Hepatitis

Acute Hepatitis

  • Hepatitis A and E cause AcutE (E rarely ➔ chronic infxn)

SSX of acute hepatitis:

  • 1-2wks: RUQ/tender hepatomegaly, fever, ± rash

  • 2wks: Pale stool and dark urine then pruritus and jaundice

Hepatits A

  • MCC of acute hepatitis worldwide, 2nd MCC in US

  • Family: Picornaviridae (non-enveloped, +ssRNA)

  • Genus: Hepatoviridae

  • Fecal-oral transmission

  • Incubates for ~6-8wks

Hepatits E

  • Family Hepeviridae (non-enveloped, +ssRNA)

  • Genus Orthohepeviridae

  • Fecal-oral transmission, incubates for 2-6wks

  • Incubates for ~6-8wks

DX:

  • ↑↑↑ (up to 5,000) AST & ALT, ↑ total bilirubin, ↑ ALP, ↑ GGT

  • Active infection: anti-HAV/HEV IgM (detectable ~1wk after exposure and ~1wk before sx develop)

  • Past infection/vaccination: anti-HAV/HEV IgG persists (no vaccine for E)

  • HAV or HEV RNA (PCR)

TX:

  • Supportive, stop etOH and hepatotoxic drugs (tylenol)

  • Routine vaccination at 1yo and 2yo

Chronic Hepatitis

  • Hepatitis B, C, D causes acute hepatitis but can develop chronic hepatitis

Hepatits B

  • Family: Hepadnavirus (enveloped, circular, partial dsDNA)

  • Genus: Orthohepadnavirus

  • Chronic infxn ➔ asx carriers or chronic inflammation ➔ ↑ risk of cirrhosis and hepatocellular carcinoma

  • MC transmission (in resource-rich areas): sexual (♂ sex with ♂, multiple partners); World wide: parental

  • Incubation 1-6mo

SSX:

  • Acute sx can persist for 6mos

  • Chronic sx: range from ASX to acute hepatitis sx with more unspecific sx like nausea, generalized ABD pain

    • Younger age of infxn ➔ ↑ risk of developing chronic infxn

DX:

  • ↑ AST & ALT, ↑ total bilirubin, ↑ ALP, ↑ GGT

  • Test for Hep C and HIV also

  • ABD US Acute hepatitis:

    • ↑ portal vein radicle wall echogenicity

    • ↓ Liver echogenicity

  • ABD US Chronic hepatitis

    • ↓ portal vein radicle wall number and echogenicity

    • ↑ Liver echogenicity

Hepatitis B testing:

  • If acute or reactivation suspected: get HBs antigen and anti-HBc IgM

  • If HBs antigen is posive, get HBeAg and HBV DNA (PCR)

    • HBe antigen and HBV DNA determine infectivity

Hepatitis B TX:

  • Acute hepatitis:

    • Supportive (low risk of developing chronic): stop etOH and hepatotoxic drugs (tylenol)

  • Health care provider exposure

    • Documented immunity needs no intervention

    • Partly vaccinated ➔ HBIG

  • Chronic hepatits:

    • Tenofovir (nucleoside analog); young with cirrhosis (but not decompensated): PEG-IFN ⍺

    • BOLO cirrhosis, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa

  • Routine vaccination at birth, 1mo, and 1yr

Hepatitis B serology

CDC - Interpretation of Hepatitis B Serologic Test Results

  • IgM means new antibodies (recently exposed)

  • IgG means old antibodies (chronic exposure) - Dr. Dre is a G and he wrote The Chronic

  • HBs antigen is in virus and vaccine

    • Positive HBs antibody with Negative HBs antigen: immunity from vaccination

  • HBc antigen only comes from the virus - NO TEST for HBc antigen but CAN TEST FOR HBc antibody

    • Positive anti-HBc: pt either had or has hep B (because the vaccine doesn't have HBc antigen)

      • Positive anti-HBc with Negative HBs antigen: immunity from previous infxn

      • Positive anti-HBc with Positive HBs antigen:

        • They are either chronically infected, usually with no anti-HBs (most chronic infxns come from lack of anti-HBs AB)

        • OR recently infected (which you would be able to tell by presence of IgM anti-HBc)

  • HBe antigen (also not in vaccine) pops up when virus is actively replicating (active chronic infxn)

    • anti-HBe is present when pt has immunity from previous infxn or inactive chronic infxn

Hepatits D (NEEDS HEP B)

  • Incomplete viral particle with defective ssRNA ∆

  • Requires HBs antigen

  • Coinfxn ➔ ↑ risk of acute hepatitis and accelerates cirrhosis

Hepatits C

  • Family: Flaviviridae (enveloped, +ssRNA)

  • Genus: Hepacivirus

  • Often results in chronic infxn (because asx) ➔ ↑ risk of cirrhosis and hepatocellular carcinoma

  • MC transmission: Needle sharing, transfusion (rarely sexual transmission)

    • Born 1945-1965 (60's-80's had highest rate of transmission)

  • Incubation 1-6mo

SSX:

  • Usually ASX

  • Chronic may present with cirrhosis, lymphoma, ITP/hemolytic anemia, membranoproliferative glomerulonephritis

DX:

  • ↑ AST & ALT, ↑ total bilirubin, ↑ ALP, ↑ GGT

  • ↓ albumin in cirrhosis

  • Test for Hep C and HIV also

Hepatitis C testing:

  • Get HCV antibodies

  • If positive get HCV RNA (PCR)

Hepatitis C TX:

  • Stop etOH and hepatotoxic drugs (tylenol)

  • positive

  • No vaccine or post exposure PPX available

Autoimmune hepatitis

  • ♀ > ♂ , bimodal age of presentation (20's and 50's)

  • Associated with other autoimmune disorders: Graves/Hashimoto, IBD, celiac, SLE, RA, T1DM

SSX:

  • Range from ASX to jaundice/hepatosplenomegaly to acute liver failure

DX:

  • Elevation of AST or ALT (2x upper normal) - AST MC than ALT

  • ↑ IgG or gamma-globulin AND/OR antibodies

  • R/O'd other causes (viral hepatitis, etOH liver disease)

  • Antibodies MC in type 1:

    • MC: anti-nuclear (ANA)

    • Anti-smooth muscle (ASMA), anti-mitochondrial antibodies,

    • Anti-soluble liver antigen/liver pancreas (anti-SLA/LP)

  • Antibodies MC in type 2:

    • Anti-liver-kidney microsomal -1 (anti-LKM-1)

    • Anti-liver cytosol -1 (ALC-1)

  • p-ANCA (common with co-existing IBD)

  • anti DNA (common with co-existing SLE)

  • Biopsy (not required) confirms dx: interface hepatitis/lymphoplasmacytic infiltrate

  • MRCP if hx of IBD or cholestasis labs (↑alk phos)

TX:

  • ASX and aminotransferase <10x upper normal ➔ PO prednisone

  • Prednisone OR prednisolone taper ± azathioprine

  • Pts typically require continued azathioprine (high rate of relapse)