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Hepatitis: Diagnosis and Management

by John Fisher, MD
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    00:00 Let's now see if we can summarize the serology of hepatitis A, B and C. First of all, let's take a look at acute hepatitis B. In that situation, you would expect the patient to have hepatitis B surface antigenemia and have IgM antibodies to hepatitis B. In chronic hepatitis B virus infection, you would expect positive surface antigen but negative for all of the rest. Let's say you have acute hepatitis A on top of chronic hepatitis B, well there is the surface antigen again, you would have antibodies to hepatitis A, you would not have IgM antibodies to hepatitis C and the anti-hepatitis C obviously will be negative. So, if a person were to have both acute hepatitis A and B, they would have surface antigenemia, they would have IgM antibodies to hepatitis A and they would have antibodies to hepatitis B of the IgM sort. If all they have is acute hepatitis A, their surface antigen would certainly be negative but they would have IgM antibodies to hepatitis A and nothing else. Well let's say a patient has both acute hepatitis A and B but that their surface antigen is below the level of detection, well naturally their surface antigen would be negative but their antibodies to hepatitis A and hepatitis B of the IgM type would be positive. Let's say the patient has acute hepatitis B but the surface antigen levels are below the level of detection. Well, the surface antigen would be negative, the IgM antibodies to hepatitis A and to hepatitis C would be negative but the IgM antibodies to hepatitis B would be positive. Let's say all they've got is acute hepatitis C. Then the surface antigen, the IgM antibodies to A and B are going to be negative. The only one that will be positive are the antibodies to hepatitis C. So this may help you solve the problem of what kind of hepatitis does the patient have and those would be the 3 most common that you would encounter. So hopefully that helps. So if it isn't viral hepatitis, what is it? Well it could be drug-induced liver injury and we use a lot of drugs that are potentially hepatotoxic in patients so reviewing the drug list of a patient is extremely important. In an older person, we have to think about ischemic hepatitis particularly if there's severe atherosclerosis. There are conditions of autoimmune hepatitis and a real feared one is this Budd-Chiari syndrome which is thrombosis of the hepatic venous system and of course that produces back-up and destruction of hepatic cells. Wilson's disease is a problem of copper retention. The metabolism of copper is abnormal and patients with Wilson's disease have high levels of copper in their blood and sometimes precipitates of that copper will appear in the iris of the eye known as Kayser-Fleischer rings. Then pregnant women have a variety of problems with the liver that are non-infectious.

    04:14 Furthermore, we have to consider Epstein-Barr virus, the cause of infectious mono, and I had the privilege of taking care of a nurse in her 50s who came in with a picture of hepatitis and it wasn't clear for several days into the work-up that what she had was infectious mononucleosis manifesting primarily as hepatitis. Cytomegalovirus can do it especially in immunocompromised individuals. Herpes simplex is a rare cause of hepatitis and some of the Flaviviruses, arthropod-borne, can cause a hepatitis. So how do we manage hepatitis? Acute viral hepatitis doesn't usually require any kind of treatment and especially hepatitis A the prognosis in almost everybody is excellent. Acute hepatitis B, we're afraid of it but the prognosis is excellent. Chronic hepatitis B is a different story. We often have to use Interferon alfa and lamivudine in combination and these patients really need to be referred to a liver specialist for evaluation and treatment. Acute hepatitis C is mainly involved in the counseling of patients initially because progression to chronic infection is usual so we usually need to advise our patients of the likelihood of chronic infection. Within the last 5 years, the treatment for hepatitis C has been revolutionized. We once had to give weekly Interferon to patients, Pegylated Interferon for long acting and Interferon makes a person feel like they've got influenza with terrible aches and pains, just tendency to be depressed, feeling awful and we have to treat them for 6 months and longer but with the discovery of certain protease inhibitors that affects non-structural proteins, the treatment has been revolutionized and we're now able to cure hepatitis C but the specifics of this require a specialist and so we need to refer them to a specialist and with acute hepatitis E most cases are self-limited and no treatment is required. For severe cases, ribavirin may be used but once again a specialist needs to be involved. So one of the things that worries physicians certainly because of the high incidence of cirrhosis is hepatitis C. So how do we approach a patient? Well, we first check for hepatitis C antibodies. If they don't have hepatitis C antibodies, they're negative or non-reactive. There's no infection with hepatitis C and that's it, we don't do anything more. On the other hand, if hepatitis C antibodies are positive, reactive, then we need to do an analysis of the amount of hepatitis C that's present in the bloodstream, so-called hepatitis C viral RNA, a viral load if you will. If there's none detected, then there's no current hepatitis C infection, they were one of the lucky ones who got over the infection themselves and you would do additional testing as appropriate but it's not hepatitis C causing the problem. If on the other hand the viral load for hepatitis C, the HCV RNA is detected, then they need treatment. They have a current infection and you need to link them to a specialist in hepatitis C.


    About the Lecture

    The lecture Hepatitis: Diagnosis and Management by John Fisher, MD is from the course Gastrointestinal Infections.


    Included Quiz Questions

    1. Test for HCV RNA (viral load)
    2. Start interferon and lamivudine
    3. Start ribaviron
    4. Genetic testing
    5. Liver imaging studies
    1. Hepatitis B surface antigen and IgM mediated Hepatitis B core antibodies
    2. Hepatitis B surface antigen only
    3. Hepatitis B surface antigen, IgM mediated Hepatitis B core antibodies, IgM mediated Hepatitis A antibodies
    4. IgM mediated Hepatitis B core antibodies only
    5. Hepatitis B core antigens only
    1. Acute hepatitis A and acute hepatitis B infections
    2. Acute hepatitis A and chronic hepatitis B infections
    3. Chronic hepatitis B infection
    4. Chronic hepatitis A and B infections
    5. Acute hepatitis C infection
    1. No treatment; it is self limiting
    2. Ribavirin
    3. Counselling for chronic disease precautions
    4. Pegylated interferon
    5. Interferon-alpha and lamivudine combination treatment
    1. Chronic hepatitis B infection
    2. Acute hepatitis B infection
    3. Chronic hepatitis C infection
    4. Acute hepatitis C infection
    5. Acute hepatitis E infection

    Author of lecture Hepatitis: Diagnosis and Management

     John Fisher, MD

    John Fisher, MD


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    Management section can be improved
    By Hamed S. on 27. March 2017 for Hepatitis: Diagnosis and Management

    Very comprehensive discussion. It would have been worthwhile to talk about criteria for starting treatment for chronic Hep B (e.g DNA count vs symptoms and livers functions). Also unclear if treatment of HepB is curative. The hepatitis talks did not mention genotypes of Hep C at all which is important for treating the condition, particularly in countries where access to direct acting antivirals is not available. Finally the talks didn't mention what percentage of patients with chronic Hep B and C go on to develop cirrhosis and hepatocellular carcinoma.