Viral Hepatitis

Hepatitis viruses cause liver disease as their chief or sole manifestation

Hepatitis A

Transmission

  • Faecal-oral spread
  • Linked to poor hygiene/overcrowding
  • Some cases imported and some clusters e.g. gay men and PWID but importance has declined in UK

Clinical features

  • Acute hepatitis, no chronic infection
  • Peak incidence of symptomatic disease in older children/young adults
  • Vaccination for those at risk e.g. travel vaccine

Hepatitis E

Transmission

  • Faecal-oral transmission in the tropics
  • Cases acquired in UK are thought to be zoonoses

Clinical features

  • Tropical genotype associated with severe disease in pregnant women
  • Some immunocompromised humans can get chronic infection
  • No vaccine yet available

Hepatitis D

  • Only found with Hepatitis B - exacerbates Hep B infection

Hepatitis B

Transmission

  • Sex
  • Mother to child
  • Blood to blood (unscreened transfusions, tattoos)

Risk factors

  • People born in areas of higher prevalence
  • Multiple sexual partners
  • PWIDs
  • Children of infected mothers

Clinical features

  • Chronic disease is more likely to result if first exposure is in childhood
  • Spontaneous cure is not uncommon, even after years of infection

Control

  • Minimize exposure - safe blood, safe sex, needle exchange etc.
  • Vaccinations - all children born August 2017 onwards, at-risk others
  • Post-exposure prophylaxis - vaccine and hyperimmune Hep B immunoglobin (HBIG)

Hepatitis C

Transmission + risk factors

  • Same as Hep B

Clinical features

  • Infection results in chronic infection in ~75% of cases
  • No vaccine - minimize exposure
  • Strongly associated with hepatocellular carcinoma
  • Once chronic infection is established, spontaneous cure is not seen

Clinical presentation

  • May be asymptomatic
  • Abdominal pain
  • Fatigue
  • Pruritis
  • Muscle and joint aches
  • Nausea and vomiting
  • Jaundice
  • Fever

Investigations

All hepatitis viruses

  • Serology - relevant IgM usually detectable by onset of illness

Hepatitis B

  • Serology
    • Hepatitis B surface antigen (HBsAg) present in blood of all infectious individuals, present for 6+ months in chronic infection
    • Hepatitis Be antigen (HBeAg) usually presents in highly infectious individuals
    • Hep B IgM more likely to be present in recently infected cases
    • Anti-HBs present in immunity (vaccine or past infection)
      • notion image
  • PCR
    • Hep B virus DNA presents in high titre in highly infectious individuals
    • Can be used to predict risk of chronic disease and monitor therapy

Hepatitis C

  • Serology
  • If serology positive → PCR (HCV RNA)
    • (+) serology but (-) PCR = past infection
    • (+) serology and (+) PCR = current infection

Management of chronic viral hepatitis

Antivirals

  • Chronic hep B - suppressive antiviral drug (more widely used) OR peginterferon alone (sustained cure possible in minority of cases)
  • Chronic hep C - choice of antiviral regime based on many factors; aim is >90% SVR
  • Cirrhotic patients at those at risk of complications treated as priority

Supportive Therapy

For symptomatic patients
  • Fever → Ibuprofen 400 mg 2x1 (don’t use Paracetamol, it is hepatotoxic)
  • Nausea & vomiting → Metoclopramide 10 mg 3x1 OR Domperidone 10 mg 3x1
  • Bloating → H2 blocker (Cimetidine 200 mg 3x1 OR Ranitidine 150 mg 2x1) OR PPI (Omeprazole 20 mg 1x1)
  • Hepatoprotector → Curcuma 1x1

Other

  • Vaccination
  • Decrease alcohol intake
  • Hepatocellular carcinoma awareness/screening
    • Serum AFT and USS
    • Even after SVR target reached in chronic hep C, carcinoma screening should continue