HEPATOLOGY

TYPES OF VIRAL HEPATITIS:

HEPATITIS B DIAGNOSIS -> SEROLOGY

.
First marker appears in the blood……surface antigen

Marker detected only by liver biopsy……Hbc

Marker of highly infectivity……….. e-Antigen

How to follow up……….PCR

Acute cases……….NO TTT

.Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON .

HEPATITIS C: .

Main route of transmission…..blood contact

.Best initial test -> Hepatitis C antibody .

Most accurate……….. Hepatitis C PCR for RNA

.Liver biopsy……determine the seriousness of the disease

TREATMENT:

Acute cases……….NO TTT

CHRONIC CASES…….. RIBAVIRIN + INTERFERON .

Breast feeding……continue

Delivery……normal vaginal

.Sex…….continue

.No vaccine & No post-exposure prophylaxis for hepatitis C .

 Hepatitis A:

History………travel to a developing country (Thailand)

Cp:

 fever, pain at right upper quadrant area

 Nausea, Vomiting, Tiredness, fatigue, Loss of appetite
 Pale or gray-colored stools
 Jaundice
 Urine is dark brownish in color, like cola or strong tea.

Investigations:

Liver enzymes………markedly increased

Detection of HAV-specific IgM and IgG

Prophylaxis against hepatitis A …….VVVVVV IMP

When………both pre and post exposure

For who??........Travellers

How??..........IVIG and inactivated vaccine

When?...........4 weeks before travel

If will travel very soon ……give IVIG

:CIRRHOSIS:

:GENERAL FEATURES OF CIRRHOSIS .

Edema -> from low oncotic pressure -> Tx: Spironolactone - 1

.Gynecomastia - 2

.Palamar erythema - 3

.Splenomegaly - 4
.)Thrombocytopenia - 5

.)Encephalopathy ..……Tx: lactulose - 6

.)Ascites …….Tx: spironolactone - 7

Esophageal varices ……Tx: propranolol will prevent - 8

bleeding - Banding if rebleed

:HYPER-ESTROGENISM : .

Gynecomastia – .

Testicular atrophy –

Spider angiomata –

palmar erhtema

:ASCITES

TTT

Paracentesis .

Diuretics……..spironolactone

Refractory………TIPS

:SPONTANEOUS BACTERIAL PERITONITIS vvvvvvv imp .

Pt with cirrhosis & ascites >-

low grade fever……..key word

abd. Pain…..key word

Dx -> Best test -> paracentesis…… Cell count > 250 neutrophils

.Tx -> IV CEFOTAXIME >-

Primary biliary cirrhosis:

Middle-aged woman

ITCHING .

XANTHELASMA .

Jaundice

hepatosplenomegaly

.H/O of other autoimmune diseases .

.IgM ++ .

Most accurate test -> Anti-mitochondrial antibody vvvv imp .

.Liver biopsy

.Tx -> Ursodeoxycholic acid .

PRIMARY SCLEROSING CHOLANGITIS

.)Inflammatory bowel disease (UC ) .

! ITCHING .

.Most accurate test -> ERCP -> BEADING of the biliary system .

.Tx -> Ursodeoxycholic acid .

:WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION

.-- Ceruloplasmin -> ++ Copper .

.Abnormal Copper deposition in liver, basal ganglia & cornea .

.Young pt < 30 ys .

LIVER……Cirrhosis .
BRAIN……. Choreiform movement disorder

Neuropsychiatric abnormalities

.Eye………… Keiser Fleischer rings vvvvv imp

Best initial test -> Slit lamp (Keiser Fleischer .

rings) & -- Ceruloplasmin level

.Most accurate test -> Liver biopsy .

.Tx -> Penicillamine .

HEMOCHROMATOSIS

:AUTOSOMAL RECESSIVE

.Genetic disorder -> over-absorption of IRON .

.Iron deposits in various body tissues .

.Heart -> Restrictive cardiomyopathy .

.Skin -> Darkening & pigmentation .

.Joint -> Psedogout & CPPD .

.Pancreas -> Bronze Diabetes .

.Pituitary -> Panhypopituitarism .

.Genitalia -> Infertility .

.Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA .

Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR .

.)CARCINOMA (Most common cause of death

.Dx -> Best initial test -> transferrin levels vvvvvvv IMP .

.Dx -> Most accurate test -> Liver biopsy .

 .Tx -> Phlebotomy .

PRONOSIS:…..WORST WITH C282Y gene mutation

Screening for hemochromatosis:

 WHO IS AT RISK?????
 All first-degree relatives of patients with haemochromatosis,
known mutation in HFE gene

 HOW TO DO SCREENING ????

First step :

Transferring saturation and serum ferritin concentration

when to say (+)????

Fasting transferrin saturation >45%

Fasting ferritin >250 µg/L on more than one occasion,

How to confirm???????

HFE mutations ……if (+)……referral for genetic counselling

when to test Children of C282Y heterozygotes ????

1- Should only be tested if the other parent has the C282Y

mutation.
2-until age 18 years unless symptomatic

Other first-degree relatives of C282Y heterozygotes should be

tested with iron studies. If these are positive…… referral for
genetic counselling
)NON-ALCOHOLIC STEATOHEPATITIS (

.Associated with obesity - DM - Hyperlipidemia .

.)Dx-> Most accurate test -> Liver biopsy (Fatty infiltration .

.Tx -> No specific therapy ….control body weight and DM

:ALPHA - 1 ANTI-TRYPSIN DEFECIENCY vvvvvvvvvv imp

.PAN-ACINAR EMPHYSEMA + CIRRHOSIS .

Young patient with emphysema

:VARICEAL BLEEDING MANAGEMENT .

The 1st step ……….RESUSCITATION .

,If you need blood ……packed RBC'S ( O- RH- low hemolysis)

Then .. Control the bleeding itself …….ENDOSCOPY

If failed……..TIPS

:HEPATIC ENCEPHALOPATHY : .

.Due to ++ AMMONIA level .

PPT factors -> hypovolemia - GIT bleeding - infection .

.TTT:

.(LACTULOSE) -> .

.)NEOMYCIN -> .

! )Lower protein in diet (BUT .. NOT PTN FREE DIET xxxx .

:ALCOHOLIC LIVER DISEASES .

.H/O of heavy alcohol use .

Stages -> .

1. Fatty liver "steatosis" –

2. Hepatitis –

."3. Fibrosis "Cirrhosis

:On CESSATION of alcohol intake .

.Steatosis & hepatitis & early fibrosis are REVERSIBLE >-

.True cirrhosis (with generation nodules) are IRREVERSIBLE, >-

:EMPHYSEMATOUS CHOLECYSTITIS .

Due to 2ry infection of the gall bladder with gas forming .

.bacteria e.g. Clostridium

.diabetic male .

.Crepitus .

.Complications -> Gangrene & perforation .

.Dx -> Abdominal radiograph -> Air fluid level .

Tx -> fluid & electrolyte resuscitation, & antibiotics .

.cholycystectomy
Very important statistics: VVVVVVV IMP

Most common cause of cirrhosis in australia……..alcohol

Most common virus causing chronicity in adult…..C

Most common virus causing chronicity in kids…..B

Most common virus causing liver cancer……..B

Most common virus to be transmitted after needle abrasion...B

Most common virus transmitted by food…..A

Virus that can kill adult while very begnin in kids….A

Viruses transmitted by food….A and E

Virus that can kill pregnant women……E

Virus that is associated with hepatitis B……D

Most common route of hepatitis B transmission…perinatal

Best inv for CHRONIC HEPATITIS -> Liver biopsy