Viral hepatitis Liver failure Cirrhosis
Hepatitis A Definition the inability of the liver to perform its Definition scarring of the liver caused by long-term liver
RNA Picornavirus normal synthetic and metabolic function damage
Faecal-oral transmission, associated w/ contaminated Aetiology Aetiology
shellfish Alcohol
Cirrhosis
Virus passes into bile after replication w/i liver cells Non-alcoholic fatty liver disease (NAFLD)
Immune system activated necrosis Acute
Infection Hep A/B, CMV, EBV, leptospirosis Viral hepatitis B and C
Predominantly of zone 3 of the hepatic lobule
Toxin Alcohol, paracetamol, isoniazid, halothane Dx
Ix Anti-HAV IgM in serum
Traditionally liver biopsy (associated w/ adverse effects
Rx Vaccine for travellers, self-resolving Vascular Budd-Chiari
At risk: people w/ chronic liver disease, pts w/ haemophilia,
such as pain + bleeding)
Other Wilson’s, AIH
men who have sex w/ men, IVDU Now more commonly used: transient elastography
Obstetrics Eclampsia, acute fatty liver of pregnancy (measures stiffness of liver = proxy for fibrosis) +
Signs + symptoms acoustic radiation force impulse imaging
Hepatitis B
1. Jaundice NAFLD patients: enhanced liver score to screen for
Partially stranded, enveloped DNA virus
It has an ‘e’-Ag more infective 2. Coagulopathy: Raised prothrombin patients who need further testing
Vertical transmission, contaminated needles, infected blood 3. Encephalopathy: asterixis, constructional Liver USS every 6 months (+/- AFP check for
products, sexual intercourse apraxia hepatocellular carcinoma)
Ix HBV DNA in serum: HBsAg, HBEAg, anti-HBC, HBsAg on + oedema/ascites Signs + symptoms
histology w/ ‘ground glass’ appearance + hypoalbuminaemia Hands clubbing, leuconychia, palmar erythema,
Rx Pegylated interferon alpha- 2a reduced viral replication Ix duputryron’s contracture
in up to 30% of chronic carrier Bloods Face pallor, xanthelasma, parotid enlargement
Tenofovir, Entecavir (anti-virals) Trunk spider naevi (>5), gynaecomastia, loss of
Fever, jaundice, raised liver transaminases
FBC infection, GI bleed, low MCV (alcohol) U&Es (Low
Urea + High Creatinine: hepatorenal syndrome) LFTs secondary sexual hair
1-5 months incubation
[AST: ALT >2 alcohol; AST: ALT <1 viral], Abdomen striae, hepatomegaly, splenomegaly,
caput medusa, testicular atrophy
Hepatitis C albumin (reduced in chronic liver failure), prothrombin
ssRNA, Flavivirus Ix
(raised in acute liver failure), clotting: raised INR, Bloods: FBC, LFTs, INR, albumin
Vertical (occasional), contaminated needles, infected blood glucose, ABG (metabolic acidosis)
products Abdo USS
Mx Ascitic tap + MCS
30% = Fatigue, arthralgia, raise in serum
aminotransferases/jaundice Manage in ITU, Rx underlying cause: NAC for Liver biopsy
Ix HCV RNA paracetamol overdose, nutrition, thiamine supplements, Mx
Rx 15-45% clear virus after acute infection prophylactic PPIs: stress ulcers Good nutrition, alcohol abstinence, Cholestyramine helps
55% Chronic Hep C (> 6months) Prescribing in liver failure reduce pruritus, screening for HCC/oesophageal varices
Protease inhibitors (e.g. Daclatasvir + Sofosubvir) w/ or w/o Avoid: opiates, oral hypoglycaemics, Na-containing IVI
ribavirin used Scoring system for liver cirrhosis Child-Pugh
Hepatotoxic drugs: paracetamol, methotrexate, classification
isoniazid, salicylates, tetracycline Score 1 2 3
Hepatitis D
Liver transplant Kings College Hospital criteria Bilirubin <34 34-50 >50
ssRNA (defective) that co-infects w/ Hepatitis B virus co-
infectivity w/ HDV leads to an increased chance of liver Paracetamol induced Non-paracetamol induced Albumin >35 28-35 <28
failure pH < 7.3 24hrs after ingestion PTs >100s Prothrombin <4 4-6 >6
Requires HBsAg to complete replication cycle Or 3 out of 5 of: time (prolonged
Contaminated needles, infected blood products Drug-induced by)
Superinfection: A HBsAg pt. subsequently develop HDV Or all of:
Age < 10 or >40 Encephalopathy none mild marked
Rx Pegylated interferon alpha-2a Prothrombin time >100 secs
> 1wk from jaundice to Ascites none mild marked
Cr > 300uM
encephalopathy
Hepatitis E Grade ¾ encephalopathy Total: A <7; B 7-9; C >9
Prothrombin time > 50s
Faecal-oral transmission, contaminated water Bilirubin > 300nM
Rx self-limiting
Hepatitis A Definition the inability of the liver to perform its Definition scarring of the liver caused by long-term liver
RNA Picornavirus normal synthetic and metabolic function damage
Faecal-oral transmission, associated w/ contaminated Aetiology Aetiology
shellfish Alcohol
Cirrhosis
Virus passes into bile after replication w/i liver cells Non-alcoholic fatty liver disease (NAFLD)
Immune system activated necrosis Acute
Infection Hep A/B, CMV, EBV, leptospirosis Viral hepatitis B and C
Predominantly of zone 3 of the hepatic lobule
Toxin Alcohol, paracetamol, isoniazid, halothane Dx
Ix Anti-HAV IgM in serum
Traditionally liver biopsy (associated w/ adverse effects
Rx Vaccine for travellers, self-resolving Vascular Budd-Chiari
At risk: people w/ chronic liver disease, pts w/ haemophilia,
such as pain + bleeding)
Other Wilson’s, AIH
men who have sex w/ men, IVDU Now more commonly used: transient elastography
Obstetrics Eclampsia, acute fatty liver of pregnancy (measures stiffness of liver = proxy for fibrosis) +
Signs + symptoms acoustic radiation force impulse imaging
Hepatitis B
1. Jaundice NAFLD patients: enhanced liver score to screen for
Partially stranded, enveloped DNA virus
It has an ‘e’-Ag more infective 2. Coagulopathy: Raised prothrombin patients who need further testing
Vertical transmission, contaminated needles, infected blood 3. Encephalopathy: asterixis, constructional Liver USS every 6 months (+/- AFP check for
products, sexual intercourse apraxia hepatocellular carcinoma)
Ix HBV DNA in serum: HBsAg, HBEAg, anti-HBC, HBsAg on + oedema/ascites Signs + symptoms
histology w/ ‘ground glass’ appearance + hypoalbuminaemia Hands clubbing, leuconychia, palmar erythema,
Rx Pegylated interferon alpha- 2a reduced viral replication Ix duputryron’s contracture
in up to 30% of chronic carrier Bloods Face pallor, xanthelasma, parotid enlargement
Tenofovir, Entecavir (anti-virals) Trunk spider naevi (>5), gynaecomastia, loss of
Fever, jaundice, raised liver transaminases
FBC infection, GI bleed, low MCV (alcohol) U&Es (Low
Urea + High Creatinine: hepatorenal syndrome) LFTs secondary sexual hair
1-5 months incubation
[AST: ALT >2 alcohol; AST: ALT <1 viral], Abdomen striae, hepatomegaly, splenomegaly,
caput medusa, testicular atrophy
Hepatitis C albumin (reduced in chronic liver failure), prothrombin
ssRNA, Flavivirus Ix
(raised in acute liver failure), clotting: raised INR, Bloods: FBC, LFTs, INR, albumin
Vertical (occasional), contaminated needles, infected blood glucose, ABG (metabolic acidosis)
products Abdo USS
Mx Ascitic tap + MCS
30% = Fatigue, arthralgia, raise in serum
aminotransferases/jaundice Manage in ITU, Rx underlying cause: NAC for Liver biopsy
Ix HCV RNA paracetamol overdose, nutrition, thiamine supplements, Mx
Rx 15-45% clear virus after acute infection prophylactic PPIs: stress ulcers Good nutrition, alcohol abstinence, Cholestyramine helps
55% Chronic Hep C (> 6months) Prescribing in liver failure reduce pruritus, screening for HCC/oesophageal varices
Protease inhibitors (e.g. Daclatasvir + Sofosubvir) w/ or w/o Avoid: opiates, oral hypoglycaemics, Na-containing IVI
ribavirin used Scoring system for liver cirrhosis Child-Pugh
Hepatotoxic drugs: paracetamol, methotrexate, classification
isoniazid, salicylates, tetracycline Score 1 2 3
Hepatitis D
Liver transplant Kings College Hospital criteria Bilirubin <34 34-50 >50
ssRNA (defective) that co-infects w/ Hepatitis B virus co-
infectivity w/ HDV leads to an increased chance of liver Paracetamol induced Non-paracetamol induced Albumin >35 28-35 <28
failure pH < 7.3 24hrs after ingestion PTs >100s Prothrombin <4 4-6 >6
Requires HBsAg to complete replication cycle Or 3 out of 5 of: time (prolonged
Contaminated needles, infected blood products Drug-induced by)
Superinfection: A HBsAg pt. subsequently develop HDV Or all of:
Age < 10 or >40 Encephalopathy none mild marked
Rx Pegylated interferon alpha-2a Prothrombin time >100 secs
> 1wk from jaundice to Ascites none mild marked
Cr > 300uM
encephalopathy
Hepatitis E Grade ¾ encephalopathy Total: A <7; B 7-9; C >9
Prothrombin time > 50s
Faecal-oral transmission, contaminated water Bilirubin > 300nM
Rx self-limiting
