Hepatitis Overview

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Hepatitis Overview

Contents

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

OVERVIEW

  • 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

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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

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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

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Follow-Up

  • 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:

Hepatitis-Viral_2

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Hepatitis-Viral_3

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chronic hepatitis B treatment

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Hepatitis-Viral_5

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treatment of chronic hepatitis B w/ elevated ALT

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Hepatitis-Viral_7

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Hepatitis-Viral_Page8

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Hepatitis-Viral_Page9

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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
Prevention

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.

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Version: 31 July 2015

Guideline References:

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