Updated: 7/7/2019

Acute Hepatitis

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Snapshot
  • A 35-year-old man is brought to the emergency department for abdominal pain and flu-like symptoms for the past 2 days. He reports that he just returned from a 2-month trip throughout South America. He reports fever, fatigue, malaise, and right upper quadrant pain but denies diarrhea, melena, hematochezia, nausea, vomiting, or weight loss. A physical examination demonstrates tender hepatomegaly and mild scleral icterus.
Introduction
  • Overview
    • condition is an acute (temporary) form of hepatitis, which describes the inflammation of the liver tissue
      • treatment is usually supportive and dependent on the etiology
  • Epidemiology
    • etiology
      • viral hepatitides (e.g., HAV, HCV, and HBV) 
      • parasites (e.g., toxoplasmosis)
      • alcohol
      • drug-induced (e.g., acetaminophen)
      • autoimmune hepatitis 
      • steatohepatitis
      • metabolic disease
    • risk factors
      • alcohol abuse
      • foreign travel
      • intravenous drug use
      • sexual contact
  • Pathogenesis
    • mechanism
      • the specific mechanism of injury depends on the etiology
      • generally, the initial insult results in hepatocyte injury leading to the activation of an inflammatory response, which can become chronic (with subsequent fibrosis and cirrhosis)
  • Associated conditions
    • medical conditions and comorbidities
      • chronic hepatitis
      • fulminant liver failure
  • Prognosis
    • the vast majority of patients with acute hepatitis recover completely without complications
    • overall, low mortality rate but prognosis may be worse if the patient has other comorbidities or initial presenting symptoms such as ascites, edema, or encephalopathy
Presentation
  • History  
    • recent travel  
    • sudden jaundice  
  • Symptoms 
    • common symptoms
      • initial prodromal phase (flu-like symptoms)
        • fatigue
        • nausea
        • vomiting
        • poor appetite
        • headaches
      • followed by jaundice (1-2 weeks after)
        • right upper quadrant (RUQ) pain
  • Physical exam
    • jaundice 
    • scleral icterus 
    • hepatomegaly
    • splenomegaly
    • RUQ tenderness
    • fever
Imaging
  • Ultrasound
    • indications
      • good initial imaging modality for rule out of other causes of abdominal pain
    • findings
      • hepatomegaly (most sensitive sign)
      • gallbladder wall thickening
Studies
  • Serum labs
    • complete blood count (CBC) may demonstrate elevated WBC count with atypical lymphocytosis in viral hepatitis
    • hepatic panel
      • mixed direct and indirect hyperbilirubinemia
      • dramatically elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
        • ALT usually higher than AST
        • if AST:ALT > 2, suspect alcoholic hepatitis
    • hepatitis viral serologies
      • determines which type of virus and the immunity status
      • IgM antibodies are present during early infection
      • IgG antibodies are present and remain after recovery
        • e.g., if a patient is positive for IgG but negative for IgM, the patient is immune via either prior infection or vaccination
 Serologic Findings  Clinical Implications
  • HBV surface antigen 
  • Anti-HBV core antibody
  • Active infection 
  • Anti-HBV surface antigen antibody
  • Immunity
  • Anti-HBV core antibody
  • HBV e-antigen
  • Highly infectious
  • HCV antibody
  • Exposure
 
Differential
  •  Chronic hepatitis 
    • key distinguishing factors
      • patient history may reveal a long period of symptoms
  • Gallbladder disease 
    • key distinguishing factors
      • ultrasound or other imaging modalities will demonstrate pathology or the presence of stones
Treatment
  • Lifestyle
    • supportive care
      • indications
        • especially for patients with acute viral hepatitis and alcoholic hepatitis
      • modalities
        • fluid and electrolyte management
        • treatment of any encephalopathy or coagulopathy
        • monitor and management for alcohol withdrawal and abstain from alcohol
        • nutritional support for acute alcoholic hepatitis
          • thiamine/folate
  • Medical
    • antiviral therapy
      • indications
        • used for the treatment of severe acute hepatitis B
      • modalities
        • nucleoside analogues (e..g, entecavir)
    • pentoxifylline and/or corticosteroids
      • indications
        • used for severe alcoholic hepatitis
Complications
  • Pancreatitis
  • Aplastic anemia
  • Peripheral neuropathy
  • Myocarditis
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.4671) A 32-year-old G2P1 at 32 weeks gestation presents to the emergency department with complaints of severe abdominal pain, fatigue, and nausea. Physical examination is significant for profound jaundice and tenderness to palpation of the right upper quadrant of the abdomen. The patient returned 2 weeks ago from a 1 month-long trip to India. She received sporadic pre-natal care while traveling and reports no known complications in her current pregnancy to date. She denies any past medical problems and states that her prior pregnancy proceeded as a normal vaginal birth without any complications. Infection with which of the following organisms would portend the worst prognosis with the highest mortality rate for this patient? Review Topic

QID: 107174
1

Hepatitis A

4%

(1/27)

2

Hepatitis B

7%

(2/27)

3

Hepatitis C

4%

(1/27)

4

Hepatitis D

7%

(2/27)

5

Hepatitis E

74%

(20/27)

M2

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SUBMIT RESPONSE 5

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(M3.GI.12) A 44-year-old woman presents to the emergency department with jaundice and diffuse abdominal pain. She denies any previous medical problems and says she does not take any medications, drugs, or supplements. Her temperature is 97.6°F (36.4°C), blood pressure is 133/87 mmHg, pulse is 86/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for sclera which are icteric and there is tenderness to palpation over the right upper quadrant. Laboratory studies are ordered as seen below.

Hepatitis B surface antigen: Positive
Hepatitis B surface IgG: Negative
Hepatitis B core antigen: Positive
Hepatitis B core IgG: Positive
Hepatitis B E antigen: Positive
Hepatitis B E IgG: Positive

Which of the following is the most likely diagnosis?
Review Topic

QID: 102718
1

Acute hepatitis B infection

25%

(1/4)

2

Chronic hepatitis B infection

25%

(1/4)

3

Hepatitis B vaccination

0%

(0/4)

4

No hepatitis B vaccination or infection

25%

(1/4)

5

Resolved hepatitis B infection

25%

(1/4)

M2

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