All You Need to Know to run a Liver Clinic

Ray Shidrawi
MD FRCP FACP FEBG

Academic Department of Medical & Surgical Gastroenterology Homerton University Hospital London
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Overview
Chronic viral hepatitis
Abnormal liver biochemistry Incidental findings on liver ultrasound

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Chronic Hepatitis B
450 million worldwide 1 million cases of HBV related HCC

Increasing incidence in UK (imported)

4500 acute HBV pa 75,000 chronic HBV pa 450 HBV related HCC pa
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Natural History of HBV Infection

<5y Anicteric illness

Chronic Infection
HBsAg +ve HBcAb +ve

Acute Infection
>20y Icteric illness

Cleared Infection
HBsAb +ve HBcAb +ve

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Chronic Hepatitis B Risk Factors

not IVDA, SEX
Vertical Transmission Tribal markings High prevalence in country of origin, ie.
Exposure to HBV in childhood
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Spontaneous e Seroconversion
HBeAg +ve HBeAb -ve HBeAg -ve HBeAb -ve HBeAg -ve HBeAb +ve

healthy carrier HBV

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E antigen positive disease

HBeAg +ve HBeAb -ve

HBV

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E antigen negative disease

HBeAg +ve HBeAb -ve HBeAg -ve HBeAb -ve HBeAg -ve HBeAb +ve

HBV

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Management of Chronic Hepatitis B

Healthy Carrier
eAg -ve eAb +ve normal LFTs HBV DNA < 2000 IU/ml

E antigen positive disease

eAg +ve eAb ve

HBV DNA > 20,000 IU/ml

E antigen negative disease

eAg -ve eAb +ve HBV DNA > 2,000 IU/ml

Active hepatitis

Primary Care
Annual LFTs / AFP / HBV DNA

Liver Biopsy

Cirrhotics
HBV DNA > 200 IU/ml

TREATMENT

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Treatment of Chronic Hepatitis B

Pegylated Interferon alpha 2a/b monotherapy

Pegasys 180 mcg s/c ow for 6-12 months

Antiviral therapy
Lamivudine 100mg od
Tenofovir 300mg

Adefovir 10mg od
Entecavir 1mg

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HUH Treatment Algorithm for HBV

PEG-IFN monotherapy for 6 months

Overlap with longterm combination antiviral
therapy:
Lamivudine 100mg od + Tenofovir 300mg od

Viral eradication vs suppression

Treatment endpoints: anti-HBs Ab, HBV DNA = 0
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Natural History of HCV Infection

Chronic Infection

80%
Acute Infection
Anicteric Anytime in life IVDA Intranasal cocaine Intra-familial Countries of high prevalence
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HCV Ab pos HCV RNA pos

Cleared Infection

20%

HCV Ab pos HCV RNA neg

Standard Treatment of Hepatitis C

HCV RNA +ve Active hepatitis ALT > 2 ULN /fibrosis HAI score > 1

PEG-Interferon ow + Ribavirin 8001200 mg/d

6-12 months

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Sustained Virological Response (SVR) in Hepatitis C

100%

G2 G3 G4 G1

Sex Age Viral load Duration of infection Alcohol / NASH

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Response Guided Therapy

Adjust duration of treatment against
individuals viral kinetics

Prediction of SVR based on rate of

decline of viral load

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Direct Acting Antivirals (DAA)

Protease Inhibitors:
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Telaprevir (Janssen) Boceprevir (MSD) For Genotype I patients with adverse prognostics factors or who have failed standard combination therapy Cost? Reimbursement? Viral Resistance?

Key Issues

Is patient suitable for therapy?

Depression / Suicide Risk Alcohol Abuse IVDA relapse

Screen / Vaccinate family

Hepatitis B vaccination at birth of children at risk

Patient Education
Barrier contraception / spouse risk Universal precautions

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Abnormal LFTs
Isolated hyper-bilirubinaemia: Gilberts?
Unconjugated (indirect) Check GGT Isoenzymes GGT normal PTH

Raised ALP: Cholestatic or Osteomalacia? Mild transaminitis: NASH?

BMI Centripetal obesity? IGT OGTT at 0,60, and 120 minutes Calculate HOMA score: Ins x Glc/22.5 (N<3)
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Chronic Liver Disease Screen

HBsAg HCV Ab Auto-antibody screen Ferritin / Transferrin saturation
raised ferritin in steato-hepatitis

Copper studies (young) Alpha 1 anti-trypsin (young)

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NASH
Metabolic Syndrome (X)
Peripheral insulin resistance HOMA score > 3 Normal ultrasound doesnt exclude this
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Triad of Choledocholithiasis
Biliary colic

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Triad of Choledocholithiasis
Biliary colic
Transient derangement in LFTs over days

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Triad of Choledocholithiasis
Biliary colic
Transient derangement in LFTs over days Gallstone disease on U/S

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Triad of Choledocholithiasis
Biliary colic
Transient derangement in LFTs over days Gallstone disease on U/S
You do not have to see stones in the duct!

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Choledocholithiasis
BEWARE of the normal CBD on transabdominal ultrasound

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Choledocholithiasis
BEWARE of the normal CBD on transabdominal ultrasound

BEWARE of the fit young patient with

ascending cholangitis

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Prehepatic
Haemolysis

Hepatic
Hepatocellular

Posthepatic
Obstructive

Sickle cell disease

G6PD def

Viral hepatitis
AIH

Gallstones

Ca pancreas Intrahepatic cholestasis ALCOHOLIC LIVER DISEASE

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Incidental Findings
Haemangiomas
< 5cm ignore > 5cm need CT imaging to confirm

Metastases / HCC Hydatid Disease

Growing up on a farm

Adult polycystic kidney disease

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