Acute Hepatitis - Etzion

Question 1

List of etiologic causes of acute hepatitis (Hepatotrophic, infectious, toxic/metabolic/ischemic

Answer 1

Hepatotrophic:

HAV
HBV
HCV
HDV
HEV

Other infectious causes:

Viruses: EBV,CMV,HSV, Adenovirus, parvo, yellow fever
Toxoplasma
Leptospirosis
Q fever
Rocky mountain spotted fever
Gram negative sepsis (other multisystem more prominent)

Toxic, metabolic, ischemic:

Alcohol
Toxins: amanita toxin, carbon tetrachloride etc.
Drugs : paracetamol, anti tuberculous, neuroleptics
Ischemic: circultory collapse
Autoimmune hepatitis (usually chronic, only when severe)

Question 2

Incubation Periods and Serologic course of Hepatotrophic Viruses

Answer 2

HAV: 4 weeks
HAV in stool: 3-8w, symptoms and high ALT 6-10w, Anti-HAV IgM 5-20w, Anti-HAV 5w-forever

HBV: 8-12 weeks
HBeAg 8-20w, HBsAg 8-24w, symptoms with high ALT 8-18w, Anti-HBc IgM 12w-40w, Anti-HBe 22-52, Anti-HBc 12w-forever, Anti-HBs 25w-forever

HCV: 7 weeks
Symptoms with RNA and ALT 4-24w, anti-HCV 12w-forever

HDV: (difficult to distinguish from HBV)

HEV: 5-6 weeks

Question 3

Symptoms of Heptatis Viruses (Phases)

Answer 3

Constitutional symptoms:
General- fatigue, malaise, low grade fever (38-39)
GI- abdominal pain, anorexia, weight loss,N&V, clay colored stool
MSK- arthralgias, myalgias
Skin- evanescent rash, cutaneous vasculitis
H&N- photophobia, headache, pharyngitis, cough & coryza
GU- dark urine
Duration: 1-2 weeks

Icteric phase:

Prodromal symptoms diminish
Clinical jaundice
Dark urine:1-5 days before jaundice
Enlarged and tender liver
RUQ pain & discomfort
Cervical adenopathy(10-20%)
Splenomegaly(10-20%)
Peak in TA levels (decreases with time) and bilirubin (beginning, conjugated and unconjugated)

Convalescence:

Constitutional symptoms disappear
Jaundice gradually resolved
Mild hepatomegaly may still be present for some time
Liver enzyme abnormalities
Complete recovery:
1-2 months A,E
3-4 months B,C

Question 4

Complications of Hepatitis

Answer 4

HAV:
No chronic course, recurrence or persistance of jandice pruritis

HBV:
Serum sickness-like (reaction against antibodies). Arthralgia /arthritis, rash,angioedema, hematuria/proteinuria- misdiagnosed as rheumatic disease
Dx: TA levels, HBsAg

Fulminant: A, B, D, E (NOT C)

Question 5

Indications for admission of acute hepatitis

Answer 5

Bilirubin>20 mg/dl
Hypoglycemia
Abnormal PT
Hypoalbuminemia
Poor oral intake
Mental change, lethargy
Low compliance
Other chronic disease

Question 6

Treatment of Hepatitis

Answer 6

Complete bed rest is not mandatory
Restriction activity (no rugby)
No special diet & Therapy (IFN-gamme for HCV if relevant, antiviral)
Drug & Alcohol avoidance ((Definitely no alcohol, especially with HCV)
Isolation is not necessary (especially HAV/HEV unless immunocompromised)
except in special cases

Monitoring:
Regular physical exam (liver, spleen, etc)
Liver size,mental state (fulminant disease),icterus
Monitor LFT,PT,BIL
Monitor HBs Ag (resolved-90% or chronic) and HCV Ab

HAV vaccine for everyone!