ABCs of Hepatitis Bruce D. Askey, MS, ANP-BC Associate Lecturer Fitzgerald Health Education Associates, Inc. North Andover, MA Adult Nurse Practitioner

ABCs of Hepatitis

Bruce D. Askey, MS, ANP-BCAssociate Lecturer

Fitzgerald Health Education Associates, Inc.North Andover, MA

Adult Nurse PractitionerDept. of Hepatology/Gastroenterology

Guthrie ClinicSayre, PA/Ithaca, NY

Objectives

• Having completed the learning activities, the participant will be able to:– Examine serology aspects of

hepatitis.– Interpret serological components of

the hepatitis profile.– Outline recommended follow-up

serologies for a patient with hepatitis.

Fitzgerald Health Education Associates, Inc. 2

Hepatitis

• Inflammation of the liver– Presents with elevation of liver

enzymes• Infectious or noninfectious

– Acute or chronic

3 Fitzgerald Health Education Associates, Inc.

Symptoms of Hepatitis

• Jaundice/pruritus• Scleral icterus


Symptoms of Hepatitis(continued)

• Acholic stools• Dark colored urine• Right upper quadrant abdominal

pain• Fatigue• Anorexia/nausea• Elevated liver enzymes


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© 2005 Elsevier



Hepatocellular Enzymes

• ALT (Alanine aminotransferase), AST (Aspartate aminotransferase): Increase with hepatocellular inflammation

• Measure of severity of hepatocellular inflammation– Severe elevations (>5 X ULN) often

result from toxins (meds, infection, herbals) or shock liver

• AST elevations in excess of ALT elevations often occur with alcohol use


Liver Panel: Acute Hepatitis C

• AST 1005 (N 15-46 U/L)• ALT 1310 (N 7-56 U/L)• Alk. phos. 194 (N 43-122 U/L)• Total bili 11.1 (N 0.2-1.3 mg/dL)

(189.81 µmol/L {3.42-22.23 µmol/L})


• Direct bili 5.3 (N 0-0.4 mg/dL) (90.63 µmol/L {0-6.84 µmol/L})

• Albumin 4.1 (N 3.4-5.0 g/dL) (41 g/L {34-50 g/L})

• INR 1.12 (0.79-1.21)


Liver Panel: Acute Hepatitis C

(continued)

Infectious Hepatitis

• Hepatitis A• Hepatitis B• Non-A, non-B

– Hepatitis C– Hepatitis D– Hepatitis E– Hepatitis G– Hepatitis ?


Hepatitis A

• Occurs worldwide– Vaccine-preventable disease (VPD)

• Incubation period: 2-6 weeks– Contagious during this time

• Does not become chronic: 3-6 month recovery

• Management is supportive• Rarely fatal: Can lead to liver failure if:

– Cirrhosis– Hepatitis B or C coinfection


Hepatitis A: Transmission

• Spread via the “fecal-oral route”– Up to 50% of U.S. cases result from

international travel: Mexico and parts south¹

¹Klevens RM, Miller JT, Iqbal K, et al. The evolving epidemiology of hepatitis a in the United States: incidence and molecular epidemiology from population-based surveillance, 2005-2007. Arch Intern Med 2010; 170:1811.


http://www.uptodate.com/contents/overview-of-hepatitis-a-virus-infection-in-adults/abstract/8





Hepatitis A: Transmission (continued)

• Sexual and household contact• Male-male activity• Food and water borne• Daycare centers• Drug use with contaminated

equipment• Perinatal transmission has not been

shown


Hepatitis A: Pregnancy

• Premature contractions• Placental separation• Premature rupture of membranes• Vaginal bleeding• Preterm labor

¹Elinav, E, et al. Acute hepatitis A infection in is associated with high rates of gestational complications and preterm labor. Gastroenterology 2006; 130(4):1129.




Hepatitis A: Serology• Hepatitis A Antibody (Anti-HAV

antibody)• Total antibody only indicates a

history of exposure but does not differentiate between past or current infection– IgM (MISERY)

• Indicates current infection• Present at the onset of symptoms• Usually clears several months later

but may persist for years– IgG (GONE)

• Indicates immunity• Indicates past or recent infection• Remains present for years, possibly

lifelong

Hepatitis A: Serology (continued)


Hepatitis E• Fecal-oral route of transmission• Incubation: 2-8 weeks• Vaccination has been developed

but is not commercially available in the U.S.

• Not generally seen in the U.S.• Occurs

– Asia– Africa– Middle East– Central America


Hepatitis E

• Rarely chronic– Organ transplant– Chronic immunosuppression

• Management is supportive


Hepatitis E: Pregnancy

• Up to 20% maternal fatality¹• Pregnant women with symptomatic

acute hepatitis E have worse fetal and obstetric outcomes than pregnant women with other forms of symptomatic acute viral hepatitis²

¹Hamid,SS, et al. Fulminant hepatic failure in pregnant women: acute fatty liver or acute viral hepatitis?. Journal of Hepatology 1996; 25(1):20.

²Patra, S, et al. Maternal and fetal outcomes in pregnant women with acute hepatitis E virus infection. Annals of Internal Medicine. 2007; 147(1):28.










Hepatitis E: Serology

• Fecal or serum polymerase chain reaction (PCR)

• Hepatitis E virus IgM antibody• No commercial testing is available in

the U.S.– May be available at research centers– www.CDC.gov



Comparing HBV and HCV

• HBV– DNA virus– Found in all body fluids– Commonly sexually transmitted– Transmitted through sharing drug

paraphernalia– Vaccine-preventable disease

Lok, A & McMahon, J. 2009. Chronic Hepatitis B: Update 2009. Hepatology. 50(3):1-36.


Comparing HBV and HCV (continued)

• HCV– RNA virus– Found primarily in the blood– Rarely sexually transmitted– Transmitted through sharing drug

paraphernalia– Vaccine not available

Ghany, M, et al. 2009. Diagnosis, Management and Treatment of Hepatitis C: An update.

Hepatology. 49(4):1335-1374.24 Fitzgerald Health Education Associates, Inc.

Hepatitis C

• The most common chronic blood-borne infection in the U.S.– #1 reason for liver transplant in the U.S.

• 10-20% will develop cirrhosis 20-30 years after exposure

• Up to 5% will develop liver cancer• 85% of those exposed will clear

spontaneously but retain the hepatitis C antibody.

• Leading cause of death in HIV patients– 4 million Americans have HCV.

Wise, M, et al., Hepatology. 2008;47:1128-113525 Fitzgerald Health Education Associates, Inc.

Symptoms of HCV

• Acute infection (<6 months)– Generally asymptomatic but jaundice

occurs in 20% of cases• Chronic infection (>6 months)

– Generally asymptomatic but may have elevated liver enzymes

• Advanced disease– Ascites, varices, encephalopathy


Risk Factors for HCV

• Clotting factors prior to 1987– 85%

• Injection drug use– 80%

• Hemodialysis– 10-20%

• Multiple sex partners– 4-6%


Risk Factors for HCV (continued)

• Sexual contact with infected partner– 2-3%

• Blood transfusion prior to July 1992– 5%

• Infants born to infected women– 4-7%


Risk Factors for HCV (continued)

• Organ recipients prior to 1992– 5%

• Healthcare workers (needle stick, etc.) – 2%

Ghany, M, et al. 2009. Diagnosis, Management and Treatment of Hepatitis C: An update. Hepatology. 49(4):1335-1374.


Possible Risk Factor


Diagnosis of Hepatitis C

• Health history– Most reliable method available to assess

risk• Physical exam

– Not reliable!!!• Abnormal liver enzymes (ALT)

– Not reliable!!!


• Hepatitis C antibody– Indicates exposure (15% have

cleared)• Hep C RNA by PCR (HCV RNA test

[Heptimax®])– Indicates current infection– Viral load (benchmark)

Ghany, M, et al. 2009. Diagnosis, Management and Treatment of Hepatitis C: An update. Hepatology. 49(4):1335-1374.


Diagnosis of Hepatitis C (continued)

Who to Screen

• Anyone with a risk factor for hepatitis C

• Anyone with elevated liver enzymes

Kuritzky L, et al. Family Practice Recertification. 2006; 28(2)41-57.


Who to Screen (continued)

• Those born between 1945-1965 (baby boomers) should be offered a 1 time screening for hepatitis C.– 5 times more likely than other adults to

have hepatitis C– 75% of adults with hepatitis C are baby

boomers.

Source- http://www.cdc.gov/features/HepatitisCTesting/index.html


http://www.cdc.gov/features/HepatitisCTesting/index.html

Serologic Tests

• Hepatitis C antibody• Hepatitis C RNA• Hepatitis C genotype


Serologic Tests (continued)

• Hepatitis C antibody– Screening test for exposure to HC– Immune cell that is made to fight off

HC– All of those exposed will generate an

antibody but 15% will clear the virus.– 85% of those with an antibody will be

currently infected.

Ghany, M, et al. 2009. Diagnosis, Management and Treatment of Hepatitis C: An

update. Hepatology. 49(4):1335-1374.


• Hepatitis C RNA– “Viral load”– Indicates current infection– Value does not correlate with degree

of liver damage or clinical symptoms.

Ghany, M, et al. 2009. Diagnosis, Management and Treatment of Hepatitis C: An

update. Hepatology. 49(4):1335-1374.



• Hepatitis C genotype– There are 6 forms (genotypes) of HC– Genotype 1 is the most common in the

U.S.– With current therapies the response

rates are similar regardless of genotype

Flamm SL. JAMA. 2003; 289:2413-2417.



HCV Screening Algorithm

Case Study

• Mr. J is a 43-year-old who presents to you as a new patient for primary healthcare needs. As part of his health history, he reveals that he had a blood transfusion in 1983.

• What test should be drawn that would indicate exposure to hepatitis C?


Hepatitis C antibody is positive.

• What is the percentage chance that he is currently infected?

• What test would indicate current infection with hepatitis C?


Viral Load Testing Indicates Current Infection

• What test will determine duration of treatment and chance of responding?


Hepatitis B

• The data and information for this section has been obtained from the following AASLD treatment guideline for management of chronic hepatitis B:

Lok, A & McMahon, J. 2009. Chronic Hepatitis B: Update 2009. Hepatology. 50(3):1-36.


Hepatitis B

• >95% of adults will clear the virus within 6-12 months of infection.

• Around 90% of infants will not clear the virus.– Hepatitis B immunoglobulin (HBIg) and

hepatitis B vaccination at birth will improve this to 10%.


Hepatitis B: Serology

• Hepatitis B surface antigen (HBsAg) – Indicates current infection

• Hepatitis B surface antibody (HBsAb)– Indicates immunity

• Previous infection with clearance• Vaccination• May reactivate if immunosuppressed


• Hepatitis B core antibody (HBcAb)– Immune response to the hepatitis B core

antigen– Does not indicate immunity without the

presence of HBsAb– IgM

• Acute infection (M=MISERY)

– IgG • Old infection (G=GONE)


Hepatitis B: Serology (continued)

• Hepatitis B e antigen (HBeAg)– “Pre-core”– Indicates active viral replication– Correlates with increased infectivity and liver

injury• Hepatitis B e antibody (HBeAb)

– Immune response to HBeAg– Lower viral replication, infectivity and

damage


Hepatitis B: Serology(continued)

• “Precore mutant”• “Core promoter protein”• Terms to indicate a mutant strain of

hepatitis B that is replicating in a HBeAg negative, HBeAb positive patient

• Hepatitis B viral DNA– The amount of virus present/milliliter of

blood49 Fitzgerald Health Education Associates, Inc.

Hepatitis B: Serology (continued)




Hepatitis D (The Delta Virus)

• Can exist only in the presence of hepatitis B– Immunization against hepatitis B also

provides immunity against hepatitis D.

• Can cause an acute hepatitis in those with chronic hepatitis B


Hepatitis D: Serology

• Must have current hepatitis B infection– Hepatitis B surface antigen positive– If acute, hepatitis B core IgM positive

• Hepatitis D antigen– Not available in the U.S.

• Hepatitis D RNA positive



56


End of Presentation

Thank you for your time and attention.

Bruce D. Askey, MS, ANP-BC

Website: www.fhea.com E-mail: [email protected]

http://www.fhea.com/


All websites listed active at the time of publication.

Documents

ABCs of Hepatitis Bruce D. Askey, MS, ANP-BC Associate Lecturer Fitzgerald Health Education Associates, Inc. North Andover, MA Adult Nurse Practitioner