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Updated: Oct 18 2019


  • 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
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