Viral hepatitis: Difference between revisions
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==Background==
==Background==
*Hepatocellular pattern of injury, where AST and ALT are higher than Tbili and Alk Phos; likely to have significantly elevated ALT and AST (20x normal or higher)
*Hepatocellular pattern of injury, where AST and ALT are higher than Tbili and Alk Phos; likely to have significantly elevated ALT and AST (20x normal or higher)
*Of note, transmission of [[Hepatitis B]] and [[Hepatitis C]] through donated blood, blood products, and organs is rare in the US since blood screening became available in 1992
*Of note, transmission of [[Special:MyLanguage/Hepatitis B|Hepatitis B]] and [[Special:MyLanguage/Hepatitis C|Hepatitis C]] through donated blood, blood products, and organs is rare in the US since blood screening became available in 1992
 


===Overview of Common Viral Hepatitis Agents===


*[[Hepatitis A]]
*[[Special:MyLanguage/Hepatitis A|Hepatitis A]]
**Fecal-oral transmission
**Fecal-oral transmission
**Associated with epidemics linked to a common source (water)
**Associated with epidemics linked to a common source (water)
**Most common risk factor is travel outside of the US <ref>Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204.</ref>
**Most common risk factor is travel outside of the US <ref>Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204.</ref>
**Not associated with chronic carrier state; incubation period is approximately 30 days, and infectivity usually resolved prior to symptom onset
**Not associated with chronic carrier state; incubation period is approximately 30 days, and infectivity usually resolved prior to symptom onset
*[[Hepatitis B]]
**Most common form of transmission occurs from asymptomatic children to adults
***Approximately only 5% of infected children symptomatic
***Whereas ~75% of adults are symptomatic
**Incubation period: 15-50d
**Prodrome: [[Special:MyLanguage/nausea/vomiting|nausea/vomiting]], malaise, [[Special:MyLanguage/fever|fever]], [[Special:MyLanguage/abdominal pain|abdominal pain]]
***1wk later: clay-colored stool, jaundice
**Death from [[Special:MyLanguage/hepatic failure|hepatic failure]] is rare
 
*[[Special:MyLanguage/Hepatitis B|Hepatitis B]]
**Transmitted parenterally, blood contact, and unprotected sex
**Transmitted parenterally, blood contact, and unprotected sex
**90% of exposed infants progress to chronic hepatitis; 10% of exposed adults progress to chronic hepatitis
**90% of exposed infants progress to chronic hepatitis; 10% of exposed adults progress to chronic hepatitis
**Serology<ref> www.cdc.gov/hepatitis </ref>
**Serology<ref> www.cdc.gov/hepatitis </ref>
**Incubation period: 1-3 months
**Presentation is similar to hep A
**Lab tests:
***HBsAg: + implies infection
***Anti-HBs: implies clearance or vaccination
***Anti-HBc: Implies prior infection; IgM = acute & in flares; only marker in window period; IgG always present
***HBe-Ag: Implies active viral replication & infectivity
***Anti-HBe: low infectivity
***HBV DNA: Similar to HBe-Ag but more sensitive


*[[Hepatitis C]]
*[[Special:MyLanguage/Hepatitis C|Hepatitis C]]
**Blood-borne, in US, most commonly transmitted through [[IV drug use]]. Infrequently transmitted through sexual contact
**Blood-borne, in US, most commonly transmitted through [[Special:MyLanguage/IV drug use|IV drug use]]. Infrequently transmitted through sexual contact
**90% of HCV infections progress to chronic hepatitis<ref>Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204</ref>
**90% of HCV infections progress to chronic hepatitis<ref>Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204</ref>
*[[Hepatitis D]]
**Unlike Hep A and B, most often asymptomatic in acute phase of infection
**>75% of patients advance to chronic stage
**Active disease identified by reactive HCV ab and positive HCV RNA
 
*[[Special:MyLanguage/Hepatitis D|Hepatitis D]]
**Transmission similar to Hepatitis B
**Transmission similar to Hepatitis B
**Can only co-infect patients with Hepatitis B (actively producing HBsAg)
**Can only co-infect patients with Hepatitis B (actively producing HBsAg)
**Presentation can range from acute self-limited disease to fulminant hepatitis or chronic infection
**Presentation can range from acute self-limited disease to fulminant hepatitis or chronic infection
*[[Hepatitis E]]
**Only occurs with comorbid hepatitis B
**High incidence of cirrhosis
 
*[[Special:MyLanguage/Hepatitis E|Hepatitis E]]
**Fecal-oral transmission
**Fecal-oral transmission
**Usually results in mild illness, but can cause fulminant hepatitis in pregnant women<ref>Rein DB, Stevens GA, Theaker J, Wittenborn JS, Wiersma ST. The Global Burden of Hepatitis E Virus Genotypes 1 and 2 in 2005. Hepatology, Vol. 55, No. 4, 2012: 988-997</ref>
**Usually results in mild illness, but can cause fulminant hepatitis in pregnant women<ref>Rein DB, Stevens GA, Theaker J, Wittenborn JS, Wiersma ST. The Global Burden of Hepatitis E Virus Genotypes 1 and 2 in 2005. Hepatology, Vol. 55, No. 4, 2012: 988-997</ref>
**Fecal-oral transmission
**No carrier state
**High associated mortality
**Common in Southeast Asia, but different genotypes found globally across Asia, Africa, Latin America<ref>Chaudhry SA et al. Hepatitis E infection during pregnancy. Can Fam Physician. 2015 Jul; 61(7): 607–608.</ref>
**Mortality in pregnancy dependent on trimester<ref>Ranger-Rogez S, Alain S, Denis F. Hepatitis viruses: mother to child transmission [article in French] Pathol Biol (Paris) 2002;50(9):568–75.</ref>
***1.5% in first trimester
***8.5% in second trimester
***21% in third trimester


===[[Hepatitis A]]===
*Most common form of transmission occurs from asymptomatic children to adults
**Approximately only 5% of infected children symptomatic
**Whereas ~75% of adults are symptomatic
*Incubation period: 15-50d
*Prodrome: [[nausea/vomiting]], malaise, [[fever]], [[abdominal pain]]
**1wk later: clay-colored stool, jaundice
*Death from [[hepatic failure]] is rare


===[[Hepatitis B]]===
==Clinical Features==
*Incubation period: 1-3 months
*Presentation is similar to hep A
*Lab tests:
**HBsAg: + implies infection
**Anti-HBs: implies clearance or vaccination
**Anti-HBc: Implies prior infection; IgM = acute & in flares; only marker in window period; IgG always present
**HBe-Ag: Implies active viral replication & infectivity
**Anti-HBe: low infectivity
**HBV DNA: Similar to HBe-Ag but more sensitive


===[[Hepatitis C]]===
</translate>
*Unlike Hep A and B, most often asymptomatic in acute phase of infection
{{Acute hepatitis features}}
*>75% of patients advance to chronic stage
<translate>
*Active disease identified by reactive HCV ab and positive HCV RNA


===[[Hepatitis D]]===
*Only occurs with comorbid hepatitis B
*High incidence of cirrhosis


===[[Hepatitis E]]===
==Differential Diagnosis==
*Fecal-oral transmission
*No carrier state
*High associated mortality
*Common in Southeast Asia, but different genotypes found globally across Asia, Africa, Latin America<ref>Chaudhry SA et al. Hepatitis E infection during pregnancy. Can Fam Physician. 2015 Jul; 61(7): 607–608.</ref>
*Mortality in pregnancy dependent on trimester<ref>Ranger-Rogez S, Alain S, Denis F. Hepatitis viruses: mother to child transmission [article in French] Pathol Biol (Paris) 2002;50(9):568–75.</ref>
**1.5% in first trimester
**8.5% in second trimester
**21% in third trimester


==Clinical Features==
</translate>
{{Acute hepatitis features}}
{{Acute hepatitis causes}}
<translate>


==Differential Diagnosis==
{{Acute hepatitis causes}}


==Evaluation==
==Evaluation==
*[[LFTs]]
 
*[[Special:MyLanguage/LFTs|LFTs]]
*INR
*INR
**[[liver disease induced coagulopathy|Coagulopathy]] correlates w/more severe liver dysfunction
**[[Special:MyLanguage/liver disease induced coagulopathy|Coagulopathy]] correlates w/more severe liver dysfunction
 
{{Acute hepatitis panel}}
 
*Acute hepatitis panel
*Acute hepatitis panel
**Hep A Ab IgM
**Hep A Ab IgM
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**Hep C Ab
**Hep C Ab


{| class="wikitable"
</translate>
! Anti-hepatitis A, IgM
{{Acute hepatitis panel}}
! Hepatitis B surface antigen
<translate>
! Anti-hepatitis B core, IgM
 
! Anti-hepatitis C
! Interpretation
|-
| Positive
| Negative
| Negative
| Negative
| Acute hepatitis A
|-
| Negative
| Positive
| Positive
| Negative
| Acute hepatitis B
|-
| Negative
| Positive
| Negative
| Negative
| Chronic hepatitis B infection
|-
| Negative
| Negative
| Positive
| Negative
| Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
|-
| Negative
| Negative
| Negative
| Positive
| Acute or chronic hepatitis C; additional tests are required to make the determination
|}


==Management==
==Management==
*Supportive care
*Supportive care
**Symptomatic management; [[antiemetics]], [[pain control]], [[IVF|rehydration]]  
**Symptomatic management; [[Special:MyLanguage/antiemetics|antiemetics]], [[Special:MyLanguage/pain control|pain control]], [[Special:MyLanguage/IVF|rehydration]]  
**Manage any complications of [[liver failure|liver dysfunction]] and/or [[cirrhosis]]
**Manage any complications of [[Special:MyLanguage/liver failure|liver dysfunction]] and/or [[Special:MyLanguage/cirrhosis|cirrhosis]]
**Avoid hepatotoxic meds
**Avoid hepatotoxic meds
*HepA: Household or close contacts may require IM HepA Ig if within 14 days of exposure
*HepA: Household or close contacts may require IM HepA Ig if within 14 days of exposure
*See also [[Hepatitis B post-exposure prophylaxis]]
*See also [[Special:MyLanguage/Hepatitis B post-exposure prophylaxis|Hepatitis B post-exposure prophylaxis]]
*Outpatient treatments for HCV include [[Interferon-α]], [ribavirin]], and newer direct acting antivirals (e.g. Harvoni)
*Outpatient treatments for HCV include [[Special:MyLanguage/Interferon-α|Interferon-α]], [ribavirin]], and newer direct acting antivirals (e.g. Harvoni)
 


==Disposition==
==Disposition==
*Admit
*Admit
**INR >2
**INR >2
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**Intractable pain
**Intractable pain
**Bilirubin >30
**Bilirubin >30
**[[Hypoglycemia]]
**[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
**Significant comorbidity/immunocompromised
**Significant comorbidity/immunocompromised
**Age >50 years
**Age >50 years


==See Also==
==See Also==
*[[Jaundice]]
 
*[[Acute Hepatitis]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
*[[Acute hepatic failure]]
*[[Special:MyLanguage/Acute Hepatitis|Acute Hepatitis]]
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]
 


==References==
==References==
<references/>
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
</translate>

Latest revision as of 00:03, 5 January 2026


Background

  • Hepatocellular pattern of injury, where AST and ALT are higher than Tbili and Alk Phos; likely to have significantly elevated ALT and AST (20x normal or higher)
  • Of note, transmission of Hepatitis B and Hepatitis C through donated blood, blood products, and organs is rare in the US since blood screening became available in 1992


Overview of Common Viral Hepatitis Agents

  • Hepatitis A
    • Fecal-oral transmission
    • Associated with epidemics linked to a common source (water)
    • Most common risk factor is travel outside of the US [1]
    • Not associated with chronic carrier state; incubation period is approximately 30 days, and infectivity usually resolved prior to symptom onset
    • Most common form of transmission occurs from asymptomatic children to adults
      • Approximately only 5% of infected children symptomatic
      • Whereas ~75% of adults are symptomatic
    • Incubation period: 15-50d
    • Prodrome: nausea/vomiting, malaise, fever, abdominal pain
      • 1wk later: clay-colored stool, jaundice
    • Death from hepatic failure is rare
  • Hepatitis B
    • Transmitted parenterally, blood contact, and unprotected sex
    • 90% of exposed infants progress to chronic hepatitis; 10% of exposed adults progress to chronic hepatitis
    • Serology[2]
    • Incubation period: 1-3 months
    • Presentation is similar to hep A
    • Lab tests:
      • HBsAg: + implies infection
      • Anti-HBs: implies clearance or vaccination
      • Anti-HBc: Implies prior infection; IgM = acute & in flares; only marker in window period; IgG always present
      • HBe-Ag: Implies active viral replication & infectivity
      • Anti-HBe: low infectivity
      • HBV DNA: Similar to HBe-Ag but more sensitive
  • Hepatitis C
    • Blood-borne, in US, most commonly transmitted through IV drug use. Infrequently transmitted through sexual contact
    • 90% of HCV infections progress to chronic hepatitis[3]
    • Unlike Hep A and B, most often asymptomatic in acute phase of infection
    • >75% of patients advance to chronic stage
    • Active disease identified by reactive HCV ab and positive HCV RNA
  • Hepatitis D
    • Transmission similar to Hepatitis B
    • Can only co-infect patients with Hepatitis B (actively producing HBsAg)
    • Presentation can range from acute self-limited disease to fulminant hepatitis or chronic infection
    • Only occurs with comorbid hepatitis B
    • High incidence of cirrhosis
  • Hepatitis E
    • Fecal-oral transmission
    • Usually results in mild illness, but can cause fulminant hepatitis in pregnant women[4]
    • Fecal-oral transmission
    • No carrier state
    • High associated mortality
    • Common in Southeast Asia, but different genotypes found globally across Asia, Africa, Latin America[5]
    • Mortality in pregnancy dependent on trimester[6]
      • 1.5% in first trimester
      • 8.5% in second trimester
      • 21% in third trimester


Clinical Features

Acute Hepatitis Features

Jaundice of the skin
Pediatric jaundice with icterus of sclera.


Differential Diagnosis

Causes of acute hepatitis


Evaluation

  • LFTs
  • INR
  • Acute hepatitis panel
    • Hep A Ab IgM
    • Hep B cAb IgM
    • Hep B sAg
    • Hep B sAb
    • Hep C Ab

Interpreting Acute Hepatitis Panel Results

Anti-hepatitis A, IgM Hepatitis B surface antigen Anti-hepatitis B core, IgM Anti-hepatitis C Interpretation
Positive Negative Negative Negative Acute hepatitis A
Negative Positive Positive Negative Acute hepatitis B
Negative Positive Negative Negative Chronic hepatitis B infection
Negative Negative Positive Negative Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
Negative Negative Negative Positive Acute or chronic hepatitis C; additional tests are required to make the determination


Management


Disposition

  • Admit
    • INR >2
    • Unable to tolerate PO
    • Intractable pain
    • Bilirubin >30
    • Hypoglycemia
    • Significant comorbidity/immunocompromised
    • Age >50 years


See Also


References

  1. ↑ Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204.
  2. ↑ www.cdc.gov/hepatitis
  3. ↑ Oyama, LC: Disorders of the Liver and Biliary Tractin Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 107: p 1186-1204
  4. ↑ Rein DB, Stevens GA, Theaker J, Wittenborn JS, Wiersma ST. The Global Burden of Hepatitis E Virus Genotypes 1 and 2 in 2005. Hepatology, Vol. 55, No. 4, 2012: 988-997
  5. ↑ Chaudhry SA et al. Hepatitis E infection during pregnancy. Can Fam Physician. 2015 Jul; 61(7): 607–608.
  6. ↑ Ranger-Rogez S, Alain S, Denis F. Hepatitis viruses: mother to child transmission [article in French] Pathol Biol (Paris) 2002;50(9):568–75.
  7. ↑ Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
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