Viral Hepatitis: Types and Symptoms

• Hepatitis is liver inflammation resulting from viral infections, alcohol use, autoimmune disorders, drugs, or toxins.

Types of Hepatitis

• Viral hepatitis includes hepatitis viruses A-E with varying severity and longevity.
• Alcoholic hepatitis is due to overconsumption of alcohol (EtOh).
• Both viral and alcoholic hepatitis can lead to chronic, unrelenting liver inflammation.

Acute Viral Hepatitis

• Inflammation of the liver is due to infection with one of the five hepatitis viruses (A-E).
• Hepatitis A virus is the most common cause, followed by hepatitis B and C.
• Hepatitis D and E are rare.
• It presents with a sudden, rapid onset and short duration (usually a few weeks).
• Symptoms range from none to severe, but nausea/vomiting (N/V), poor appetite, fever, right upper quadrant (RUQ) pain, and jaundice are common.

Comparing Hepatitis Virus Types

• Usually no specific treatment is necessary for hepatitis A, B, and E; instead, a watch-and-wait approach is adopted.
• Antiviral treatments are available for hepatitis C and D.
• Hepatitis C is the most likely to become chronic.
• Hepatitis D can only be acquired if you have hepatitis B, which can be a serious form of hepatitis.
• Vaccines exist for hepatitis A and B, and therefore D, while hepatitis E has a vaccine in China (not approved in Canada/US).
• There is no vaccine for hepatitis C.
• Severity depends on the instigating virus and the host response.
• Hepatitis A and C are often mild, sometimes unnoticed, while hepatitis B and E are more severe.
• Co-infection of hepatitis B with hepatitis D increases severity, resulting in the highest mortality of all hepatitis infections.

Common Signs and Symptoms

• Symptoms have sudden onset.
• Prodromal symptoms include poor appetite, N/V, and fever.
• Other symptoms include RUQ pain and splenomegaly.
• Hepatitis B can cause joint pain and urticaria, which can also be caused by hepatitis C.
• Progressive symptoms include dark urine and jaundice.
• As other symptoms disappear, jaundice lingers for about 1 month.
• Hepatitis A can cause cholestasis, resulting in pale stool and itchiness.
• Progression to liver failure is rare, but more common with hepatitis B virus.

Diagnosis

• Initial suspicion is based on positive symptoms.
• Palpation of RUQ reveals tenderness and hepatomegaly in 50% of acute viral hepatitis.
• Liver function tests (LFT) blood work can indicate liver function and inflammation.
• Varying ratios of blood tests can differentiate viral infections from alcohol use.
• Antigen/antibody blood tests reveal the specific virus causing hepatitis.
• Ultrasound of the liver detects any changes.
• If the diagnosis is unclear, a biopsy is done, though this is usually not indicated.

Prevention

• Vaccines are available for hepatitis A and B viruses.
• There are no current vaccines for hepatitis C, D, or E.
• Hepatitis D cannot occur without hepatitis B infection, therefore, hepatitis B vaccine will reduce risk of hepatitis D.
• Other preventative measures include thoroughly washing hands before handling food, not sharing needles or items that could contain blood (razors, toothbrushes), and practicing safe sex.

General Treatment & Prognosis

• Typically, no treatment is needed.
• Diet and activity restrictions are unnecessary, and vitamin supplementation is not required.
• Avoid alcohol and medications metabolized in the liver.
• Return to most activities of daily living (ADL) after jaundice clears, even if LFTs are not within normal limits (WNL).
• Severe cases may require hospitalization.
• Acute viral hepatitis usually clears in 4-8 weeks, but some cases can turn chronic.

Fulminant Hepatitis

• Rare, life-threatening complication of acute hepatitis.
• Marked by the presence of massive liver necrosis.
• Viral hepatitis can progress to fulminant hepatitis if it's not the B, D, or E strain.
• Hepatitis E infections are more likely to become fulminant in pregnant women.
• Signs and symptoms include encephalopathy (including edema), GI bleeds, and kidney failure.
• It has a high mortality rate of 40-80%.

Hepatitis A

Transmission

• Fecal-oral transmission occurs through poor hygiene from food handlers, child care workers, shellfish from water with raw sewage, and diaper changing at childcare centers.
• Epidemics are often linked to contamination of the water supply.
• It can also spread through blood.

Epidemiology

• Rare in Canada.
• From 2011 to 2015, the yearly average was 236 reported cases.
• Highest reported rates are in age groups 30-59 years.
• It can be endemic in areas with poor water sanitation, such as South Asia, Sub-Saharan and North Africa, parts of the Far East (except Japan), South and Central America, and the Middle East.

Signs and Symptoms

• Incubation period of 2-6 weeks.
• Can be asymptomatic, and the infection goes unrecognized.
• Mild fever, nausea/vomiting, loss of appetite, and jaundice are symptoms.
• Rare symptoms include arthropathy, pancreatitis, and renal failure.

Prognosis

• Complete recovery within days to months.
• Does not result in chronic hepatitis.
• There is no carrier state or chronic hepatitis from hepatitis A infections.

Prevention

• Proper hand hygiene.
• Avoid contamination of water supplies.
• Vaccination (Twinrix) is recommended for all children and for adults at high risk of exposure.

Hepatitis B

Transmission

• Transmitted via blood and body fluids.
• Sexual intercourse through blood (highest risk), semen, and vaginal fluids.
• Needle sharing without sterilization, recreational drug use, tattoos, and prescription medications.
• Blood transfusions are a rare risk due to increased screening procedures.
• Birth (vaginal and cesarean) usually is due to mothers infected secretions or blood at the time of delivery.

Epidemiology

• Rare in Canada.
• In 2019, there were 178 reported acute cases.
• In 2019, there were 3,790 reported chronic cases trending downward since 2010.
• More common in some countries in Asia, Africa, South America, and the Caribbean.

Signs and Symptoms

• Incubation period of 40-180 days.
• Generally more serious than hepatitis A.
• Symptoms range from mild to severe.
• Illness is followed by fever, jaundice, and choluria (cholesterol in urine).
• Joint pain and urticaria are more likely in hepatitis B infection.
• Occasionally fatal, especially in immunocompromised individuals or those with concomitant infection with hepatitis D.

Diagnosis

• Blood tests confirm the presence of infection or immunity to hepatitis B.
• The Hepatitis B Surface Antigen Test (HBsAg) tests for the presence of hepatitis B surface antigens in blood.
• A positive test indicates acute or chronic infection.
• Antibody serology tests check for presence or level of specific antibodies in the blood.

Prognosis

• More cases self-resolve in 4-8 weeks.
• 5-7% of adults develop chronic hepatitis B, with an inverse correlation between age and risk.
• Estimated 5-year survival rates include 97% for patients with chronic persistent hepatitis and 55% for those with chronic active hepatitis with cirrhosis.
• Can have a carrier state.

Healthy Carriers

• 10% of infected individuals become healthy carriers.
• Surface antigen is present for months, years, or sometimes for life, but the person is otherwise healthy and unaware of their status.
• They must have had the infection in order to be a carrier.
• 70% of carriers develop chronic persistent hepatitis B.
• Most do not appear to be ill.

Phases of Hepatitis B Infection

• Pre-icteric phase lasts days to weeks and includes mild fever, nausea/vomiting, anorexia, myalgia, malaise, and weakness.
• Icteric phase lasts one to two months and includes jaundice, hepatomegaly with tenderness, and urticaria with pruritis.
• Pre-icteric symptoms abate.
• Convalescent phase lasts up to six months, with resolution of symptoms.
• Viral antigens disappear, and immune antibodies appear.

Prevention

• Vaccination is recommended for everyone under 18 (3 doses, usually given at birth), but especially for those at risk of exposure.
• Immunocompromised individuals, those with cirrhosis, and those on dialysis may need a booster.
• Avoid needle sharing.
• Engage in safe sex practices.
• If exposed, persons are given hepatitis B immunoglobulin and the vaccine.
• The combination prevents chronic hepatitis B in most.

Hepatitis C

Transmission

• Transmitted via blood.
• Needle sharing without sterilization is the most common cause.
• Transmission via profusion is rare due to screening.
• Transmission via sex is rarer than hepatitis B due to spread through blood, not bodily fluids.
• Transmission via pregnancy and birth is rare.
• For unknown reasons, 20% of persons with alcoholic liver disease develop hepatitis C.

Signs and Symptoms

• Unpredictable course of symptoms.
• Initial infection (acute) is usually mild and without symptoms.
• Clinical presentation is indistinguishable from hepatitis B, but often less severe.
• Illness is followed by fever, jaundice, and choluria.
• Urticaria is more likely in hepatitis C infection.
• LFTs ebb and flow for several months or years.

Prognosis

• Chronic infection results in 75% of cases.
• Usually mild for decades but can eventually lead to steatosis.
• Cirrhosis occurs in 20-30% of those with chronic infection.
• Cirrhosis can lead to liver cancer.
• Carrier state occurs in a small portion of healthy people.

Prevention

• No vaccine is currently available.
• Avoid high-risk behaviors like needle sharing.

Hepatitis D and E

Hepatitis D

• Can only infect people who are also infected by the hepatitis B virus (HBV).
• HBV can cause severe symptoms and serious illness that can lead to liver damage and even death.

Hepatitis E

• Fecal-oral transmission.
• Usually a mild disease but especially dangerous to pregnant women.
• At risk of the complication of fulminant hepatitis.

Massage & Viral Hepatitis

• Appropriateness of massage is determined by patient's symptoms.
• Treatment is contraindicated if a fever is present.
• Until 24 hours fever free without the use of antipyretics.