Hepatitis C and Related Conditions Quiz
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Questions and Answers

What is the most prevalent genotype of HCV in Egypt?

  • Genotype 3
  • Genotype 7
  • Genotype 4 (correct)
  • Genotype 1

    • What is a common mode of transmission for hepatitis C?

  • Fecal-oral transmission
  • Vector-borne transmission
  • Airborne transmission
  • Bloodborne transmission (correct)

    • Which of the following conditions is a known complication of chronic hepatitis C?

  • Type 1 diabetes mellitus
  • Hypertension
  • Autoimmune thyroiditis (correct)
  • Rheumatoid arthritis

    • What is the typical incubation period for hepatitis C?

    <p>6-7 weeks</p> Signup and view all the answers

    What is one of the recommended treatments for acute hepatitis C?

    <p>A 6-week course of ledipasvir and sofosbuvir</p> Signup and view all the answers

    Which of the following is NOT a risk factor for HCV transmission?

    <p>Excessive alcohol consumption</p> Signup and view all the answers

    What laboratory method is used to confirm a diagnosis of hepatitis C?

    <p>HCV RNA PCR test</p> Signup and view all the answers

    Which symptom is commonly associated with clinical illness in hepatitis C patients?

    <p>Markedly elevated transaminases</p> Signup and view all the answers

    What is the initial step in diagnosing acute hepatitis E?

    <p>Testing for IgM antiHEV in serum</p> Signup and view all the answers

    For HBeAg-positive patients without cirrhosis, when should treatment be initiated?

    <p>When Hepatitis B DNA is &gt;20,000 international units/mL and ALT is &gt;2 x ULN</p> Signup and view all the answers

    What is the treatment approach for patients with compensated cirrhosis?

    <p>Antiviral therapy should be provided regardless of HBeAg status</p> Signup and view all the answers

    What is the recommended timing for pregnant patients to initiate therapy to prevent HBV transmission to their child?

    <p>Late second or early third trimester if viral load is high</p> Signup and view all the answers

    What is the recommended treatment for all patients with hepatocellular carcinoma (HCC)?

    <p>Nucleos(t)ide analogs to reduce the risk of HCC recurrence</p> Signup and view all the answers

    What percentage of individuals with acute hepatitis C develop chronic hepatitis?

    <p>85%</p> Signup and view all the answers

    Which diagnostic test is NOT typically used to confirm chronic hepatitis C?

    <p>Liver biopsy</p> Signup and view all the answers

    What indicates that a patient is cured of hepatitis C?

    <p>Sustained virological response 3 months after treatment</p> Signup and view all the answers

    What is the risk of developing cirrhosis in chronic hepatitis C patients?

    <p>30%</p> Signup and view all the answers

    What is the primary mode of transmission for hepatitis E?

    <p>Feco-oral</p> Signup and view all the answers

    Which hepatitis virus infection is characterized by the presence of both anti-HDV and HDAg in serum?

    <p>Hepatitis D</p> Signup and view all the answers

    In which scenario is hepatitis E most commonly misdiagnosed?

    <p>Drug-induced liver injury</p> Signup and view all the answers

    How can superinfection with hepatitis D affect prognosis?

    <p>It commonly leads to acute liver failure</p> Signup and view all the answers

    What is the minimum FibroScan value indicating significant fibrosis that would recommend treatment?

    <p>7 kPa</p> Signup and view all the answers

    What is the main goal of chronic hepatitis B treatment?

    <p>Induction of long-term suppression of HBV-DNA levels</p> Signup and view all the answers

    Which of the following is a recommended HBV vaccine schedule for infants?

    <p>Initial vaccination at birth, repeat at 1-2 months and 6-18 months</p> Signup and view all the answers

    Which of these drugs is administered at a dose of 300 mg per day for chronic hepatitis B?

    <p>Tenofovir fumarate</p> Signup and view all the answers

    What type of therapy does Peginterferon alfa-2a represent?

    <p>Nucleotide analogue</p> Signup and view all the answers

    For which group is Hepatitis B immune globulin (HBIG) recommended as postexposure prophylaxis?

    <p>Those with recent exposure to an HBV infected patient</p> Signup and view all the answers

    What is a significant complication that current hepatitis B treatments aim to prevent?

    <p>Hepatocellular carcinoma</p> Signup and view all the answers

    Which of the following statements about the HBV vaccine is true?

    <p>It has a seroconversion rate greater than 95%</p> Signup and view all the answers

    What is the serum-ascites albumin gradient (SAAG) equation used for in diagnosing ascites?

    <p>Serum albumin minus ascitic albumin</p> Signup and view all the answers

    What is true about ascitic total protein levels in cirrhosis?

    <p>They are usually low in cirrhosis patients.</p> Signup and view all the answers

    Which treatment is considered first-line for managing ascites in cirrhosis?

    <p>Dietary sodium restriction</p> Signup and view all the answers

    What defines refractory ascites?

    <p>Persistent ascites despite adequate sodium restriction and maximum-dose diuretics</p> Signup and view all the answers

    What is the typical action of spironolactone in treating ascites?

    <p>Blocks aldosterone action on kidneys</p> Signup and view all the answers

    In the context of ascitic fluid analysis, which test is not routinely performed?

    <p>Liver biopsy</p> Signup and view all the answers

    What indicates portal hypertension with high accuracy when using SAAG?

    <p>SAAG greater than or equal to 1.1 g/dL</p> Signup and view all the answers

    If ascitic total protein is greater than 2.5 g/dL and SAAG is less than 1.1 g/dL, what should be considered?

    <p>Peritoneal carcinomatosis</p> Signup and view all the answers

    What is the recommended prophylaxis for perinatal exposure to HBsAg positive patients?

    <p>HBIG plus vaccination at time of birth</p> Signup and view all the answers

    Which of the following is NOT a manifestation of portal hypertension in liver cirrhosis?

    <p>Gynecomastia</p> Signup and view all the answers

    What is the cause of elevated hydrostatic pressure leading to ascites in cirrhosis?

    <p>Portal vein pressure exceeding normal limits</p> Signup and view all the answers

    Which laboratory finding is commonly associated with liver cirrhosis?

    <p>Elevated alpha-fetoprotein levels in HCC</p> Signup and view all the answers

    What alteration occurs during the activation of hepatic stellate cells in cirrhosis?

    <p>Increased collagen production leading to fibrosis</p> Signup and view all the answers

    Which imaging method can show characteristic features of an irregular liver surface in cirrhosis?

    <p>CT triphasic scan</p> Signup and view all the answers

    Which of the following symptoms is associated with liver cell dysfunction?

    <p>Palmar erythema</p> Signup and view all the answers

    What is a common clinical feature of patients with liver cirrhosis related to portal hypertension?

    <p>Nausea and dyspepsia</p> Signup and view all the answers

    Study Notes

    Chronic Hepatitis & Liver Cirrhosis

    • HCV is a single-stranded RNA virus similar to flaviviruses
    • Seven major genotypes of HCV have been identified
    • Genotype 4 is most common in Egypt
    • Transmission modes include blood-borne infections
    • Injection drug use is the leading cause of transmission, with over 60% of cases
    • Body piercings, tattoos, and hemodialysis are risk factors
    • Sexual and mother-to-child transmission are rare
    • Multiple sexual partners increase risk of both HCV and HIV infection
    • Incubation period for hepatitis C is 6-7 weeks
    • Acute illness is often mild, usually asymptomatic
    • Occasionally, fever, right upper quadrant pain, nausea, vomiting, and jaundice are observed
    • Significantly elevated transaminase levels
    • High rate of chronic hepatitis (greater than 80%) is a characteristic feature
    • In pregnant patients, serum aminotransferase levels usually normalize despite persistent viremia then increase again post-partum

    Acute Hepatitis C

    • The incubation period for hepatitis C is 6–7 weeks
    • Acute illness is often mild and usually asymptomatic
    • Fever, right hypochondrial pain, nausea, vomiting, and jaundice are observed occasionally
    • Significantly elevated transaminase levels
    • High rate of chronic hepatitis (greater than 80%) is a characteristic feature
    • In pregnant patients, serum aminotransferase levels typically normalize despite persistent viremia then increase again post-partum

    Lab Diagnosis

    • HCV antibodies are detected using enzyme immunoassay (EIA)
    • Diagnosis is confirmed with PCR for HCV RNA
    • Presence of anti-HCV antibodies without HCV RNA suggests recovery from prior infection

    Course of Acute and Chronic Hepatitis C

    • A graph demonstrates the fluctuating levels of jaundice, symptoms, ALT, anti-HCV, and HCV RNA (PCR) over time (months and years)

    Complications

    • Mixed cryoglobulinemia and membranoproliferative glomerulonephritis
    • Autoimmune thyroiditis
    • Lymphocytic sialadenitis
    • Idiopathic pulmonary fibrosis
    • Sporadic porphyria cutanea tarda
    • Monoclonal gammopathies
    • Type 2 diabetes mellitus
    • 20-30% or more increased risk of B-cell non-Hodgkin lymphoma
    • Genotype 1 is associated with end-stage renal disease risk
    • Hepatic steatosis is common and associated with HCV infection
    • HCV infection in pregnancy can lead to premature birth and intrahepatic cholestasis

    Treatment of Acute Hepatitis C

    • Direct-acting antivirals (DAAs), such as a 6-week course of ledipasvir and sofosbuvir are effective
    • DAAs can prevent chronic hepatitis in acute genotype 1 hepatitis C patients who do not spontaneously clear the infection within 3 months
    • Drug treatment is particularly recommended for individuals who inject drugs

    Chronic Hepatitis C

    • Most infections are initially asymptomatic (75%)
    • Chronic hepatitis may progress to cirrhosis in 25% of cases within 20 years
    • Patients may experience insidious fatigue and elevated transaminases, with incidental diagnosis during routine checkups

    Diagnosis

    • Elevated transaminases
    • Positive HCV antibodies
    • Positive PCR for HCV

    Treatment of Chronic Hepatitis C

    • Treatment strategies for chronic hepatitis C are described

    HCV Virus

    • The HCV virus is a 9.6kb RNA virus
    • The virus has different proteins: NS3/NS4A Protease Inhibitors; NS5A Inhibitors; and NS5B Polymerase Inhibitors
    • Corresponding medications are mentioned (e.g., Ledipasvir, Sofosbuvir)

    Patient Cured

    • The patient is considered cured when HCV RNA is negative 3 months after treatment, this is known as sustained virological response

    Prognosis

    • Chronic hepatitis progresses slowly in many cases and develops in up to 85% of individuals with acute hepatitis C.
    • Cirrhosis can develop in up to 30% of those with chronic hepatitis C
    • Risk of cirrhosis and hepatic decompensation is higher in patients coinfected with HBV or HIV
    • Patients with cirrhosis have a 3-5% per year risk of hepatocellular carcinoma (HCC)

    Hepatitis D

    • HDV is an RNA virus requiring HBV for replication
    • Co-infection with HBV is generally similar in severity to acute hepatitis B alone
    • Superinfection with HDV has a worse prognosis, often leading to acute liver failure or rapid progression to cirrhosis
    • Diagnosis involves detecting antibodies to hepatitis D antigen (anti-HDV) and, where available, hepatitis D antigen itself (HDAg) or HDV RNA in serum.

    Hepatitis E

    • HEV is a 27- to 34-nm RNA hepevirus in the Hepeviridae family.
    • A major cause of acute hepatitis in Central and Southeast Asia.
    • Transmission is primarily through the fecal-oral route
    • Should be considered in patients experiencing acute hepatitis after travel to endemic areas

    Hepatitis E (continued)

    • The illness is generally self-limiting (no chronic carrier state)
    • Some cases of genotype 3 HEV have been reported to cause chronic hepatitis, especially in transplant recipients taking tacrolimus.
    • Diagnosis is usually made through IgM anti-HEV tests in serum. The tests might have varying levels of accuracy

    Liver Disease Progression

    • Diagram illustrates healthy liver to acute hepatitis to recovery to chronic hepatitis to cirrhosis to liver cancer.

    Serologic Diagnosis of Hepatitis B

    • Table shows various markers (HBsAg, Anti-HBs, HBc-IgM, HBc-IgG, HBeAg, Anti-HBe, HBV DNA) and their correlation with disease stages.

    Acute Hepatitis B

    • Graph shows the fluctuating levels of HBsAg, HBV DNA (PCR), IgM Anti-HBc, Anti-HBc, and HBsAb over time (months)

    Hepatitis B Treatment

    • HBeAg-negative chronic hepatitis treatment is indicated if ALT > 2 x ULN and HBV DNA > 2000 IU/mL
    • HBeAg-positive chronic hepatitis treatment is indicated if HBV DNA > 20,000 IU/mL and ALT > 2 x ULN.

    Hepatitis B Treatment (continued):

    • Compensated cirrhosis with detectable HBV DNA warrants antiviral therapy, regardless of HBeAg status or ALT levels.
    • Acute liver failure or decompensated cirrhosis necessitates immediate antiviral therapy initiation.
    • Patients on immunosuppressive therapy should receive antiviral treatment before starting immunosuppression.
    • Pregnant women with high viral loads (> 2 x 105 IU/mL) should begin therapy during late second or early third trimester

    Hepatitis B Treatment (continued):

    • Patients with hepatocellular carcinoma (HCC) should use a nucleo(s)tide analog (tenofovir or entecavir)
    • Treatment is recommended for people with significant fibrosis (≥ F2), based on FibroScan value >7 kPa, or based on clinical cirrhosis criteria and FibroScan value > 12.5 kPa
    • Treatment should not depend only on HBV DNA or ALT levels

    Treatment Aim

    • Suppress viral replication
    • Decrease inflammatory damage to liver
    • Prevent or reverse complications (e.g., cirrhosis)

    Treatment Aim (continued):

    • Reduce risk of hepatocellular carcinoma
    • Current therapy for chronic hepatitis B does not eradicate the virus and has limited long-term efficacy.

    Drug Therapy

    • List of medications (PegInterferon Alfa-2a, Tenofovir alafenamide, Tenofovir fumarate, and Entecavir), including dosages and routes of administration

    Hepatitis B Vaccine

    • Plasma-derived and recombinant vaccines use the HBsAg to create anti-HBs response for immunity, with an effectiveness rate > 95%.
    • Vaccination is recommended for infants at birth and at 1-2 and 6-18 months. Adults should be vaccinated as well if at high risk (including dialysis patients, health care workers)

    Hepatitis B Vaccines (continued)

    • The recommended schedule for adult vaccination includes a primary dose followed by repeated doses at one and six months after the initial dose.

    Postexposure Prophylaxis for Hepatitis B

    • Hepatitis B immune globulin (HBIG) provides passive immunization
    • Vaccination is also advised in those at increased risk of infection

    Liver Cirrhosis

    • It's a histological diagnosis marked by advanced fibrosis, structural changes (nodules), and vascular alterations
    • Chronic liver inflammation leads to stellate cell activation and endothelial damage
    • Activated stellate cells produce collagen (fibrosis) and lead to vascular and organ contractions

    Liver Cirrhosis (continued)

    • Clinical manifestations stem from the loss of liver function, causing portal hypertension and HCC

    Clinical Presentation of Liver Cirrhosis

    • Patients may report early satiety, increased abdominal girth, weight gain, and respiratory distress
    • Physical exam may show abdominal distension, bulging flanks with shifting dullness, fluid wave, and a palpable liver/spleen. (more sensitive)

    Clinical Presentation (continued)

    • General stigmata of cirrhosis are often present (spider angiomata, palmar erythema), associated with portal hypertension manifestations

    Investigations for Liver Cirrhosis

    • Laboratory tests may reveal elevated or normal transaminase levels, high bilirubin levels (with biphasic pattern), low albumin, and elevated alpha-fetoprotein in cirrhosis and HCC.
    • Viral markers can be screened.
    • Autoimmune markers (antimitochondrial antibodies), LKM antibody, soluble liver antigen may be screened, along with metabolic markers like hemochromatosis and Wilson's disease.

    Investigations (continued)

    • Imaging, such as ultrasound, can identify irregular surface, dilated portal vein, or splenomegaly
    • CT scans and endoscopy provide further assessment for focal lesions or esophageal/gastric varices.

    Ascites

    • Pathogenesis arises from elevated hydrostatic pressure (portal hypertension); renal sodium retention due to sympathetic activation of the renin-angiotensin-aldosterone system; and low oncotic pressure (hypoalbuminemia)

    Treatment of Ascites

    • Dietary sodium restriction (limit to under 2g/day)
    • Diuretics (spironolactone and furosemide) are employed
    • Goal of diuretic therapy is increased urinary sodium (> 78 mmol/day), a urinary sodium/potassium ratio greater than 1, or a maximum weight loss of 0.5 kg/day (1.0 kg/day in edema).

    Refractory Ascites

    • This describes persistent ascites despite adequate sodium restriction and diuretic therapy.
    • Serial large-volume paracentesis (LVP), potentially with albumin infusions (6-8g/L), may be employed
    • Transjugular intrahepatic portosystemic shunt (TIPS) might be considered for suitable patients
    • Liver transplantation may be considered in some cases.

    Spontaneous Bacterial Peritonitis (SBP)

    • Occurs in approximately 10% of hospitalized cirrhotic patients with ascites.
    • Potential sequela of ascites, with mortality ranging from 10-20% during hospitalization.
    • Mortality risk is predicted by worsening renal function.

    SBP (continued)

    • Recurrence rate within 1 year is approximately 70%.
    • Median survival is about 9 months after SBP development.

    Complications of Liver Cirrhosis

    • Included conditions include hepatorenal syndrome (HRS), hepatic encephalopathy, hepatocellular carcinoma(HCC), and spontaneous bacterial peritonitis (SBP).

    SBP Risk Factors

    • Upper gastrointestinal hemorrhage, ascitic fluid protein concentration ( < 1g/dL), a history of previous SBP episodes are risk factors.

    SBP Clinical Presentation

    • Possible clinical signs include worsening jaundice, encephalopathy, or renal failure.
    • Some patients may also experience chills, fever, and generalized abdominal pain; however, a significant portion of cirrhosis and SBP cases do not present with fever or leukocytosis.

    SBP Diagnosis

    • Diagnosis is made when ascitic fluid demonstrates polymorphonuclear cell (PMN) counts of 250/mm3 or above
    • PMN count >1000/mm3 suggests bowel perforation

    SBP Treatment

    • Empiric antibiotic treatment with cefotaxime or ceftriaxone is used.
    • Albumin infusion (1.5 g/kg body weight on Day 1, 1.0 g/kg on Day 3) following diagnosis.

    SBP Long-Term Prophylaxis

    • Long-term use of fluoroquinolones or trimethoprim-sulfamethoxazole might be used in patients successfully recovering from an episode of SBP.

    Hepatorenal Syndrome (HRS)

    • HRS is a renal dysfunction related to advanced liver disease and portal hypertension.
    • Characterized by oliguria, azotemia, reduced urine sodium excretion.

    Hepatic Encephalopathy

    • Neurologic/psychiatric disturbances related to acute or chronic liver insufficiency and/or portosystemic shunting.
    • It can span from disorientation/ asterixis to coma, which are graded according to West Haven Criteria (WHC)
    • Failure of liver function to clear intestinal toxins (e.g., ammonia).

    Hepatic Encephalopathy: Precipitating Factors

    • Diuretics
    • High protein meals
    • Electrolyte imbalances
    • Gastrointestinal hemorrhage

    Hepatic Encephalopathy Treatment

    • Supportive measures involving treating precipitating causes, lactulose, rifaximin, and chronic protein restriction.

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