Viral hepatitis: Difference between revisions

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


===Hepatitis B===
===[[Hepatitis B]]===
*Incubation period: 1-3 months
*Incubation period: 1-3 months
*Presentation is similar to hep A
*Presentation is similar to hep A
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**HBV DNA: Similar to HBe-Ag but more sensitive
**HBV DNA: Similar to HBe-Ag but more sensitive


===Hepatitis C===
===[[Hepatitis C]]===
*Unlike Hep A and B, most often asymptomatic in acute phase of infection
*Unlike Hep A and B, most often asymptomatic in acute phase of infection
*>75% of patients advance to chronic stage
*>75% of patients advance to chronic stage
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==Evaluation==
==Evaluation==
*Hepatitis panel, which typically consists of:
*LFTs
**HepA-Ab, IgM
*INR
**HBsAg
**Coagulopathy correlates w/more severe liver dysfunction
**HBc-Ab, IgM
*Acute hepatitis panel
**HC-Ab
**Hep A Ab IgM
*PT correlates well with severity and prognosis of acute hepatitis
**Hep B cAb IgM
**Hep B sAg
**Hep B sAb
**Hep C Ab
 
{| class="wikitable"
! 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==
==Management==
*Household or close contacts of positive HepA individual may require IM HepA Ig if within 14 days of exposure
*Supportive care
**Symptomatic management; [[antiemetics]], [[pain control]], rehydration
**Manage any complications of [[liver dysfunction]] and/or [[cirrhosis]]
**Avoid hepatotoxic meds
*HepA: Household or close contacts may require IM HepA Ig if within 14 days of exposure
*See also [[Hepatitis B post-exposure prophylaxis]]
*Outpatient treatments for HCV include [[Interferon-α]], [ribavarin]], and newer direct acting antivirals (e.g. Harvoni)


==Disposition==
==Disposition==

Revision as of 18:52, 27 January 2019

Background

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

  • 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

  • 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

  • Only currently with hepatitis B
  • High incidence of cirrhosis

Hepatitis E

  • Fecal-oral transmission
  • No carrier state
  • High associated mortality
  • Common in Southeast Asia, but different genotypes found globally across Asia, Africa, Latin America[1]
  • Mortality in pregnancy dependent on trimester[2]
    • 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
    • Coagulopathy correlates w/more severe liver dysfunction
  • Acute hepatitis panel
    • Hep A Ab IgM
    • Hep B cAb IgM
    • Hep B sAg
    • Hep B sAb
    • Hep C Ab
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. ↑ Chaudhry SA et al. Hepatitis E infection during pregnancy. Can Fam Physician. 2015 Jul; 61(7): 607–608.
  2. ↑ Ranger-Rogez S, Alain S, Denis F. Hepatitis viruses: mother to child transmission [article in French] Pathol Biol (Paris) 2002;50(9):568–75.
  3. ↑ 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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