• Hepatitis (plural hepatitides) implies injury to the liver characterized by the presence of

inflammatory cells in the tissue of the organ.

• The condition can be self-limiting, healing on its own, or can progress to scarring of the

liver.

• Hepatitis is acute when it lasts less than six months and chronic when it persists longer.

Acute Hepatitis

• Viral hepatitis: Hepatitis A up to E (more than 95% of viral cause), Herpes simplex,

Cytomegalovirus, Epstein-Barr, yellow fever virus, adenoviruses.

• Non viral infection: Toxoplasma, Leptospira, Q fever, rocky mountain spotted fever

• Alcohol

• Toxins: Amanita toxin in mushrooms, carbon tetrachloride, asafetida

• Drugs: Paracetamol, amoxicillin, anti-tuberculosis drugs, and minocycline

• Ischemic hepatitis (circulatory insufficiency)

• Auto immune conditions e.g. systemic lupus erythematosus (SLE)

• Metabolic diseases e.g.Wilson's disease

Chronic Hepatitis

• Viral hepatitis

Hepatitis B with or without hepatitis D

Hepatitis C

• Autoimmune hepatitis

• Alcohol

• Drugs: methyldopa, nitrofurantoin, isoniazid, ketoconazole

• Non-alcoholic steatohepatitis

• Wilson's disease, alpha 1-antitrypsin deficiency

• Primary biliary cirrhosis and primary sclerosing cholangitis occasionally mimic chronic

hepatitis

Symptoms and Signs of Acute Hepatitis

• Clinically, the course of acute hepatitis varies widely from mild symptoms requiring no

treatment to fulminant hepatic failure needing liver transplantation.

• Acute viral hepatitis is more likely to be asymptomatic in younger people.

• Symptomatic individuals may present after the convalescent stage of 7 to 10 days, with the

total illness lasting 2 to 6 weeks.

• Initial features are of non-specific flu-like symptoms, common to almost all acute viral

infections and may include

Malaise muscle

Joint aches

Fever

Nausea or vomiting

Diarrhea

Headache

• More specific symptoms, which can be present in acute hepatitis from any cause, are

Profound loss of appetite

Aversion to smoking among smokers

Dark urine

Yellowing of the eyes and skin (i.e., jaundice)

Abdominal discomfort

• Physical findings are usually minimal, apart from

Jaundice (33%)

Tender hepatomegaly (10%).

Occasional lymphadenopathy (5%) or splenomegaly (5%).

Symptoms and Signs of Chronic Hepatitis

• Majority of patients will remain asymptomatic or mildly symptomatic, abnormal blood

tests being the only manifestation.

• Features maybe related to the extent of liver damage or the cause of hepatitis

• Many experience return of symptoms related to acute hepatitis

• Jaundice can be a late feature and may indicate extensive damage

Other Features

• Abdominal fullness from enlarged liver or spleen

• Low grade fever

• Fluid retention(ascites)

• Extensive damage and scarring of the liver (i.e. cirrhosis) leads to

weight loss from extensive damage and scarring of the liver (i.e., cirrhosis)

Easy bruising and bleeding tendencies

• Acne, abnormal menstruation, lung scarring, inflammation of the thyroid gland and

kidneys may be present in women with autoimmune hepatitis.

• Findings on clinical examination are usually those of cirrhosis or are related to etiology.

Physical Findings

• Spider-like blood vessels (spider angiomas) that develop on the skin as the disease

progresses

• Weight loss

• Palpable non-tender liver

Differential Diagnoses, Investigations, Treatment, and Complications

Differential Diagnosis

• Alcoholic hepatitis

• Hepatocellular carcinoma

• Liver cirrhosis

• Congestive cardiac failure

Investigations

• All the specific investigations for hepatitis are done at the hospital level and therefore

referring the patient is necessary. The investigations are outlined below

-Full Blood Picture

Anemia: Normochromic normocytic

Low white blood count

Reduced platelets due to hypersplenism

Raised ESR

-Liver function test

Moderate to very high elevation in acute hepatitis of AST, ALT enzymes,

moderately raised in chronic hepatitis. ALT is more elevated than AST in acute and

chronic hepatitis.

Raised serum bilirubin-may continue to rise despite falling serum

aminotransferase levels

Slightly lowered albumin

Prolonged prothrombin time Hypoalbuminaemia and progressive prolongation of

Prothrombin Time (PT) occur in severe acute hepatitis and severe chronic

hepatitis

• Several viral markers can be identified in the serum and the liver for example

-Serum hepatitis B surface antigen (HBsAg) (in developed countries, serologic tests

for Hepatitis A, B, D and C are available). These are more useful in chronic hepatitis

-Liver biopsy is rarely necessary or indicated in acute viral hepatitis except when the

diagnosis is questionable or when clinical evidence suggests a diagnosis of chronic

hepatitis. When indicated, it will confirm the diagnosis.

• Other supportive investigations include

-Abdominal ultrasound

-CT scan-abdomen

Treatment

• In the dispensary and health center levels, no specific treatment is available and therefore

patients should be referred to hospitals for proper management.

• Give pre-referral treatment for example anti-pains, intravenous fluids whenever

necessary.

• Note that even at higher levels, not all hospitals will be able to deliver them all treatments.

The availability of the medications may be limited.

• The main treatment medication that can be used include

Interferon alfa (IFN-a)

Lamivudine

Telbivudine

Adefovir

Entecavir and

Tenofovir

• Other drugs include

IFN-a treatment with 5 million units per day or 10 million units 3 times per week

subcutaneously (SC) for 4 months.

Supportive Treatment of Acute Attack

• In hepatitis B, among previously healthy adults who present with clinically apparent

acute hepatitis, recovery occurs in approximately 99%; therefore, antiviral therapy is not

likely to improve the rate of recovery and is not required.

• In most cases of typical acute viral hepatitis, specific treatments generally are not necessary.

Although hospitalization maybe required for clinically severe illness, most patients do

not require hospital care.

• Forced and prolonged bed rest is not essential for full recovery, but many patients will

feel better with restricted physical activity.

• A high-calorie diet is desirable, and because many patients may experience nausea late in

the day, the major caloric intake is best tolerated in the morning.

• Drugs capable of producing adverse reactions such as cholestasis and drugs metabolized

by the liver should be avoided.

• If severe pruritus is present, the use of the bile salt-sequestering resin cholestyramine will

usually, alleviate this symptom.

• Glucocorticoid therapy has no value in acute viral hepatitis. In fact, such therapy may be

hazardous.

• Hospitalized patients may be discharged when there is substantial symptomatic

improvement.

Supportive Treatment of Fulminant Hepatitis

• The goal of therapy is to support the patient by

o Maintenance of fluid balance

o Support of circulation and respiration

o Control of bleeding

o Correction of hypoglycemia

o Treatment of other complications of the comatose state in anticipation of liver

regeneration and repair

• Protein intake should be restricted, and oral lactulose or neomycin administered

Treatment of Chronic Hepatitis

• Certain patients may benefit from pharmacologic therapy.

• For chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infections in

particular, the goals of therapy are to

Reduce liver inflammation and fibrosis.

Prevent progression to cirrhosis and its complications.

• The nucleoside analogs lamivudine and adefovir have shown promising results in the

treatment of patients with chronic HBV.

• For patients with chronic HCV infection, one current treatment option is combination

therapy with pegylated interferon (PEG-IFN) and the antiviral ribavirin.

• This regimen may be recommended for a certain subset of patients with moderate or

severe inflammation and/or fibrosis.

• The combination of the 2 drugs provides a more sustained clearance of HCV RNA from

the serum of infected individuals when compared to monotherapy.

Prophylaxis

• Because application of therapy for acute viral hepatitis is limited and antiviral therapy for

chronic viral hepatitis is effective in only a proportion of patients, emphasis is placed on

prevention through immunization.

• The prophylactic approach differs for each of the types of viral hepatitis.

• Currently, for hepatitis A and B, active immunization with vaccines is available as well.

Complications

• Acute/sub acute hepatic necrosis

• Chronic active hepatitis

• Chronic hepatitis

• Cirrhosis

• Hepatic failure

• Hepatocellular carcinoma (HBV, HCV).                                                        

REFERENCES;

•      Braunwald & Fauci (2001). Harrison’s principles of internal medicine 15th Ed.  Oxford: McGraw Hill

•      Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

•      Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold

•      Longmore, M., Wilkinson, I., Baldwin, A., & Wallin, E. (2014). Oxford handbook of clinical medicine. Oxford

•      Macleod, J. (2009). Macleod's clinical examination. G. Douglas, E. F. Nicol, & C. E. Robertson (Eds.). Elsevier Health Sciences.

•      Nicholson N., (1999), Medicine of Non-communicable diseases in adults. AMREF

•      Stuart and Saunders (2004): Mental health Nursing principles and practice. 1st Ed. Mosby

•      Swash, M., & Glynn, M. (2011). Hutchison's clinical methods: An integrated approach to clinical practice.