Hepatitis Web Study has 5 New Cases Available - Hepatitis Web Study

Viral Hepatitis Updates from CDC
Hepatitis Web Study has 5 New Cases Available
Hepatitis Web Study (www.HepWebStudy.org) provides interactive, case-based modules related to the clinical care of persons with viral hepatitis.

1. Evaluation of New Onset Ascites in a Patient with Chronic Hepatitis C
2. Treatment Regimens for Chronic Hepatitis C Virus Infection
3. Management of Ascites Caused by Cirrhosis
4. Counseling the Patient with Chronic Hepatitis B Infection (Health Education)
5. Counseling the Patient with Hepatitis C Infection (Health Education)


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► 1. Evaluation of New Onset Ascites in a Patient with Chronic Hepatitis C
Author: Atif Zaman, MD, MPH
Associate Professor of Medicine
Section Chief, Division of Gastroenterology and Hepatology
Director of Clinical Hepatology
Oregon Health & Science University

Disclosure: None

Last Updated: July 3, 2010

Learning Objectives

1. Understand the appropriate steps required to perform diagnostic paracentesis.
2. List the appropriate initial tests to order when performing a diagnostic paracentesis.

A 45-year-old male patient with chronic hepatitis C infection is receiving peginterferon and ribavirin therapy. Prior to treatment he was noted to have well-compensated cirrhosis. Eight weeks into treatment the patient develops worsening hepatic function, with increased total bilirubin, a decreased serum albumin level, and an increased prothrombin time (international normalization ratios [INR] of 1.6). He was also noted to have a low-grade fever and a distended, tender abdomen. “Shifting dullness” is observed on examination and an abdominal ultrasound confirms a moderate amount of ascites. The interferon-based treatment is immediately stopped.

What would you recommend in the initial evaluation of this patient’s new-onset ascites?
A The most valuable test to perform in this setting is an abdominal computed tomographic (CT) scan. A diagnostic paracentesis is not indicated since the procedure has a very high risk and is unlikely to yield useful information.
B Perform a diagnostic abdominal paracentesis, but the patient must receive fresh frozen plasma prior to the procedure because his prothrombin time is increased (INR = 1.6).
C Perform a diagnostic abdominal paracentesis and obtain the following studies on the ascitic fluid: cell count and differential, total protein, albumin, and culture. In addition, calculate the serum-ascites albumin gradient (SAAG).
D Perform a diagnostic abdominal paracentesis and obtain the following studies on the ascitic fluid: cell count and differential, total protein, albumin, and cancer antigen CA 125. In addition, calculate the serum-ascites albumin gradient (SAAG).

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Evaluation of New Onset Ascites in a Patient with Chronic Hepatitis C - Common Management Issues - Hepatitis Web Study



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► 2. Treatment Regimens for Chronic Hepatitis C Virus Infection
Authors: Margaret C. Shuhart, MD, MS
Associate Professor of Medicine
Division of Gastroenterology
University of Washington
Disclosure: None
H. Nina Kim, MD, MSc
Assistant Professor of Medicine
Division of Allergy and Infectious Diseases
University of Washington
Disclosure: None

Last updated: November 3, 2010

Learning Objectives

1. Understand goals of treatment for chronic hepatitis C virus infection.
2. Discuss the optimal dosing and duration of therapy for chronic hepatitis C infection.

A 47-year-old Caucasian male with chronic hepatitis C virus infection presents to your office to further discuss hepatitis C treatment. He has not previously been treated. His evaluation to date reveals that he is infected with genotype 1a and has a hepatitis C viral load of 1.7 million IU/mL. His liver biopsy shows findings typical of chronic hepatitis C with bridging fibrosis (stage 3 of 4, where 4 is cirrhosis). He is otherwise well and has no major medical or psychiatric problems.


Which of the following would you recommend for the treatment of hepatitis C in this patient?
A Begin pegylated interferon once weekly and ribavirin twice daily for a planned 24 week course.
B Begin pegylated interferon once weekly and ribavirin twice daily for a planned 48 week course.
C Begin pegylated interferon once weekly for a planned 36 week course. Ribavirin is not indicated.
D Begin interferon three times weekly for a planned 72 week course. Ribavirin is not indicated.

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Treatment Regimens for Chronic Hepatitis C Virus Infection - Management - Hepatitis C - Hepatitis Web Study




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► 3. Management of Ascites Caused by Cirrhosis
Author: Atif Zaman, MD, MPH
Associate Professor of Medicine
Section Chief, Division of Gastroenterology and Hepatology
Director of Clinical Hepatology
Oregon Health & Science University

Disclosure: None

Last Updated: September 10, 2010

Learning Objectives

1. Discuss appropriate use of sodium restriction and diuretic therapy for the management of ascites.
2. Summarize the approach to patients with refractory ascites.

A 57-year-old woman with chronic hepatitis C infection has cirrhosis that has been complicated by ascites and encephalopathy. She has had a history of hospitalizations for encephalopathy, but currently, her encephalopathy is well controlled on lactulose. Her laboratory studies 4 weeks prior showed a serum total bilirubin of 4.7 mg/dL, albumin 2.3 g/dL, international normalized ratio (INR) 2.0, and creatinine 1.0 mg/dL. Her ascites has been well controlled on furosemide 120 mg daily and spironolactone 300 mg daily, but recently the ascites has become more difficult to control and her furosemide is increased to 160 mg daily and spironolactone to 400 mg daily. Follow-up laboratory studies a week later notably shows that serum sodium has dropped from 132 to 120 mEq/L, serum potassium from 3.6 to 3.0 mEq/L, and creatinine has increased from 1.0 to 1.4 mg/dL. The patient's ascites has not improved. She is classified as Child-Pugh-Turcotte Class C and she has a calculated Model for End-Stage Liver Disease (MELD) score of 23.

What would you recommend as the next step in managing this patient’s ascites?
A Slowly increase diuretics further with close laboratory monitoring.
B Restrict the patient’s fluid intake to 1 liter a day to correct hyponatremia and continue current diuretic doses for another week to see if ascites improves.
C Stop diuretics, perform large volume paracentesis as needed to control ascites, and refer for evaluation of possible liver transplantation.
D Proceed with a transjugular intrahepatic portosystemic shunt (TIPS) procedure to manage the refractory ascites.

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Management of Ascites Caused by Cirrhosis - Common Management Issues - Hepatitis Web Study



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► 4. Counseling the Patient with Chronic Hepatitis B Infection
Author: H. Nina Kim, MD, MSc
Assistant Professor of Medicine
Division of Allergy and Infectious Diseases
University of Washington
Disclosure: None

Last updated: October 5, 2010

Learning Objectives

1. Understand basic information on hepatitis B epidemiology and transmission.
2. Describe the impact that chronic hepatitis B infection on a person’s health.

A 26-year-old woman was recently told that she has chronic hepatitis B. She underwent hepatitis B surface antigen testing at a local public health clinic, and the test was repeated 6 months later and confirmed again to be positive. She is upset about her new diagnosis, stating, "I feel well, I don’t know how I could be infected." She was born in the Philippines. She says that she was vaccinated as an adolescent and thought the vaccine would have protected her. She is worried about how to break the news to her fiancé. She and her fiancé have been sexually active together for approximately 1 year. Her partner has not received hepatitis B vaccine.

Which of the following statements would be considered accurate information when counseling this woman with newly diagnosed chronic hepatitis B?
A Most individuals who have chronic hepatitis B experience no symptoms.
B In many cases, people born outside the U.S get the infection from their mothers during childbirth or from infected household contacts as children. A person can also become infected with the hepatitis B virus when exposed to contaminated blood, having unprotected sex with an infected person, or through injection drug use.
C Hepatitis B vaccines do not offer protection to people who are already infected with hepatitis B virus.
D The woman’s fiancé should undergo testing for hepatitis B status. He should receive the hepatitis B vaccination if he does not have immunity to hepatitis B.
E All of the answers listed are correct.

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Counseling the Patient with Chronic Hepatitis B Infection - Health Educator - Hepatitis Web Study



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► 5. Counseling the Patient with Hepatitis C Infection
Author: Linda Gorgos, MD, MSc
Medical Director
Infectious Disease Bureau, Public Health Division
New Mexico Department of Health
Disclosure: None
Jeanne Marrazzo, MD, MPH
Professor of Medicine
Division of Allergy and Infectious Diseases
Medical Director, Seattle STD/HIV Prevention Training Center
University of Washington
Disclosure: Gilead: Advisory Committees or Review Panel

Last updated: November 5, 2010

Learning Objectives

1. Understand basic information on hepatitis C epidemiology and transmission
2. Describe the impact that chronic hepatitis C infection on a person's health.

After donating blood at a local blood drive, a 55-year-old man was notified that he tested positive on an antibody test for hepatitis C virus. He is upset about the test results, stating, "I don't know how I could have with hepatitis C. I only tried injecting drugs once or twice with my friends when I was in my 20's." He is very worried about how this may affect his health.

Which of the following statements would be appropriate for addressing some of his concerns?
A It is unlikely that he got infected with hepatitis C through injection drug use since that was years ago and occurred only for brief period of time.
B His test result indicates that he has chronic hepatitis C infection.
C Chronic hepatitis C infection can be associated with long term complications such as liver failure, cirrhosis, and liver cancer.
D Most individuals who have hepatitis C experience jaundice and flu-like symptoms from this infection.


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Counseling the Patient with Hepatitis C Infection - Health Educator - Hepatitis Web Study


Medscape CME Activity - Recommendations for Identification and Public Health Management of Persons With Chronic Hepatitis B Virus Infection
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Medscape CME Activity - Recommendations for Identification and Public Health Management of Persons With Chronic Hepatitis B Virus Infection
This CME activity is intended for primary care clinicians, public health professionals, and other health clinicians caring for patients with or at risk for HBV infection. The goal of this activity is to describe CDC recommendations for identification and public health management of chronic HBV infection. If you do not already have a Medscape login, you will need to sign up by providing your name, email address and profession.
http://cme.medscape.com/viewarticle/732116



Surveillance Data for Acute Viral Hepatitis – United States, 2008
The 2008 Surveillance Data for Acute Viral Hepatitis is now available and reflects a new online version of the information. This year’s data will not be published as an annual MMWR Surveillance Summary, as CDC is transiting to a more comprehensive surveillance report that will incorporates acute and chronic viral hepatitis statistics.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5943a3.htm




MMWR – Evaluation of Acute Hepatitis C Infection Surveillance - United States, 2008
The Institute of Medicine recently recommended a comprehensive evaluation of the national hepatitis B and C surveillance system. Complete and timely surveillance data are essential for early identification and response to outbreaks and for implementation of evidence-based prevention strategies. To assess these attributes, CDC compared acute hepatitis C surveillance data reported in 2008 from the National Notifiable Diseases Surveillance System (NNDSS) and the Emerging Infections Program (EIP), which conducts enhanced surveillance for acute hepatitis C in selected states. This report summarizes the results of that analysis.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5943a3.htm

For more information on viral hepatitis please visit the CDC website: http://www.cdc.gov/HEPATITIS/