Hepatitis Overview Quiz

Hepatitis Overview

• Topics covered include acute/chronic hepatitis, active viral hepatitis (causes, clinical picture, sequelae, complications, investigations, and management), and chronic viral hepatitis (clinical picture, investigations, and treatment).

Acute Hepatitis

• Infections: Viral hepatitis (types A, B, C, D, and E), other viruses (EBV, CMV, HSV, yellow fever), and bacterial hepatitis (Neisseria meningitidis, gonorrhea, Salmonella, Brucella, and Campylobacter).
• Drugs and toxins: Alcohol, halothane, isoniazid, paracetamol.
• Metabolic disorders: Wilson's disease.

Chronic Hepatitis

• Duration: Inflammation of the liver lasting at least six months.
• Viral hepatitis: Types B, C, and D.
• Autoimmune hepatitis.
• Drugs and toxins: Alcohol, isoniazid (INH), and methyldopa.
• Metabolic disorders: Wilson's disease and a-1 antitrypsin deficiency.

Acute Viral Hepatitis

• Types: HAV, HBV, HCV, HDV, HEV
• Genomes: HAV (RNA), HBV (DNA), HCV (RNA), HDV (RNA), HEV (RNA)
• Transmission: HAV (oral), HBV (blood, sexual, vertical), HCV (blood, community acquired), HDV (blood, sexual, vertical), HEV (oral)
• Incubation periods/incidence: Vary based on the virus, some are sporadic or epidemic
• Age of affected population: Varies based on the virus
• Acute attack severity: Varies based on the virus, some are mild, some are severe, and some are characterized by jaundice
• Chronicity/HCC relation: Varies based on the virus, some are more linked to chronicity and hepatocellular carcinoma (HCC).

Hepatitis A Virus (HAV)

• Transmission: Fecal-oral
• Affected population: Children and young adults
• Incidence: Sporadic or epidemic
• Incubation period: 2-6 weeks
• Acute attack: Usually mild; no chronicity or HCC
• Prophylaxis: Vaccination or immunoglobulins

Hepatitis E Virus (HEV)

• Transmission: Fecal-oral
• Affected population: Children and young adults
• Incidence: Sporadic or epidemic
• Incubation period: 2-6 weeks
• Acute attack: Usually mild, except in pregnant females
• Chronicity/HCC relation: Not associated with chronic hepatitis or HCC
• Prophylaxis: None available

Hepatitis B Virus (HBV)

• Transmission: Blood, sexual, vertical (mother to child)
• Affected population: Any age
• Incidence: Sporadic
• Incubation period: 1-6 months
• Acute attack: Usually severe; associated with chronicity and HCC
• Prophylaxis: Vaccination or immunoglobulins

Hepatitis C Virus (HCV)

• Transmission: Blood, community acquired
• Affected population: Any age (more common in adults)
• Incidence: Sporadic
• Incubation period: 1-6 months
• Acute attack: Usually mild or unnoticed; associated with chronicity and HCC
• Prophylaxis: None available

Hepatitis D Virus (HDV)

• Transmission: Blood, sexual, vertical
• Affected population: Any age
• Incidence: Sporadic
• Incubation period: 1-6 months
• Acute attack: Potentially severe (co-infection), and associated with chronicity when it's a super-infection
• Prophylaxis: Vaccination against HBV

Clinical Picture

• Anicteric hepatitis: Often overlooked; mild cases with influenza-like symptoms without jaundice.
• Icteric hepatitis: Jaundice is prominent.
  • Pre-icteric stage: (3 days-2 weeks) symptoms include fever, anorexia, nausea, and vomiting, and accompanied by dull, aching pain in the right hypochondrium (upper right abdomen) or epigastrium (upper central abdomen)
  • Icteric stage: (1-4 weeks) improvement in fever, symptoms, and signs. Symptoms include dark urine, and pale stools with an enlarged liver that's painful and soft to the touch.
  • Convalescence stage: gradual improvement and disappearance of symptoms. Full liver recovery can take up to 6 months.

Sequelae

• Complete recovery (common in HAV, HEV, less frequent in HBV/HDV. Very infrequent in HCV)
• Hepatic Complications: relapse (attack recurs), cholestatic hepatitis (prolonged cholestasis resulting in elevated ALP, pruritus, and jaundice that may last 8-28 weeks)
• Fulminant hepatitis (rare; massive liver necrosis)
• Post-hepatitis syndrome (transaminitis; abnormal liver enzymes, and fatigue, anorexia).

Extrahepatic complications

• Arthritis
• Aplastic Anemia
• Guillain-Barré syndrome
• Glomerulonephritis
• Polyarteritis nodosa
• Cryoglobulinemia

Investigations

• Liver function tests
• Abdominal ultrasound
• Urine analysis
• Stool analysis
• Blood picture
• Hepatitis markers (antibodies and markers in blood)
• PCR (polymerase chain reaction)

Management

• Bed rest until symptom and liver tenderness cease, and serum bilirubin levels decrease (<1.5 mg/dL)
• Diet: high carbohydrate, low fat; protein restriction only with liver failure
• Symptomatic treatment (for nausea, domperidone; for pruritus, cholestyramine)
• Treatment of complications (e.g., corticosteroids for cholestatic hepatitis)

Chronic Viral Hepatitis

• Asymptomatic or non-specific symptoms (fatigue, anorexia, general ill health)
• Hepatomegaly (firm liver), Jaundice, Right hypochondrial pain, splenomegaly, complications to cirrhosis, LCF, PH, and HCC
• Extra-hepatic symptoms (cryoglobulinemia, glomerulonephritis, arthritis), notably in autoimmune cases

Investigations for Chronic Hepatitis

• Liver Function Tests (liver enzymes, albumin, bilirubin)
• Abdominal Ultrasound (liver size, cirrhosis, etc.)
• Liver Biopsy (tissue examination for inflammation, fibrosis, etc.) - can detect inflammation, and fibrosis, specific for different viruses (e.g. "ground glass" appearance in HBV
• Hepatitis markers (antibodies and markers in blood)
• PCR to detect viral replication
• Auto-antibodies for autoimmune hepatitis (ANA, ASMA, ALKMA)

Treatment of Chronic Hepatitis

• Chronic HBV: Immune modulator drugs (e.g., interferon) and antiviral drugs (e.g., entecavir, tenofovir, lamivudine)
• Chronic HCV: Direct-acting antiviral (DAA) therapy; treatment goals include preventing complications, improving quality of life, and preventing transmission of HCV
  • Therapy endpoint (SVR): undetectable serum HCV RNA (<15 IU/ml) at 12 or 24 weeks post-treatment
  • Treatment protocols in genotype 4 patients and cases requiring special considerations (e.g., liver failure, existing complications) are needed