Viral Hepatitis

Hepatitis A, which is transmitted through a fecal-oral route, is a common cause of jaundice in ED patients. In most cases the diagnosis is made on the basis of the patient's history of earlier nonspecific symptoms that have become complicated by jaundice and abdominal pain.

Hepatitis B, C, and D are transmitted parenterally. Hepatitis B, the most virulent, accounts for a large percentage of adult cases. A chronic carrier state develops in up to 10% of patients. Hepatitis C is responsible for 80% to 90% of posttransfusion cases of hepatitis, and approximately one third become chronic. Hepatitis D (delta) requires concomitant hepatitis B infection.

Other viruses (e.g., cytomegalovirus and Epstein-Barr virus), bacteria, rickettsia, and protozoa can also cause liver inflammation.

Causes

Hepatitis A is usually transmitted from feces on unwashed hands (putting dirty hands into the mouth) and by ingesting contaminated food and water (for example, seafood from sewage contaminated water). It can also be transmitted through close contact with someone who has the virus.

Hepatitis B and C are transmitted via blood; therefore, blood transfusion, intravenous (IV) drug use with contaminated needles, and sexual activity are all ways that people have contracted either of these viruses. In as many as 40% of the cases of hepatitis C, the specific cause of transmission is unknown. Blood and blood products that are used for transmission can now be tested for both hepatitis B and C. The latter test has been available since 1992.

Symptoms

• Asymptomatic incubation phase of varying length in viral hepatitis (hepatitis A, 2 to 6 weeks; hepatitis B, 2 to 6 months; hepatitis C, 2 to 22 weeks)
• Viral symptoms in prodromal phase, with fever ++++, nausea +++, vomiting +++, malaise, fatigue, anorexia, headache, and chills
• Icteric phase characterized first by dark urine then light (clay­colored) stools, scleral icterus, and jaundice (as serum bilirubin exceeds 3 to 4 mg/dl)
• Pruritic rash, arthralgias, and arthritis, especially with hepatitis B
• Altered mental status and seizures suggest hepatic encephalopathy in fulminant disease.
• Disturbance of taste

Signs

• Jaundice +++
• Tender hepatomegaly +++
• Lymphadenopathy ++
• Splenomegaly +
• Scleral or sublingual icterus
• Low-grade fever
• Skin excoriations caused by itching
• Asterixis, hyperreflexia, and occur with hepatic encephalopathy.

Treatment

In viral hepatitis resolve spontaneously and require no specific treatment. Strict bed rest is not necessary. The patient may undertake any activity that does not exacerbate symptoms. Diet can be liberal, encouraging a high calorie intake but excluding alcohol. Fatty foods are poorly tolerated and are best avoided. Hospitalization is not necessary. All drugs, especially tranquilizers and sedatives, should be avoided. Corticosteroids do not alter the degree of hepatitis or rate of healing and should be avoided to allow a normal immunologic response, which then can eliminate the virus. Indeed, their use in acute viral hepatitis may increase the risk of a chronic carrier state. Alpha-interferon may be useful in acute hepatitis C, but this approach remains investigational.

Prevention

• Follow good hygiene and avoid crowded, unhealthy living conditions.
• Take extra care, particularly when drinking and swimming, if you travel to areas of the world where sanitation is poor and water quality is uncertain.