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Updated: Dec 6 2021

Acute Hepatitis

  • 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
    • 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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