Hepatitis Overview


Signs & Symptoms Of Acute Hepatitis
Lab Tests
Hep A
Hep B
Hep C
Hep D
Hep E
Prevention & Post-exposure Prophylaxis of Viral Hepatitis
Guideline References


  • The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis
  • Hepatitis A generally causes minor illness in childhood w/ >80% of infections being asymptomatic
    • Adults are more likely to produce clinical symptoms
  • Hepatitis B, C & D may also be asymptomatic
  • Symptomatic hepatitis B will depend on the mode & time of transmission
    • Vertical transmission from mother to child is almost always asymptomatic
    • Other routes of transmission are more likely to produce symptomatic disease (30% of cases transmitted by IV drug use are icteric)
Refer to Symptoms for more information

Below is an overview of disease management of Hepatitis-Viral:

overview of disease management chart of hepatitis - viral


Monitor Patient (Hepatitis B)
During Therapy
  • Monitor ALT, HBeAg, anti-HBe, &/or HBV DNA at least every 3-6 mth; HBsAg every 6-12 mth
  • Monitor renal function (eg creatinine, phosphate) if Tenofovir, Entecavir, or Adefovir are used
  • Monitor for adverse effects (ie CBC, TSH) if Interferons are used
End of Therapy
  • Monitor ALT & HBV markers (including HBV DNA) to detect relapse every 3-6 mth for the 1st year then every 6-12 mth
  • Every 3 mth in patients w/ cirrhosis or HBeAg/HBV DNA positive
  • May monitor every 6 mth in patients who responded to therapy
  • Further monitoring of HBV DNA every 3-6 mth in non-responders is recommended to recognize delayed response & to plan retreatment if required
  • Monitor for hepatocellular carcinoma (HCC) in high-risk patients every 6-12 mth using ultrasound & alpha-fetoprotein
Chronic hepatitis B patients who are not treated but need continuous monitoring:
  • Patients age <30 yr w/o cirrhosis, w/ PNALT, HBV DNA >20,000 IU/mL
  • HBeAg-negative patients age <30 yr w/o cirrhosis, ALT levels intermittently abnormal, HBV DNA between 2000 and 20,000 IU/mL


Clinical Decision (Hepatitis C)
Consequences of HCV Infection
  • 55-85% of patients who acquire acute hepatitis C will remain HCV infected
    • 5-20% of these patients may develop cirrhosis over the next 20-25 yr
    • HCV-related cirrhosis is associated w/ risk of developing end-stage liver disease (30% risk over 10 yr) as well as hepatocellular carcinoma (HCC)
  • In patients w/ persistent infection, the evolution to cirrhosis is the primary concern
    • Usually occurs ≥20 yr after initial infection & occurs more often in patients at older ages (esp men), those who drink >50 g of alcohol/day, those who are obese or have substantial hepatic steatosis & in those w/ HIV infection
Antiviral therapy is currently widely accepted for the following Hepatitis C patient groups:
  • ≥18 yr of age
  • Normal & abnormal ALT levels
  • Liver biopsy showing chronic hepatitis w/ significant fibrosis (stage F1 or above)
  • HCV genotype 2 or 3 regardless of stage
  • Compensated liver disease
  • Acceptable hematological & biochemical indices
  • If there is a history of depression, the condition is well controlled
  • Willing to be treated & conform to patient requirements
  • Treated previously for HCV infection
Therapy should be individualized in patients w/ any of the following:
  • Failed prior treatment of either Interferon given alone or in combination w/ Ribavirin or Peginterferon given alone
  • Current illicit drug user or alcoholic but willing to participate in substance abuse program or alcohol support program
  • No or mild fibrosis on liver biopsy
  • Acute hepatitis C
  • Coinfected w/ HIV
  • <18 yr
  • Chronic renal disease
  • Decompensated cirrhosis
  • Liver transplant recipient
Therapy is contraindicated in patients w/ any of the following1
  • Major, uncontrolled depressive illness
  • Renal, heart or lung transplant recipient
  • Autoimmune hepatitis or other condition known to be exacerbated by Interferon & Ribavirin
  • Untreated hyperthyroidism
  • <3 yr of age
  • Pregnant or unwilling/unable to comply w/ adequate contraception
  • Severe concurrent disease (eg hypertension, HF, uncontrolled DM, etc)
  • Known hypersensitivity to drugs used to treat HCV
  • Hepatic decompensation



  • Monitor patient to ensure that fulminant liver failure does not develop
  • Monitor LFT every 1-4 wk until normal; ALT every 3-6 mth if patient did not meet criteria for treatment
  • Repeat serologic testing 6 mth after infection to rule out development of chronic hepatitis
Below is the overview of treatment of Hepatitis - Viral:





chronic hepatitis B treatment




treatment of chronic hepatitis B w/ elevated ALT








Prevention & Post-Exposure Prophylaxis Of Viral Hepatitis

Prevention & Post-Exposure Prophylaxis of Viral Hepatitis
Patient Group for Whom Prevention or Post-exposure Prophylaxis is Recommended Recommended Prevention or Post-exposure Prophylaxis Regimen

Hepatitis A
Susceptible persons traveling to HAV-endemic areas
Household contacts, daycare children & staff
Healthcare personnel potentially exposed to HAV
Patients who will undergo blood transfusion
Immunocompromised children (suboptimal response)
Men who have sex w/ men (MSM)
Illegal drug users (both injection & non-injection drug users)
Persons w/ chronic liver disease, including persons w/ chronic HBV & HCV infection who have evidence of chronic liver disease

Hepatitis A Vaccine1

Hepatitis B
Unvaccinated children, adolescents & adults
Premature infants w/ immediate risk of HBV infection
Unvaccinated persons who attend STD clinics, including pregnant women
Persons w/ any of the following sexual risk factors: History of STD, multiple sex partners, sex w/ an injection drug user, MSM, victims of sexual assault
Illegal IV drug users
Household members, sex partners & drug-sharing partners of a person w/ chronic HBV infection2
Persons on hemodialysis, or are receiving clotting factor concentrates, or who have occupational exposure to blood

Hepatitis B Vaccine
Post-exposure Prophylaxis

Hepatitis A
Unvaccinated or nonimmune persons exposed to hepatitis A virus (HAV) through household or sexual contact or by sharing illegal drugs w/ a person who has hepatitis A3

Administer a single IM dose of human immunoglobulin (Ig) as soon as possible but not >2 wk after exposure

Hepatitis B
Unvaccinated or nonimmune sex partners of persons w/ acute hepatitis B

Administer Ig w/in 14 days after the most recent sexual contact

1Postvaccination serologic testing is not indicated because most persons respond to the vaccine
2Vaccination of household contacts (esp children & adolescents) of persons w/ acute HBV infection is also encouraged. Consider postvaccination testing (anti-HBs) for sex partners of persons w/ chronic HBV infection. Those found to be antibody negative should receive a second, complete, vaccination series
3A person who has had 1 dose of hepatitis A vaccine at least 1 mth before exposure to HAV does not need Ig

See Treatment for dosing information.


Version: 31 July 2015

Guideline References:

  1. American Association for the Study of Liver Diseases & Infectious Diseases Society of America. Recommendations for testing, managing, and treating hepatitis C. HCV Guidelines. http://www.hcvguidelines.org/sites/default/files/full_report.pdf. 12 Mar 2014. Accessed 20 Mar 2014
  2. Ancell CD, Phipps J, Young L. Thymosin alpha-1. Am J Health Syst Pharm. 2001 May;58(10):879-885. PMID: 11381492
  3. Australian National Council on AIDS, Hepatitis C and Related Diseases (ANCAHRD) Hepatitis C Committee and Clinical Trial and Research Committee (CTARC). A model of care for the management of hepatitis C infection in adults. http://www.bvsde.paho.org/bvsacd/cd49/model.pdf. Jul 2003
  4. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2002. MMWR. 2002 May;51(RR-6):59-66. http://www.ncbi.nlm.nih.gov/pubmed/12184549. PMID: 12184549
  5. Cheney CP. Overview of hepatitis A virus infection in adults. UpToDate. http://www.uptodate.com/index. 05 Apr 2012. Accessed 03 Aug 2012
  6. College of Paediatrics, Academy of Medicine Malaysia. Malaysian immunisation manual. http://www.acadmed.org.my/. 2001
  7. Cooksley WG. Peginterferon-alpha 2a for the treatment of hepatitis B infection. Expert Opin Pharmacother. 2005 Jul;6(8):1373-1380. PMID: 16013986
  8. Cramp M, Rosenberg W. British Society for Gastroenterology guideline on the treatment of hepatitis C incorporating the use of pegylated interferons. http://www.bsg.org.uk/clinical-guidelines/liver/guidance-on-the-treatment-of-hepatitis-c-incorporating-the-use-of-pegylated-interferons.html. 2001
  9. Dienstag JL, McHutchison JG. American Gastroenterological Association medical position statement on the management of hepatitis C. Gastroenterology. 2006 Jan;130(1):225-230. http://www.gastrojournal.org/article/S0016-5085(05)02271-7/pdf. PMID: 16401485
  10. Entecavir (Baraclude) for chronic hepatitis B. Med Lett Drugs Ther. 2005 Jun;47(1210):47-48. http://www.ncbi.nlm.nih.gov/pubmed/?term=15933618. PMID: 15933618
  11. European Association for Study of Liver. EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol. 2014 Feb;60(2):392-420. http://www.easl.eu/assets/application/files/bdb06ff135c7ccb_file.pdf. Accessed 20 Mar 2014. PMID: 24331294
  12. European Association for the Study of the Liver. EASL clinical practice guidelines: management of chronic hepatitis B virus infection. Mar 20, 2012. J Hepatol. 2012 Jul;57(1):167-185. http://www.ncbi.nlm.nih.gov/pubmed/22436845. PMID: 22436845
  13. European Association for the Study of the Liver. EASL recommendations on treatment of hepatitis C 2014. J Hepatol. 2014 Aug;61(2):373-395. doi: 10.1016/j.jhep.2014.05.001. Accessed 07 Oct 2014. PMID: 24818984
  14. European Association for the Study of the Liver. EASL recommendations on treatment of hepatitis C 2015. J Hepatol. 2015 Jul;63(1):199-236. doi: 10.1016/j.jhep.2015.03.025. Accessed 08 Jul 2015. PMID: 25911336
  15. Ghany MG, Nelson DR, Strader DB, et al. An update on the treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases. Sep 26, 2011. Hepatology. 2011 Oct;54(4):1433-1444. http://www.ncbi.nlm.nih.gov/pubmed/?term=Ghany++MG%2C++Nelson++DR%2C++Strader++DB%2C++et++al%09%22An++update++on+treatment+of+genotype+1+chronic+hepatitis+c+virus+infection%3A2011+practice+guideline+by+the+American+Association+for+the+Study+of+Liver+Disea. PMID: 21898493
  16. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis c: an update. Hepatology. 2009 Apr;49(4):1335-1374. doi: 10.1002/hep.22759. PMID: 19330875
  17. Gish RG. Current treatment and future directions in the management of chronic hepatitis B viral infection. Clin Liver Dis. 2005 Nov;9(4):541-565. doi:10.1016/j.cld.2005.08.005. PMID: 16207563
  18. Hepatology Society of the Philippines (HSP) Hepatitis C Virus Consensus Core Group. The 2014 Hepatology Society of the Philippines consensus statements on the diagnosis and treatment of hepatitis C. HSP website. http://www.liverphil.org/docs/HCV%20guidelines-snw%201-15-15-%20pamphlet.pdf. 2014. Accessed 27 Feb 2015.
  19. Hepatology Society of the Philippines (HSP). 2014 HSP consensus statements on the management of chronic hepatitis B. HSP website. http://www.liverphil.org/docs/HEP%20B%20GUIDELINES%20-%20BOOKLET.pdf. 2014. Accessed 27 Feb 2015.
  20. Kim AI, Saab S. Treatment of hepatitis C. Am J Med. 2005 Aug;118(8):808-815. http://dx.doi.org/10.1016/j.amjmed.2005.01.073. PMID: 16084169
  21. Lau GK, Piratvisuth T, Luo KX, et al. Peginterferon alfa-2a lamivudine, and the combination of HBeAg-positive chronic hepatitis B. N Engl J Med. 2005 Jun;352(26):2682-2695. http://www.ncbi.nlm.nih.gov/pubmed/?term=Lau+GKK%2C+Piratvisuth+T%2C+Kang+XL%2C+et+al%09Peginterferon+alfa-2a%2C+lamivudine+and+the+combination+for+HBeAg-positive+chronic+hepatitis+B. PMID: 15987917
  22. Liaw YF, et al. 2008 Guidelines for HBV management: summary of recommendations. Mar 2008
  23. Liaw YF, Kao JH, Piratvisuth T, et al. Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2012 update. Hepatol Int. 2012 Jun;6(3):531-561
  24. Lok AS, McMahon BJ. Chronic Hepatitis B. Hepatol. 2007 Feb;45(2):507-539. PMID: 17256718
  25. Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Jul 28, 2009. Hepatol. 2009 Sep;50(3):001-36. http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/chronic_hep_b_update_2009%208_24_2009.pdf. PMID: 19714720
  26. Ministry of Health Singapore, Gastroenterological Society of Singapore, National Medical Research Council. Clinical practice guidelines: chronic hepatitis B infection. http//www.moh.gov.sg/cmaweb/attachments/publication/cpg.hepb.pdf. Mar 2003
  27. National Guideline Clearinghouse. Association for Genitourinary Medicine, Medical Society for the Study of Venereal Disease. Complete summary of 2002 national guideline on the management of viral hepatitides A, B, C. http://www.guideline.gov/summary/summary.aspx?doc_id=3454&nbr=2680&string=viral+AND+hepatitis.
  28. Negro F, Lok ASF. Pathogenesis, epidemiology, natural history, and clinical manifestations of hepatitis D virus infection. UpToDate. http://www.uptodate.com/index. May 2012. Accessed 03 Aug 2012
  29. Negro F, Lok ASF. Treatment and prevention of hepatitis D virus infection. UpToDate. http://www.uptodate.com/index. Jan 2012. Accessed 03 Aug 2012
  30. Omata M, Kanda T, Yu ML, et al. APASL consensus statement and management algorithms for hepatitis C virus infection. Hepatol Int. 2012 Apr;6(2):409-435
  31. Radcliffe K. European STD guidelines. Int J STD AIDS. 2001 Oct;12(Suppl 3):1-102. http://www.iusti.org/sti-information/pdf/guidelines.pdf. PMID: 11589789
  32. Rudolph A, Wang G, Sherman KE, et al. Therapeutic strategies for liver disease. Gastroenterol Hepatol. 2006 Jul;2(7):003-12
  33. Rutherford AE. Acute viral hepatitis. Merck Manual; 2013 Mar. http://www.merckmanuals.com/professional/hepatic_and_biliary_disorders/hepatitis/acute_viral_hepatitis.html. Accessed 02 Oct 2013
  34. Rutherford AE. Chronic hepatitis. Merck Manual; 2013 Mar. http://www.merckmanuals.com/professional/hepatic_and_biliary_disorders/hepatitis/chronic_hepatitis.html. Accessed 02 Oct 2013
  35. Ryder SD, Beckingham IJ. ABC of diseases of liver, pancreas and biliary system: acute hepatitis. BMJ. 2001 Jan;322(7279):151-153. PMID: 11159575
  36. Sarri G, Westby M, Bermingham S, et al; Guideline Development Group. Diagnosis and management of chronic hepatitis B in children, young people, and adults: summary of NICE guidance. BMJ. 2013 Jun;346:f3893. doi: 10.1136/bmj.f3893. Accessed 07 Oct 2014. PMID: 23804177
  37. Scientific Working Group on Viral Hepatitis Prevention, Dept of Health. Recommendations on hepatitis B vaccination regimens in Hong Kong. Jan 2001
  38. Strader DB, Wright T, Thomas DL, et al; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004 Apr;39(4):1147-1171. PMID: 15057920
  39. Umashanker R, Chopra S. Hepatitis E virus infection. UpToDate. http://www.uptodate.com/index. May 2012. Accessed 03 Aug 2012
  40. Wedemeyer H, Pischke S, Manns MP. Pathogenesis and treatment of hepatitis E virus infection. Gastroenterology. 2012 May;142(6):1388-1397. doi: 10.1053/j.gastro.2012.02.01. PMID: 22537448
  41. Wolf DC. Viral hepatitis. eMedicine. http://www.emedicine.com/med/topic3180.htm. 2004
  42. Workowski KA, Berman S, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010 Dec;59(RR-12):1-110. http://www.ncbi.nlm.nih.gov/pubmed/21160459. Accessed 01 Jun 2012. PMID: 21160459
  43. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf. Accessed 08 Jul 2015. PMID: 26042815
  44. World Health Organization. Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. WHO. http://www.who.int/hiv/pub/hepatitis/hepatitis-b-guidelines/en. Mar 2015. Accessed 08 Jul 2015.
  45. World Health Organization. Guidelines for the screening, care and treatment of persons with hepatitis C infection. WHO. http://www.who.int/hiv/pub/hepatitis/hepatitis-c-guidelines/en/. Apr 2014. Accessed  07 Oct 2014.