Viral Hepatitis

Question 1

How is Hep A transmitted?

Answer 1

Fecal-Oral, contaminated food/water

Question 2

Symptoms of HepA

Answer 2

Abdominal Pain, Jaundice, pale stools, dark urine, loss of appetite

Question 3

Is hepA acute or chronic?

Answer 3

Acute: usually lasts less than 2 months

Question 4

Can hepA be transmitted via sex or drug use?

Answer 4

Yes, of course!

Question 5

What are risk factors for getting hepA?

Answer 5

A. Travel to or living in an area with poor sanitation or lacking safe water
B. Men who have sex with men
C. Recreational drug use
D. Direct contact with an infected person
1. Living in same home
2. Sexual partner
E. Clotting factor disorders
F. Working with non-human primates
G. Most outbreaks have been due to homelessness and illicit drug use

Question 6

What is the significance of Anti-HAV IgG vs IgM?

Answer 6

IgM is only elevated during infection and is diagnostic of a current or recent infection. IgG can stay elevated for decades.

Question 7

What are the 4 phases of HepA infection?

Answer 7

Phase 1: viral replication
D. Phase 2: prodromal phase (anorexia occurs here)
E. Phase 3: icteric phase (dark urine, pale stools, upper GI pain)
F. Phase 4: convalescent phase (symptoms usually resolve, liver enzymes end up returning back to normal)

Question 8

Management of HepA?

Answer 8

Self-limiting. Avoid APAP. Fluid replacement is the most important.

Question 9

Who should get HepA vaccine, and what is the schedule?

Answer 9

Anyone over 1 year of age, or at risk.

2 doses at least 6 months apart.

Question 10

Who gets hepA immune globulin?

Answer 10

Someone exposed but not vaccinated.

Question 11

What HepA vaccines are there, and what are the differences?

Answer 11

All are inactivated. Neomycin allergy is a problem. Can give during preg. If second dose is delayed, series does not need to start over.
Havrix: Hep-A only. 0.5 ml for 1-18yo, 1 ml for adults. 2 doses 6-12 months apart
Vaqta: Hep-A only. Same dosing as Havrix. 2 doses 6-18 months apart.
Twinrix: Both Hep-A and Hep-B. For adults. Two schedules:
3-dose: 0, 1, 6 months
4-dose: 0,7,21-30 days, then HepB booster at 12mo.

Question 12

What about pre-exposure prophy for HepA for peds < 1 year? (If traveling to high risk area)

Answer 12

If the kid is under 6 mo:
May give HepA immune globulin 0.1 ml/kg for 1 month, 0.2 for 2 months travel, or 0.2 ml/kg every 2 months for longer travel durations.

If the kid is 6-12 mo: Just give the vaccine, but this does not count towards the series.

Question 13

What about adults needing hepA prophy for travel? (For non-immune travelers)

Answer 13

For pts 1-40 yo, give a dose of the vaccine ASAP, and finish the series on schedule.

For pts > 40 yo, or immune compromised, or chronic liver dx: Give vaccine + 0.1-0.2 ml/kg immune globulin (same dosing as peds < 6 mo)

Question 14

What about post-exposure prophy for hepA (for non-immune individuals).

Answer 14

Give within 2 weeks of exposure.
Similar to pre-exposure scheme. If you can give the vaccine, do that. Otherwise give the immuneglobulin. E.g. kids under 6 mo and adults over 40 or immune compromised or liver dx, give immune globulin.

Question 15

Is hepB acute or chronic?

Answer 15

Chronic!

Question 16

How is HepB transmitted?

Answer 16

Blood or body fluids

Question 17

What does the HepB acute infection look like?

Answer 17

Looks similar to HepA. Often asymptomatic. Treat with supportive measures only.

Question 18

What does the HepB chronic infection look like?

Answer 18

A. Commonly asymptomatic
B. Ascites
C. Encephalopathy
D. Extrahepatic manifestations
  1. Polyarteritis nodosa
  2. Glomerular disease
E. Jaundice
F. Peripheral edema
G. Splenomegaly
H. Transaminitis

Requires the use of antivirals to treat.

Question 19

Risk factors for HepB infection?

Answer 19

A. Direct contact with an infected person
1. Living in same home
2. Sexual partner
B. Mother-to-child transmission during child birth
C. MSM
D. Occupational exposure to blood or blood-contaminated body fluids
E. Hemodialysis

Question 20

Consequences of untreated Hepatitis?

Answer 20

Cirrhosis, Hepatocellular carcinoma, 5-year survival with compensated cirrhosis is around 85%, while for decompensated (ascites or bleed varices) it is around 14-35%

Question 21

How to assess prognosis of liver disease and estimate cirrhosis severity?

Answer 21

Child-Turcotte-Pugh (CTP) Score
Assigned class A B or C depending on points (5-6, 7-9, 10-15). Based on ascites, hepatic encephalopathy, INR, Serum albumin, and total bilirubin.

Question 22

What are the different tests for HepB?

Answer 22

Hepatitis B Surface Antigen (HBsAg) Assists in diagnosing acute/chronic active infection. Patient is infectious
Hepatitis B Surface Antibody (HBsAb or anti-HBs) Assesses immunity and recovery from infection
Hepatitis B Core Antibody (Total) (HBcAb or Total anti-HBc) Appears at onset of infection and remains for life
Hepatitis B Core Antibody (IgM) (IgM anti-HBc) Indicates acute infection
Hepatitis B Envelope Antigen (HBeAg)
Indicates active viral replication. Patient is infectious
Hepatitis B Envelope Antibody (HBeAb or anti-HBe)
No replication occurring
Hepatitis B Virus DNA (HBV DNA) How rapidly the virus is reproducing in the liver

Question 23

When to treat hepB?

Answer 23

AASLD: HBV DNA > 20,000 and ALT > 2x ULN OR Cirrhosis
EASL: Similar but adds that with HBV DNA > 2,000 with any ALT elevation and/or moderate inflammation or fibrosis you can also treat (like everything is medium at the same time)

Question 24

Which two antiretrovirals share the same resistance pattern and what is the significance of that?

Answer 24

Lamivudine and Emtricitabine:

-If resistance to one, don’t use the other.

Question 25

Which Hep B treatments are preferred for elderly patients or those with preexisting bone or renal disease.

Answer 25

Entecavir or TAF

Question 26

Hep B therapy of choice for pregnant patients?

Answer 26

TDF

Question 27

How young can should you start HepB vaccination?

Answer 27

“b” is for Birth!