Hepatitis simplified

By | March 5, 2017
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Hepatitis: it can be acute or chronic.

Acute hepatitis: it is an infection or inflammation of the liver. Most cases of acute hepatitis are from viral hepatitis A or B. Hepatitis C for unknown reasons rarely presents with an acute infection, and is found as a silent infection on blood tests or unfortunately when patients present with cirrhosis. Hepatitis D exists exclusively in those who have active viral replication of hepatitis B.

Transmission:

  • Sex , blood, perinatal (parenteral): Hepatitis B, C, D
  • Food and water (enteric) Hepatitis A and E

 

Presentation: There is no way to detect the etiology or specific type of hepatitis from the acute symptoms. All forms of acute hepatitis present with:

  • Jaundice
  • Fever, weight loss, and fatigue
  • Dark urine
  • Hepatosplenomegaly
  • Nausea, vomiting, abdominal pain

 

Diagnostic tests:

  • Increased direct bilirubin
  • Increased ratio of alanine aminotransferase (ALT) to aspartate amino-transferase (AST)
  • Increased alkaline phosphate

Disease specific Diagnostic tests:

Hepatitis A,C,D,E: The best initial diagnostic test for each of these is simply an IgM antibody for the acute infection and IgG antibody do detect resolution of infection.

Disease activity of hepatitis C is assessed with PCR for RNA level, which tells the amount of active viral replication. Hepatitis B and C PCR levels are the first thing to change as an indication of improvement with treatment and are the best correlate of treatment failure if they rise.

Hepatitis B diagnostic tests: The first test to become abnormal in acute hepatitis B infection is the surface antigen. Elevation in ALT, e-antigen, and symptoms all occur after the appearance of hepatitis B surface antigen. The following table shows the appearance of the antigens and antibodies through the course of the disease:

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Chronic hepatitis B gives the same serologic pattern as acute hepatitis B, but it is based on persistence of the surface antigen beyond 6 months.

 

These 3 tests are essentially equal in meaning. They all indicate active viral replication:

  • Hepatitis B DNA polymerase = e-Antigen = Hepatitis B PCR for DNA

Treatment: Acute Hepatitis

  • Hepatitis A and E resolve spontaneously over a few weeks and are always benign conditions.
  • Hepatitis B becomes chronic in 10% of patient and no form of treatment has been found to alter this.
  • There is no treatment for acute hepatitis.
  • Acute hepatitis C, in the few cases in which it is detected, should be treated with interferon, ribavirin and either boceprevir or telaprevir. They decrease the likelihood of developing a chronic infection with hepatitis C.

Chronic Hepatitis:

Treatment: chronicity of hepatitis B is defined as persistence of surface antigen for more than 6 months. If these patients are positive for e-antigen with an elevated level of DNA polymerase , treatment is any one of the following. Entecavir, edefovir, lamivudine, telbivudine, interferon or tenofovir. Because interferon is an injection and has the most adverse effects. It is not the best first choice.

Chronic hepatitis C: Treat with interferon combined with ribavirin and boceprevir or telaprevir.

Vaccination: Vaccination for both hepatitis A and B is now done universally in childhood. For adults, the strongest indications for vaccination for both hepatitis A and B are the following:

  • · Chronic liver disease. Someone with cirrhosis or another cause of liver disease who develops hepatitis A or B is at much greater risk of fulminant hepatitis.
  • · Household contacts of those with hepatitis A or B
  • · Men who have sex with men
  • · Chronic recipients of blood products
  • · Injection drug users

Specific indications for vaccines are as follows:

  • · Hepatitis A vaccine

— Travelers

  • · Hepatitis B vaccine

— Health care workers

— Patients on dialysis

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— Diabetes

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