Hepatitis

Acutely unwell + jaundice – consider

• Viral hepatitis A-E
• Infectious – EBV, CMV, adenovirus, Q fever, HIV, syphillis
• Alcoholic hepatitis
• Drug-induced hepatitis
• Wilson’s disease
• Autoimmune hepatitis
• Acute cholangitis
• Acute cholecystitis

Causes:

Infectious causes:

• Hepatotropic viruses:
  • Hepatitis A Virus(HAV)
  • Hepatitis B Virus (HBV)
  • Hepatitis C Virus (HCV)
  • Hepatitis D Virus (HDV)
  • Hepatitis E Virus (HEV)
• Nonhepatotropic virus:
  • Epstein-Barr virus (EBV)
  • Cytomegalovirus (CMV)
  • Herpes simplex virus (HSV)
  • Coxsackievirus
  • Adenovirus
  • Dengue virus
  • Coronavirus-19(COVID-19)
• Bacteria, fungi, and parasites 

Toxin or substance-related causes include: 

• Alcohol-related: fatty liver disease, acute alcoholic hepatitis, or alcoholic cirrhosis
• Drugs and toxins
  • Dose-dependent, e.g. acetaminophen (paracetamol)
  • Non-dose-dependent, e.g., idiosyncratic drug reaction most commonly related to antibiotics and anticonvulsants but also statins, NSAIDs, herbal/nutritional supplements
  • Other toxins, e.g., mushroom (Amanita phalloides), herbal and dietary supplements, carbon tetrachloride, sea anemone sting  

Immunologic or inflammatory conditions 

• Autoimmune hepatitis
• Biliary disease such as primary biliary cholangitis or primary sclerosing cholangitis.

Metabolic or hereditary 

• Nonalcoholic fatty liver disease
• Hemochromatosis
• Wilson’s disease

Pregnancy-related 

• Preeclampsia
• Acute fatty liver of pregnancy
• HELLP syndrome

Ischemic and Vascular 

• Cardiogenic/Distributive shock
• Hypotension
• Heatstroke
• Cocaine, methamphetamine, ephedrine
• Acute Budd-Chiari syndrome
• Sinusoidal obstruction syndrome

Miscellaneous 

• Acute fatty liver of pregnancy
• Malignancy
• Eclampsia
• HELLP syndrome
• Reye’ syndrome
• Primary graft non-function after liver transplantation

Viral Hepatitis

	A	B	C	D	E
Agent	Enterovirus Capsid ssRNA	Hepadna Enveloped dsDNA	Unclassified enveloped ssRNA	Unclassified Enveloped ssRNA	Unclassified unenveloped ssRNA
Transmission	Fecal-oral→ ingestion of contaminated food/water Raw shell fish	Blood borne→ parenteral sex IVDU Blood transfusions	Blood borne→ parenteral sex IVDU Blood transfusions	Blood borne→ parenteral Contaminated water	Waterborne→ Faecal-oral→ Sexual
Incubation	Short 2 – 6 weeks  by time symptoms appear, most of virus shed in faeces	Long 4wk-3mth	Intermediate 2wk-6mths	Intermediate 4-7 wks – ALWAYS with HBV	Short 6 weeks
Clinical features	Asymptomatic or Mild – self limiting disease	acute hepatitis with resolution chronic hepatitis fulminant hepatitis → necrosis→ Hep D infection	progression to cirrhosis is common	acute severe hepatitis mild HBV hep converted to fulminant disease chronic → cirrhosis	self-limiting disease N.B. high mortality rate in pregnancy Fs
Carrier state?	No	Yes	Yes	Yes – but rare	Unknown
Chronic hepatitis?	No	Yes(5-10%)	Yes(>85%)	Yes	No
Hepatocellular carcinoma?	No	Yes	Yes	Yes, but no ↑ above HBV	Unknown, unlikely
Distribution	Worldwide Endemic in countries with poor hygeince	Worldwide	Worldwide	Areas worldwide	SE Asia, India, Middle East, Africa, Mexico
Public Health Measures	Hygiene Vaccination	VaccinationEducation	EducationNO vaccine	Vaccine for Hep B	NO vaccine
Notes	Benign & self-limiting (mild and asymptomatic)		Episodic ↑ in serum liver transaminases is common	Requires B