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Hepatitis

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Topic updated on 12/13/16 3:48pm

Snap Shot
  • A 35-year-old with duodenal ulcer diseae had a 10 unit blood transfusin for upper GI bleeding 3 months ago. He presents with flu-like symptoms, malaise, and tender hepatomegaly. Labs show an atypical lymphocytosis.
Introduction
  • Inflamation of the liver caused by
    • viruses
      • see Hepatitis viruses topic
    • drug-induced
      • isoniazid, halothane, methyldopa, acetaminophen
    • alcohol
    • autoimmune
      • most often seen in young women
      • HLA DR3, DR4 association
      • can be combined with other autoimmune disorders (e.g. Grave's disease)
    • neonatal
      • associated with CMV, inborn errors of metabolism
    • other causes include
      • mononucleosis
      • Metabolic syndrome - nonalcoholc steatohepatitish (NASH) 
      • Wilson's Disease
  • Risk factors
    • IV drug use
    • alcohol
    • foreign travel
Presentation
  • Symptoms
    • often starts with viral prodrome symptoms
      • malaise/fatigue
      • joint pain
      • nausea/vomiting
  • Physical exam
    • jaundice
      • scleral icterus
    • tender hepatomegaly
Evaluation
  • Labs
    • ↑ WBC with a atypical lymphocytosis in viral hepatitis
    • mixed direct and indirect hyperbillirubinemia
      • conjugated:unconjugated billirubin ratio 0.2-0.5
    • ↑↑↑ elevated AST and ALT (ALT>AST)
      • AST:ALT > 2 suggests alcoholic hepatitis
      • transaminasemia is the best marker for hepatitis
  • Hepatitis B virus serologies
    • HBV surface antigen (HBsAg)= active infection
      • alone indicates early exposure
      • if it remains past acute phase may indicate carrier status
        • HBsAg + HBcAb = healthy carrier
        • HBsAg + HBcAb + HBeAg/HBV DNA = infective carrier
    • HBV envelope antigen/HBV DNA (HBeAg/HBV DNA) = highly infectious
      • are the only infectious particles of the virus
    • anti-HBV surface antibody (HBsAb)= immunity
      • alone indicates immunity from vaccine
        • vacine is a recombinant HBsAb produced by yeast
    • anti-HBV core antibody (HBcAb) = immunity
      • presence indicates recovery from prior exposure
  • Other hepatitis serologies
    • see Hepatitis viruses topic
  • Autoimmune hepatitis serologies
    • anti-smooth muscle antibody
    • anti-nuclear antiboby

Treatment
  • Treatment varries based on etiology
    • HBV
      • pegalated alpha-interferon + / - lamivudine 
        • decrease liklihood of developing chronic hepatitis
    • HCV
      • pegalated alpha-interferon + / - ribavirin for HCV
        • decrease liklihood of developing chronic hepatitis
    • autoimmune
      • steroids + azathioprine
    • most other causes
      • rest and wait for the resolution of symptoms
      • steroids for severe alchoholic hepatitis
    • Chronic liver disease - must admister HAV and HBV vaccines 
Prognosis, Prevention, and Complications
  • ↑ risk of postnecrotic cirrhosis secondary to chronic hepatitis
    • may progress to hepatocellular carinoma


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Qbank (2 Questions)

TAG
(M1.GI.7) A pathologist is reviewing a number of unlabeled liver biopsy slides which need to be assigned to the correct patient. Which of the following slides best corresponds to a patient who has a history of type II diabetes, obesity, and hyperlipidemia but no history of alcohol intake or liver pathology? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(M1.GI.42) A 51-year-old male with an unknown past medical history presents to a free medical clinic because he is concerned about recent changes to his health. He states that over the past year he has noticed that his eyes appear yellow in color and he has seemed to put on a large amount of weight. He denies any alcohol use but endorses previous and continuing IV drug use. On exam, the patient's vitals are shown as Temp: 36 deg C, HR: 81 bpm, BP: 121/90 mmHg, RR: 11, SaO2: 99% on RA. The physician observes the findings shown in Figure A and B. Furthermore, when the patient holds his hands as demonstrated in Figure C, they oscillate as though he is slapping the air. A liver biopsy is subsequently obtained which is demonstrated in figure D. Which of the following vaccines should this patient receive? Topic Review Topic
FIGURES: A   B   C   D    

1. Subunit vaccine and inactivated vaccine
2. Inactivated vaccine only
3. Toxoid vaccine and live attenuated vaccine
4. Conjugate vaccine and toxoid vaccine
5. Live attenuated vaccine only

PREFERRED RESPONSE ▶

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