Causes of Hepatitis Overview
Common causes of hepatitis include:
- Viral hepatitis
- Autoimmune hepatitis
- Alcoholic hepatitis
- Toxic hepatitis
- Bacterial hepatitis
- Steatohepatitis
Viral hepatitis includes A, B, C, D, E, CMV, EBV. Usually, AST and ALT are elevated.
HAV hepatitis feco-oral route transmission. Vaccinate people at risk and give immunoglobulin to unvaccinated people 2 weeks prior to travel or within 2 weeks of exposure. will have positive anti-HAV IgM. Protective antibodies against HAV develop in response to infection and may persist for life; no specific antiviral therapy effective against HAV is currently available.
HBV hepatitis will have HBs Ag, HBe Ag, anti-HBcAb IgM and HBV DNA positive. Polyarteritis nodosa, cryoglobulinemia and membranous glomerulonephritis are known extrahepatic manifestations. HBV load correlates with risk of HCC development. Anti-HBV surface antibodies mean immunity. See our post on treatment of chronic hepatitis B.
HCV hepatitis is diagnosed with anti-HCV. Test for viral replication with PCR. It may present with cardiomyopathy, lymphoma, glomerulonephritis, cryoglobulinemia, vasculitis or porphyria cutanea tarda. 35% of patients will have normal transaminases. Genotype testing is needed to determine the treatment. See our post on treatment of chronic hepatitis C.
HDV hepatitis either co-infect with HBV or superinfect with HBV as it is a partial RNA. The later is more severe with worse outcome than co-infection. Pegylated interferon alpha is the generally recommended treatment for hepatitis D virus infection. Treatment should last for at least 48 weeks irrespective of the patient’s response.
HEV hepatitis is diagnosed with anti-HEV IgM and IgG. There is no specific treatment capable of altering the course of acute hepatitis E. Immunosuppressed people with chronic hepatitis E benefit from specific treatment using ribavirin, an antiviral drug. In some specific situations, interferon has also been used successfully.
CMV hepatitis affects mainly immunocompromised especially after liver transplant. Diagnosis is with CMV Ag, CMV PCR or CMV culture. Treatment included intravenous ganciclovir or oral valganciclovir.
EBV hepatitis (can be part of infectious mononucleosis) is usually asymptomatic except in immunocompromised patients especial post hepatic transplant. Diagnose with lymphocytosis and heterophile antibodies, if negative, can proceed with EBV PCR. (Symptomatic EBV infection typically presents with tonsillitis, cervical lymphadenopathy predominantly posterior, and fever characteristic of infectious mononucleosis). Treatment for infectious mononucleosis hepatitis is usually supportive as it is generally self-limiting with no available effective EBV antiviral medications.
Autoimmune Hepatitis (AIH) Predominantly affects women (female to male ratio for type 1 AIH is 4:1; for type 2 AIH, it’s 10:1) Diagnosis by Autoantibodies: ANA, SMA, LKM-1, and SLA/LP and especially Elevated IgG levels. Liver Biopsy: Interface hepatitis, periportal necrosis, Plasma cell infiltration and Hepatocyte rosettes. Treatment includes prednisone with or without azathioprine. For non-responders or those with severe side effects, options include mycophenolate mofetil, tacrolimus, or cyclosporine. Liver transplantation considered for patients progressing to liver failure.
Alcoholic Hepatitis characterized by AST double ALT or more. Liver biopsy shows steatosis, steatonecrosis and cirrhosis with both neutrophilic and lymphocytic infiltrates. Corticosteroids help with acute phases but be aware of contraindications. Pentoxifylline is the 2nd line in these cases.
Toxic Hepatitis presents with liver damage with history of certain substance ingestion or exposure like acetaminophen, alcohol, statins, antibiotics (like isoniazid, amoxicillin-clavulanate, nitrofurantoin, flucloxacillin, and trimethoprim-sulfamethoxazole), alcohol, industrial substance (carbon tetrachloride and vinyl chloride) and herbal supplements (kava, comfrey, ...).
Bacterial Hepatitis common causative bacteria are Leptospira, Salmonella, and Brucella. In severe cases, it can lead to liver abscesses or sepsis.
Steatohepatitis usually have elevated transaminases. Other nonspecific autoimmune and blood markers like ferritin might be also increased (not to confuse with other diagnosis).
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This post covers the points you need to know for your board exams as well as for teaching residents on the daily rounds. Medical professionals can't use the information here to treat their patients nor people can use the information her to treat themselves. If you are having any medical issues, contact your local emergency services. Please refer to your doctor for medical advice.