Hepatitis
- In a patient presenting with hepatitis symptoms and/or abnormal liver function tests, take a focused history to assist in establishing the etiology (e.g., new drugs, alcohol, blood or body fluid exposure, viral hepatitis).
- In a patient with abnormal liver enzyme tests interpret the results to distinguish between obstructive and hepatocellular causes for hepatitis as the subsequent investigation differs.
- In a patient where an obstructive pattern has been identified,
- Promptly arrange for imaging,
- Refer for more definitive management in a timely manner.
- In patients positive for Hepatitis B and/or C,
- Assess their infectiousness,
- Determine human immunodeficiency virus status.
- In patients who are Hepatitis C antibody positive determine those patients who are chronically infected with Hepatitis C, because they are at greater risk for cirrhosis and hepatocellular cancer.
- In patients who are chronically infected with Hepatitis C, refer for further assessment and possible treatment.
- In patients who are at risk for Hepatitis B and/or Hepatitis C exposure,
- Counsel about harm reduction strategies, risk of other blood borne diseases,
- Vaccinate accordingly.
- Offer post-exposure prophylaxis to patients who are exposed or possibly exposed to Hepatitis A or B.
- Periodically look for complications (e.g., cirrhosis, hepatocellular cancer) in patients with chronic viral hepatitis, especially hepatitis C infection.
General Overview
General Overview
- Hepatitis: Acute vs. Chronic (> 6 months)
- Cirrhosis: Compensated vs Decompensated (decreased function)
- Platelet count helpful for early signs of liver disease and varices
- AST/platelet ratio index <0.5 unlikely fibrosis
- Platelet count helpful for early signs of liver disease and varices
DDx
DDx
- Noninfective
- Alcohol
- NAFLD/NASH
- Drug-induced (Acetaminophen, INH, tetracyclines, antiepileptics/phenytoin)
- Autoimmune
- Infective
- Hepatitis B/C/D (Blood/body fluid/sexual)
- Hepatitis A/E (Fecal/oral, usually self-limited)
History
History
- Exposures
- Medication history (OTC, herbal and dietary supplements)
- Alcohol consumption
- IVDU / Needle stick exposures
- Tattoos or body piercings
- High-risk sexual contact
- Blood transfusion prior to 1992
- Travel to areas endemic for hepatitis
- Signs and Symptoms
- Light-colored stools, pruritus, dark urine (bilirubinuria)
- Acute pain in RUQ, ascites (hematologic diseases, may have hepatic vein thrombosis)
- Fever/weight loss/night sweats (acute viral hepatitis of any etiology)
- Prior hepatobiliary disease (including gallstones)
- Prior inflammatory bowel disease (autoimmune)
- History of diabetes, skin pigmentation, cardiac disease, arthritis, hypogonadism (hemochromatosis)
- History of blood disorders (hemolysis)
- Family history of inherited liver disorders
Physical Exam
Physical Exam
- Jaundice
- Malnutrition
- Temporal and proximal muscle wasting
- Hormonal
- Spider nevi, caput medusa, palmar erythema, gynecomastia, testicular atrophy
- Hepatomegaly, splenomegaly
- Decompensated Cirrhosis
- Ascites, peripheral edema
- Neuro
- Hepatic encephalopathy
- Asterixis
- Alcohol abuse
- Dupuytren’s contracture, parotid enlargement, testicular atrophy
Serology
Serology
- Anti-HAV Ab: Past or current infection
- Anti-HCV Ab: Past or current infection
- HBsAg: Infection (if persists >6 months = chronic infection)
- Anti-HBs: Immunity due to infection or immunization
- Anti-HBc total (IgM and IgG): Past or current infection (IgG usually persists for life)
- HBeAg: High infectivity (viral replication)
- Anti-HBe:
- Appears with recovery from acute infection
- In chronic infection, the presence of Anti-HBe suggests low infectivity
Isolated Anti-HBc positive
- DDx
- False positive result/lab error (most common)
- Positive Anti-HBe infers prior HBV exposure, and unlikely false positive
- "Window phase" - resolving acute infection before the appearance of anti-HBs
- "Remote resolved HBV infection" - undetectable anti-HBs due to a decline in antibody titre over time
- "Occult HBV", chronic infection with undetectable HBsAg (rare)
- False positive result/lab error (most common)
- Consider
- HBV DNA viral load
- If negative
- Booster (or complete series) and follow-up HBsAb after 1-2 months if responds with immunity
- If no response to booster to ensure not occult HBV, consider repeat viral load q3-6 months until undetectable x 2-3
- If negative
- Test co-infection HIV/HCV
- See below (Positive Hepatitis) if chronic carrier
- HBV DNA viral load
Screening
Screening
- Hepatitis B screening (HBsAg, anti-HBs, anti-HBc total)
- Review HBV immunization history, previous testing
- Consider screen if high-risk (eg. exposures, travel, family history, abnormal liver tests)
- Screen all pregnancy, HIV/HCV, immunocompromised (or planned therapy)
- Hepatitis C screening
- IVDU, needle-stick injury, hemodialysis, pregnancy
- Canadian Taskforce does not recommend people born in Canada between 1950-1975 be screened
Prevention
Prevention
- Abstain from alcohol
- Vaccination against Hep A/B
- Screen pregnancy
- Mothers with high HBV viral loads should be given antiviral therapy to further reduce the risk of infection in the newborn
- Follow-up infants (HBV vaccine and HBIG within 12h after birth, with repeat vaccine at 1 and 6 months)
- Mothers with high HBV viral loads should be given antiviral therapy to further reduce the risk of infection in the newborn
Hepatitis Post-Exposure Prophylaxis (PEP)
Hepatitis Post-Exposure Prophylaxis (PEP)
- Clean wounds, avoid any further blood/body fluid exchange until cleared
- Vaccinate Hep A/B as indicated
- Screen all contacts and offer PEP as indicated
Hepatitis A PEP
Hepatitis A PEP
- Hygiene practices: Handwash, avoid tap water, raw foods, heating foods >85°C
- Hep A PEP only indicated in close personal contacts, child care contacts, food handlers (not warranted in a single case of Hep A in school or hospital)
- For healthy individuals aged 12 months to 40 years
- HAV Vaccine (Havrix 1mL IM x1)
- For individuals ≥41 years or <12 months, immunocompromised, chronic liver disease, allergic to the vaccine
- Hepatitis A immune globulin 0.02 mL/kg IM x1
- The combination vaccine TWINRIX should not be used for postexposure prophylaxis
- For healthy individuals aged 12 months to 40 years
Hepatitis B PEP
Hepatitis B PEP
- PEP not required if either source or exposed has either
- Recorded previous (at any time) anti-HBs ≥10 IU/L
- History of recovery from HBV infection
- Hep B vaccine (0, 1-2, and 4-6 months) if source HBsAg-positive or HBV-unknown
- Within 24 hours of exposure, and complete three-dose series (zero, one, six months) if not vaccinated
- HBIG 0.06 mL/kg IM x1 if source HBsAg-positive or high risk (e.g., IVDU, MSM)
- As soon as possible, within 7 days of percutaneous exposure or within 14 days of sexual exposure
- Repeat dose at 28-30 days after exposure in non-responders to Hepatitis B vaccine or in patients who refuse vaccination
- If PEP given, do anti-HBc and HBsAg after 6 months to assess for HBV transmission
Hepatitis C
Hepatitis C
- No PEP recommended
- Close observation for those who had percutaneous or high-risk sexual exposure (unless source negative HCV RNA)
- If source HCV RNA positive, repeat HCV RNA at 4w, and HCV RNA + HCV Ab at 3 and 6 months
- If source HCV RNA unknown, repeat HCV Ab six months after exposure
- Delay treatment for six months minimum to monitor for spontaneous clearance of HCV RNA
Positive Hepatitis B or C
Positive Hepatitis B or C
- Education on harm reduction
- Inform health care providers (dentist, nurse, other physicians) and other providers eg. (acupuncturist, tattoo artist) of infection
- Do not donate blood/semen/tissues
- Safely dispose of blood (hygiene products, floss, bandages, needles)
- Cover cuts/sores
- Do not share personal hygiene materials and sharp instruments (razors, nail clippers, toothbrushes, glucometers)
- Ensure all partner/household members/drug use partners are tested and immunized if susceptible (Hep B vaccine free for susceptible contacts)
- Condom-use until partners test immune
- Avoid medication or alternative therapies (herbals) that may affect or be affected by liver
- Go to ER if black stools or vomiting blood
- Labs
- Bilirubin (total and direct), albumin, INR (PT), creatinine
- ALT, AST, ALP
- CBC
- Test co-infection HIV status, Hep B/C
- Assess infectiousness - HBV DNA, HbeAg
- Vaccinate Hep A/B as indicated
- Screen all contacts and offer PEP/vaccinations as indicated
- Follow-up
- Psychiatric illness, alcohol/substance use
- Complications
- Hepatocellular carcinoma
- Decompensated cirrhosis
- Ascites
- Upper GI Bleed
- Encephalopathy
HBsAg positive
HBsAg positive
- Management focus on relief of symptoms, monitoring, prevention of complications and transmission
- Does not require antiviral treatment for acute Hep B as most (95%) will clear
- Refer if deteriorating liver failure (INR, bilirubin, platelet, encephalopathy)
- Repeat HBsAg at 6 months after baseline to confirm Chronic carrier (95% clear)
- If confirmed chronic carrier
- HIV/HCV (if not done already)
- HBeAg
- Repeat labs
- ALT q6 months
- HBV DNA (viral load) q1 year
- Ultrasound (+/- AFP) q6-12 months for HCC
- Cirrhosis
- HIV/HCV co-infection
- African descent>20yo
- Men>40yo, Women>50yo
- Family history of hepatoma
- Referral to specialist (treatment with interferon injections or oral nucleoside/nucleotide analogues)
- Usually if elevated ALT or HBV DNA >2000 IU/mL
- If confirmed chronic carrier
Anti-HCV Ab positive
Anti-HCV Ab positive
- HCV RNA testing for Chronic carrier (20% clear)
- If positive, add HCV genotype
- Refer to hepatologist for treatment (eg. Harvoni x 12w) or liver transplant
- Level of fibrosis predicts outcome (Metavir scoring system)
- Screening in cirrhosis,
- Upper endoscopy q1-2y for varices
- Liver ultrasound q6-12mo for HCC