Cram The Pance - S1E14 Hepatitis

Episode Date: February 24, 2021

Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E review for your Pance, Panre, and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so today on the podcast, we're going to be going to be hepatitis. So that's going to be hepatitis A, B, C, D, and E. I just wanted to send a quick thank you to everybody who's left a review on the podcast or a comment. I really do appreciate that. So let's go ahead and get started with hepatitis A virus. So this is a viral infection of the liver. The thing you need to know about this, transmission is most commonly going to be through fecal oral transmission. So whether this is going to be from contaminated food or water via person-to-person contact, daycare workers are very susceptible due to changing diapers, et cetera. Fecal oral transmission is what you really need to know. The way I remember that, I think of hepatitis A and I think of hepatitis anus. So that kind of makes you think of like fecal matter and fecal oral transmission is what you need to know for hepatitis A.

It's also seen in developing countries that have poor sanitation. And interestingly enough that there's in these developing countries that have poor sanitation, there's almost a hundred percent infection rate in children under nine with hepatitis A. It's that prevalent in these areas that have this poor sanitation. And it's also seen in men who have sex with men, about a 17% rate of the cases are from that. But overall, the one you need to know the most is going to be fecal oral transmission. That's what you need to know for hepatitis A as far as really the boards and the way they're going to ask you. Now, history and exam, you're going to see a really big overlap for all of the hepatitis A, B, C, and E. It's all pretty similar in history and exam. So I'm not going to

go crazy on these. But with hepatitis A, symptoms are typically pretty mild. Many patients will be asymptomatic, particularly children under six will rarely have symptoms at all. If symptoms do present, again, like in all the hepatitis, you'll see fevers, fever's going to be one of the more common symptoms. Then you have your constitutional symptoms, general malaise, nausea, vomiting, things like that. And then on an exam, again, hepatomagally may be seen in about 80% of the patients. It is pretty common. jaundice and right up our quadrant tenderness.

Again, this isn't very specific to hepatitis A. this is really seen in all of them. So it's not really something they can ask you in the vignette, just about like a history and exam, because you can't differentiate with just that. Diagnosis, again, this is something that you'll see another overlap. Your LFTs are going to be elevated on all of these. AST, A-L-T, your Billy Rubin.

And your A-L-T in a patient with acute hepatitis is going to be in the thousand, sometimes up to 10,000. And that's important to know in clinical, because a lot of times you'll see patients that have an AST or an ALT of maybe like 150. And a lot of times a patient will think, oh, my liver enzymes are elevated. Could it be hepatitis? But really, if they have acute hepatitis, it's going to be in the thousands. So keep that in mind.

If it is a chronic infection, sometimes it'll be in like the hundreds, like a few hundreds. But LFTs, normally your AST and ALT will be elevated. But then the way you really differentiate between the different hepatitis is going to be with an IGM anti-hypotitis A. So you'll use this antibody to test for acute infection. So you can also do an IgG hepatitis A virus test. This is going to be for past infection. And we're going to go over the difference between IGM and IGG once we get to hepatitis B serology.

But what you need to know is IGG is going to be for chronic infection and IGM is going to be for acute infection. And I'll go over the way that I learned to remember that. But as far as testing again, diagnosis will mainly be with IGM anti-I. hepatitis A, H-A-V, and this is going to be for acute infection, and then IG, again, for chronic infection. So that's how you'll diagnose it. Now, treatment, it's mostly going to be supportive, rest and fluids. It's a self-limited condition. It doesn't usually progress to a chronic state. It almost really never progresses to a chronic state, and it almost never leads to fulmin and hepatitis, less than 1%. In case you're not familiar with the term fulminate hepatitis,

This is acute hepatic failure in patients with hepatitis. It's basically when the liver is failing within days or weeks. And most of the time, the only definitive treatment for it is a liver transplant. So hepatitis A almost never happens and it almost never progresses to chronic either. Also be aware that there is a hepatitis A vaccine and immunoglobulin available for post-exposure prophylaxis. And the hepatitis A vaccine is part of the immunization schedules in children here in the United States, as well as other countries. And in most cases for post-exposure prophylaxis,

the hepatitis A vaccine is preferred over the immunoglobulin. Unless the patient is immunocompromised or has previous pre-existing chronic liver disease, then you give both the hepatitis A vaccine and the immunoglobulin. It's not that important, but it's just a little side note there. So overall, hepatitis A, what you need to know is that it's almost always acute, almost never progresses the chronic fecal oral is going to be the most common transmission, fecaloral route, diagnosed with the IGM hepatitis A virus antibody, and then treatment is mainly going to be supportive. All right. So moving on to hepatitis B, it's a little bit more dense.

Hepatitis B, again, viral infection of the liver. And it can cause both acute and chronic infection. So this one can progress to chronic a little bit more common than hepatitis A. And let's first start with the mode of transmission. So hepatitis B, the way I remember, the most common transmission for hepatitis B is I remember hepatitis B and B stands for babies and bodily fluids. So what does that mean? It all depends on the prevalence of hepatitis B in the region. So in high prevalence regions, so here's where hepatitis B is more common, you're going to think babies. So that's the first B. And what does babies mean? Well, that means perinatal or it's known as vertical transmission. It's when the mother passes it along to the child during birth. So the infection rates of infant,

born to hepatitis B positive mothers. That's going to be your most common cause or most common transmission in high prevalence regions. And that's the reason why pregnant women, at least here in the United States, are screened for hepatitis B because if they do see that they're positive for hepatitis B, it's almost a 90% transmission rate. So you want to make sure that they have the immunoglobulum prior to that. So that's the first B babies. That's going to be transmission in high prevalence regions.

going to be vertical transmission, mother to baby. And then the second one, bodily fluids. So in low prevalence regions, like in the U.S., your most common cause is going to be bodily fluid. So whether that's unprotected sexual intervenous drug use, these are going to be the most common cause of hepatitis B transmission in these unvaccinated individuals. So again, hepatitis B transmission, babies, bodily fluids, babies, vertical transmission, mother to baby, high prevalence areas, and then low prevalence regions, bodily fluids. So, So IV drugs, unprotected sexual intercourse. Okay, that's transmission.

Let's move on to clinical manifestations. Again, a lot of overlap here. Let's not go crazy with this because it's not very specific to any of them. So we need to know is around 30% of hepatitis B patients will develop something known as the Icturic phase. And this just basically means that they have jaundice. So it's just basically means jaundice. So about 30% will develop jaundice. And then 70% will be what's called the subclinical or an itchteric phase.

So non-jondis. just some constitutional symptoms like malaise, nausea, vomiting, anorexia, just like in hepatitis A. And then fulminant hepatic failure, a fulminant hepatitis is pretty rare in hepatitis B as well, but a little bit more common than hepatitis A, but really only around 0.5% of patients will get to this stage. So acute failure, acute hepatic failure. As far as chronic, some of the clinical manifestations, again, really nonspecific. like fatigue, they may have jaundice as well, ascites and things like that. Now, we're going to move on to the more difficult, I would say, as far as diagnosis. So this is the infamous hepatitis B serologies.

And they can become pretty complicated. And I'll give a little warning. I would not go crazy learning these. In fact, in PA school, I only knew a few things about it because I felt like to take the time with everything else that you have to know for maybe the one question you'll get on the boards, I just don't think it's worth the time. But with that being said, I have developed a way I feel you can know a good amount of the material you need to know for the serologies without investing too much time. So if you want to hear it and learn about this, again, I don't think you should go crazy, but let me just go over a few things. I think you can

pretty easily catch most of the questions with this. So really you only need to know four things. The first thing that you need to know, or the first two things you need to know is you need to know the difference between IgG and IGM. So IGB is going to be for chronic infection. If you see IgG positive, you should be thinking this is a chronic case of hepatitis B. Now, if you see IGM positive, you should be thinking of acute infection. The way that I remember that is IGG. I think of the G stands for gone. Acute infection is gone. This is progressed to chronic. When I think of IGM, I take the M and I think of minute. This is an up-to-the-minute infection. They've only had the infection for a minute. It's acute. It's like a sudden, it hasn't been a long time. So I-G-G-G-G-of-gone. It's gone from the acute phase. It's

chronic. And IGM up to the minute. This is, they've only had the infection for a minute. It's acute. So you need to know that first. And those are going to fall under something known as anti-HBC serology, which would be the IgG and the IGM. So don't worry too much about the name. Just know the difference between IGG and IGM. So that's That's two of the four things that you need to know. The other two things that you need to know, you need to know the difference between hepatitis B surface antibodies and hepatitis B surface antigens.

So hepatitis B surface antibodies, sometimes they're listed as anti-HBS, and then hepatitis B-surface antigens are sometimes known as HB-S-A-G. So just the AG antigen, and then anti-H-B-H-B-S, the anti-stands, stands for antibody. So hepatitis B surface antibody, hepatitis B surface antigen. The difference, you need to think antibody. Think of a B. Antigen, think of a G. So when you see hepatitis B surface antibody positive, take that B, and you're going to think of two things for that B in antibody. You're going to think of booster and you're going to think of beat it. So if you see hepatitis B surface antibody, B, think of booster or beat it. What do those mean? So if you see that B an antibody, you should think of booster. And booster, means that they had the hepatitis B vaccine or the booster shot.

So booster is the first B. If you see that positive, think of booster or vaccine. And then the other B, beat it, means that they beat hepatitis B. It's resolved. They cure the infection, essentially. So if you see hepatitis B surface antibody B, think booster, the booster vaccine, or B, beat it. They beat the hepatitis B virus and they've resolved the infection. Okay.

Now, hepatitis B surface antigen with a G. So if you see antigen with a G, you should think of got it. G stands for got it, meaning they got it. They have hepatitis B. Now, whether it's acute or chronic is decided again by the IGG or IGM. But if you see surface antigen with a G, you need to think they got it. They have hepatitis B. The only thing we need to decide now is whether it's acute or chronic, which again, we decide from IGG or IGM. So let's go over a few examples. Now, say somebody has only, hepatitis B surface antibody positive. That's all that's positive. So what's what should you be thinking? You should be thinking booster or beat it. Which one is it? Did they have a booster? Did they have the vaccine or did they beat it? Did they resolve the hepatitis B virus? The way you decide this is you look at your your IGG or IGM. If it shows IGG, that means they beat it. So if IGG is positive, that means they beat it. So if you see IgG along with hepatitis B surface antibody, that means they beat it. If you just see hepatitis B surface antibody, that means they got the booster. So that's the

difference between the two surface antibody, booster and beat it. Booster is if it's only hepatitis B surface antibody positive, that's the only thing that's positive. And beat it, they have a resolved hepatitis B infection if the surface antibody plus IgG, that core antibody. is positive. Now, let's move on to the surface antigen. So if surface antigen is positive, you should be thinking, remember the G, they got it. They have hepatitis B. Now, how do we decide whether it's a chronic or an acute infection? We look at our IGG or IGM. Now, if they have surface antigen positive and they have an IGG, what does the G stand for? Gone, meaning it's a chronic infection. It's no longer acute. Now, if IGM is positive, think of minute, up to the minute infection. It's

It's an acute infection. So surface antigen positive, IGG, chronic infection, surface antigen positive with IGM, acute infection. Okay. So those are the four things you need to know that I'll get you a lot of questions. If you're only going to remember one, I would say just remember surface antibody. If that's the only thing positive, they got the vaccine. Because that was one of the ones that I remember in school coming up a lot. That was a lot of times the question because it's super easy and they were nice to the students, I guess, in our school.

but remember that one. But remember those four things because if you remember those four things, you can probably get the question they're going to ask you. I know that was really in depth. And it even goes a little bit further than that going into the, when they look at chronic to see if it's replicative or non-replicative, do not waste your time on that. Most likely they're not going to go that far. And even if they did and you didn't know you'd miss one question, I just wouldn't go crazy with it. Anyways, I hope that helps. I know it's hard to go over in a podcast. Remember, I do have a YouTube channel where I can kind of have some visuals and things like that so you can pause it and go through and try to absorb the info a little bit better. All right. So that's really the hardest part with hepatitis. Let's move on to treatment.

If it's acute, it's mostly going to be supportive. You know, so like acetamenefin, rest, fluids, things like that. And again, this is only going to progress to chronic in about 5% of the cases. So not very common that it's going to progress to chronic. But if it did, you're going to treat with your antiviral agents. Don't worry so much about the names. Just know that if it is chronic, you treat with antivirals. There's a few. different ones. There's intacavir, Lamuvedine, Tenofaver, and most likely they're not going to ask you a different agent or why would you use this one over another one. That's further than we need to go for

what we need to know for our boards. But just know if it is chronic, you're going to treat with these antiviral agents. And then of course be aware that there is a hepatitis B vaccine. It's given in three doses generally at birth, one to two months later, your second dose. And then third is normally given around six months of age. So remember that. That's going to be or you're preventative. That's given us part of the, the, I'm sorry, the immunizations that we give here in the United States. So that's hepatitis B. Let's move on to hepatitis C. We're getting there about halfway through. So hepatitis C virus is, in my mind, or at least the way I remember it, the most important thing about hepatitis C is that hepatitis C of all of these progresses to chronic

stages, more so than any of them. About 85% of patients who have hepatitis C will go on to develop chronic infection. The way that I remember that, hepatitis C, the C stands for chronic. So really easy to remember hepatitis C almost always progresses to chronic infection. So hepatitis C stands for chronic. 85% of the time is going to progress to chronic. About 5 to 30% of individuals who have, who progressed to chronic hepatitis C will go on to develop cirrhosis and about a 20 to 30 year period. So there are some comorbidities associated with this, obviously. And in the U.S. Hepatitis C is the most common cause of chronic liver disease. And it's the most common reason that patients here in the U.S. need a liver transplant. So remember that, hepatitis C can get

pretty serious, a lot of comorbidities with that. As far as transmission and developed countries like here in the U.S., the most common mode of transmission is going to be through percutaneous exposure to infected blood. So IV drug use. That's overall in the U.S., you're most common rate of transmission is IV drug use. And compared to hepatitis A and C, intercourse, perinatal transmission is not really common in hepatitis C. So really you need to just focus hepatitis C, IV drug use is going to be the most common mode of transmission for this. Clinical manifestations, again, I'm not going to bore you with this. It's going to be pretty similar to all the other ones. Constitutional symptoms, malaise, anorexia, myalgia, jaundice, you know, clay-colored stools as well.

I may not have mentioned that before, but that's common as well, just due to the buildup of Billy Rubin. So again, nothing specific here. Just know that it's pretty similar in all of these. That's how it's going to present. Diagnosis. Now, much easier than hepatitis B. There's really only two that you need to know for diagnosis. So again, all of these are going to have increased LFTs.

All of your liver functions are going to be increased with hepatitis. But with hepatitis C, you need to know two different tests. So screening for hepatitis C is going to be with the hepatitis C antibody immunowassay. So this hepatitis C antibody screening is going to be the initial test. You're just screening with this. And if it's positive, it indicates either a current infection, acute or chronic, or it can even indicate a past or resolved infection. So it's not really specific.

And that's why it's just your screening test. It can pick up a lot of different causes, but it's not very specific. So once you get the hepatitis C antibody virus antibody test positive, now you want to confirm the infection. infection. And what you do that with is something known as the hepatitis C virus RNA test. So this is a PCR test, a polymerase chain reaction test, and it's much more sensitive and specific compared to the hepatitis C virus antibody. If this is positive, the patient has an acute infection, whether it's acute or chronic, and if it's negative, you essentially rule out active hepatitis C infection. So just review hepatitis C virus antibody, that's going to be your screening test, and hepatitis C virus.

RNA test, the polymerase chain reaction test is going to be your confirmatory test. So just the two for hepatitis C, much more simple than in hepatitis B, obviously. As far as treatment, don't worry so much. There's a bunch of different regimens for hepatitis C, a bunch of different names for these meds. Remember, they're not going to go that far. But you just need to know that in patients with hepatitis C, you initiate antiviral treatment and the newer antiviral regimens have close to a 95% cure rate. in these patients. So you can essentially cure hepatitis C in most patients. Some of the antivirals, la dipsovasevere, sophos, I'm not even going to bother. The names are really difficult to pronounce,

but I wouldn't worry about that. Just know that the antivirals essentially can cure this. And there are a bunch of different regimens and regimens. And it really goes into depth choosing the regimens, whether or not they have cirrhosis. They don't have cirrhosis if they're treatment naive. there's so many different factors to decide on the regimen, but it's way out of our scope, and it's not something that you need to know for the board. So just no antivirals is how you're going to treat the infection essentially to cure it. All right. So we're in the home stretch.

Let's finish up with hepatitis D and E. There's a lot less to learn with these. There's really only a few things to go over. So hepatitis D virus. The most important thing to remember about hepatitis D more than anything else is that hepatitis D doesn't exist without a co-infection of hepatitis B. So it's a defective virus and it requires this superimposed hepatitis B virus. So remember that D does not exist without B. And the way that I remember that is that I remember that hepatitis D stands for dependent because hepatitis D is dependent upon

co-infection of hepatitis B. So remember hepatitis D when you see that. Remember it's dependent. It needs hepatitis B to exist. Now transmission, it's mainly from exposure, from, infected blood, IV drug users in particular at a higher risk. Clinical manifestations, again, blah, blah, blah, same as all the others. Many are asymptomatic, but if they do develop symptoms, jaundice, myelgia, nausea, same thing. Diagnosis, you have a couple different tests. You have one known as an anti-HDV antibody, so that's going to be your antibody test. And then you have HDV RNA. Again, another PCR test that's going to be the more sensitive of the two. So HDV antibody test, of a screening and then HDV RNA test, which is going to be your more sensitive test. So those are the two

ways to diagnose. Again, of course, increased LFTs in all patients with hepatitis. Treatment, asymptomatic patients with normal ALT levels, you're just going to monitor and you follow up about every six months to look for signs of active disease. So asymptomatic, just monitor. If they do require therapy generally, it's going to be with something known as interferon alpha. It's another antiviral medication. So asymptomatic, no treatment, just monitor if they do require treatment, interfere on alpha. And then, of course, the way you're going to prevent hepatitis D is with the hepatitis B vaccine. So make sure that, you know, you're vaccinated. If they don't get hepatitis B, they can get hepatitis D. So that's what you really need to know. It's really about prevention

hepatitis D. Now, let's move on to the last one, hepatitis E. There's not much to know here. There's really only a few things. So hepatitis E, transmission is generally fecal oral route just like hepatitis A, so contaminated food or water. Clinical manifestations, same as all the other ones. Diagnosis, increased L of T's like all the other ones. And then there's also something, the antibody for this one is the H.E.V. antibody, IGM. So that's what you're going to look for in diagnosis.

And then this is the most important thing you need to know about hepatitis E more than all the other things, is that generally hepatitis E is a self-limited infection. It resolves. Normally it doesn't require any treatment, doesn't progress to a chronic state, very rare. But the only time hepatitis E is a major threat is if the patient is pregnant. During pregnancy, a patient with hepatitis E has about a 25% as high as 25% mortality rate. And it's because in pregnant patients, hepatitis E has this really high frequency of developing into fulminate hepatitis. So, pregnant patients with hepatitis E have a really high mortality rate, and that's what you need to remember about this. It's the most important thing to know about hepatitis E is the danger to pregnant

women. And the way I remember that is hepatitis E. The E stands for embryo. So when you think of embryo, you think of pregnancy, the fetus, that helps you remember that that increased mortality rate in pregnancy. So hepatitis E, remember embryo. Really quick review. We're done. You made it. Let's just go over the little pneumonics I had for each. So hepatitis A, remember, for a so fecal oral route hepatitis b remember baby and bodily fluids so baby remember that vertical transmission mother to baby um bodily fluids ivy drug use sexual intercourse most common route in the lower prevalent areas hepatitis c the c stands for chronic remember c is going to progress to the chronic stage in about 85 percent of patients hepatitis d remember stands for

dependent because hepatitis d is dependent on b you need hepatitis b to have hepatitis d and then remember hepatitis E stands for embryo because remember pregnant patients about a 25% mortality rate with this infection. Okay, that's hepatitis. Thank you so much for listening. I hope this was helpful. And as always, good luck on your pants, your panery, your EORs, and good luck in PA school.