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Hepatology Kate Brown kbrown48@qub.ac.uk What We will Cover Interpret LFTS Viral Hepatitis 9/3/20XX AutoimPresentation Title 2 Non Alcoholic Fatty Liver DiseaseInterpreting LFTs 9/3/20XX Presentation Title 3 • Interpret GGT and ALP together Acute Cholestasis 1. ALP raised with normal GGT: bone disease hepatocellular 2. ALP and GGT: cholestasis damage 3. Isolated GGT: alcohol excess ALT ↑↑ Normal or ↑ • Albumin: synthesised by liver, AST ↑↑ Normal or ↑ nonspecific marker of synthetic ALP Normal or ↑ ↑↑ function, decreased indicated severe liver disease as albumin has half life of GGT Normal or ↑ ↑↑ 20 days Bilirubin Range from Range from • Bilirubin: marker of severity normal to ↑↑ normal to ↑↑ Presentation Title 4Hepatitis Transmission Vaccine Treatment Type of Virus Hepatitis A RNA Faecal-oral route Yes Supportive Supportive/antiviral Hepatitis B DNA Blood/bodily fluids Yes s Hepatitis C RNA Blood No Direct-acting antivirals Always with Pegylated Hepatitis D RNA hepatitis B No interferon alpha 9/3/20XX Presentation Title 59/3/20XX Presentation Title 6Hepatitis B Serology Acute Hepatitis B + HBsAg + Anti Hbc IgM - Anti HBc IgG HbsAg: specific to acute infection or - Anti HbS chronic infection of more 6 months Chronic Hepatitis B + HbsAg Anti HBs: Antibodies present those got - Anti HBc IgM immunity either vaccine or clearing the +Anti HBc IgG vaccine - Anti HbS Anti HbC IgM: produce acutely Anti Hbc IgG: gradually replace the IgM, Immunity previous Infection - HbAg --Anti HBc IgM and persist long term + Anti HBc IgG + Anti HbS Vaccination - HbsAg - Anti HBc IgM -Anti HBc IgG + Anti HbS 7 Case 1 HBsAg negative • A 27-year-old woman presents to Anti-HBs positive occupational health.She has no Anti-HBc IgG negative past medical history and takes no medications.She remembers her Anti-HBc IgM negative uncle having a liver condition when she was a child but does not What are the interpretation of the results? remember which kind. A. Acute Hepatitis B Infection B. Chronic Hep B Infection The team runs multiple tests, including hepatitis B serology which C Immunity due to previous Hep B infection shows the following results: D Previous Hep B immunisation E Susceptibility to Hep infection 9/3/20XX Presentation Title 8 Case 1 HBsAg negative • A 27-year-old woman presents to occupational health before Anti-HBs positive beginning her new job as a Anti-HBc IgG negative healthcare assistant.She has no Anti-HBc IgM negative past medical history and takes no medications.She remembers her What are the interpretation of the results? uncle having a liver condition when she was a child but does not A. Acute Hepatitis B Infection B. Chronic Hep B Infection remember which kind. C Immunity due to previous Hep B infection The team runs multiple tests, D Previous Hep B immunisation including hepatitis B serology which shows the following results: E Susceptibility to Hep infection 9/3/20XX Presentation Title 9Interpret the Serology • A: acute infection with Hep B anti-HBc IgG Positive • B: chronic infection with Hep B • C: Immunity following previous anti-HBc IgM Negative infection with Hep B • D: Immunity following previous anti-HBs Negative vaccination with Hep B • E: no previous contact with Hep B HBsAg Positive 9/3/20XX Presentation Title 10 • A: acute infection with Hep B anti-HBc IgG Positive • B: chronic infection with Hep B • C: Immunity following previous anti-HBc IgM Negative infection with Hep B • D: Immunity following previous anti-HBs Negative vaccination with Hep B • E: no previous contact with Hep B HBsAg Positive 9/3/20XX Presentation Title 11Patient X with Chronic Hep B present with 2 week history of RUQ pain, jaundice, weight loss. What is most likely diagnosis? 9/3/20XX Presentation Title 12Patient X with Chronic Hep B present with 2 week history of RUQ pain, jaundice, weight loss. What is most likely diagnosis? 9/3/20XX Presentation Title 13A42-year-old dentist presents with persistent lethargy. Routine bloods show abnormal liver function tests, so a hepatitis screen is sent. The results are shown below: •A: Acute infection with Hep B Anti-HAV IgG negative •B: Hep C infection •C: Hep B and C infection HBsAg negative •D: Hep C infection, previous Hep Anti-HBs positive B vaccination •E: Hep B and C vaccine Anti-HBc negative Anti-HCV positive 9/3/20XX Presentation Title 14A42-year-old dentist presents with persistent lethargy. Routine bloods show abnormal liver function tests, so a hepatitis screen is sent. The results are shown below: •A: Acute infection with Hep B Anti-HAV IgG negative •B: Hep C infection •C: Hep B and C infection HBsAg negative •D: Hep C infection, previous Anti-HBs positive Hep B vaccination •E: Hep B and C vaccine Anti-HBc negative Anti-HCV positive 9/3/20XX Presentation Title 15Case 2 A. Genetic Testing B. Liver MRI C. Liver biopsy D. Ciprofloxacin E. Prednisolone 9/3/20XX Presentaion Title 16Case 2 A. Genetic Testing B. Liver MRI C. Liver biopsy D. Ciprofloxacin E. Prednisolone 9/3/20XX Presentaion Title 17Autoimmune Hepatitis - rare cause of chronic hepatitis - type I: 40F present fatigue, feature liver disease, less acute than type II - type II: child, acute hepatitis with high transaminase and jaundice IX - ALT, AST raised- hepatic picture, raised IgG - I: ANAand anti smooth muscle antibody RX - II: anti liver/kidney microsomal type I - high dose steroids antibodies - aziothioprine - liver biopsy: inflammation= piecemeal - liver transplant necrosis 9/3/20XX Presentation Title 18 Total 170 Bilirubinµmol/L (3 - 17) Case 3 Conjug • A 41-year-old man with type 2 diabetes presents to ated 152 (3 - 17) the GP surgery complaining of painless jaundice. His bilirubinµmol/L current medications include metformin and Unconju gliclazide, although the gliclazide may soon be gated 18 (3 - 17) stopped due to his obesity. However, over last µmol/L 3months he has been increasingly lethargy and has bilirubin lost 20kg. A few blood tests are ordered which (30 - reveal the following: ALP 189 u/L 100)  A. Acute Hepatitis B ALT 143 u/L (3 - 40) B. Hemochromatosis C. Gilbert Syndrome HBsAg Neg - D. Acute on Chronic non-alcoholic HBsAb Pos - fatty liver disease HBcAb Neg - E. Autoimmune Hepatitis HCV Ab Neg - ANA Neg - ASMA Neg - 9/3/20XX Presentation TitlALKM Neg - 19 Total 170 Bilirubinµmol/L (3 - 17) Case 3 Conjug • A 41-year-old man with type 2 diabetes presents to ated 152 (3 - 17) the GP surgery complaining of painless jaundice. His bilirubinµmol/L current medications include metformin and Unconju gliclazide, although the gliclazide may soon be gated 18 (3 - 17) stopped due to his obesity. However, over last µmol/L 3months he has been increasingly lethargy and has bilirubin lost 20kg. A few blood tests are ordered which (30 - reveal the following: ALP 189 u/L 100)  A. Acute Hepatitis B ALT 143 u/L (3 - 40) B. Hemochromatosis C. Gilbert Syndrome HBsAg Neg - D. Acute on Chronic non-alcoholic HBsAb Pos - fatty liver disease HBcAb Neg - E. Autoimmune Hepatitis HCV Ab Neg - ANA Neg - ASMA Neg - 9/3/20XX Presentation TitlALKM Neg - 20What is the single most important step to help prevent the progression of her disease? 9/3/20XX Presentation Title 21What is the single most important step to help prevent the progression of her disease? 9/3/20XX Presentation Title 22Afollow up liver ultrasounds reported fatty changes, and liver screen blood are abnormal, what is next appropriate step? 9/3/20XX Presentation Title 23Afollow up liver ultrasounds reported fatty changes, and liver screen blood are abnormal, what is next appropriate step? 9/3/20XX Presentation Title 24Non-Alcoholic Fatty Liver Disease •T2DM with abnormal LFTS- NASH •Required liver screen, ultrasound and biopsy to confirm •NAFLD- manifestation of metabolic syndrome, insulin resistance key mechanism to steatosis •NICE enhanced liver fibrosis blood test- check advanced fibrosis •FIB4 score or NALFD fibrosis score used in combination with fibroscan- measure stiffness •Mainstay is weight loss 9/3/20XX Presentation Title 25 (135- Hb 142 g/L 180) Platelets 234 * (150 - Case 4 109/L 400) WBC 9.2 * (4.0 - 109/L 11.0) • Mr Rowan, 66-year-old man Na+ mmol/L 145) - 4.1 presents to the emergency K+ mmol/L (3.5 - 5.0) department. He has been Bicarbonat e 27 mmol/L (22 - 29) experiencing abdominal pain, fever Urea 6.6 (2.0 - 7.0) for the last two days. He is Bilirubin µmol/L (3 - 17) Creatinine 110 µmol/L (55 - 120) currently very drowsy. On ALP 45 u/L (30 - 100) examination, he looks in pain and you can observe a distended ALT 110 u/L (3 - 40) abdomen and jaundiced sclera. AST 240 u/L (0 - 35) γGT 99 u/L (8 - 60) His blood tests are shown Albumin 35 g/L (35 - 50) • What is most likely diagnosis 9/3/20XX Presentation Title 26 • A. Acute cholecystitis • B. Acute Pancreatitis (135- Hb 142 g/L 180) Platelets 234 * (150 - Case 4 109/L 400) WBC 9.2 * (4.0 - 109/L 11.0) • Mr Rowan, 66-year-old man Na+ mmol/L 145) - 4.1 presents to the emergency K+ mmol/L (3.5 - 5.0) department. He has been Bicarbonat e 27 mmol/L (22 - 29) experiencing abdominal pain, fever Urea 6.6 (2.0 - 7.0) for the last two days. He is Bilirubin µmol/L (3 - 17) Creatinine 110 µmol/L (55 - 120) currently very drowsy. On ALP 45 u/L (30 - 100) examination, he looks in pain and you can observe a distended ALT 110 u/L (3 - 40) abdomen and jaundiced sclera. AST 240 u/L (0 - 35) γGT 99 u/L (8 - 60) His blood tests are shown Albumin 35 g/L (35 - 50) • What is most likely diagnosis 9/3/20XX Presentation Title 27 • A. Acute cholecystitis • B. Acute PancreatitisAdecision about whether to start glucocorticoid therapy was made. What test result is required to make this decision? 9/3/20XX Presentation Title 28Adecision about whether to start glucocorticoid therapy was made. What test result is required to make this decision? 9/3/20XX Presentation Title 29 Alcoholic Liver Disease • Alcoholic liver disease covers spectrum of conditions: alcoholic fatty liver disease, alcoholic hepatitis, cirrhosis • Alcoholic Hepatitis - Abdominal pain, distension,confusion,jaundice - High bilirubin, normal ALP, elevated AST and ALT 2:1 - 2:1 AST:ALT: characteristic of acute alcoholic hepatitis - Steroid- acute episodes of alcoholic hepatitis - Maddrey’s Discrimant function- calculated by formula based on prothrombin time and serum bilirubin, determine if steroid necessary - Liver USS- fatty changes, should used scree for HCC, fibroscan used to assess elasticity of liver- determine degree of scarring 9/3/20XX Presentation Title 30Mr Rowan, continued to drink after his first admission to A&E, he presents again 2years later with worsening tiredness, complaints of bruising. It is suspected Mr Rowan has developed cirrhosis. What is the single laboratory finding that should prompt an immediate A. Platelet count= 90 x109 consiB. AST=90 U/L with ALT=85 U/Lnd urgent review by hepatology? C. ALP 155G/L D. Urea 11mmol/l E. Hb=85G/L 9/3/20XX Presentation Title 31Mr Rowan, continued to drink after his first admission to A&E, he presents again 2years later with worsening tiredness, complaints of bruising. It is suspected Mr Rowan has developed cirrhosis. What is the single laboratory finding that should prompt an immediate A. Platelet count= 90 x109 consiB. AST=90 U/L with ALT=85 U/Lnd urgent review by hepatology? C. ALP 155G/L D. Urea 11mmol/l E. Hb=85G/L 9/3/20XX Presentation Title 32Liver Cirrhosis 9/3/20XX Presentation Title 33Complications Malnutrition Portal HTN, varices Ascites • Cirrhosis affects protein • Cirrhosis increased • Fluid in peritoneal cavity, metabolism in liver, reduce resistance to blood flow in increase pressure in portal amount protein produced in liver, increase back system fluid leak out liver, less protein available pressure, get portal HTN, • Fluid loss in peritoneal for maintaining muscle result splenomegaly cavity, reduce pressure to tissue • Collateral from- esophageal kidneys, activate RAAS, • Rx; regular meal, high varices, caput medusae reabsorption of fluid and protein diet, reduce sodium sodium to minimize fluid • Propranolol, variceal bang retention ligation • Ix: low sodium diet, aldosterone antagonist, paracentesis, prophylactic antibiotics 9/3/20XX Presentation Title 34Complication 2 Hepatorenal Syndrome Hepatic encephalopathy • Portal HTN, cause • Build up neurotoxin in the vasodilators released, brain especially ammonia vasodilation in splanchnic • Reduced consciousness, circulation, activate RAAS, confusion vasoconstriction of renal vessels, kidney reduced • Lactulose, antibiotics, blood flow, reduced kidney nutritional support function 9/3/20XX Presentation Title 35 A. ALP >200 Mr Rowan now has B. Caput medusae variety of signs and symptoms of liver C. Ascites cirrhosis. Which of the following is most likely to D. Gynaecomastia indicated poor prognosis? E. Splenomegaly 9/3/20XX Presentation Title 36 A. ALP >200 Mr Rowan now has B. Caput medusae variety of signs and symptoms of liver C. Ascites cirrhosis. Which of the following is most likely to D. Gynaecomastia indicated poor prognosis? E. Splenomegaly 9/3/20XX Presentation Title 37 Mr Rowan deteriorates What is most likely organism will and is admitted as he be found on ascitic fluid culture. develops nausea, vomiting and abdominal A. Staph aureus tenderness. Paracentesis is B. E coli performed revealing ascitic neutrophil count of C. Strep pyogenes 314 x10 D. Candida species What is most likely organism will be found on E. Staph epidermis ascitic fluid culture. 9/3/20XX Presentation Title 38 Mr Rowan deteriorates What is most likely organism will and is admitted as he be found on ascitic fluid culture. develops nausea, vomiting and abdominal A. Staph aureus tenderness. Paracentesis is B. E coli performed revealing ascitic neutrophil count of C. Strep pyogenes 314 x10 D. Candida species What is most likely organism will be found on E. Staph epidermis ascitic fluid culture. 9/3/20XX Presentation Title 39 What additional medication should be included in discharge? Mr Rowan does not improve and develops A. Aspirin Spontaneous bacterial B. Ciprofloxacin peritonitis; he has been on C. Furosemide the gastro ward for two weeks. Upon discharge he D. Naproxen has been prescribed E. Ramipril spironolactone, lactulose, vitamins, propranolol. 9/3/20XX Presentation Title 40 What additional medication should be included in discharge? Mr Rowan does not improve and develops A. Aspirin Spontaneous bacterial B. Ciprofloxacin peritonitis; he has been on C. Furosemide the gastro ward for two weeks. Upon discharge he D. Naproxen has been prescribed E. Ramipril spironolactone, lactulose, vitamins, propranolol. 9/3/20XX Presentation Title 41Spontaneous Bacterial Peritonitis • form of peritonitis: Ascites, abdominal pain, fever • E coli is most common organism of SBP, diagnosis is based on paracentesis of neutrophil count of >250cell/ul • patient with SBP require antibiotic prophlaxis, decontaminate the GI tract to reduce episodes • Antibiotic prophylaxis should be given to patients with ascites if: • patients who have had an episode of SBP • patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome • NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved' 9/3/20XX Presentation Title 42 Mr Rowan is then referred to gastroenterology A. MRI liver outpatient clinic for B. Liver biopsy review after being sent C. Endoscopic ultrasound home. Aworkup is being D. Urinary fibroblast quantification done to assess his liver E. Transient elastography cirrhosis. What is the most appropriate test to perform. 9/3/20XX Presentation Title 43 Mr Rowan is then referred to gastroenterology A. MRI liver outpatient clinic for B. Liver biopsy review after being sent C. Endoscopic ultrasound home. Aworkup is being D. Urinary fibroblast quantification done to assess his liver E. Transient elastography cirrhosis. What is the most appropriate test to perform. 9/3/20XX Presentation Title 44 kbrown48@qub.ac.uk Any Questions? 9/3/20XX Presentation Title 45