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Description : Clinical approach of viral hepatitis for GP and family physicians

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Published on : Dec 07, 2020 | Views : 5932 | Downloads : 79

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Clinical approach to patients with viral Hepatitis Presented by : Supervised by: Bader Alrabiah‏ Dr. Abdullah AlRibdi Abdullah Almohaimeed
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index What is viral Hepatitis Clinical presentation Hepatitis A Hepatitis B Hepatitis C Chronicity and malignant transformation (B & C) Screening When to refer
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What is viral hepatitis? Viral Hepatitis is an infection that causes inflammation of the liver. The inflammatory process can be self limiting, or can progress to fibrosis (scarring), cirrhosis or liver cancer. We have 5 main types of viral hepatitis: A, B, C, D, and E. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (eg, alcohol and certain drugs), and autoimmune diseases can also cause hepatitis.
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Clinical presentation Many people with hepatitis do not have symptoms and do not know they are infected. If symptoms occur with an acute infection, they can appear anytime from 2 weeks to 6 months after exposure. Symptoms of chronic viral hepatitis can take decades to develop.
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Sign & symptoms Nausea Vomiting Diarrhea Dark urine (bilirubinuria) Pale stool jaundice Fever Headache Abdominal pain Hepatomegaly and splenomegaly Weight loss / lost of appetite
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Labs Laboratory findings in persons who are symptomatic show marked elevation in serum transaminase, total and direct bilirubin, and alkaline phosphatase levels. With any type of viral hepatitis, the alanine transaminase (ALT) level is typically higher than the aspartate transaminase (AST) level, and the range for both is usually between 500 and 5,000 U per L (8.35 to 83.5 μkat per L). Elevations in transaminase levels occur before bilirubin elevation, but may coincide with the onset of clinical.
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Hepatitis A
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Basics Enveloped RNA agent classified as a picornavirus Humans are only natural host Not associated with chronic liver disease Most patients recover within two months of infection 10 to 15 percent of patients will experience a relapse in the first six months Fulminant hepatic failure occurs in less than 1 percent of patients (severe acute liver injury with encephalopathy , >50 yrs , hepatitis B or C) Transplant!
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Rote of Transmission Fecal-oral route Close person-to-person Contact with an infected person Ingestion of contaminated food or water Sexual contact with an infected person (homosexual men) Fetal-maternal transmission is rare
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Epidemiology The anti-HAV prevalence rate in KSA was recently estimated at 18.6%, a considerable drop from the 90-100% rates reported only 2 decades ago in the adult population.
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People at Risk! International travelers ( except 6 countries ) Close contact with infected patient. Close contact with an international adoptee from a country of high or intermediate endemicity Men who have sex with men Persons who use illegal drugs Persons who have a clotting factor disorder Persons with occupational risk (work with hepatitis A-infected primates or with hepatitis A virus in a laboratory setting) Persons with chronic liver disease
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Clinical Assessment History
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Clinical Assessment History In children aged <6 years --- Asymptomatic ( 70 % ) or w/o jaundice. older children and adults --- Jaundice in 70 % Physical Examination Jaundice Hepatomegaly ( 80% ) RUQ pain
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Labs High serum aminotransferases (usually >1000 IU/dL) , ALT > AST Elevated total bilirubin ( 5 -10 mg/dl ) Elevated alkaline phosphatase In fulminant hepatitis: ↑ Urea ↑ Creatinine ↑ Prothrombin time
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Diagnosis IgM anti-HAV Is the gold standard for the detection of acute illness. detectable 5--10 days before onset of symptoms . declines to undetectable levels < 6 months after infection. IgG anti-HAV Appears early in the convalescent phase of the disease . Remains detectable for decades . HAV RNA in blood & stool Detectable during the acute phase of infection NAAT Expensive
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Natural Course
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TREATMENT Usually self-limited, the treatment is supportive. ≈ 85 % → full clinical and biochemical recovery within 3 months, Nearly all → complete recovery by 6 months . Return to work -- > after fever and jaundice subside Avoid alcohol intake Fulminant hepatitis -- > liver transplant
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PREVENTION
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Pre-exposure Prophylaxis
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People at Risk Traveling to or working in countries with high or intermediate rates of HAV infants age 6 to 11 months should be vaccinated ( not counted in routine tow-doses ) Men who have sex with men (MSM ) People who use or inject drugs People with clotting-factor disorders People who work with HAV-infected primates or with HAV in a research laboratory People with chronic liver disease Close contacts of recent adoptees from countries with high or intermediate hepatitis A endemicity People with direct contact with anyone who has hepatitis A People experiencing homelessness
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Passive Immunization
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Post-exposure prophylaxis A single dose of single-antigen Hepatitis A vaccine or IG (0.1 mL/kg) as soon as possible, within 2 weeks after exposure
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Vaccines Inactivated and attenuated hepatitis A vaccines . Administered IM into the deltoid muscle. 2-dose schedule . Duration of immunity from vaccination: 15 –20 years in children. 20 years in adults
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a. She is most infectious while she is jaundiced. b. Most infected adults are asymptomatic. c. This infection never results in chronic hepatitis. d. Relapses are common. e. Fecal shedding of the virus continues until liver enzymes have normalized. A 45-year-old woman comes to your office after her husband noticed that her “skin turned yellow.” She reported “flu symptoms” a couple of weeks ago, with weakness, loss of appetite, nausea, and abdominal pain for 2 days. She has felt better since, but noted the skin discoloration yesterday. On examination, her skin tone, conjunctivae, and mucous membranes are yellow-tinged. Serologies indicate acute hepatitis A infection. Which of the following is true about this infection?
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The answer is C. Hepatitis A is the most commonly reported hepatitis virus. It is spread via the fecal-oral route, most commonly through the ingestion of contaminated food or water. Hepatitis A causes acute hepatitis only and never results in chronic hepatitis. Lifelong immunity is expected for all patients that recover, therefore relapses are uncommon. Fecal shedding of the virus occurs early, and declines once jaundice develops. When patients are jaundiced, they are less infectious than during the prodrome. Symptoms of infection change with age. Ninety percent of those infected before the age of 10 years are asymptomatic, but up to 70% of infected adults have symptoms.
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Hepatitis B
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Hepatitis B risk factors Hepatitis B is primarily spread when blood, semen, or certain other body fluids- even in microscopic amounts – from a person infected with the hepatitis B virus enters the body of someone who is not infected. The hepatitis B virus can also be transmitted from: Birth to an infected mother Sex with an infected person Sharing equipment that has been contaminated with blood from an infected person, such as needles, syringes, and even medical equipment, such as glucose monitors Sharing personal items such as toothbrushes or razors
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Hepatitis B diagnosis The diagnosis of HBV infection requires the evaluation of the patient's blood for HBsAg, hepatitis B surface antibody (HBsAb), and hepatitis B core antibody (HBcAb).
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Hepatitis B management Several medications are approved in the United States for the treatment of HBV infection. Although interferon is approved for treatment, pegylated interferon alfa-2a (subcutaneous) has higher effectiveness, with a similar adverse effect profile, and is preferred over interferon.
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Complications of hepatitis B Cirrhosis and its complications, including ascites, portal hypertension, hemorrhage, and hepatocellular carcinoma. Hepatocellular carcinoma surveillance in patients with chronic HBV infection is often performed every 6 to 12 months Confection with hepatitis D (delta) virus may occur in patients with chronic HBV infection; this increases the risk of cirrhosis and fulminant hepatitis.
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Hepatitis C
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Hepatitis C risk factors HCV is transmitted primarily through: Sharing contaminated needles, syringes, or other equipment to inject drugs Less commonly through: Birth to an infected mother Sexual contact with an infected person Unregulated tattooing Needle-sticks or other sharp instrument injuries
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Hepatitis C diagnosis An anti-HCV antibody test is recommended to screen for HCV infection If the anti-HCV antibody test result is positive, current infection should be confirmed with a qualitative measurement of HCV RNA. If the anti-HCV antibody test result is negative in a patient who may have been exposed to HCV within the previous six months, HCV RNA should be measured every four to eight weeks for at least six months or follow-up anti-HCV antibody testing should be performed in 12 weeks. Patients with a positive anti-HCV antibody test result but a negative HCV RNA test result are not considered to have HCV infection. Quantitative HCV RNA testing is recommended before initiating therapy to determine the baseline viral load, and testing for HCV genotype is recommended to help guide treatment decisions.1,6
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Hepatitis C management Monitoring of treatment effectiveness is assessed by repeated measurement of HCV RNA. A sustained viral response (SVR), defined by the absence of HCV RNA on polymerase chain reaction testing 24 weeks after cessation of treatment, is associated with a 99% chance of being HCV RNA negative during long-term follow-up. SVR 12 weeks after treatment is a new primary end point in many recent drug trials. A small post hoc analysis of patients with HCV genotype 1 found that the SVR at 12 weeks has a 100% positive predictive value for SVR at 24 weeks.
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WHO Recommendation
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Complications of Hepatitis C Hepatocellular carcinoma. Decompensated cirrhosis. Ascites. Upper gastrointestinal tract bleeding. Encephalopathy
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A 45-year-old carpenter has a history of hepatitis C. He is returning for a check-up and is doing well without complaints. You should make which of the following recommendations? A) Ibuprofen is considered safe. B) Even low-dose acetaminophen should be avoided. C) Vaccination for hepatitis A and B is recommended. D) Milk thistle should be avoided. E) Mild-to-moderate alcohol use has little detrimental effect.
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The answer is C. Because alcohol in the setting of hepatitis C can increase the development of cirrhosis, patients with hepatitis C infection should abstain from alcohol use. Because associated infections with hepatitis A or B virus can lead to liver failure, vaccination of both is recommended. Medications that are potentially hepatotoxic should be avoided or used with caution in patients with chronic liver disease. In general, NSAIDs should be avoided; acetaminophen in a dosage below 2 g per day is a safer alternative. Many herbal remedies are potentially hepatotoxic and should also be avoided. Milk thistle can be used safely in patients who have chronic liver disease and may be beneficial. Ref: Additional Reading: Hepatitis C: diagnosis and treatment. Am Fam Physician. 2010;81(11):1351–1357.
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Chronicity and malignant transformation in hepatitis B and C Hepatitis B and C are both one of the leading causes of liver cancer and liver transplant. Hepatitis B and C can range from a mild illness, lasting a few weeks, to a serious, life-long (chronic) infection.
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Screening Recommendation CDC recommends hepatitis B testing for:
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Screening Recommendations CDC recommends hepatitis C testing for: Current or former injection drug users, including those who injected only once many years ago Everyone born from 1945 to 1965 Anyone who received clotting factor concentrates made before 1987 Recipients of blood transfusions or solid organ transplants before July 1992 Long-term hemodialysis patients People with known exposures to hepatitis C virus, such as health care workers or public safety workers after needle sticks involving blood from someone infected with hepatitis C virus and recipients of blood or organs from a donor who tested positive for the hepatitis C virus People with HIV Children born to mothers with hepatitis C
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Screening Recommendations The U.S. Preventive Services Task Force: recommends hepatitis C testing for additional groups including: People in jails or prisons People who use drugs snorted through the nose (in addition to people who inject drugs), People who get an unregulated tattoo
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When to refer Hepatitis B: When there’s consideration of initiating treatment persistent elevation of LFTs or HBV DNA Abnormal liver biopsy Evidence of complications (HCC, cirrhosis) Hepatitis C: Refer to HCV provider for consideration of treatment Refer to GI/ID provider with medical expertise, ideally at liver transplant center, if decompensated cirrhosis or infection with multiple genotypes
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An adult male sees you for follow-up of metabolic syndrome associated with type 2 diabetes andhyperlipidemia. Routine laboratory findings include an AST level of 73 U/L (N 10–59) and an ALT level of 62 U/L (N 13–40). These levels are persistently elevated 3 months later. He states that he drinks 1–2 glasses of wine per week and does not use acetaminophen. His medications include metformin (Glucophage) and atorvastatin (Lipitor). Which one of the following would be most appropriate at this point? A) Discontinue atorvastatin B) Discontinue metformin C) Screen for hepatitis and hemochromatosis D) Order CT of the abdomen E) Refer for a liver biopsy
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ANSWER: C This patient most likely has nonalcoholic fatty liver disease (NAFLD). The initial evaluation should include studies to rule out uncommon, but not rare, causes of liver disease. This would include viral hepatitis studies, iron studies for hemochromatosis, serum albumin levels, and a CBC. Discontinuing statin therapy is generally not necessary because statins have been shown to be safe for patients with chronic liver disease. Metformin is not commonly associated with elevated transaminases. If NAFLD is determined to be the most likely cause, an NAFLD fibrosis score should be calculated to preclude the need for a liver biopsy. Ref: Oh RC, Hustead TR, Ali SM, Pantsari MW: Mildly elevated liver transaminase levels: Causes and evaluation. Am Fam Physician 2017;96(11):709-715.
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A 35-year-old male has a negative past medical history and a normal physical examination. He reports that he smokes half a pack of cigarettes per day and has 3–4 beers per week. A comprehensive metabolic panel reveals an ALT (SGPT) of 30 U/L (N 10–40) and an AST (SGOT) of 84 U/L (N 10–30). The remaining laboratory studies are negative. There is no family history of liver disease. The laboratory findings suggest which one of the following? A) Hepatitis C B) Hemochromatosis C) Gilbert syndrome D) Alcoholic liver disease E) Nonalcoholic liver disease
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ANSWER: D An AST to ALT ratio greater than 2:1 suggests alcoholic liver disease, and a ratio of 3:1 or higher is highly suggestive of alcoholic liver disease. With most hepatocellular disorders, including nonalcoholic fatty liver disease, viral hepatitis, and iron overload disorder, the patient will have an AST to ALT ratio <1.
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Should you get vaccinated or tested for viral hepatitis? Take the 5 minute CDC Hepatitis Risk Assessment to get a personalized report of your recommendations for vaccination and/or testing. Start assessment now.
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Click here
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References/Resources
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Thanks