Hepatitis on the CCFP exam

Approach

• Ask about every medicine, including over-the-counter and herbal products, and when each one was started.
• Ask about alcohol: how much, how often, and for how long.
• Ask about blood exposure: injecting drugs, tattoos, body piercing, blood transfusions, and sexual risk.
• Ask about travel or living abroad, and about chemicals at work or in hobbies.
• Ask about autoimmune disease, and liver disease in the family.
• Ask about right upper belly pain, dark urine, pale stool and yellow eyes.

Approach

• Liver-cell injury: alanine aminotransferase (ALT) and aspartate aminotransferase (AST) lead. Blocked bile flow: alkaline phosphatase (ALP) leads.
• Call it liver-cell injury only when ALT or AST rises at least twice as far as the ALP, in multiples of normal. Similar rises lean toward blocked flow.
• ALP also rises in pregnancy and bone disease. A raised gamma-glutamyl transferase (GGT) confirms it comes from the liver or bile ducts.
• Check albumin, bilirubin and the international normalized ratio (INR). Abnormal values mean the liver is not doing its work.
• Liver-cell pattern: test hepatitis B surface antigen (HBsAg), hepatitis C antibody and immunoglobulin M (IgM) antibody to hepatitis A, which shows a recent infection.
• Then add antinuclear antibody, ceruloplasmin if under 40 years old, iron studies if over 40, and an ultrasound if fatty liver is likely.
• AST above ALT points to alcohol or cirrhosis. The ratio means nothing once the enzymes pass 1000 U/L.

Approach

• Order an abdominal ultrasound for any blocked-flow pattern. It looks for widened (dilated) bile ducts and for masses.
• Dilated ducts: refer straight away for endoscopic retrograde cholangiopancreatography (ERCP), a scope that finds and clears the block. A drain placed through the skin is the other route.
• The same applies after gallbladder removal, which can widen the ducts a little.
• A mass on ultrasound needs more imaging, and often a biopsy if cancer is suspected.
• No dilated ducts or mass: a stone may have passed. Hold any drug the patient can do without, especially one started in the last 3 months, and recheck the enzymes.
• Then test antimitochondrial antibody for primary biliary cholangitis, and think of sclerosing cholangitis.
• Refer when the liver is failing: low albumin, high bilirubin or a long INR.

Approach

• Screen for hepatitis B with HBsAg, surface antibody (anti-HBs) and core antibody (anti-HBc).
• HBsAg positive: add hepatitis B e antigen (HBeAg), its antibody (anti-HBe) and the viral load (HBV DNA). These show whether the virus is actively copying.
• Hepatitis C antibody positive: check hepatitis C RNA (HCV RNA). Detectable RNA means a current infection that spreads through blood.
• Test every patient with hepatitis B or C for human immunodeficiency virus (HIV) and for the other hepatitis virus. Co-infection is common.
• Test household members and sexual partners of a hepatitis B carrier. Vaccinate those who are not immune.

Approach

• Order HCV RNA for every positive antibody. About a quarter of infected people clear the virus on their own.
• RNA detected: current infection. With a positive antibody from years ago, RNA today confirms it is chronic. No 6-month wait is needed.
• RNA not detected: the infection has most likely cleared.
• Chronic infection raises the risk of cirrhosis and liver cancer. Confirming it opens the path to cure.

Approach

• Consider every patient with chronic hepatitis C for treatment. Act sooner with advanced liver scarring (fibrosis).
• Use interferon-free direct-acting antivirals (DAAs). They cure more people and are far easier to tolerate than interferon.
• Injecting drugs or taking methadone does not rule out treatment. Curing people who still share equipment may cut new infections.
• Stage fibrosis with transient elastography (FibroScan, a liver stiffness scan) or a blood-marker score. These can replace biopsy, which carries a small risk of bleeding.
• A normal ALT does not rule out serious fibrosis. It is no reason to wait.
• Before referral: blood count, liver tests, INR, albumin, creatinine, abdominal ultrasound, and HIV, hepatitis A and hepatitis B tests.
• Review every prescription, over-the-counter and herbal product for interactions with the antivirals.

Approach

• Shared injecting equipment causes most new hepatitis C infections in Canada. Advise new equipment for every injection, and point to a local harm reduction program.
• Explain how hepatitis B, hepatitis C and HIV spread. Test for all three.
• Offer treatment to a partner who also has hepatitis C. Curing people who share equipment may cut new infections.
• Hepatitis B vaccine: for people who inject drugs, household and sexual contacts of carriers, and anyone with chronic liver disease, including hepatitis C. Test HBsAg and anti-HBs first.
• Hepatitis A vaccine: for people who inject drugs and anyone with chronic liver disease. Use the combined A and B vaccine when both are due.
• Start the vaccines now. Fibrosis staging and antiviral treatment do not need to come first.

Approach

• Hepatitis A: offer prophylaxis to household and close contacts, and to child care contacts. Give it as soon as possible, ideally within 14 days of the last exposure.
• Healthy contacts 6 months and older get hepatitis A vaccine. Under 6 months, give immune globulin (Ig), 0.1 mL/kg.
• Contacts with chronic liver disease or a weak immune system get Ig plus vaccine. At 60 and older, Ig may be added.
• School, workplace and health care contacts need nothing unless an outbreak is suspected.
• Hepatitis B: vaccine is the key step. Add hepatitis B immune globulin (HBIg), 0.06 mL/kg, for a person who is not immune, ideally within 48 hours.
• HBIg may still be given up to 7 days after a needle or splash exposure, and up to 14 days after sex. A person known to be immune needs nothing.
• Baby of a mother with hepatitis B: vaccine and HBIg, ideally within 12 hours of birth.

Approach

• Stage fibrosis first. In hepatitis C, liver cancer checks are for patients with cirrhosis.
• Clues to cirrhosis: low platelets, low albumin, high bilirubin or INR, or a shrunken, nodular liver or big spleen on imaging.
• Liver cancer checks mean an abdominal ultrasound every 6 months, the same interval used in hepatitis B.
• Cured before cirrhosis: no long-term liver follow-up is needed. With cirrhosis, keep checking.
• Chronic hepatitis B: review at least once a year. While the virus is active, check ALT, HBV DNA and blood count every 6 months.
• Hepatitis B carriers at higher risk of liver cancer (cirrhosis, high viral load, older age) need an ultrasound every 6 months.
• Advise cutting alcohol. It speeds liver damage.