Snapshot A 40-year-old obese woman presents to her family medicine doctor for intermittent abdominal pain for the past few months as well as fatigue. She has a past medical history of hyperlipidemia, diabetes, and hypertension. She has been trying to lose weight but has not been successful. She reports drinking alcohol socially, on average 2 times per month. On exam, she is not jaundiced and has no tenderness to palpation. Her liver is noted to be enlarged. Laboratory evaluation reveals mildly elevated liver enzymes, and she is referred for liver biopsy to confirm the diagnosis of nonalcoholic steatohepatitis. (Chronic hepatitis) Introduction Overview acute hepatitis acute inflammation of the liver chronic hepatitis > 6-month duration of liver inflammation Epidemiology etiology viral hepatitides (e.g., HAV, HCV, and HBV) chronic (HCV and HBV +/- HDV) parasites (e.g., toxoplasmosis) alcohol drug-induced acute (e.g., acetaminophen) chronic (e.g., isoniazid, methyldopa, and nitrofurantoin) autoimmune hepatitis nonalcoholic steatohepatitis metabolic disease Wilson disease hemochromatosis alpha-1-antitrypsin deficiency risk factors alcohol abuse foreign travel intravenous drug use sexual contact Pathogenesis mechanism the specific mechanism of injury depends on the etiology generally, the initial insult results in hepatocyte injury leading to the activation of an inflammatory response, which can become chronic (with subsequent fibrosis and cirrhosis) Prognosis vast majority of patients with acute hepatitis recover without complications some may develop chronic hepatitis of these, many may have longterm chronic hepatitis without significant liver injury however, chronic hepatitis increases the risk of liver failure, cirrhosis, and hepatocellular carcinoma Presentation Acute hepatitis history recent travel sudden jaundice symptoms prodrome (flu-like symptoms) fatigue fever nausea vomiting poor appetite headache followed by jaundice (1-2 weeks after prodrome) right upper quadrant pain hepatosplenomegaly Chronic hepatitis history history of acute hepatitis symptoms malaise poor appetite fatigue vague abdominal discomfort jaundice is rare may have hepatomegaly Imaging Ultrasound of liver indications chronic hepatitis screen for hepatocellular carcinoma findings liver mass hepatomegaly Studies Serum labs complete blood count (CBC) elevated WBC count with atypical lymphocytes in acute viral hepatitis liver function panel acute and chronic hepatitis elevated AST and ALT if AST:ALT>2, suspect alcoholic hepatitis autoimmune hepatitis antibodies anti-smooth muscle antibody anti-nuclear antibody hepatitis viral serologies determines type of virus and immunity status IgM antibodies are present during early infection IgG antibodies are present and remain after recovery Serologic Findings Clinical Implications HBV surface antigen Anti-HBV core antibody Active infection Anti-HBV surface antigen antibody Immunity Anti-HBV core antibody Immunity HBV e-antigen Highly infectious HCV antibody Exposure Differential Gallbladder disease key distinguishing factors ultrasound or other imaging modalities with pathology of the biliary system or presence of stones Treatment Management approach management depends on etiology of acute or chronic hepatitis all patients with chronic liver disease should undergo HAV and HBV vaccines Medical supportive care indication acute viral hepatitis or alcoholic hepatitis modalities fluid and electrolyte management treatment of encephalopathy or coagulopathy nutritional support for acute alcoholic hepatitis antiviral treatment indication treat hepatitis B or C modalities interferon + ribavirin or sofosbuvir for hepatitis C infection other antivirals such as lamivudine or tenofovir for hepatitis B infection immunosuppression indication autoimmune hepatitis modalities corticosteroids azathioprine Complications Hepatocellular carcinoma Cirrhosis