Hepatitis (Acute/Chronic)

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

Jump to content

Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Hepatitis is a collective term that refers to the inflammation of the liver. This condition can arise from numerous causes, including viral infections, excessive alcohol consumption, certain medications, toxins, or autoimmune disorders.
Viral hepatitis is the most common form, with five distinct types: Hepatitis A, B, C, D, and E.

1. Viral Hepatitis
Viruses are the most common cause of hepatitis worldwide and are categorised as hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E viruses. Each virus has its unique mode of transmission, severity, and long-term consequences:

• Hepatitis A Virus (HAV): Transmitted through the consumption of contaminated food or water, this virus causes acute hepatitis. It rarely results in chronic infection and can be prevented through sanitation and vaccination.

• Hepatitis B Virus (HBV): This virus spreads through contaminated blood, sexual contact, or from an infected mother to her newborn. HBV can lead to acute or chronic hepatitis, increasing the risk of liver cirrhosis and liver cancer.

• Hepatitis C Virus (HCV): Primarily transmitted through exposure to infected blood or blood products, HCV often results in chronic liver disease. It is a leading cause of liver cirrhosis and hepatocellular carcinoma.

• Hepatitis D Virus (HDV): HDV is an incomplete virus that requires the presence of HBV for replication. Co-infection with HDV and HBV can exacerbate liver damage.

• Hepatitis E Virus (HEV): Mostly contracted through contaminated water, HEV infections are typically self-limiting. However, in pregnant women, it can lead to severe complications.

2. Alcohol-induced Hepatitis
Excessive alcohol consumption places significant stress on the liver, resulting in alcoholic hepatitis. While not everyone who drinks heavily develops this condition, chronic alcohol abuse is a major risk factor. Alcohol-induced hepatitis can lead to liver inflammation, fibrosis, cirrhosis, and increased vulnerability to other hepatic diseases.
3. Toxin-related Hepatitis
Certain toxins and medications, when ingested, inhaled, or administered, can damage the liver and cause hepatitis. Common culprits include industrial chemicals, solvents, overdose of medications (e.g., acetaminophen), herbal remedies, and recreational drugs. The severity of toxin-induced hepatitis may range from mild inflammation to life-threatening liver failure, depending on the substance involved and the duration of exposure.
4. Autoimmune Hepatitis
Autoimmune hepatitis is a condition where the body's immune system mistakenly targets and attacks healthy liver cells, leading to inflammation and liver damage. The exact cause is unknown, but genetic predisposition, environmental triggers, and certain infections or medications may contribute. This type of hepatitis predominantly affects women and may lead to chronic liver disease if not managed properly.

Hepatitis viruses initially enter the body through various routes, including contaminated food or water (hepatitis A & E) or blood and body fluids (hepatitis B, C, & D). After entering the body, the viruses reach the liver through the bloodstream. Once inside the liver, they target the hepatocytes, the main functional cells of the liver.
The virus then begins to replicate within the hepatocytes, leading to their destruction. This replication process triggers an immune response, which further contributes to liver damage. The immune system recognizes the infected hepatocytes and releases inflammatory mediators, such as cytokines, to eliminate the virus. Unfortunately, the excessive activation of the immune system and the prolonged presence of the virus lead to chronic inflammation, impairing liver function.
The ongoing inflammation and destruction of hepatocytes result in a range of pathological changes in the liver. These changes include hepatocellular necrosis (cell death), fibrosis (scarring), and possibly cirrhosis (extensive scarring). Fibrosis occurs as a result of the liver's attempt to repair the damaged tissue, leading to the production and accumulation of excess connective tissue. Over time, this fibrotic tissue replaces the normal liver parenchyma, impairing its function.
In chronic hepatitis, the continuous presence of the hepatitis virus and the persistent immune response can lead to further complications. One such complication is the development of hepatocellular carcinoma, a type of liver cancer. The chronic inflammation and the accompanying genetic mutations play a crucial role in the progression to hepatocellular carcinoma.

1. Exposure to Infected Blood and Body Fluids
One of the primary risk factors for hepatitis transmission is direct exposure to infected blood and body fluids. This can occur through the sharing of contaminated needles, syringes, or other drug paraphernalia, which is commonly associated with hepatitis B and C. Additionally, unsafe medical practices or procedures, such as the inadequate sterilisation of medical instruments, can also contribute to viral transmission.
2. Unprotected Sexual Contact
Engaging in unprotected sexual intercourse with an infected partner is another significant risk factor for hepatitis transmission, primarily hepatitis B and C. These viruses can be present in semen, vaginal fluids, and blood, increasing the chances of transmission during sexual activities. People with multiple sexual partners, those engaging in high-risk sexual practices, or individuals with sexually transmitted infections (STIs) are particularly susceptible to contracting hepatitis.
3. Mother-to-Child Transmission
Pregnant women infected with hepatitis B or C can potentially transmit the infection to their babies during childbirth. This vertical transmission occurs when the baby comes into contact with the mother's infected blood or body fluids during the birthing process. Hepatitis B is the most common type transmitted from mother to child, while hepatitis C transmission is relatively rare in this manner.
4. Unsafe Tattooing and Piercing Practices
Hepatitis B and C can be transmitted through the use of contaminated equipment during tattooing and body piercing procedures. If sterile needles, ink, or jewellery are not used, the risk of viral transmission increases significantly. Individuals who opt for such procedures in unregulated environments or with untrained practitioners are particularly vulnerable.

1. Fatigue and Weakness

One of the early symptoms of hepatitis is a general feeling of tiredness, weakness, and fatigue. This can sometimes be mistaken as a result of daily life stress or lack of sleep. However, in the context of hepatitis, this fatigue is often more severe and prolonged.

2. Jaundice

Jaundice is a classic sign of hepatitis and is characterised by a yellowing of the skin and eyes. It occurs due to the buildup of bilirubin, a yellow pigment produced when red blood cells are broken down. Jaundice can be accompanied by dark urine and pale stools.

3. Loss of Appetite and Nausea

Hepatitis can cause a loss of appetite, leading to a decrease in food intake. As a result, nausea and vomiting may also be experienced. These symptoms can contribute to weight loss and overall malnutrition if not addressed.

4. Abdominal Pain

Hepatitis often causes abdominal discomfort and pain in the upper right quadrant of the abdomen where the liver is located. This pain can range from mild to severe and may be accompanied by a feeling of fullness or bloating.

5. Joint and Muscle Pain

Some individuals with hepatitis may experience joint pain or muscle aches, which can be generalised or localised. This discomfort can vary in intensity and may interfere with everyday activities.

6. Fever and Flu-like Symptoms

Many people with hepatitis may initially present with flu-like symptoms such as fever, chills, and body aches. These symptoms can be mild or severe, and they may come and go intermittently.

7. Dark Coloured Urine and Pale Stools

Hepatitis can affect the production and flow of bile, leading to changes in urine and stool colour. Dark urine is a result of bilirubin buildup in the bloodstream, while pale stools occur due to decreased bilirubin excretion into the intestine.

8. Other Possible Symptoms

In some cases, hepatitis may also cause additional symptoms such as itchy skin, skin rashes, enlarged liver, enlarged spleen, and abdominal swelling.

1. History Taking:
A PA should gather information on risk factors, symptoms, exposure to infected individuals, previous medical conditions, and lifestyle choices. This information helps doctors narrow down the potential causes of hepatitis and guide further investigations.
2. Physical Examination:
A thorough physical examination is performed to identify any signs and symptoms associated with hepatitis. The PA should examine the abdomen for tenderness, enlargement of the liver or spleen, jaundice (yellowing of the skin and eyes), and other relevant findings that may indicate liver dysfunction.
3. Blood Tests:
These tests include:
a. Liver Function Tests (LFTs): LFTs measure various enzymes, proteins, and bilirubin levels in the blood. Elevations in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) indicate liver inflammation or damage.
b. Viral Serology: Serologic tests are used to detect antibodies and antigens specific to various hepatitis viruses (A, B, C, D, and E). These tests help determine the type of viral hepatitis and its stage.
c. Hepatitis A IgM antibody: Detects current or recent hepatitis A infection.
d. Hepatitis B surface antigen (HBsAg): Indicates current hepatitis B infection.
e. Hepatitis B core antibody (anti-HBc IgM): Detects recent hepatitis B infection.
f. Hepatitis C antibody (anti-HCV): Identifies past or ongoing hepatitis C infection.
4. Imaging Studies:
a. Ultrasound: Used to visualise the liver and evaluate its size, shape, and blood flow. It helps detect abnormalities such as cirrhosis, fibrosis, or the presence of masses.
b. CT scan or MRI: These advanced imaging techniques provide a more detailed view of the liver, helping to detect tumours, abscesses, cysts, or other abnormalities.
5. Liver Biopsy (specialist gastroenterologist):
In some cases, a liver biopsy may be recommended to further evaluate the extent of liver damage and determine the specific cause. This procedure involves obtaining a small sample of liver tissue for microscopic examination, which helps confirm the diagnosis and guide treatment decisions.

1. Antiviral medications (specialist management):
   NICE recommends antiviral therapy for eligible patients with chronic hepatitis B and C infections. The choice of treatment and its duration should be based on factors such as the severity of liver disease, viral genotype, and the individual's overall health.

2. Lifestyle Modifications:
   To minimise liver damage and improve overall health, NICE advises patients with viral hepatitis to make several lifestyle modifications. These include abstaining from alcohol consumption, maintaining a healthy diet, and engaging in regular exercise. Additionally, individuals should be counselled on the importance of practising safe sex and avoiding intravenous drug use to prevent transmission or further infection.

3. Vaccination:
   NICE guidelines highlight the significance of hepatitis immunisation. Vaccination against hepatitis A and B is recommended for individuals at increased risk, including healthcare workers, people who inject drugs, men who have sex with men, and those with chronic liver disease. Vaccinating household contacts and close contacts of hepatitis-infected individuals is also recommended.

4. Monitoring and Surveillance:
   NICE emphasises the importance of regular monitoring and surveillance of patients with chronic hepatitis. This includes assessing liver function tests, viral load levels, and screening for hepatocellular carcinoma (HCC) using ultrasound.

5. Specialist Referral:
   NICE suggests that patients with acute hepatitis presenting with severe symptoms or signs of liver failure should be urgently referred to a specialist. Similarly, individuals with chronic hepatitis who require specialised interventions like liver transplantation should be referred to an appropriate transplant centre. Timely referrals ensure that patients receive the necessary care and expertise for their specific condition.

Jump to other topics below: