Viral hepatitis

Medicine > Infection

Background knowledge 🧠

Definition

Viral hepatitis is an inflammation of the liver caused by a viral infection.
Commonly caused by hepatitis A, B, C, D, and E viruses.
Can lead to both acute and chronic liver disease.

Epidemiology

Hepatitis B and C are the most common causes of chronic viral hepatitis globally.
Hepatitis A and E are typically self-limiting and more common in regions with poor sanitation.
Hepatitis B is highly endemic in sub-Saharan Africa and East Asia.
Hepatitis C is prevalent among intravenous drug users and in countries with low medical safety standards.
Hepatitis D requires the presence of hepatitis B and is seen in areas where hepatitis B is common.

Aetiology and pathophysiology

Hepatitis A and E: Faecal-oral transmission, often due to contaminated food or water.
Hepatitis B, C, and D: Bloodborne transmission (e.g., needle sharing, blood transfusions, sexual contact).
Chronic infection with hepatitis B and C can lead to cirrhosis and hepatocellular carcinoma.
Hepatitis D causes more severe disease when co-infected with hepatitis B.
Pathophysiology involves immune-mediated liver cell injury.

Types

Hepatitis A: Acute, self-limiting; no chronic stage.
Hepatitis B: Can be acute or chronic; chronic infection can lead to severe liver disease.
Hepatitis C: Often asymptomatic in acute phase; chronic infection is common and can lead to liver cirrhosis.
Hepatitis D: Requires hepatitis B co-infection; increases severity of hepatitis B.
Hepatitis E: Similar to hepatitis A; usually self-limiting but can be severe in pregnant women.

Clinical Features 🌡️

Symptoms

Fatigue, malaise.
Nausea, vomiting.
Loss of appetite.
Abdominal pain, particularly in the right upper quadrant.
Jaundice (especially in hepatitis A and E).

Signs

Jaundice: Yellowing of skin and sclera.
Hepatomegaly: Enlarged liver on palpation.
Dark urine and pale stools.
Pruritus (especially in cholestatic hepatitis).
Spider naevi and palmar erythema (in chronic hepatitis).
Signs of decompensated liver disease in advanced chronic hepatitis: ascites, encephalopathy.

Investigations 🧪

Tests

Liver function tests (LFTs): Elevated ALT and AST.
Viral serologies: Hepatitis A IgM, Hepatitis B surface antigen (HBsAg), Hepatitis C antibody.
PCR for viral RNA/DNA (e.g., HCV RNA, HBV DNA).
Ultrasound: Assess liver size, rule out biliary obstruction.
Liver biopsy: If diagnosis is uncertain or to assess fibrosis in chronic hepatitis.

Management 🥼

Management

Hepatitis A and E: Supportive care; hydration, avoid hepatotoxic drugs.
Hepatitis B: Antiviral therapy (e.g., tenofovir, entecavir) in chronic cases or severe acute cases.
Hepatitis C: Direct-acting antivirals (e.g., sofosbuvir, ledipasvir) for chronic infection.
Hepatitis D: Pegylated interferon in chronic cases; no specific antiviral therapy available.
Vaccination: Hepatitis A and B vaccines available; no vaccine for hepatitis C.
Liver transplantation: In cases of fulminant hepatitis or end-stage liver disease.

Complications

Chronic hepatitis (B and C) can lead to cirrhosis.
Increased risk of hepatocellular carcinoma in chronic hepatitis B and C.
Fulminant hepatitis: Acute liver failure with high mortality.
Co-infection with HIV increases morbidity and mortality.
Autoimmune hepatitis may be triggered by viral hepatitis.

Prognosis

Hepatitis A and E: Excellent prognosis; full recovery in most cases.
Hepatitis B: Variable prognosis; chronic infection in 5-10% of adults.
Hepatitis C: High rate of chronicity; cirrhosis and liver cancer in untreated cases.
Hepatitis D: Poorer prognosis due to more severe liver disease.
Complications lead to increased mortality and morbidity.

Key points

Vaccination is crucial in preventing hepatitis A and B.
Early detection and treatment of hepatitis B and C can prevent severe complications.
Public health measures are vital to control the spread of viral hepatitis.
Multidisciplinary care is often required for managing chronic hepatitis.

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