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99 TOPICS TEACHING ROUNDS
SABRINA SQUIRE, PGY2 FMSEPT 8 , 2015
Viral Hepatitis
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Objectives
In a patient presenting with hepatitis symptoms and/or abnormal liver function tests, take a focused history to assist in establishing the etiology (e.g.,new drugs, alcohol, blood or body fluid exposure, viral hepatitis).
In a patient with abnormal liver enzyme tests interpret the results to distinguish between obstructive and
hepatocellular causes for hepatitis as the subsequent investigation differs. In a patient where an obstructive pattern has been identified, Promptly arrange for imaging, Refer for more
definitive management in a timely manner. In patients positive for Hepatitis B and/or C, Assess their infectiousness, Determine human immunodeficiency
virus status. In patients who are Hepatitis C antibody positive determine those patients who are chronically infected with
Hepatitis C, because they are at greater risk for cirrhosis and hepatocellular cancer. In patients who are chronically infected with Hepatitis C, refer for further assessment and possible treatment.
In patients who are at risk for Hepatitis B and/or Hepatitis C exposure, Counsel about harm reduction strategies, risk of other blood borne diseases, Vaccinate accordingly.
Offer post exposure prophylaxis to patients who are exposed or possibly exposed to Hepatitis A or B. Periodically look for complications (e.g., cirrhosis, hepatocellular cancer) in patients with chronic viral hepatitis,
especially hepatitis C infection.
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I N A PAT I E N T P R E S E N T I N G W I T H HEPATITIS SYMPTOMS A N D / O R ABNORMAL LIVER
FUNCTION TESTS , TA K E A FOCUSED HISTORY T O A SS I S T I N E S TA B L I S H I N G T H E
ETIOLOGY ( E . G. , N E W D R U G S, A L C O H O L , B L O O D O R B O D Y F LU I D E X P O S U R E , V I R A L
H E PAT I T I S ) .
Objective 1
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Symptoms
AsymptomaticFeverMalaiseAnorexiaNausea/vomitingJaundiceAbdominal painDark urinePale, clay coloured stools
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HISTORY
Identify potential risk factors for liver disease
Exposures Alcohol Drug use (identify/quantify all prescription,
herbals and illicit) Occupational/recreational (mushroom picking,
industrial vinyl choride) Risk for viral hepatitis
A = fecal/oral, close contact (household, sexual, daycares), blood exposure (rare)
B = parenteral, sexual, household, vertical C = parenteral (IVDU, tattoo), endemic (Pakistan,
Egypt), blood transfusion before 1992, higher risk sexual activities, vertical
Other disorders associated with liver disease AutoAbs (autoimmune) Tox screen (hepatotoxins) Right sided HF (congestive hepatopathy) Obesity, DM, hyperlipidemia (NAFLD) Systemic disease (hemochromatosis, a1
antitrypsin, wilson’s) Pregnancy (gallstones) IBD (Primary sclerosing cholangitis)
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PHYSICAL EXAM
Look for clues to etiology and signs of chronic liver disease
Temporal and proximal muscle wasting Jaundice, icterus Spider nevi Palmar erythema Gynecomastia Caput medusa Hepatic encephalopathy Asterixis Advanced etoh cirrhosis: Dupuytren’s contractures,
parotid enlargement, testicular atrophy Abdominal malignancy: enlarged left supraclavicular
node (Virchow’s node) or periumbilical nodule Hepatic congestion: increased JVP Right sided pleural effusion Ascites (fluid wave, shifting dullness, bulging flanks) Palpable spleen Liver exam:
Grossly enlarged, nodular or obvious mass = malignancy Tender – viral or alcoholic hepatitis + Murphy’s: cholecystitis or ascending cholangitis
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EnzymesElevation = damage to liver or biliary obstruction
Serum aminotransferases Alanine aminotransferase
(ALT) Aspartate aminotransferase
(AST)Alkaline phosphatase
(ALP)Gamma-glutamyl
transpeptidase (GGT)Lactate Dehydrogenase
(LDH)
AlbuminProthrombin
time/International normalized ratio (INR)
Bilirubin
Liver Biochemical and Function Tests
FunctionAbnormalities = impaired synthetic function
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IN A PATIENT WITH ABNORMAL L IVER ENZYME TESTS I NTERPRET THE RESULTS TO
DISTINGUISH BETWEEN OBSTRUCTIVE AND HEPATOCELLULAR CAUSES FOR
HEPATITIS AS THE SUBSEQUENT INVESTI GATION DIFFERS
Objective 2
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Hepatocellular pattern Cholestatic pattern
AST&ALT vs ALP+/- Bilirubin+/- Abnormal
synthetic function
ALP vs AST&ALT+/- Bilirubin+/- Abnormal
synthetic function
Etiology
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IN A PATIENT WHERE AN OBSTRUCTIVE PATTERN HAS BEEN IDENTI FI ED, PROMPTLY ARRANGE FOR IMAGING , REFER FOR MORE
DEFINITIVE MANAGEMENT IN A T IMELY MANNER.
Objective 3
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Cholestasis
Ultrasonography Ddx: extrahepatic cholestasis:
Choledochololithiasis Malignant obstruction (pancreas, GB, ampulla, bile duct
cancer) PSC Chronic pancreatitis w/ stricturing of distal bile duct AIDS cholangiopathy
ERCP Confirm Dx and facilitate biliary drainage Consider MRCP in chronic or high risk for ERCP
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Hepatocellular Pattern
Viral hepatitis serologies IgM & IgG anti-hepatitis A Hepatitis B surface antigen/antibody and anti-
hepatitis B core Anti-hepatitis C antibody and hepatitis C RNA
Other: CMV, EBV, HSV, VZV
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IN PATIENTS POSITIVE FOR HEPATITIS B AND/OR C , ASSESS THEIR
INFECTIOUSNESS , DETERMINE HUMAN IMMUNODEFICIENCY VIRUS STATUS.
Objective 4
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IN PATIENTS WHO ARE HEPATI T I S C ANTI B ODY POSIT I VE DETERMINE THOSE
PATIENTS WHO ARE CHRONICALLY INFECTED WITH HEPATITIS C , BECAUSE
THEY ARE AT GREATER RISK FOR CIRRHOSIS AND HEPATOCELLULAR CANCER.
Objective 5
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Serology Interpretation – Hepatitis B
Surface Antigen(HBsAg)
Surface Antibody(anti-HBs)
Core Antibody(anti-HBc)
Interpretation
- - - Susceptible
- + - Immunity by Vaccination
- + + Immunity by natural infection
+ - +IgM antiHBc
+
Acute infection
+ - +IgM antiHBc
-
ChronicInfection
- - + 4 possibilities-Recovering acute-Distant immunity-Susceptible w/ FP
core-Chronic infxn w/
undetectible Ag
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Serology Interpretation – Hepatitis C
Anti-HCV Non-reactive: no further action
If recent exposure: test HCV RNA Reactive: presumptive HCV infection
HCV PCR and genotype Detected: Current HCV infection Not detected: no current HCV infection
Chronic infection 70-90% develop chronic infection Fluctuating or persistently elevated liver enzymes (>6m) 5-20% develop cirrhosis 1-5% develop HCC
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IN PATIENTS WHO ARE CHRONICALLY INFECTED WITH HEPATITIS C , REFER FOR
FURTHER ASSESSMENT AND POSSIBLE TREATMENT
Objective 5
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HCV Treatment
Indications All patients with chronic hepatitis C who have compensated liver
disease, are willing to undergo therapy and have no contraindications, should be considered candidates for antiviral treatment. Absolute: Pregnancy Strong: Etoh abuse, hepatic decompensation, CAD, solid organ transplant Relative: major depression, major psychosis, autoimmune, renal failure No longer CI: Normal ALT, IVDU, stable methadone maintenance,
neutropenia, anemia, TCP, controlled seizure disorder, >65yo, etoh use
Current PEG-Interferon + Ribavirin Primary objective is complete viral elimination (sustained
virological response) Success and duration of treatment depends on genotype
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IN PATIENTS WHO ARE AT RISK FOR HEPATI T I S B AND/OR HEPATIT I S C
EXPOSURE, COUNSEL AB OUT HARM REDUCTION STRATEGIES , R ISK OF OTHER
BLOOD B ORNE DISEASES, VACCINATE ACCORDINGLY.
Objective 6
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Prevention and Risk-Reduction
Vaccinations – avoid further hepatic insults Havrix (o,1,6m) HepB Vaccine (0,1,6m) Consider Pneumovax, Influenza
Harm reduction Safe injection sites, crack pipe exchange Safe sex practices (increased progression with co-
infection HDV, HIV)
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OFFER POST EXPOSURE PROPHYLAXIS TO PATIENTS WHO ARE EXPOSED OR POSSI BLY
EXPOSED TO HEPATIT IS A OR B .
Objective 7
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Hepatitis A Hepatitis B
Ig within 14 daysRoutinely to household
and intimate contactsSelected situations in
institutions or with common source exposure (food prepared by infected food handler)
Vaccination
Ig within 48hVaccination
Post-exposure Prophylaxis
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PERIODICALLY LOOK FOR COMPLICATIONS (E .G. , C IRRHOSI S, HEPATOCELLULAR
CANCER) IN PATIENTS WITH CHRONI C V IRAL HEPATI T I S, ESPECI ALLY HEPATIT IS C
INFECTION.
Objective 8
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Surveillance
Liver fibrosis Clinical exam Ultrasound
Nodular shrunken liver, splenomegaly or portal hypertensive collaterals
FibroScan measures liver stiffness as a surrogate for fibrosis Traditionally, liver biopsy
Staging fibrosis Serum Markers:
Routine biochem (AST, ALT, platelets) Indirect markers (a-2 macroglobulin and haptoglobin) Direct markers (hyaluronic acid and tissue inhibitor of matrix
metalloproteinase 1)
Hepatocellular Carcinoma Screening at 6-month intervals with ultrasound + AFP
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References
Family Medicine Notes: Preparing for the CCFP Exam 2014
UptoDateOverview of Viral Hepatitis Lecture by Dr. Curtis CooperPocket Medicine Fourth EditionCDC WebsiteMultidisciplinary Canadian consensus recommendations
for the management and treatment of hepatocellular carcinoma, Curr Onc 2011
An update on the management of chronic hepatitis C: Consensus guidelines from the Canadian Association for the Study of the Liver, Can J Gastroenterology 2012