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Hepatitis

Hepatitis is a topic covered in the 5-Minute Emergency Consult.

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Emergency Central

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Basics

Description

  • Inflammation of the liver owing to infectious, toxic, and autoimmune disorders
    • Progression from hepatocellular injury (hepatitis) to scarring (cirrhosis)
  • Infectious causes are the most common

Etiology

  • Unknown etiology in 5–10% of acute and chronic hepatitis cases and up to 50% in fulminant hepatic failure (FHF)
  • Hepatitis A (HAV):
    • Transmission: Fecal–oral
    • Incubation period: 2–7 wk
    • FHF in 0.1%
    • No chronic phase
      • 10% will have a relapsing course over months
  • Hepatitis B (HBV):
    • Transmission: Mucous membrane, percutaneous exposure to bodily fluids, perinatal
    • Incubation period: 8–22 wk
    • Subclinical in 70%
    • FHF in 1%
    • Risk of chronic hepatitis increased with age at infection and comorbidities:
      • Neonatal: >90%
      • Infant: 50%
      • Child: 20%
      • Immunocompetent adult: 1–5%
      • Immunocompromised adult: 50%
    • Risk of cirrhosis, hepatocellular carcinoma
  • Hepatitis C (HCV):
    • Transmission: Blood >> sexual and perinatal
    • Incubation period: 6–10 wk
    • FHF rare
    • 80% progress to chronic disease
    • Risk of cirrhosis, hepatocellular carcinoma
  • Hepatitis D (HDV):
    • HDV can be transmitted only in the presence of HBV infection
      • 2 patterns of infection: Simultaneous infection with HBV and HDV or HDV superinfection in an individual with chronic HBV
    • Same transmission as HBV
    • Incubation period: 3–7 wk
    • FHF in 3%
    • 5% progress to chronic disease
    • Risk of cirrhosis 3 times higher in HDV-infected individual compared with HBV infection alone
  • Hepatitis E (HEV):
    • Most common cause of acute hepatitis and jaundice worldwide
    • Rarely found outside developing countries
    • Typically seen as outbreaks
    • Transmission: Fecal–oral, waterborne, foodborne
    • Incubation period: 3–8 wk
    • FHF in 10%
    • Chronic infection almost exclusively in immunocompromised persons
  • Alcoholic hepatitis:
    • Associated with >14 drinks/wk in women and >21 drinks/wk in men
    • Sequelae of chronic use:
      • Hepatic steatosis in 90–100%
      • Hepatitis in 10–35%
      • Cirrhosis in 5–15%
    • Increased association with chronic viral hepatitis
    • Maddrey discriminant function (MDF) ≥32 associated with only 50–65% survival
      • MDF = 4.6 × [prolongation of PT above control](s) + serum bilirubin(mg/dL)
  • Abscess-induced hepatitis:
    • Entamoeba histolytica, pyogenic
  • Secondary hepatitis viruses:
    • CMV, EBV, HSV, HIV
  • Medication and toxin induced
  • Autoimmune hepatitis:
    • Display concurrent stigmata of autoimmune disease

Pediatric Considerations
  • Vast majority of cases are caused by HAV
  • Perinatal HBV infection develops into chronic disease 90% of the time


Pregnancy Considerations
  • 20% case fatality for HEV during pregnancy.
  • Acute fatty liver of pregnancy (AFLP):
    • May progress to DIC
  • Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome
  • Immunoprophylaxis is safe during pregnancy

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Citation

Rosen, Peter, et al., editors. "Hepatitis." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307583/all/Hepatitis.
Hepatitis. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307583/all/Hepatitis. Accessed April 26, 2019.
Hepatitis. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307583/all/Hepatitis
Hepatitis [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 26]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307583/all/Hepatitis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Hepatitis ID - 307583 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307583/all/Hepatitis PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -