17 - liver symposium

what are the enteric hepatitis'

A and E

what are the parenteral hepatitis'

B, C and D

what are the self limiting acute hepatitis'

A and E

what hepatitis' cause chronic disease

B, C, D

what is the only DNA hepatitis

hepatits B

transmission of hep A

faecal oral

what hepatitis' are the only ones with a vaccine available

A and B

treatment of hepatitis A

supportive - self limiting acute virus

hepatitis B transmission

blood and body fluids

treatment of hepatitis B

antivirals (NOT curative)

supportive

transmission of hepatitis C

bloodborne

treatment of hepatitis C

direct acting antivirals

transmission of hepatitis D

alongside hep B

treatment of hep D

pegylated interferon alpha

hepatits E transmission

faecal oral

treatment of hepatitis E

supportive - self limiting same as A

what can hepatitis A cause

cholestasis

pruritis

significant jaundice

flu like symptoms

nausea and vomiting

dark urine

pale stool

Is hepatitis A acute or chronic?

acute

is hepatitis A symptomatic or asymptomatic

asymptomatic (especially in children) but can cause symptoms

what is diagnosis of hepatitis A based on

IgM antibodies

what is a rare complication of hepatitis A

acute liver failure (fulminant hepatitis)

how does vertical transmission occur in hepatitis B

infection passed on from mother to child during childbirth

- most children recover within 2 months

what is the hepatitis B structure

HBV DNA

outer lipid envelope with antigens (HBsAg)

inner protein core (HBeAg)

DNA polymerase

markers of hep B (Ag)

- HBsAg indicates....

active infection

Hepatitis B surface antigen

markers of hep B (Ag)

- E antigen HBeAg

marker of viral replication - high infectivity

markers of hep B (Ab)

- HBcAb

Hepatitis B core antibody

past or current infection

markers of hep B (Ab)

- IgM high titre

ACUTE

IgM low titre in hep B

chronic

markers of hep B (Ab)

- IgG

CHRONIC or past infection if HBsAg is negative

markers of hep B (Ab)

- HBsAb

Hepatitis B surface antibody

implies vaccination OR past infection

HBV DNA

indicates active replication of virus, direct count of viral load

- used for monitoring treatment

what is done if there is a hep B positive mother and you want to reduce the risk of the baby contracting Hep B at birth

neonates are given

- hep B vaccine

- hep B immunoglobulin infusion

MUST BE DONE WITHIN 24 HOURS

pathway of chronic hepatitis B

acute turns chronic

normal liver

- 2 pathways

1. no further progression

2. cirrhosis

cirrhosis can develop into HCC or end stage liver disease

treatment options for hepatitis B

oral antivirals

pegylated interferon

complications of hepatitis C

liver cirrhosis

HCC

when do symptoms appear in hepatitis C

when it develops to cirrhosis

what is the problem with vertical transmission of hep C

antivirals are unsafe in pregnancy and there are no additional measures such as vaccination to reduce risk of transmission

hep C testing

Anti-HCV, HCV RNA to confirm diagnosis

- calculate viral load

- identify genotype

how does hepatitis D survive in patients

patients who have a hep B infection as D is attached to HBsAg

what is the problem with hepatitis D in terms of hep B

increased complications and severity of hep B

treatment regime of hepatitis D

pegylated interferon alpha over 48 WEEKS

what is the issue with pegylated interferon alpha

not very effective and significant side effects

what can drugs cause in terms of drug induced liver disease

toxic necrosis

acute hepatitis

chronic hepatits

cholestasis

mixed pattern hepatocellular/cholestasis

hepatic vein thrombosis

veno-occlusion disease

steatosis

granulomatous hepatitis

what is the antidote for paracetamol

N-acetylcysteine (NAC)

standard administration of NAC

3 stage IV infusion

- 150mg/kg over 1 hour

- 50mg/kg over 4 hours

- 100mg/kg over 16 hours

characteristics of NAFLD

excessive fat in liver cells esp triglycerides interfering with function

4 stages of NAFLD

NAFLD

non alcoholic steatohepatitis (NASH)

fibrosis

cirrhosis

risk factors for NAFLD

middle age

obesity

poor idet

low activity

type 2 diabetes

high cholesterol

HTN

smoking

investigations for NAFLD

LFTs

liver ultrasound

enhanced liver fibrosis blood test

NAFLD fibrosis score

FIB-4 score

transient elastography (fibroscan)

liver biopsy - GOLD STANDARD, tells extent of steatosis and if fibrosis or no fibrosis

LFTs findings in NAFLD

raised AST - 1st indication

ultrasound findings in NAFLD

hepatic steatosis - increased echogenicity

what is the first line investigation or assessing fibrosis in NAFLD

enhanced liver fibrosis blood test

markers in enhanced liver fibrosis blood test

HA

PIIINP

TIMP-1

10.51 or more in enhanced liver fibrosis blood test

ADVACNED fibrosis

under 10.51 in ehanced liver fibrosis test

fibrosis unlikely - check every 3 years

low risk fibrosis points on NAFLD fibrosis score

<45yo

no diabetes

BMI <30

AST:ALT <1

platelet count >150 normal

albumin normal >34

high risk fibrosis points on NAFLD fibrosis score

>45yo

diabetic

BM >30

AST:ALT >1

low platelet count <150

low albumin <34

FIB-4 score <1.45

no advanced cirrhosis

FIB-4 score >3.25

cirrhosis

How is FIB-4 calculated?

age (years) x AST/platelet count x square root ALT

what does an AST:ALT ratio greater than 1.5 suggest

alcoholic liver disease

treatment of NAFLD

weight loss

healthy diet

exercise

avoid/limit alcohol

stop smoking

control diabetes, BP and cholesterol

refer patients with advanced fibrosis to specialists

specialist treatment of NAFLD

bariatric surgery

liver transplant

vitamin E

pioglitazone

tests of liver disease

cytokeratin-18 - elevated CK18 levels correlate with the severity and progression of NAFLD and NASH. 

fibroscan - diagnoses scarring

MR/CT

MR spectroscopy - quanitfy fat

medication for autoimmune hepatitis

long term azathioprine

medication for primary biliary cholangitis

UDCA (Ursodeoxycholic acid) treatment of choice

treatment for primary sclerosing cholangitis

liver transplant

biliary stents

When is liver transplant given

chronic liver disease with poor survival

chronic liver disease with poor quality of life

hepatocellular carcinoma

acute liver failure

genetic diseases