Hepatitis

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Hepatitis is an inflammation or injury of the liver with multiple causes. It may present as an acute illness with jaundice and altered liver function tests.

Causes

Viral hepatitis

Non-viral hepatitis

-       Hepatitis A virus (HAV)

-       Hepatitis B virus (HBV)

-       Hepatitis C virus (HCV)

-       Hepatitis D virus (HDV)

-       Hepatitis E virus (HEV)

-       Bacteria

-       Autoimmune

-       Parasites

-       Fungi

-       Alcohol

-       Medicines

-       Toxins

-       Haemorrhagic fevers (Ebola and Marburg)

 

Hepatitis virus

Transmission route

Incubation period (days)

Serological markers

Complications

HAV

-    Oro-faecal

15–50

-    Anti-HAV IgM

-    Recovery in about 3                months

-    No chronic phase

HBV

-    Sexual 

- Blood-contaminated instruments

-    Contaminated blood products

-    Mother to child

30-180

-    HBsAg

-    Anti-HBc

-    HBeAg 

-    Fulminant hepatitis

-    Cirrhosis

-    Hepatocellular Carcinoma

HCV

- Blood-contaminated instruments

-    Rarely

-    Sexual 

-    Mother to child

14–180

-    Anti-HCV IgM

-    HCV RNA

-    Cirrhosis

-    Hepatocellular Carcinoma

HDV

- Blood-contaminated instruments

-    Rarely

-    Sexual 

-    Mother to child

45–160

 

-    HDV-RNA

-    Anti-HDV IgM

-    Fulminant hepatitis

-    High risk of severe chronic liver disease

HEV

-    Oro-faecal

15–64

Anti-HEV IgM

-    Fulminant hepatitis

-    High mortality rate in             pregnant women

Signs and symptoms

Acute hepatitis

  • May be asymptomatic
  • Prodromal phase presents with non-specific and flu-like symptoms
  • Fever
  • Fatigue
  • Malaise
  • Abdominal discomfort (right upper quadrant)
  • Nausea
  • Diarrhoea
  • Anorexia

Followed by

  • Jaundice
  • Dark urine
  • Clay coloured stool

Chronic hepatitis

  • May be asymptomatic
  • Weakness and malaise
  • Low grade fever
  • Nausea
  • Loss of appetite
  • Vomiting
  • Pain or tenderness over the right upper abdomen
  • Jaundice
  • Dark urine, severe pruritus
  • Enlarged liver

Investigations

  • Complete blood count
  • Liver function tests
  • Serology for Hepatitis A,B,C,D, E
  • Abdominal ultrasound scan
  • Slide or RDT for malaria parasites

Management

Virus type

Treatment objectives

Treatment

Complications

Prevention

HAV

-    Reduce symptoms

-    Supportive

-    Recovery in about 3 months

-    No chronic phase

-  Safe drinking water

-  Food hygiene

- Immunization

HBV

-    Reduce                symptoms

-    Prevent complications

-    Inhibit viral         replication

-    Acute: supportive

-    Chronic: interferon α- or tenofovir

-  Fulminant hepatitis

-    Cirrhosis

-    Hepatocellular            Carcinoma

-    Safe sex

-    Screen blood           products

-    Use sterile instruments

-  HBV vaccination

-    PEP

HCV

-    Decrease replication or eradicate HCV

-    Prevent disease progression to cirrhosis and hepatocellular carcinoma

-    Reduce symptoms

-    Treat extrahepatic complications

-    Acute: interferon-α or peginterferon-α  Chronic: interferonα plus ribavirin or DAAs             (cure possible)

-    Liver transplantation

-   Cirrhosis

-   Hepatocellular            Carcinoma

-  Safe sex

-  Screen blood products

-  Use sterile instruments

-  No vaccination          available

- No PEP

HDV

-    Reduce symptoms

-    Peginterferon-α PLUS Lamivudine

-   Fulminant hepatitis

-    High risk of severe  chronic liver disease

-    Safe sex

-    Screen blood          products

-    Use sterile instruments

-    HBV vaccination

-    PEP

HEV

-    Reduce symptoms

-    Acute: supportive

-   Fulminant hepatitis

-    High mortality rate in pregnant women

-    Safe drinking water

-    Food hygiene

 

Non-pharmacological management

  • Encourage rest and hydration
  • Encourage high intake of carbohydrates and vegetable proteins.
  • Discourage intake of animal proteins e.g. meat
  • Avoid unnecessary medicines, especially sedatives and hepatotoxic drugs
  • No alcohol consumption
  • Avoid ferrous a
  • Limit vitamin supplements that contain fat-soluble vitamins and vitamin C
  • Ensure effective infection control measures

Pharmacological management

Hepatitis B Virus (HBV)

Tenofovir oral

300mg once daily for life

OR

Entecavir oral

0.5mg–1mg once daily for life

OR

Lamivudine oral

100mg once daily for life

Hepatitis C Virus (HCV)

Ledipasvir oral

90mg in divided doses orally for 12–24 weeks

PLUS

Sofosbuvir oral

400mg in divided doses for 12–24 weeks

PLUS

Ribavirin oral

600mg–1000mg in divided doses for 12–24 weeks

Referral

  • Refer negative results for Hepatitis A & B for vaccination
  • Refer all positive cases for specialist care