Hepatitis, a condition characterized by inflammation of the liver, manifests in various forms, each with its own causes, symptoms, and treatment protocols. Classified primarily into hepatitis A, B, C, D, and E, this ailment poses significant health challenges worldwide, impacting millions annually. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer.
Table of Contents
Types of Hepatitis
Hepatitis - A
- caused by the hepatitis A virus.
- It is a single stranded RNA virus.
- Transmission is primarily by the oral-fecal route.
- Incubation period is usually 14–28 days. This is when the virus is busy replicating in your body. When the virus has replicated enough to register as a threat, your immune system launches an attack against it. This is where the symptoms come from.
- It is typically a self-limiting disease and usually causes mild illness.
- In children of age 6 years or younger, it is usually asymptomatic.
- In adults, symptoms such as
- fever
- fatigue
- abdominal
- discomfort
- diarrhea
- nausea
- jaundice.
- Diagnosis –
- based upon signs and symptoms
- serologic tests for IgM anti-HAV and d IgG anti-HAV
- prevention –
- Passive immunization – administration of HAV immune globulin either before the exposure or within 2 weeks following exposure.
- Active immunization – Those considered to be at increased risk of HAV infection should be vaccinated-
- people traveling internationally
- drug users
- people with chronic liver disease
- occupational risks.
Hepatitis - B
- Caused by the Hepatitis B virus (DNA virus).
- It is a highly infectious virus It is a potentially life-threatening liver infection
- it produces three distinct particles during replication:
- The Dane particle or complete virus (HBV), composed of an outer shell and an inner core
- 22 nm non-infectious spherical particles
- Non-infectious filamentous units.
- The outer shell of the Dane particle carries the hepatitis B surface antigen (HBsAg), which is anchored in a lipid bilayer derived from the host cell.
- Internally, the inner core is composed of a protein known as the –
- hepatitis B core antigen (HBcAg)
- hepatitis B early antigen (HBeAg), an antigenic component derived from the cleavage of the core antigen.
Transmission
via body fluids like
- blood
- semen
- vaginal secretions,
Etiology
- transfer of the virus from infected people to non-immune people
- Horizontal transmission: It involves the transmission of hepatitis B through sexual contact or mucosal surface contact. Unprotected sex and injection drug use are major modes of transmission in low to intermediate prevalence areas.[1]
- Vertical transmission: Vertical transmission involves the maternal-to-newborn perinatal transmission of the virus. It is the predominant mode of transmission in high-prevalence areas.
(Sexual contact includes unprotected intercourse (vaginal, oral, or anal) and mucosal contact involves any contact involving an infected patient’s saliva, vaginal
secretion, semen, and blood.)
Incubation period
- between 30 and 180 days.
- while recovery is common in immunocompetent patients, a small percentage can progress to a chronic state
- serologically defined as the presence of HBsAg for greater than six months.
Sign and Symptoms
- Anorexia
- Nausea
- Vomiting
- Low-grade fever
- Myalgia
- Fatigability
- Disordered gustatory acuity and smell sensations (aversion to food and cigarettes)
- Right upper quadrant and epigastric pain (intermittent, mild to moderate)
Patients with fulminant and subfulminant hepatitis may present with the following:
- Hepatic encephalopathy
- Somnolence
- Disturbances in sleep pattern
- Mental confusion
- Coma
- Ascites
- Gastrointestinal bleeding
- Coagulopathy
Diagnosis
examination in patients with acute hepatitis may demonstrate the following:
- Low-grade fever
- Jaundice (10 days after appearance of constitutional symptomatology; lasts 1-3 mo)
- Hepatomegaly (mildly enlarged, soft liver)
- Splenomegaly (5-15%)
- Palmar erythema (rarely)
- Spider nevi (rarely)
Signs of chronic liver disease include the following:
- Hepatomegaly
- Splenomegaly
- Muscle wasting
- Palmar erythema
- Spider angiomas
- Vasculitis (rarely)
Patients with cirrhosis may have the following findings:
- Ascites
- Jaundice
- History of variceal bleeding
- Peripheral edema
- Gynecomastia
- Testicular atrophy
- Abdominal collateral veins (caput medusa)
Laboratory studies
The following laboratory tests may be used to assess the various stages of hepatitis B disease:
- Alanine aminotransferase and/or aspartate aminotransferase levels
- Alkaline phosphatase levels
- Gamma-glutamyl transpeptidase levels
- Total and direct serum bilirubin levels
- Albumin level
- Hematologic and coagulation studies (eg, platelet count, complete blood count [CBC], international normalized ratio)
- Ammonia levels
- Erythrocyte sedimentation rate
- Serologic tests
The serologic tests should include the following laboratory studies:
- Hepatitis B surface antigen (HBsAg)
- Hepatitis B e antigen (HBeAg)
- Hepatitis B core antibody (anti-HBc) immunoglobulin M (IgM)
- anti-HBc IgG
- Hepatitis B e antibody (anti-HBe)
- hepatitis B virus (HBV) deoxyribonucleic acid (DNA)
Imaging studies
The following radiologic studies may be used to evaluate patients with hepatitis B disease:
- Abdominal ultrasonography
- Abdominal computed tomography (CT) scanning
- Abdominal magnetic resonance imaging (MRI)
Differential diagnosis
broad due to the presence of non-specific symptoms such as fatigue, abdominal pain, nausea, and vomiting.
- Alcoholic hepatitis
- Autoimmune hepatitis
- Cirrhosis
- Drug-induced liver injury
- Hemochromatosis
- Hepatitis A
- Hepatitis C
- Hepatitis D
- Hepatitis E
- Hepatocellular carcinoma
- Human immunodeficiency virus
- Wilson disease
Managment
- Acute hepatitis B infection is self cleared in 95% of healthy adults.
- Patients need antiviral treatment:
- with severe acute disease
- bilirubin more than 10 mg/dl,
- INR more than 1.6
- hepatic encephalopathy
- protracted acute severe disease (total bilirubin more than 3 mg/dl or direct bilirubin more than 1.5 mg/dl, INR more than 1.5, hepatic encephalopathy, or ascites) need antiviral treatment.
- with severe acute disease
- Management include
- identification of HIV, hepatitis C, and hepatitis D coinfection, hepatitis B virus replication status, and severity of the disease.
- The severity of the disease is based on clinical assessment-
- blood counts
- liver enzymes
- liver histology.
- alanine transferase, for patients with elevated or fluctuating alanine transferase,
- liver biopsy is necessary to identify if they need antiviral treatmen
- Medication –
- interferons (peginterferon alfa-2a, interferon alfa-2b)
- nucleoside analogs (entecavir, lamivudine, telbivudine)
- nucleotide analogs (adefovir, tenofovir)
Management in pregnant women
Hepatitis C
It causes inflammation and swelling, which cause chronic liver inflammation and long-term damage. hepatitis C is one of the leading causes of liver failure and liver transplantation in the United States.
Etiology
- It caused by Hepatitis C virus (RNA Virus)
- It encodes a polyprotein that then gets processed into at least ten proteins. These include three “structural” proteins: the nucleocapsid protein, core (C), and two envelope proteins (E1 and E2).
- Transmission occurs when the blood of an infected person enters the body of an uninfected person.
- exposure to needles or sharp objects at work, especially in healthcare.
- Tattoos or body piercings performed with unsterilized equipment.
- Sharing a razor or toothbrush with somebody who might have bled using it.
- Less commonly, through sexual contact that leads to blood exposure.
Incubation
1. Acute infection
- period can last from 2 weeks to 6 months. The acute stage of infection begins when your immune system kicks in. It’s also when you begin to experience symptoms. Most viral infections at the acute stage cause symptoms of illness, such as fever and inflammation in your body. With hepatitis, though, the inflammation is mainly in your liver, and you might not notice it.
- Only 20% of people with acute hepatitis C infection have symptoms. People who have symptoms can treat the infection with antivirals. But most don’t have symptoms and don’t know to seek treatment.
2. Chronic infection
- Most people (80%) are unable to clear the virus by themselves and develop a long-term, chronic infection. This means that their livers are constantly inflamed and swollen.
- Chronic hepatitis causes liver damage by a process known as cirrhosis.
- The constant inflammation of the liver eventually leads to scarring.
- Cirrhosis progresses slowly over several decades. It might go faster if you have additional liver damage from other causes, such as excessive alcohol use.
- scar tissue prevents your liver from doing its job
Symptoms
Acute symptoms of hepatitis C infection may resemble flu symptoms, such as:
- Fever.
- Fatigue.
- Body aches.
- Loss of appetite.
They may also resemble the symptoms of acute liver failure, such as:
- Jaundice (yellowing of lighter skin and the whites of the eyes).
- Abdominal pain (especially in the upper right quadrant).
- Nausea and vomiting.
- Dark-colored pee and light-colored poop.
Diagnosis
- based principally on the detection of antibodies
- to recombinant HCV polypeptides
- by assays for HCV RNA.
(These are enzyme immunoassays that measure antibodies directed against NS4, core, NS3, and NS5 sequences.)
- HCV Rapid Antibody Test with PCR. there are three scenarios in which the HCV RNA test should be considered upfront:
- exposure within the past six months,
- an immunocompromised host,
- suspicion for reinfection.
(RNA PCR test looks for evidence of the actual virus in your blood, not just the antibodies. This test is necessary to confirm that you’re still infected. You might still have antibodies even if you’ve spontaneously cleared the virus. Your provider can also use this test to measure the quantity of the virus in your blood and to find out which strain you have.)
- other medicl test –
- Liver function tests. Liver function tests are a series of blood tests that evaluate the health of your liver.
- Elastography. An elastography is a noninvasive imaging test that measures the stiffness or fibrosis of your liver tissue. It uses ultrasound or MRI.
- Liver biopsy. As a last resort, when other tests aren’t conclusive, your healthcare provider may take a sample of tissue from your liver to test in the lab. They can usually do this through a hollow needle inserted through your abdominal wall in a simple bedside procedure.
Management and Treatment
- Acute HCV infection is self-limited.
- Treatment of chronic HCV infection is achieved by eradicating HCV RNA by the attainment of a sustained virologic response (SVR).VR is achieved when HCV RNA is no longer detectable in the blood after 12 weeks of therapy, with a decline in antibody titers and improved liver pathology.
Hepatitis D
- it is a defective RNA virus that uses the HBV surface antigen as a viral enve?lope.
- can occur as a coinfection or superinfection in individuals infected with HBV, which may then progress to severe fulminant infection.
- Transmission can occur via infected blood or blood products
- intravenous drug users
- hemophiliacs.
- sexual activity.
Types
- An acute (short-term) infection that often resolves on its own without any problems.
- It is chronic (long-term), In some people, causing progressive injury to the liver.3
How and when you get hepatitis D can make a big difference in the course of the infection. There are two different ways that a person can get the virus.4
- HBV/HDV coinfection: When a person is simultaneously infected with HBV and HDV
- HDV superinfection: When a person who is chronically infected with HBV is later infected with HDV
The differences might not sound extreme, but a superinfection is considered to be a far more serious condition. Around 80% of superinfected people will go on to develop a chronic infection, compared to only 5% of coinfected individuals
Etiology
- Hepatitis D virus infection is an acute and chronic inflammatory process transmitted parenterally.
- Hepatitis D replicates independently within hepatocytes but requires hepatitis B surface antigen for propagation.
- Hepatic cell death occurs due to direct cytotoxic effects of hepatitis D virus or a host-mediated immune response.
- Perinatal transmission is uncommon.
The hepatitis D virus, also known as the delta virus, is unique in that it cannot replicate on its own.It is considered a “satellite virus” because it needs HBV to complete its life cycle and make copies of itself.
In most cases, HDV is the dominant virus in the infection. As it suppresses HBV to low levels, it utilizes HBV’s surface proteins to assemble new copies of itself. Any liver damage that occurs, therefore, is the result of hepatitis D rather than hepatitis B.
Symptoms
- Incubation period – 3–7 weeks.
- fever, fatigue, loss of appetite, nausea, vomiting, dark urine, pale-coloured stools, jaundice (yellow eyes) and even fulminant hepatitis.
acute symptoms tend to resolve within two to four weeks, although it may take longer for jaundice to fully disappear.
Symptoms of this complication include jaundice, vomiting, abdominal swelling, confusion, tremors, and a fruity breath smell.
Diagnosis
This includes immunoglobulin M (IgM) produced during early-stage infection and immunogilobulin G (IgG) produced when IgM levels start to decrease
The IgM/IgG pattern can help determine if the infection is acute or chronic, or if a coinfection or superinfection is involved
Treatment
Treatment options for hepatitis D are limited and optimal treatment is not known. There are no known treatments for acute hepatitis D.
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