Updated: 10/26/2020

Chronic Hepatitis

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
2
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0
100%
0%
Evidence
8
0
0
Topic
Snapshot
  • A 35-year-old man presents to his primary care physician for routine check-up. During this visit, review of systems reveals that he has been feeling excessively fatigued with weight loss, lack of energy, and vague abdominal discomfort. He has a history of alcohol abuse as well as acute hepatitis. On physical exam, he has mild tenderness to palpation and no hepatomegaly. Laboratory evaluation shows elevated liver enzymes and positive anti-HCV antibodies.
Introduction
  • Overview
    • chronic hepatitis is defined by hepatic inflammation of > 6-month duration
  • Epidemiology
    • risk factors
      • alcohol use
      • IV drug use
      • international travel
      • unprotected sexual practices
    • etiology
      • hepatitis C virus (most common)
      • hepatitis B virus with or without hepatitis D coinfection
      • nonalcoholic steatohepatitis
      • alcoholic hepatitis
      • autoimmune hepatitis
      • alpha-1-antitrypsin deficiency
      • Wilson disease
      • hemochromatosis
      • medications, when taken long term
        • isoniazid
        • methyldopa
        • nitrofurantoin
  • Pathogenesis
    • mechanism
      • chronic hepatitis can last for years but remain mild without significant hepatic injury
      • chronic hepatitis can also result in cirrhosis, liver failure, and increase the risk for hepatocellular carcinoma
  • Associated conditions
    • hepatocellular carcinoma
Presentation
  • History           
    • patients may have a history of acute hepatitis
  • Symptoms
    • common symptoms
      • malaise
      • poor appetite
      • fatigue
      • abdominal discomfort
  • Physical exam
    • inspection
      • jaundice is rare
    • palpation       
      • hepatomegaly
Imaging
  • Ultrasound of liver
    • indications
      • screen for hepatocellular carcinoma
    • findings
      • liver mass
Studies
  • Serum labs
    • liver function tests 
      • elevated AST and ALT (at least 3x higher than normal)
        • degree of elevation does not correlate with disease severity
        • AST:ALT > 2 suggests alcoholic hepatitis
      • elevated prothrombin time (PT)
    • hepatitis viral panel
      • HBV
        • quantitation of 
          • HBsAg
          • presence of anti-HBc IgM/IgG, anti-HBs Ab
      • HCV
        • presence of anti-HCV Ab, genotyping, and HCV RNA quantitation
  • Invasive studies
    • liver biopsy
      • confirm diagnosis and assess for degree of inflammation/cirrhosis
Differential
  • Acute hepatitis
    • key distinguishing factor
      • acute onset with flu-like symptoms, jaundice, abdominal pain, and transaminitis
Treatment
  • Management approach
    • depends on underlying etiology
    • see individual topics for treatment regimens
  • Lifestyle
    • weight loss
    • alcohol cessation
  • Medical
    • antiviral treatment
      • indications
        • chronic hepatitis B
          • monitor therapy with HBV DNA and alanine aminotransferase (ALT) levels
      • chronic hepatitis C
        • based on genotype, previous treatment history and, if cirrhosis is present, degree of severity based on MELD-Na score
        • examples of regimens include interferon + ribavirin
    • immunosuppression
      • indication
        • autoimmune hepatitis
  • Surgical
    • liver transplant
      • indication
        • end-stage liver disease and/or for those refractory to medical therapy.
Complications
  • Cirrhosis
  • Hepatocellular carcinoma
  • Portal hypertension

Please rate topic.

Average 3.8 of 9 Ratings

Questions (2)

(M2.GI.15.49) A 42-year-old male with a history significant for IV drug use comes to the emergency department complaining of persistent fatigue and malaise for the past three weeks. On physical exam, you observe a lethargic male with icteric sclera and hepatomegaly. AST and ALT are elevated at 600 and 750, respectively. HCV RNA is positive. Albumin is 3.8 g/dL and PT is 12. A liver biopsy shows significant inflammation with bridging fibrosis. What is the most appropriate treatment at this time?

QID: 106336
1

Interferon

5%

(4/74)

2

Ribavirin

4%

(3/74)

3

Lamivudine

0%

(0/74)

4

Combined interferon and ribavirin

69%

(51/74)

5

Combined interferon and lamivudine

19%

(14/74)

M 7 D

Select Answer to see Preferred Response

(M2.GI.15.27) A 46-year-old female with a history of hypertension and asthma presents to her primary care physician for a health maintenance visit. She states that she has no current complaints and generally feels very healthy. The physician obtains routine blood work, which demonstrates elevated transaminases. The physician should obtain further history about all of the following EXCEPT:

QID: 104818
1

Alcohol intake

9%

(2/23)

2

IV drug use

4%

(1/23)

3

International travel

4%

(1/23)

4

Sex practices

9%

(2/23)

5

Smoking history

70%

(16/23)

M 6 D

Select Answer to see Preferred Response

Evidence (8)
EXPERT COMMENTS (11)
Private Note