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Gastro > Viral Hepatitis & Interpretation of Liver function tests > Flashcards

Viral Hepatitis & Interpretation of Liver function tests Flashcards

1
Q

What causes hepatitis [13]

A

Hep ABCDE
CMV
EBV
HIV
Herpes
Enterovirus
VZV
Rubella
Q-fever
Yellow fever
Psittacosis
Leptospirosis
Ischaemia

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2
Q

How is hep A spread [2]

A

Foecal oral eg ano-oral sex

Contaminated food or drink

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3
Q 
Hep A
Incubation period
Prognosis
Presentation in <5yo
Presentation in adult &amp; adolescent [4]
A

Short incubation - 28 days
Prog: Benign and self limiting

<5yo: subclinical, no jaundice
Adult, adolescent: 
- fever, malaise, anorexia
- N&amp;V, abdominal pain
- intrahepatic jaundice 
- hepatosplenomegaly 10-14d later (dark urine, pale stool)
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4
Q

Who is at high risk and offered immunisation [6]

A 
Travellers
CLD
Occupational exposure
Haemophiliac
Homosexual 
PWID
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5
Q

How do you Dx Hep A [3]

A

LFT increased

o Anti-HAV IgM: present at onset of symptoms; falls to non-detectable levels by 3-6m
o Anti-HAV IgG: indicates previous infection

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6
Q

How do you treat Hep A [5]

A

No treatment as self limiting
Relieve pain / itching / nausea

Prevention

  • General: good personal hygiene, sanitation
  • Patients should avoid work or school for 7 days after symptom onset.
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7
Q

What are complications of Hep A

Compare the protection that active versus passive immunization confers

A

Prolonged fatigue / jaundice
No chronic damage or HCC risk

  • Passive immunisation: HNIG provides immediate passive protection for 4m for close contacts
  • Active immunisation: inactivated vaccine gives single dose protection by 2w followed by a booster at 6-12m for 20y protection
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8
Q

How is Hep B spread [5]

Describe epidemiology of Hep B [2]

A 
Blood
Sexual 
Vertical (mother to baby)
Horizontal (households)
Carrier states exist

Ep: sub-Saharan Africa and SEA

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9
Q

How infective is Hep B?
Incubation

What are 2 rare complications of Hep B?

A

Very 100x more than HIV
Long incubation - 6 weeks (need to wait 4 to test)

Complications

  • intrahepatic jaundice
  • fulminating hepatitis
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10
Q

What are the symptoms of Hep B?
Acute [4]
Chronic [5]

A

Acute

  • Onset: within few weeks or 6m
  • Anorexia, lethargy, fever
  • N+V+D, abdominal discomfort
  • Pruritus, dark urine, pale stool

Chronic:

  • Hepatitis
  • Fulminant liver failure
  • HCC
  • GN
  • Cryoglobulinemia
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11
Q

Who is at risk of hep B [7]

A 
MSM, Travellers, 
Haemophiilac, dialysis
IVDU, Tattoo / piercing
Blood transfusion pre-screen
Healthcare workers
Chronic liver
Babies born to infected mothers
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12
Q

What is fulminant hepatic encephalopathy [4]

A

DIC
Encephalopathy
Hypoglycaemia
Prolonged PT

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13
Q

Hep B serology [6]

A

HBsAg = surface antigen (first to appear in acute infection)
HBcAg = core antigen
- IgM
- IgG
HBeAg = breakdown of core antigen in infection liver cells
HBV DNA = viral DNA

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14
Q

What suggests highly infectious

A

HBeAg + HBV DNA

Consider infectious even if e antigen is -ve due to risk of mutation

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15
Q

What suggests chronic hep B

A

HBeAg >6 months
Anti-HBc IgG

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16
Q

How do you interpret serology

A

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

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17
Q

What suggests previous immunisation [2]

A

Anti-Hbs

All other -ve

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18
Q

What suggests hep B 6 months ago [4]

A

Anti-Hbs
Anti-HBc
IgG HBc
HBsAg -ve

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19
Q

What suggest previous hep B but now carrier [2]

A

HbsAg +ve = chronic

Anti-HBc

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20
Q

How do you dx hep B [2]

A

Serology

Liver enzymes

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21
Q

What should you do if testing for hep B and why?

A

Test for HIV and hep D

Hep D because it requires HBV surface particle to complete replication and transmission cycle

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22
Q

Who gets tested for hep B [5]

A 
All demographics with risk factors +
Anti-TB tx
Immunosuppressed
Persistent abnormal LFT with no cause
Pregnant
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23
Q

How do you Rx acute hep B

A

No Rx

Self limiting

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24
Q

What do you advice someone with hep B [5]

A 
Public health
<5% become chronic
NO alcohol / sex
Household precaution
Vaccinate contacts
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25
Q

When do you test for HIV / HBV / HCV

A

6 months

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26
Q

What are complications of HBV [7]

A 
10% chronic
Cirrhosis, Liver failure
HCC
Membranous GN
Polyarteritis nodosa
Cyroglobulinuria
Vasculitis rash
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27
Q

When do you consider treatment of chronic [5]

A

2+ of:

  • Abnormal LFT
  • High viral load
  • Abnormal fibroscan / cirrhosis
  • HbeAg +ve (DNA / ALT raised)
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28
Q

What do you do otherwise

A

Monitor

Some stages of chronic are highly infectious

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29
Q

How would you treat Hep B [3]

A
  1. Anti-viral (nucleoside analogue) = 1st line
    Pegylated interferon (anti-viral + immune)
  2. Liver transplant if cirrhotic
  3. Monitor renal function

Interferon less successful in chronic

30
Q

What is prophylaxis in hep B [2]

A

Vaccine to newborn and human Ig

If on chemo / immunosuppressed / contact = vaccine and Ig

31
Q

What do you do after vaccine

A

Check Anti-Hbs levels

32
Q

How do you monitor and follow up hep B [3]

A

In clinic:

  • ALT / LFT
  • Fibroscan
  • Advise if become immunocompromised
33
Q

Who is at risk of no response to vaccine [5]

A 
Obesity
Alcohol
Smoking
>40
Immunocompromsie
34
Q

How do you treat hep B in pregnancy [5]

A
  • Tenofavir
  • Obstetric team to advise delivery
  • Passive and active immunisation - newborn
  • Can breast feed
  • Test baby at 1 year
35
Q

How is hep C. spread [3]

A

Blood/tissue donation
IVDU
Vertical and breastfeeding transmission is rare

36
Q

Can you become immune to hep C

Incubation period

A

No so can get reinfected

Short incubation 6-9w

37
Q

What are the symptoms of hep C [6]

A 
Flu like symptoms 
- Malaise
- Anorexia
- Fatigue
- Arthralgia
10% jaundice
38
Q

What are complications of hep C [6]

A 
85% = chronic hepatitis
Cirrhosis
HCC
Sjogren
Cryoglobulinuria
Membranous GN
39
Q

Who is more likely to het fulminant hepatitis [2]

A

Pregnancy

Immunocompromised

40
Q

What suggests cirrhosis [2]

A

ALT up

Platelet down

41
Q

Who is at risk of hep C [4]

A

Alcohol accelerates
IVDU
Haemophiliac, Dialysis
Tattoo / piercing

42
Q

How do you Dx hep C [4]

A

Increased LFTs

HCV RNA - PCR * detectable 1-2m
Anti-HCV IgG - detectable 3m
No IgM test

43
Q

When do you retest for hep C

If Ab +ve but RNA -ve? What is the likely diagnosis?

A

3-6 months to make sure

If Ab +ve but RNA -ve = cleared or treated

44
Q

When do you treat hep C

A

If Ab and antigen +ve

45
Q

How do you treat hep C [5]

A

General:

  • Avoid alcohol
  • Test for other BBV
  • Offer immunisation

Antivirals

  • protease inhibitor combination e.g. DACLATASVIR + SOFOSBUVIR +/- RIBAVARIN
  • 3 months
46
Q

What are SE of ribavirin [3]

A

Teratogenic
Haemolytic anaemia
Cough

47
Q

What are the SE of interferon [5]

A 
Thrombocytopenia
Leukapenia
Fatigue
Depression
Flu
48
Q

What does response to Rx of hep C depend on [4]

A

Age
Gender
Liver disease
Amount of virus

49
Q

What are types of response to hep C Rx

A

Non Responder
Viral Breakthrough
Relapse - when Rx stopped
Sustained viral after 6 months = 95%

50
Q

How is hep D transmitted

A

Same routes as hep B

But requires HBV surface particle to complete replication and transmission cycle

51
Q

What are the symptoms of hep D

A

More severe hep B and rapid progression if co-infection

52
Q

How do you Dx hep D [2]

A

IgM and IgG

Reverse PCR = Dx

53
Q

How do you treat hep D [4]

A

NO vaccine
Pegylated interferon
Transplant
Prevent hep B

54
Q

What are the complications of hep D [4]

A

Chronic B
Cirrhosis
HCC
Fulminant hepatitis

55
Q

How is hep E spread

A

Foecal oral

56
Q

What is the most common hepatitis

Incubation period

A

Hep E
Screen in any acute liver injury

Short incubation = 40 days

57
Q

Clinical presentation Hep E [3]

A
  • Presentation resembles HAV
  • Subclinical/mild in women, more severe in elderly men
  • Extra-hepatic features

Jaundice <1%

58
Q

When is hep E dangerous [2]

A

Pregnancy = high infant mortality (diff hep A) due to tendency to progress to fulminant
Elderly men

59
Q

What are extra hepatic complications of hep E [6]

A 
AKI - think if no cause
Pancreatitis
Bell's Palsy, GBS
Neuralgic arthropathy - brachial plexus pain
Arthritis
Anaemia
60
Q

Who is at risk of hep E

A

Occupational - farm

Blood transfusion due to short viraemia phase

61
Q

When do you suspect hep E

A

Deranged LFT for alcohol consumption

62
Q

How do you Dx hep E [3]

A

IgG and IgM
HEV PCR serology
Abnormal LFT

63
Q

What is chronic hep E [2]

A

> 3 months

No dip in HEV RNA 6 months

64
Q

How do you treat hep E [2]

A

No specific Rx or vaccine

Clean water and avoid undercooked meat

65
Q

What are complications of hep E [2]

A

Persistent in immunocompromsied

Liver failure if CLD

66
Q

Interpretation of liver function tests: source
Bilirubin
ALT and AST
ALP and GGT
Albumin
PT or INR

A

Bilirubin: Hb breakdown
ALT and AST: hepatocytes
ALP and GGT: biliary epithelium
Albumin: synthesised by hepatocytes
PT or INR: synthesised by livers

67
Q

Different patterns of liver biochemistry suggesting different causes:
Hepatocellular
Cholestatic
Isolated hyperbilirubinemia

A
  1. Hepatocellular: ALT and aspartate transaminase (AST) raised in excess of other liver enzymes.
  2. Cholestatic: ALP and gamma-glutamyl transferase (GGT) raised in excess of other liver enzymes.
  3. Isolated hyperbilirubinaemia (other liver biochemistry normal): conjugated (e.g. Gilbert’s) or
    unconjugated (e.g. haemolysis).
68
Q

Mechanisms of jaundice

A
  1. Overproduction of bilirubin: predominantly unconjugated, rarely >70 μmol/L, caused by increased red cell breakdown (i.e. haemolysis, haematoma dissolution).
  2. Failure of bilirubin conjugation: either impaired delivery of bilirubin to the liver (e.g. congestive cardiac failure, portosystemic shunting) or enzymatic defects (e.g. Gilberts disease, Crigler–Najjar syndrome).
  3. Failure to export bilirubin across the canalicular membrane: conjugated. Divided into intrahepatic (e.g. viral or alcoholic hepatitis, MRP2 mutation in Dubin–Johnson syndrome) and extrahepatic (e.g. bil- iary obstruction). May also occur in non-hepatic conditions (e.g. sepsis).
69
Q

Liver screen [7]

A

FBC
Ferritin
Copper studies
BBV screen
Ig
Anti-mitochondrial, anti-smooth muscle or anti-nuclear antibodies
Alpha-1 antitrypsin

70
Q

Liver screen - expected abnormalities and what they suggest?
FBC, ferritin, Immunoglobulins

A

FBC- macrocytosis, thrombocytopenia, may indicate alcohol excess, hypersplenism relation to portal hypertension
Ferritin - elevated ferritin, associated with haematochromatosis, non-alcoholic and alcoholic fatty liver disease
Immunoglobulins - elevated IgG and IgM suggesting PBC, autoimmune liver disease.

71
Q

Patterns of abnormal LFT (raised more than 5x the upper limit of normal)
ALT>AST
AST>ALT

A

ALT>AST
- Autoimmune hepatitis
- Coeliac disease
- Drug induced liver injury
- Haemachromatosis
- NAFLD
- Viral hepatitis
- Wilsons disease

AST>ALT
- Alcoholic liver disease
- Cirrhosis

Gastro (17 decks)

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