Hepatitis

• Hepatitis describes inflammation in the liver, causes include:

  • Viral hepatitis
  • Alcoholic hepatitis
  • Non-alcoholic steatohepatitis
  • Autoimmune
  • Drug induced
• Viral hepatitis may be asymptomatic or present with non-specific symptoms of:

  • RUQ pain
  • Pruritus (itching)
  • Jaundice
  • Flu-like illness
  • Nausea and vomiting
• The average time for acute hepatitis B symptoms to appear (incubation period) after infection is 90 days
• A “hepatitic picture” on liver function tests refers to high transaminases (AST and ALT) with proportionally less of a rise in ALP. Transaminases are liver enzymes released into the blood due to inflammation of the liver cells.

  Bilirubin can also rise as a result of inflammation of the liver cells. High bilirubin causes jaundice.
• Hepatitis A is the most common viral hepatitis worldwide but relatively rare in the UK. It is transmitted via the faecal-oral route, usually in contaminate water or food
• Hepatitis A has a vaccine available for people who are at risk of catching it

  Diagnosis is based on IgM antibodies to hepatitis A

  Hepatitis A usually resolves without treatment and does not progress to chronic hepatitis

  Rarely it can lead to acute liver failure - fulminant hepatitis

  Management is supportive with basic analgesia
• Hepatitis A can cause cholestasis - pruritus, significant jaundice, dark urine and pale stools
• Hepatitis D is an RNA virus that can only survive in patients who also have a hepatitis B infection

  It attaches itself to the HBsAg and cannot survive without this protein

  Hepatitis D increases the complications and disease severity of hepatitis B
• Hepatitis D can be treated with pegylated interferon alpha over at least 38 weeks - treatment is not very effective and has significant side effects
• Hepatitis E is transmitted by the faecal-oral route. It usually only produces a mild illness that clears within a month with no treatment.

  Rarely it can progress to chronic hepatitis and liver failure, usually in immunocompromised patients
• There is no vaccination available for hepatitis E infection
• Hepatitis C is transmissible through blood, and can be spread through sexual contact, needles, and tattoos
• There is no vaccine available for hepatitis C
• Early hepatitis C infection is mostly asymptomatic but around 85% develop chronic infection
• Risk factors for chronic hepatitis C:

  • Male
  • Older age
  • High viral load
  • Alcohol load
  • HIV / HBV infection
• 25% of those with chronic hepatitis C infection get liver cirrhosis

  They are also at an increased risk of hepatocellular carcinoma
• There are no tests for acute hepatitis C infection.

  Chronic - hepatitis C antibody and viral load

  Genotype is tested to direct drug treatment
• Treatment of hepatitis C:

  Direct acting antivirals for 8-12

  Successfully cures most patients
• Hepatitis B is a DNA virus transmitted through blood and bodily fluids, risk factors are:

  • IV drug use
  • Unprotected sexual intercourse
  • Childbirth (vertical transmission)
  • Occupation
• A vaccine for hepatitis B is available - injection of surface antibodies
• The average incubation period of hepatitis B infection is 90 days
• 5-15% of those with hepatitis B become chronic carriers
• Signs of acute hepatitis B:

  • Jaundice
  • Hepatomegaly
  • RUQ pain
  • Fever
  • Nausea/vomiting
  • Dark urine
  • Pale stools
• There is no specific treatment for an acute hepatitis B infection, treatment is supportive
• Tests for acute hepatitis B:

  • Positive HBsAg
  • Raised IgM anti-HBc
  • Positive Anti-HBe
  • Positive HBV DNA
• A positive IgG HBcAb test is a marker of chronic infection with HBV
• HBeAg is a marker of viral replication and raised levels indicate high infectivity
• If tests indicate a current HBV infection, HBeAg and HBV DNA should be tested
• Patients with a HBV infection should also be screened for other infections:

  • HIV
  • Hepatitis A
  • Hepatitis C
  • Hepatitis D
• Management of hepatitis B:

  • Contact tracing
  • Avoid alcohol
  • Regular monitoring for complications - fibroscan and ultrasound liver
  • Antiviral medications can be used to slow progression e.g. entecavir
• Hepatitis B positive patients with advanced fibrosis should have 6 monthly ultrasound scans and fetoprotein for hepatocellular carcinoma
• Complications of hepatitis B include hepatocellular carcinoma, liver cirrhosis, and liver failure
• Autoimmune hepatitis is a rare cause of chronic hepatitis. Mostly affects females.
• Patients with autoimmune hepatitis usually have a history or family history of other autoimmune disease:

  • Pernicious anaemia
  • Diabetes mellitus
  • Thyroid disease
  • IBD
  • Coeliac disease
  • Primary biliary cholangitis
• Type 1 autoimmune hepatitis - females in their 40s-50s

  Type 2 - children/young females
• About 25% of people with AIH are asymptomatic at diagnosis as may be found incidentally with LFTs and signs of chronic liver disease on examination
• AIH may present as an 'acute hepatitis' with jaundice, fever, nausea, weight loss

  There will also be signs of autoimmune disease on examination such as polyarthritis and rashes
• Investigations for AIH will show high transaminases (ALT and AST) and minimal change in ALP levels (a “hepatitic” picture). Raised immunoglobulin G (IgG) levels are an important finding.
• Positive autoantibodies in AIH:

  • Smooth muscle antibody
  • Antinuclear antibody
• A liver biopsy is essential for AIH diagnosis - interface hepatitis and plasma cell infiltration