Updated: 12/6/2021

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
    • Associated conditions
      • medical conditions and comorbidities
        • chronic hepatitis
        • fulminant liver failure
  • Epidemiology
    • Risk factors
      • alcohol abuse
      • foreign travel
      • intravenous drug use
      • sexual contact
  • ETIOLOGY
    • 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)
    • Metabolic disease
    • Steatohepatitis
    • Autoimmune hepatitis
    • Drug-induced (e.g., acetaminophen)
    • Alcohol
    • Parasites (e.g., toxoplasmosis)
    • Viral hepatitides (e.g., HAV, HCV, and HBV)
  • 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
      • Immunity 
      • HBV e-antigen
      • C
      • 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
  • 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
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(M2.GI.15.4671) 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?

QID: 107174

Hepatitis A

6%

(2/33)

Hepatitis B

9%

(3/33)

Hepatitis C

3%

(1/33)

Hepatitis D

9%

(3/33)

Hepatitis E

70%

(23/33)

M 8 E

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(M3.GI.12.12) 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: Negative

Which of the following is the most likely diagnosis?

QID: 102718

Acute hepatitis B infection

17%

(1/6)

Chronic hepatitis B infection

50%

(3/6)

Hepatitis B vaccination

0%

(0/6)

No hepatitis B vaccination or infection

17%

(1/6)

Resolved hepatitis B infection

17%

(1/6)

M 10 E

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