QuestionSBA
QuestionChoice
Hepatitis C is more classically associated with chronic illness with most infected patients experiencing no acute symptoms within 6 months of infection. Hepatitis C may cause chronic liver disease, with corresponding signs such as spider naevi, ascites, caput medusae.
10015790
e
Hepatitis C
QuestionChoice
Hepatocellular carcinoma is unlikely to present acutely and would classically be associated with a background of chronic hepatitis B, C, or alcoholism. Constitutional symptoms such as weight loss and night sweats may be present.
10015788
c
Hepatocellular carcinoma
QuestionChoice
Pregnant women are at increased risk of contracting acute HEV infection after eating raw or undercooked meat, especially pork. These patients are at higher risk of developing severe complications including fulminant acute liver failure which can be fatal.
10015786
a
Hepatitis E
QuestionChoice
This is a sensible differential however the vignette points towards an infective picture with the recent BBQ. Pork in particular is a major reservoir of HEV. In addition, most cases would be unlikely to cause such a severe presentation.
10015787
b
Acute fatty liver of pregnancy
QuestionChoice
Hepatitis A normally runs a self-limiting course. It is unlikely to cause such a severe clinical picture.
10015789
d
Hepatitis A
QuestionComment
didnt understand why but based on questions in terms of acute viral hepatitis causes

foreign travel= hep A
overall most common= hep A

pregnant=hepE
pork=hepE
BBQ=hepE
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Ajan
QuestionComment
wow this hit hard...
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ACE
QuestionComment
This is why pork is haram kids

45825
QuestionComment
frl
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Haemolytic antibody
QuestionComment
mashallah brother 

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Salaamattack
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nysald
QuestionComment
Way to remember it: hepatitis E in pregnancEE
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Edema Otitis
QuestionComment
I cooked the chicken
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Cranium Crusher 
QuestionComment
this is so sad .. 
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Opal
QuestionComment
"Pigs sleep and root in sh*t, that's a filthy animal. I don't eat nothin' that ain't got sense enough to disregard its own feces."
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Amnesia Gland
QuestionComment
Hepatitis E for enormous belly (pregnancy)
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Nightshift Bradykinin
QuestionComment
nah thats so sad
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butterfly needle
QuestionComment
well that took a turn....
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Niamh B
Concept
Chapter
### Summary

Hepatitis means inflammation of the liver and may be caused by a range of infectious and non-infectious aetiologies.

All infectious hepatitis cases are notifiable diseases in the UK.

The most common causes of viral hepatitis in the UK are hepatitis A, B and C viruses. These can all cause acute disease, but HBV and HCV can also cause chronic infection. The latter can lead to liver fibrosis and hepatocellular carcinoma.

Other causes of viral hepatitis include:

- Hepatitis D Virus (can cause chronic hepatitis)
- Hepatitis E Virus
- CMV
- EBV
- Adenovirus

Clinical Features:

- Malaise and fatigue
* Nausea and vomiting
* Right upper quadrant pain
* diarrhoea (may have pale stools and dark urine)
* Jaundice
* Hepatomegaly
* Splenomegaly and lymphadenopathy
* Liver failure: characterised by hepatic encephalopathy, jaundice, ascites and abnormal clotting.
* Other causes of acute hepatitis include drugs, toxins, alcohol, EBV, CMV, hepatitis E, leptospirosis, and malaria.

### Hepatitis A

- Virus type and transmission route
	* RNA picornavirus, transmitted by the faecal-oral route (occasionally through food sources or through anal sex)
- Epidemiology of Hepatitis A
	- Prevalence is high in developing countries.
	- Increasing age is the only fundamental determinant of disease severity, with the most significant morbidity and mortality in those over 50 years old.
	- Travelers and those at risk can be offered immunisation
- Presentation of Hepatitis A
* Flu-like symptoms followed by jaundice, pale stools (in some), dark urine and abdominal pain.
* Incubation period of 2-6 weeks
* Complete recovery can take up to 6 months.
- Investigations of Hepatitis A:
	- IgM and IgG antibodies to HAV.
- Management of Hepatitis A
	- Management is largely supportive

### Hepatitis B

- Virus type
	- dsDNA virus of the Hepadnaviridae family
- Hepatitis B Virus Epidemiology
	- The most common cause of hepatitis globally
	- High prevalence regions include sub-Saharan Africa, Asia and the Pacific Islands.
	- The disease is declining in children and adolescents in the UK due to routine vaccination
- The incubation period is usually 60-90 days.
- Hepatitis B Virus transmission
	* Transmission is via infected blood or body fluids
	* Vaginal/anal intercourse
	* Transfusion
	* Vertical transmission (in 90% of pregnancies where the mother is HBeAg positive, and 10% where this is negative).
	* In developing countries, infection is mostly in childhood through vertical or horizontal transmission. In areas of low endemicity (such as the UK), infections are mostly acquired in adulthood.
* Hepatitis B Infection features
	* Only 5% of children have jaundice and severe symptoms, but the majority cannot clear the infection and develop chronic disease.
	- 30-50% of adults experience jaundice, fever, malaise, darkening of urine and lightening of stool. Some develop fulminant liver failure with decompensation (ascites, encephalopathy etc.). The risk of developing chronic disease is low (<5%).
- Serology of Hepatitis B (**See detailed section below**)
	- HBsAg is detected 3-5 weeks after infection. If present for >6 months, this defines carrier status (5-10% of infections).
	- In carriers, HBeAg-positive patients are the most infectious.
	- If HBeAg-negative (and anti-HBe-antibody positive), they have lower infectivity.
	- Antibodies to HBsAg (anti-HBs) indicate previous vaccination
	- Antibodies to hep B core antigen (anti-HBc) indicate past infection.
	- Patients with chronic infection who are HBeAg -ve may have an immune escape phase when the virus mutates despite anti-HBe antibodies being present. These patients are the main pool for the spread in the UK, so all chronically infectious patients need yearly screens to identify this.
	- Patients with acute infection have raised IgM to HBcAg, which is negative in chronic infection.
- Management of Hepatitis B
	- Only adults who are HBsAg-positive, have compensated liver disease, are pregnant or are of a young age may be referred for treatment
	- Peginterferon alfa-2a is the first line, with tenofovir and entecavir as second-line alternatives.

### Hepatitis B Serology Interpretation
	

#### I. Hepatitis B Surface Antigen (HBsAg)

This is the first detectable viral antigen in the course of infection and is a marker of active infection.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | Possible acute or chronic Hepatitis B infection |
| Negative | No active Hepatitis B infection |

#### II. Hepatitis B Surface Antibody (anti-HBs)

This is an antibody produced by the immune system in response to the Hepatitis B surface antigen. It confers immunity against HBV.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | Immunity to Hepatitis B (due to past infection or vaccination) |
| Negative | No immunity to Hepatitis B |

#### III. Hepatitis B Core Antigen (HBcAg)

This antigen is not detectable in the blood but triggers the production of core antibodies.

#### IV. Hepatitis B Core Antibody (anti-HBc)

It can be present in both acute and chronic infection. IgM anti-HBc appears early in the infection and indicates a recent infection. IgG anti-HBc remains indefinitely and indicates past exposure.

| Result  | Interpretation |
| ------- | -------------- |
| IgM Positive | Acute or recent Hepatitis B infection |
| IgG Positive | Past Hepatitis B infection or chronic infection |

#### V. Hepatitis B e Antigen (HBeAg)

This is a marker of high replicative activity, indicating a high degree of infectivity.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | High level of Hepatitis B replication; high infectivity |
| Negative | Lower levels of Hepatitis B replication; lower infectivity |

#### VI. Hepatitis B e Antibody (anti-HBe)

It appears after the clearance of HBeAg and indicates lower infectivity.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | Lower level of Hepatitis B replication; lower infectivity |
| Negative | Higher levels of Hepatitis B replication; higher infectivity |

#### VII. Hepatitis B DNA (HBV DNA)

This test measures the amount of Hepatitis B viral load in the blood.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | Active Hepatitis B replication |
| Negative | No active Hepatitis B replication |

#### VII. Hepatitis B DNA (HBV DNA)

This test measures the amount of Hepatitis B viral load in the blood.

| Result  | Interpretation |
| ------- | -------------- |
| Positive | Active Hepatitis B replication |
| Negative | No active Hepatitis B replication |

#### Summary

Below is a table summarizing the serological patterns associated with different stages of Hepatitis B infection:


| Status/Marker  | HBsAg | anti-HBs | IgM anti-HBc | IgG anti-HBc | HBeAg | anti-HBe | HBV DNA |
| ------------- | ------- | --------- | ------------ | ------------ | ------- | --------- | ------- |
| Acute HBV Infection with Immunity | Positive | Negative | Positive | Positive | Positive | Negative | Positive |
| Chronic HBV Infection | Positive | Negative | Negative | Positive | Positive/Negative | Positive/Negative | Positive/Negative |
| Immune due to Natural Infection | Negative | Positive | Negative | Positive | Negative | Positive | Negative |
| Immune due to Hepatitis B Vaccination | Negative | Positive | Negative | Negative | Negative | Negative | Negative |




### Hepatitis C

- Virus type
	- RNA virus of the Flaviviridae family, with six major genetic types (genotypes 1 and 3 are most common in the UK, and genotype one is associated with more prolonged treatment and worse prognosis).
- Hepatitis C Virus transmission
	- Transmitted via exchange of blood (the vast majority) and bodily fluids:
	* Intravenous drug use
	* Blood transfusion
	* Haemodialysis (rare in the UK)
	* Sexual transmission (less than 1% per year of relationship, but rate higher if co-infected with HIV)
	* Needlestick injuries in healthcare facilities - 3% risk of transmission.
	* Perinatal infection from infected mother.
* Incubation period of 6-9 weeks.
* Natural history of Hepatitis C:
	- Most infections are asymptomatic
	- Only 15-25% clear the virus; 75% go on to develop chronic infection
	- Patients with chronic infection have persistently high LFTs
	- Cirrhosis develops in 20-30%.
	- 1-4% of patients with cirrhosis develop hepatocellular carcinoma, and 2-5% develop liver failure.
- Investigations of Hepatitis C
	- Anti-HCV serology - 90% are positive three months after infection, but it may take many months to become positive for some.
	- HCV RNA - if positive for more than two months, it needs to be treated.
- Management of Hepatitis C
	- Symptomatic treatment in the early stages of the disease
	- Drug therapy should be considered for all patients and depends on the genotype of the virus. Nucleoside analogues are generally preferred, e.g. Sofosbuvir, and often lead to undetectable viral loads
	- Antivirals have a proven benefit in basically every patient, irrespective of the amount of cirrhosis and fibrosis
	- Manage any underlying cirrhosis

### Hepatitis D

- Virus type:
	- RNA virus
- Hepatitis D viral transmission:
	- Infected blood products
	- Intravenous drug use
	- Sexual intercourse
- Hepatitis D only occurs as a superinfection in patients with concurrent hepatitis B infection; consider this as a differential in a patient with established hepatitis B who has a sudden deterioration in hepatic function/decompensated liver disease.
- Investigation in Hepatitis D:
	- Hepatitis D (IgM, IgG) antibody test
- Management:
	- Pegylated interferon-alpha (low success rates)
- Prevention:
	- No hepatitis D vaccination is available
	- Hepatitis B vaccination may be preventative (the patient needs to develop hepatitis B first to then develop hepatitis D).

### Hepatitis E

- Virus type:
	- Single-stranded RNA virus
- Hepatitis E viral transmission:
	- faecal-oral transmission
	- Contaminated food
		- Classically transmitted through undercooked pork and seafood
	- Vertical transmission
- Incubation period of 2-9 weeks
- Endemic regions include Asia, the Middle East, Africa, and Central America
- Pregnant women are at risk of severe disease; may develop fulminant hepatitis.
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Infection
15701
Pregnant women have an increased risk of severe complications and fulminant liver failure from Hepatitis E infection, especially following consumption of raw or undercooked meat.
A 29 year old woman has nausea and fatigue and appears jaundiced. She is 28 weeks pregnant with her first child. She appears confused. Her husband reports attending a family BBQ last month. She deteriorates over the next few days and unfortunately dies.

What is the most likely diagnosis?
a