Viral hepatitis

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

Differential Diagnosis

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
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.
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