Hepatitis

Snapshot

A 40-year-old obese woman presents to her family medicine doctor for intermittent abdominal pain for the past few months as well as fatigue. She has a past medical history of hyperlipidemia, diabetes, and hypertension. She has been trying to lose weight but has not been successful. She reports drinking alcohol socially, on average 2 times per month. On exam, she is not jaundiced and has no tenderness to palpation. Her liver is noted to be enlarged. Laboratory evaluation reveals mildly elevated liver enzymes, and she is referred for liver biopsy to confirm the diagnosis of nonalcoholic steatohepatitis. (Chronic hepatitis)

Introduction

Overview
- acute hepatitis
  - acute inflammation of the liver
- chronic hepatitis
  - > 6-month duration of liver inflammation
Epidemiology
- etiology
  - viral hepatitides (e.g., HAV, HCV, and HBV)
    - chronic (HCV and HBV +/- HDV)
  - parasites (e.g., toxoplasmosis)
  - alcohol
  - drug-induced
    - acute (e.g., acetaminophen)
    - chronic (e.g., isoniazid, methyldopa, and nitrofurantoin)
  - autoimmune hepatitis
  - nonalcoholic steatohepatitis
  - metabolic disease
  - Wilson disease
  - hemochromatosis
  - alpha-1-antitrypsin deficiency
- 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)
Prognosis
- vast majority of patients with acute hepatitis recover without complications
- some may develop chronic hepatitis
  - of these, many may have longterm chronic hepatitis without significant liver injury
however, chronic hepatitis increases the risk of liver failure, cirrhosis, and hepatocellular carcinoma

Presentation

Imaging

Studies

Serologic Findings	Clinical Implications
HBV surface antigenAnti-HBV core antibody	Active infection
Anti-HBV surface antigen antibody	Immunity
Anti-HBV core antibody
HBV e-antigen	Highly infectious
HCV antibody	Exposure

Snapshot

A 40-year-old obese woman presents to her family medicine doctor for intermittent abdominal pain for the past few months as well as fatigue. She has a past medical history of hyperlipidemia, diabetes, and hypertension. She has been trying to lose weight but has not been successful. She reports drinking alcohol socially, on average 2 times per month. On exam, she is not jaundiced and has no tenderness to palpation. Her liver is noted to be enlarged. Laboratory evaluation reveals mildly elevated liver enzymes, and she is referred for liver biopsy to confirm the diagnosis of nonalcoholic steatohepatitis. (Chronic hepatitis)

Introduction

Overview
- acute hepatitis
  - acute inflammation of the liver
- chronic hepatitis
  - > 6-month duration of liver inflammation
Epidemiology
- etiology
  - viral hepatitides (e.g., HAV, HCV, and HBV)
    - chronic (HCV and HBV +/- HDV)
  - parasites (e.g., toxoplasmosis)
  - alcohol
  - drug-induced
    - acute (e.g., acetaminophen)
    - chronic (e.g., isoniazid, methyldopa, and nitrofurantoin)
  - autoimmune hepatitis
  - nonalcoholic steatohepatitis
  - metabolic disease
  - Wilson disease
  - hemochromatosis
  - alpha-1-antitrypsin deficiency
- 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)
Prognosis
- vast majority of patients with acute hepatitis recover without complications
- some may develop chronic hepatitis
  - of these, many may have longterm chronic hepatitis without significant liver injury
however, chronic hepatitis increases the risk of liver failure, cirrhosis, and hepatocellular carcinoma

Presentation

Imaging

Studies

Serologic Findings

Clinical Implications

Differential

Gallbladder disease
- key distinguishing factors
ultrasound or other imaging modalities with pathology of the biliary system or presence of stones

Treatment

Management approach
- management depends on etiology of acute or chronic hepatitis
- all patients with chronic liver disease should undergo HAV and HBV vaccines
Medical
- supportive care
  - indication
    - acute viral hepatitis or alcoholic hepatitis
  - modalities
    - fluid and electrolyte management
    - treatment of encephalopathy or coagulopathy
    - nutritional support for acute alcoholic hepatitis
- antiviral treatment
  - indication
    - treat hepatitis B or C
  - modalities
    - interferon + ribavirin or sofosbuvir for hepatitis C infection
    - other antivirals such as lamivudine or tenofovir for hepatitis B infection
- immunosuppression
  - indication
    - autoimmune hepatitis
  - modalities
    - corticosteroids
azathioprine

Complications