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Viral hepatitis

Fulminant Hepatitis, Infectious Hepatitis

What is it?

This describes a viral infection of the liver. There are at least seven distinct hepatitis viruses that may cause infection. The symptoms of infection are similar for the different viruses. But there are distinct routes of infection, as well as complications and prognosis, and the main diagnostic categories are described as viral hepatitis A, B, or C (see discussions for each specific type).

The infection can be spread by ingestion of contaminated food or water, and anal sexual practices. Occasionally, infection is spread in contaminated blood; health care workers are at high risk to infection from accidental needle pricks. Often, simultaneous infection occurs with multiple types of hepatitis viruses. In the US, acute viral hepatitis is commonly seen in American Indian reservations, in native Alaskan villages, and among international travelers. There are other endemic areas of viral hepatitis throughout the world.

How is it diagnosed?

History of hepatitis A is often of international travel, especially to areas with less stringent standards of water purification or food preparation; eating of seafood, especially shellfish; or anal sexual practices.

Spread of hepatitis B, C, D and G may be accomplished by exposure to contaminated blood, and during sexual intercourse with an infected person. The source of infection is often difficult to trace because of the extended (and variable) period between contraction of the virus and the appearance of disease symptoms.

Symptoms may occur suddenly or slowly. The initial symptoms are typically fatigue and weariness, followed by anorexia, nausea and upper abdominal pain. These early symptoms may be followed by headache, fever, influenza-like symptoms, arthralgia, rash, intermittent nausea or diarrhea. The duration of clinical symptoms varies between two to eight weeks.

Occasionally, acute viral hepatitis is marked by repeated relapses; this is especially true of hepatitis A or D infections. Acute viral hepatitis can progress to fulminant hepatitis in its most extreme form.

Physical exam may show jaundice and dark urine during the early phases of the illness, accompanied by lightening of the stools and generalized itching. Weight loss usually occurs, averaging five to fifteen pounds. The onset of fulminant hepatitis is marked by the appearance of abnormal behavior, drowsiness, confusion, sleepiness, and possibly coma. Deep jaundice, biochemical signs of liver failure and coagulation abnormalities are usually present.

Tests: Routine liver biochemical tests may be used to distinguish viral from nonviral hepatitis, but cannot discriminate between the different types of viral hepatitis. Antibodies to the various hepatitis viruses may be detected in the blood during active infection and for many subsequent months, even after liver enzyme levels return to normal. For hepatitis B and C viruses, the presence of specific antiviral antibodies in the blood is a diagnostic tool for monitoring the progression of the infection. In cases of fulminant or chronic hepatitis, a liver biopsy may be performed to evaluate the extent of liver disease.

How is it treated?

In most cases, acute forms of viral hepatitis (A, B, C and E) resolve without treatment. However, chronic hepatitis (B, C and D) requires treatment with various forms of medication. People with chronic Hepatitis C should have their blood monitored for any changes in the number of viral particles. When the number becomes very high, indicating they have a substantial amount of virus present, they will require treatments. These treatments are available in injection and pill form and may last several weeks or several months, with the nature of the treatment dependent upon the severity of infection. It is important to note that not every patient is a candidate for treatment, and the need for treatment is determined by a patient's physician.

Although there is no cure for these forms of hepatitis, medications can reduce copies of the virus to the point that they are undetectable. If the virus remains undetectable for six months after treatment is finished, the patient is considered to have a sustained virologic response and is unlikely to experience further liver problems. New drugs and drug combinations are being developed to help treat chronic hepatitis in individuals who do not respond to traditional hepatitis medications.

In extreme cases, damage to the liver may be so great that a liver transplant may be necessary. Patients with some forms of hepatitis may be unsuitable transplant candidates. For hepatitis B patients, a transplanted liver will probably become reinfected with the virus. Hepatitis C patients may also be reinfected, but the recurrence is mild and may not seriously damage the new liver for many years.

Medications

Rebetol (Ribavirin), Reglan (Metoclopramide), Famvir (Famciclovir)

What might complicate it?

The severity of acute viral hepatitis is influenced primarily by the type of virus and the immune status of the individual. If the individual is older, pregnant, or immunodeficient, the disease tends to be more severe, to last longer, and has a higher probability of becoming a chronic infection; chronic disease may lead to cirrhosis, liver cancer, or liver failure. Simultaneous infection with multiple types of hepatitis viruses may complicate the infection and contribute to the development of more serious disease.

Predicted outcome

Symptoms of acute viral hepatitis resolve two to eight weeks. Damage to the liver may heal within three to six months after the cessation of active viral infection. There are no expected long-term effects of uncomplicated acute viral hepatitis. Liver cancer may occur in hepatitis B and C. Fulminant hepatitis may result in death, unless liver transplantation can be performed quickly. The long-term impact of the transplantation will depend upon the health of the individual. Older individuals and those suffering from immunodeficiencies may experience greater difficulty in recovering from the surgery.

Alternatives

A number of other infectious agents, including other viruses, bacteria and yeast can cause hepatitis but the biochemical profile of the disease is different than with the hepatitis viruses. The demonstration of antibodies to hepatitis virus proteins is also diagnostic of acute viral infection.

Appropriate specialists

Gastroenterologist and infectious disease specialist.

Last updated 7 July 2021