MC 3 Lesson 9

VIRAL HEPATITIS
(Hepatitis A, B, C, D, E)

Hepatitis is inflammation of the liver tissue. Some people or animals with hepatitis have no symptoms, whereas
others develop yellow discoloration of the skin and whites of the eyes (jaundice), poor appetite, vomiting,
tiredness, abdominal pain, and diarrhea. Hepatitis is acute if it resolves within six months, and chronic if it lasts
longer than six months. Acute hepatitis can resolve on its own, progress to chronic hepatitis, or (rarely) result in
acute liver failure. Chronic hepatitis may progress to scarring of the liver (cirrhosis), liver failure, and liver
cancer.

Hepatitis is most commonly caused by the virus hepatovirus A, B, C, D, and E. Other viruses can also cause
liver inflammation, including cytomegalovirus, Epstein–Barr virus, and yellow fever virus. Other common
causes of hepatitis include heavy alcohol use, certain medications, toxins, other infections, autoimmune
diseases, and non-alcoholic steatohepatitis (NASH). Hepatitis A and E are mainly spread by contaminated
food and water. Hepatitis B is mainly sexually transmitted, but may also be passed from mother to baby during
pregnancy or childbirth and spread through infected blood. Hepatitis C is commonly spread through infected
blood such as may occur during needle sharing by intravenous drug users. Hepatitis D can only infect people
already infected with hepatitis B.

Hepatitis A, B, and D are preventable with immunization. Medications may be used to treat chronic viral
hepatitis. Antiviral medications are recommended in all with chronic hepatitis C, except those with conditions
that limit their life expectancy. There is no specific treatment for NASH; physical activity, a healthy diet, and
weight loss are recommended. Autoimmune hepatitis may be treated with medications to suppress the immune
system. A liver transplant may be an option in both acute and chronic liver failure.

Worldwide in 2015, hepatitis A occurred in about 114 million people, chronic hepatitis B affected about 343
million people and chronic hepatitis C about 142 million people. In the United States, NASH affects about 11
million people and alcoholic hepatitis affects about 5 million people.[9][13] Hepatitis results in more than a
million deaths a year, most of which occur indirectly from liver scarring or liver cancer.[3][14] In the United
States, hepatitis A is estimated to occur in about 2,500 people a year and results in about 75 deaths. The word
is derived from the Greek hêpar (ἧπαρ), meaning "liver", and -itis (-ῖτις), meaning "inflammation".

HEPATITIS A AND E
Hepatitis A
Hepatitis A accounts for 20 percent to 25 percent of hepatitis cases in developed countries. Hepatitis A is
usually transmitted through the fecal-oral route, meaning a person somehow ingests contaminated feces from
an infected person. If an infected person did not wash his or her hands properly after using the bathroom, the
disease may spread from the person’s hands. The incubation period is two to six weeks, during which the
infected individual is contagious.
Another cause of hepatitis A is eating shellfish harvested from contaminated water. Developing countries
experience hepatitis A epidemics caused by drinking water contaminated with raw sewage.
The prognosis for hepatitis A patients is excellent with self-limiting course, and recovery is complete. About 85
percent of people with hepatitis A recover within three months, and almost all recover within six months. The
disease does not become chronic, and there are no long-term health implications.

Hepatitis E
Hepatitis E, also called enteric hepatitis (enteric means related to the intestines), is similar to hepatitis A, and
more prevalent in Asia and Africa. It is also transmitted through the fecal-oral route. It is generally not fatal,
though it is more serious in women during pregnancy and can cause fetal complications. Most patients with
hepatitis E recover completely.

Hepatitis A and E Symptoms

Hepatitis A and hepatitis E present with similar symptoms. The diseases may develop without any signs or
symptoms, or symptoms may be nonspecific. If you experience any of the symptoms below for more than two
weeks, make an appointment with a gastroenterologist.

There are three phases of hepatitis A and E, and symptoms may differ depending on the stage. Early in the
disease, called the prodromal phase, symptoms may include:
 Fever  Rash
 Joint pain or arthritis  Edema (swelling)

Symptoms of the next phase, the preicteric phase , include:

 Fatigue  Myalgia (muscle pain)

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  Anorexia  Cough
 Nausea and/or vomiting  Abdominal pain and/or diarrhea
 Fever  Dark urine and light stool color

During the icteric phase :

 Jaundice (yellowing of the skin and whites of the eyes) develops
 Anorexia, nausea and vomiting may worsen
 Irritated skin lesions may develop
 Other symptoms may subside

Hepatitis A and E Diagnosis

The diagnosis phase of hepatitis A and E includes:
 History and physical examination  Blood tests

History and Physical Examination

A diagnosis begins with comprehensive physical exam, during which you describe your symptoms and medical
history. Perhaps more than other diseases, the diagnosis of hepatitis A and E is largely dependent on medical
history. Your doctor will pay close attention to your particular risk factors and physical exam.

You will be asked about:

 Recent travels  Medications
 Sexual activity  Exposure to water or shellfish that may
 Intravenous drug use have been contaminated by sewage

Blood Tests
Hepatitis A: A blood test will reveal certain antibodies in your blood, called anti-HAV IgM. These antibodies
indicate whether you were infected with hepatitis A. The peak levels occur early in the infection and persist for
about four to six months.

Hepatitis E: Your doctor can diagnose hepatitis E by testing your blood and/or stool for certain antibodies, or by
detection of the virus.

Labs will also look for:

 The presence (or elevated levels of) certain enzymes in your blood
 High levels of bilirubin
 Low white blood cell count

HEPATITIS B
Hepatitis B is a viral infection that causes liver inflammation and damage. Inflammation is swelling that occurs
when tissues of the body become injured or infected. Inflammation can damage organs. Viruses invade normal
cells in your body. Many viruses cause infections that can spread from person to person. The hepatitis B virus
spreads through contact with an infected person’s blood, semen, or other body fluids. You can take steps to
protect yourself from hepatitis B, including getting the hepatitis B vaccine. If you have hepatitis B, you can take
steps to prevent spreading hepatitis B to others.

The hepatitis B virus can cause an acute or chronic infection.

Acute hepatitis B
Acute hepatitis B is a short-term infection. Some people have symptoms, which may last several weeks. In
some cases, symptoms last up to 6 months. Sometimes the body is able to fight off the infection and the virus
goes away. If the body isn’t able to fight off the virus, the virus does not go away, and chronic hepatitis B
infection occurs.
Most healthy adults and children older than 5 years who have hepatitis B get better and do not develop a
chronic hepatitis B infection.

Chronic hepatitis B
Chronic hepatitis B is a long-lasting infection. Your chance of developing chronic hepatitis B is greater if you
were infected with the virus as a young child. About 90 percent of infants infected with hepatitis B develop a
chronic infection. About 25 to 50 percent of children infected between the ages of 1 and 5 years develop
chronic infections. However, only about 5 percent of people first infected as adults develop chronic hepatitis B.
Those with chronic hepatitis B infection are at an increased risk for development of liver cancer. If you have
chronic hepatitis B infection, your doctor will monitor you closely with surveillance imaging (usually every six
months).

Hepatitis B Symptoms
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Hepatitis B may develop without any signs or symptoms, or symptoms may be nonspecific and short-lived.

Acute Hepatitis B Symptoms

There are three phases of acute hepatitis B infection, and symptoms may differ depending on the stage. Early
in the disease, called the prodromal phase, symptoms may include:
 Fever  Rash
 Joint pain or arthritis  Edema (swelling)

Symptoms of the next phase, the preicteric phase, include:

 Fatigue  Fever
 Myalgia (muscle pain)  Cough
 Anorexia  Abdominal pain and/or diarrhea
 Nausea and/or vomiting  Dark urine and light stool color

During the icteric phase:

 Jaundice (yellowing of the skin and whites  Irritated skin lesions may develop
of the eyes) develops  Other symptoms may subside
 Anorexia, nausea and vomiting may worsen

Chronic Hepatitis B Symptoms

Most patients with chronic hepatitis B are asymptomatic unless their disease progresses. Others might have
nonspecific symptoms, such as fatigue.
Some patients experience worsening of the infection and develop signs and symptoms similar to acute
hepatitis.

If patients with chronic hepatitis B progress to cirrhosis (when the liver becomes severely scarred) they will
develop signs and symptoms of liver failure, including:
 Jaundice  Encephalopathy (When the liver isn't
 Splenomegaly (an enlarged spleen) functioning well, it can't clear toxins from the
 Ascites (fluid retention in the abdomen) body. These toxins build up in the blood and
 Peripheral edema (swelling of extremities, affect brain function, leading to confusion.)
especially in the legs and feet)  Hepatocellular carcinoma (liver cancer)

Hepatitis B Diagnosis
Hepatitis B diagnosis begins by conducting a thorough physical examination, during which you describe your
symptoms and medical history. Other procedures used to diagnose hepatitis B:
 Diagnostic Tests  Liver Biopsy

Diagnostic Tests
A blood test will be ordered to look for abnormal levels of certain enzymes in your blood. Your doctor may
order a liver panel, which is a series of blood tests used to gauge liver function. It is also common for a patient
with hepatitis B to have a low white blood cell count, so your doctor may also request a complete blood count.
If the blood tests show the presence of hepatitis B surface antigen (HBsAg) for longer than six months, that is a
sign of chronic hepatitis B.
There are also non-invasive imaging tests that your doctor may order to estimate the amount of scar tissue in
the liver (called fibrosis), which results from liver inflammation over time. These tests are ultrasound or
magnetic resonance imaging (MRI) elastography.

Liver Biopsy
During a liver biopsy, liver tissue is removed and sent to a pathology lab for analysis to determine if you have
hepatitis B and how much scar tissue is present.
It may be necessary if:
 Other tests were inconclusive
 Your symptoms were atypical
 Your doctor found evidence of chronic liver disease

HEPATITIS C
Hepatitis C is a viral infection that causes liver inflammation and damage. Inflammation is swelling that occurs
when tissues of the body become injured or infected. Inflammation can damage organs.
Viruses invade normal cells in your body. Many viruses cause infections that can be spread from person to
person. The hepatitis C virus spreads through contact with an infected person’s blood.

Hepatitis C can cause an acute or chronic infection.

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Although no vaccine for hepatitis C is available, you can take steps to protect yourself from hepatitis C. If you
have hepatitis C, talk with your doctor about treatment. Medicines can cure most cases of hepatitis C.

Acute hepatitis C
Acute hepatitis C is a short-term infection. Symptoms can last up to 6 months. Sometimes your body is able to
fight off the infection and the virus goes away.

Chronic hepatitis C
Chronic hepatitis C is a long-lasting infection. Chronic hepatitis C occurs when your body isn’t able to fight off
the virus. About 75 to 85 percent of people with acute hepatitis C will develop chronic hepatitis C.

Early diagnosis and treatment of chronic hepatitis C can prevent liver damage. Without treatment, chronic
hepatitis C can cause chronic liver disease, cirrhosis, liver failure, or liver cancer.

Hepatitis C Symptoms
Hepatitis C may develop without any signs or symptoms, or symptoms may be nonspecific and short-lived.
There are three phases of hepatitis C, and symptoms may differ depending on the stage.

Early in the disease, called the prodromal phase , symptoms may include:
 Fever  Rash
 Joint pain or arthritis  Edema (swelling)

Symptoms of the next phase, the preicteric phase , include:

 Fatigue  Fever
 Myalgia (muscle pain)  Cough
 Anorexia  Abdominal pain and/or diarrhea
 Nausea and/or vomiting  Dark urine and light stool color

During the icteric phase :

 Jaundice (yellowing of the skin and whites  Anorexia, nausea and vomiting may worsen
of the eyes) develops  Irritated skin lesions may develop
 Other symptoms may subside

Hepatitis C Diagnosis
Often, patients with hepatitis C do not experience any symptoms. Many are diagnosed after routine blood
works shows abnormal liver enzymes. Sometimes, patients are tested because of their risk factors, such as
exposure to needles or a history of blood transfusions.

To diagnose hepatitis C, we may run the following tests:

 Blood Tests  Liver Biopsy

Blood Tests
The hepatitis C antibody is found in almost every patient with hepatitis C. However, the antibody takes weeks
or even months to develop, so if you are tested early after exposure, a false negative may result.

If the blood test is positive for hepatitis C antibody, we will confirm the findings with a sensitive test that can
detect even minute amounts of hepatitis C in the blood. This test is called a PCR-based test.

Liver Biopsy
During a biopsy, some of your liver tissue is removed and sent to a pathology lab for analysis. A liver biopsy is
an invasive procedure that carries some risk but allows your doctor to determine the exact nature and severity
of your condition.

Sometimes, a biopsy can be helpful when deciding how to treat the disease. For example, if the biopsy is close
to normal, you may decide to postpone treatment. If the biopsy shows extensive disease, you may choose to
begin treatment immediately.

HEPATITIS D
Hepatitis D is a viral infection that causes liver inflammation and damage. Inflammation is swelling that occurs
when tissues of the body become injured or infected. Inflammation can damage organs. Viruses invade
normal cells in your body. Many viruses cause infections that can spread from person to person.
The hepatitis D virus is unusual because it can only infect you when you also have a hepatitis B virus infection.
In this way, hepatitis D is a double infection. You can protect yourself from hepatitis D by protecting yourself
from hepatitis B by getting the hepatitis B vaccine.

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Hepatitis D spreads the same way that hepatitis B spreads, through contact with an infected person’s blood or
other body fluids.
The hepatitis D virus can cause an acute or chronic infection, or both.

Acute hepatitis D
Acute hepatitis D is a short-term infection. The symptoms of acute hepatitis D are the same as the symptoms
of any type of hepatitis and are often more severe.19 Sometimes your body is able to fight off the infection and
the virus goes away.

Chronic hepatitis D
Chronic hepatitis D is a long-lasting infection. Chronic hepatitis D occurs when your body is not able to fight off
the virus and the virus does not go away. People who have chronic hepatitis B and D develop complications
more often and more quickly than people who have chronic hepatitis B alone.20

How do hepatitis D and hepatitis B infections occur together?

Hepatitis D and hepatitis B infections may occur together as a coinfection or a superinfection. People can only
become infected with hepatitis D when they also have hepatitis B.

Coinfection
A coinfection occurs when you get both hepatitis D and hepatitis B infections at the same time. Coinfections
usually cause acute, or short-term, hepatitis D and B infections. Coinfections may cause severe acute
hepatitis. In most cases, people are able to recover from and fight off the acute hepatitis D and B infections
and the viruses go away. However, in less than 5 percent of people with a coinfection, both infections become
chronic and do not go away.

Superinfection
A superinfection occurs if you already have chronic hepatitis B and then become infected with hepatitis D.
When you get a superinfection, you may have severe acute hepatitis symptoms. Up to 90 percent of people
with a superinfection are not able to fight off the hepatitis D virus, and develop chronic hepatitis D.20 As a
result, these people will have both chronic hepatitis D and chronic hepatitis B.

How common is hepatitis D?

Hepatitis D is more common in other parts of the world, including Eastern and Southern Europe; the
Mediterranean region and Middle East; parts of Asia, including Mongolia; Central Africa; and the Amazon River
basin in South America.
Hepatitis D infection occurs only in people who have hepatitis B. People are more likely to have hepatitis D in
addition to hepatitis B if they are injection-drug users
have lived with or had sex with someone who has hepatitis D are from an area of the world where hepatitis D is
more common.

Complications
Acute hepatitis D. In rare cases, acute hepatitis D can lead to acute liver failure, a condition in which the liver
fails suddenly. Although acute liver failure is uncommon, hepatitis D and B infections are more likely to lead to
acute liver failure than hepatitis B infection alone.

Chronic hepatitis D. Chronic hepatitis D may lead to cirrhosis, liver failure, and liver cancer. People who have
chronic hepatitis B and D are more likely to develop these complications than people who have chronic
hepatitis B alone.20 Early diagnosis and treatment of chronic hepatitis B and D can lower your chances of
developing serious health problems.

Cirrhosis. Cirrhosis is a condition in which the liver slowly breaks down and is unable to work normally. Scar
tissue replaces healthy liver tissue, partly blocking the flow of blood through the liver. In the early stages of
cirrhosis, the liver continues to work. As cirrhosis gets worse, the liver begins to fail.

Liver failure. Also called end-stage liver disease, liver failure progresses over months or years. With end-stage
liver disease, the liver can no longer perform important functions or replace damaged cells.

Liver cancer. Having chronic hepatitis B and chronic hepatitis D increases your chance of developing liver
cancer. Your doctor may suggest blood tests and an ultrasound or other type of imaging test to check for liver
cancer. Finding cancer at an early stage improves the chance of curing the cancer.

Symptoms
Most people with acute hepatitis D have symptoms, which may include:
 feeling tired  pain over the liver, in the upper part of the
 nausea and vomiting abdomen
 poor appetite  darkening of the color of urine
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  lightening of the color of stool  yellowish tint to the whites of the eyes and
skin, called jaundice

In contrast, most people with chronic hepatitis D have few symptoms until complications develop, which could
be several years after they were infected. Some symptoms of cirrhosis include:
 weakness and feeling tired  swelling of the ankles, called edema
 weight loss  itching skin
 swelling of the abdomen  jaundice

What causes hepatitis D?

 The hepatitis D virus (HDV) causes hepatitis D. The hepatitis D virus spreads through contact with an
infected person’s blood or other body fluids. Contact can occur by:
 sharing drug needles or other drug materials with an infected person
 having unprotected sex with an infected person
 getting an accidental stick with a needle that was used on an infected person
 The hepatitis D virus rarely spreads from mother to child during birth.