Viral hepatitis: Difference between revisions
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== | ==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 | |||
**Whereas ~75% of adults are symptomatic | |||
*Incubation period: 15-50d | *Incubation period: 15-50d | ||
*Prodrome: | *Prodrome: [[nausea/vomiting]], malaise, [[fever]], [[abdominal pain]] | ||
**1wk later | **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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**HBsAg: + implies infection | **HBsAg: + implies infection | ||
**Anti-HBs: implies clearance or vaccination | **Anti-HBs: implies clearance or vaccination | ||
**Anti-HBc: Implies prior infection; IgM = acute & in flares; IgG always present | **Anti-HBc: Implies prior infection; IgM = acute & in flares; only marker in window period; IgG always present | ||
**HBe-Ag: Implies active viral replication & infectivity | **HBe-Ag: Implies active viral replication & infectivity | ||
**Anti-HBe: low infectivity | |||
**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 | *>75% of patients advance to chronic stage | ||
*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]]=== | |||
*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== | |||
{{Acute hepatitis features}} | |||
==Differential Diagnosis== | |||
{{Acute hepatitis causes}} | |||
==Evaluation== | |||
*[[LFTs]] | |||
*INR | |||
**[[liver disease induced coagulopathy|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 | |||
{| 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== | |||
*Supportive care | |||
**Symptomatic management; [[antiemetics]], [[pain control]], [[IVF|rehydration]] | |||
**Manage any complications of [[liver failure|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]], [ribavirin]], and newer direct acting antivirals (e.g. Harvoni) | |||
==Disposition== | ==Disposition== | ||
*Admit | |||
**INR >2 | |||
**Unable to tolerate PO | |||
**Intractable pain | |||
**Bilirubin >30 | |||
**[[Hypoglycemia]] | |||
**Significant comorbidity/immunocompromised | |||
**Age >50 years | |||
==See Also== | ==See Also== | ||
[[Jaundice]] | *[[Jaundice]] | ||
*[[Acute Hepatitis]] | |||
== | ==References== | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:ID]] | [[Category:ID]] |
Revision as of 16:50, 30 September 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 occurs with comorbid 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
- Nausea/Vomiting
- RUQ pain
- Enlarged, tender liver
- Fever
- Jaundice
- Bilirubinuria
Differential Diagnosis
Causes of acute hepatitis
- Acetaminophen toxicity (most common cause of acute liver failure in the US[3])
- Viral hepatitis
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson's disease
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
- 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, [ribavirin]], and newer direct acting antivirals (e.g. Harvoni)
Disposition
- Admit
- INR >2
- Unable to tolerate PO
- Intractable pain
- Bilirubin >30
- Hypoglycemia
- Significant comorbidity/immunocompromised
- Age >50 years
See Also
References
- ↑ Chaudhry SA et al. Hepatitis E infection during pregnancy. Can Fam Physician. 2015 Jul; 61(7): 607–608.
- ↑ Ranger-Rogez S, Alain S, Denis F. Hepatitis viruses: mother to child transmission [article in French] Pathol Biol (Paris) 2002;50(9):568–75.
- ↑ 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.