression not cure
  • Resistance can develop
44
Q

What are the adverse effects of peginterferon alpha?

A

Common:

  • flu like symptoms: chills, sore muscles, malaise etc

Less common but more severe:

  • Thyroid disease
  • Autoimmune disease
  • Psychiatric disease
45
Q

What is the general management of someone with chronic hepatitis infection ?

A
  • Specific treatment depending on if its B or C
  • Vaccination; against other hepatitis viruses and if cirrhotic: influenza, pneumococcal
  • Infection control
  • Alcohol↓
  • Hepatocellular carcinoma awareness/screening esp for those with cirrhosis; done via serum -alpha fetoprotein (AFP) and ultrasonography
46
Q

What type of virus if hep C ?

A

RNA flavivirus

47
Q

How is hepatitis C transmitted and what is its incubation period ?

A

Transmission is the same as Hep B:

  • Sex
  • Mother to child
  • Blood
  • IVDU

Incubation period: 6-9 weeks

48
Q

Who are the 2 main groups of people at risk of hep C infection ?

A

IVDU and patients who received a blood transfusion prior to 1991 (e.g. haemophiliacs).

49
Q

What are the clinical features of hep C infection ?

A

After exposure to the hepatitis C virus only around 30% of patients will develop features such as:

  • a transient rise in serum aminotransferases / jaundice
  • fatigue
  • arthralgia
50
Q

Once chronic hep C infection is established can spontaneous cure occur ?

A

No

51
Q

What are the potential complications of hep C infection ?

A
  • Cirrhosis
  • Hepatocellular cancer
  • Rheumatological problems: arthralgia, arthritis
  • Eye problems: Sjogren’s syndrome
  • Cryoglobulinaemia
  • Porphyria cutanea tarda (PCT)
  • Membranoproliferative glomerulonephritis
52
Q

How is Hep C infection diagnosed ?

A
  • 1st = Test for antibodies to hepatitis C virus (HCV), which indicates if a person has ever been infected with HCV.
  • 2nd = If the antibody test is positive, or in immunocompromised people, send a blood sample for HCV RNA (to check if HCV infection is active) and genotype analysis.
53
Q

Is there a vaccine to prevent hep C transmission ?

A

No

54
Q

How is Hep C treated ?

A

Currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

55
Q

What is the main side effect of ribavirin?

A

Haemolytic anaemia

56
Q

What is the aim of hep C treatment ?

A

Aim is to achieved a sustained virological response (SVR) = undetectable serum HCV RNA six months after the end of therapy

Y4 Gastrointestinal (28 decks)

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