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Hepatitis

• An inflammation of the liver
• Acute hepatitis is less than six months. Chronic is greater than six months

Causes

• Viruses
  • Hep A
  • Hep B
  • Hep C
  • Hep D
  • Hep E
  • And several others including CMV & Epstein Barr
• Alcohol
• Drugs
• Non alcoholic fatty liver disease
• Autoimmune disease

Symptoms

• Jaundice
• Nausea
• Poor appetite
• Right upper quadrant pain
• Fever

Physical Exam Findings

• Enlarged liver
• Tender liver

Labs & Studies

• Liver function test (LFTs)
  • Alanine transaminase (ALT) 7 – 55 U/L
    • An enzyme found predominantly in the liver. Liver damage may cause an elevation in serum ALT.
  • Aspartate transaminase (AST) 8 – 48 U/L
    • An enzyme found predominantly in the liver. Liver damage may cause an elevation in serum AST.
  • Alkaline phosphatase (ALP) 40- 129 U/L
    • An enzyme found predominantly in the liver. Liver damage may cause an elevation in serum ALP.
  • Albumin 3.5 – 5.0 g/dL
    • A protein produced by the liver. Liver damage may cause a decrease in serum albumin.
  • Total protein 6.3 – 7.9 g/dL
    • Liver damage may cause serum protein to decrease.
  • Bilirubin 0.1 – 1.2 mg/dL
    • A by-product of red blood cell breakdown (think yellow bruises). The liver filters bilirubin from the blood and then adds it to bile. It is excreted as stool. Liver damage may cause an elevation in serum bilirubin.
  • Prothrombin time (PT) 9.4 to 12.5 seconds
    • The liver creates most of the clotting factors. Liver damage may result in prolonged clotting times.
• Serology
  • Hepatitis A virus IgM antibody (anti HAV)
  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B surface antigen-antibody (anti-HBs)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis B envelope antigen (HBeAg)
  • Hepatitis B envelope antibody (anti-HBe)
  • Antibody to hep C virus
  • Antibody to hep C RNA

Treatment

• Supportive care
• Remove offending agents

Hepatitis A Virus (HAV)

• Hep A spreads by the oral-fecal route
• Symptoms usually last 2-3 weeks
• Disease is self-limiting. Hep A does not cause chronic hepatitis.

Clinical Presentation

• Prodrome of anorexia, nausea, vomiting, and malaise
• Fever
• Jaundice
• Mild RUQ pain

Labs, Studies & Physical Exam Findings

• Hepatomegaly
• Jaundice
• Normal or low WBC
• Elevated bilirubin
• Elevated aspartate and alanine aminotransferase
• IgM anti-HAV positive acute HAV infection
• IgG anti-HAV positive previous HAV infection or vaccination

Treatment

• Prevention
  • Good hygiene
  • Vaccination is available
• Supportive care
  • Self limiting with a full recovery

Hepatitis B

• Transmitted through exposure to contaminated body fluids
• Hep B has an incubation period of 6 weeks to 6 months
• Symptoms typically last 2-3 weeks
• Infection typically resolves in 16 weeks but may become chronic in 5-10% of infections
• Chronic Hep B significantly increases the risk of cirrhosis and hepatocellular carcinoma

Clinical Presentation

• Prodrome of anorexia, nausea, vomiting, and malaise
• Arthralgia
• Diarrhea
• Fever
• Jaundice
• Mild RUQ pain

Physical Exam Findings

• Hepatomegaly
• Tenderness over the liver
• Jaundice

Labs & Studies

• Elevated
  • Aspartate
  • Alanine aminotransferase
  • Bilirubin
• Serum antigen and antibody tests
  • HBsAG (Hep B surface antigen)
    • Found throughout the clinical illness
  • Anti-HBs (Antibody to Hep B surface antigen)
    • Signals that patient was either immunized or has recovered from an HBV infection
  • Anti-HBc (Antibody to Hep B core antigen)
    • Indicates an acute Hep B infection
  • Hepatitis B envelope antigen (HBeAg)
    • Indicates a highly infectious active infection
  • Hepatitis B envelope antibody (anti-HBe)
    • Indicates active infection with a lower infection rate

Treatment

• Preventative
  • There is a vaccination available and is offered to all infants in the U.S.
  • Behavioral risk reduction
    • Limit sexual partners
    • Medical staff use of universal precautions
    • Not sharing used needles
• Acute
  • Usually, self limiting with symptoms resolving in 2-3 weeks and full recovery in 16 weeks
  • Antiviral therapy is an option if the patient is immunocompromised or has a concomitant HIV infection
• Chronic
  • Antiviral drugs
  • Liver transplant

Hepatitis C

• Transmitted via exposure to contaminated body fluids
• 30% of HIV patients are found to have Hep C as well, and together the progression of cirrhosis is increased
• Chronic hep C occurs in 80% of patients
• 30% of patients with chronic hep C will develop cirrhosis
• No vaccination is available

Clinical Presentation

• Asymptomatic
• Nonspecific flu-like symptoms

Labs & Studies

Elevated
– Aspartate transaminase
– Alanine transaminase
– Alkaline phosphatase
– Bilirubin

• Anti- HCV
• HCV RNA

Treatment

• Preventative
  • Behavrioural risk reduction
    • Limit sexual partners
    • Medical staff use of universal precautions
    • Not sharing used needles
• Acute
  • Supportive care
  • Antiviral therapy should be started upon diagnosis
• Chronic
  • Antiviral drugs – effective in 95% of patients
  • Liver transplant

Hepatitis D

• Transmitted through exposure to contaminated body fluids
• Patient must have Hep B to contract Hep D
• In the acute phase, Hep B is not made worse by Hep D infection
• Risk of cirrhosis and cancer for Hep B patients increase with a Hep D infection

Clinical Presentation

• Jaundice
• RUQ pain
• Anorexia
• Malaise

Labs, Studies and Physical Exam Findings

• Anti hepatitis D antigen (Anti-HDV)

Treatment

• Preventative
  – Behavrioural risk reduction
  – Limit sexual partners
  – Medical staff use of universal precautions
  – Not sharing used needles
• Acute
  • Supportive care
  • Interferon-alfa or pegylated interferon-alpha
  Hepatitis E
• Transmitted through oral-fecal route

Clinical Presentation

• Jaundice
• RUQ pain
• Anorexia
• Malaise

Labs, Studies and Physical Exam Findings

• IgM antibody to HEV (IgM anti-HEV)

Treatment

• Prevention
  • Good hygiene
• Supportive care
  • Self limiting with a full recovery