Acute Hepatitis

DR WAQAS MANZOOR
SENIOR REGISTAR AL TIBRI MEDICAL
COLLEGE AND HOSPITAL
 Anatomy Of Liver
• Liver is dark Reddish Brown Organ that weighs about 3
pounds.

• The liver is located in the upper right-quadrant portion of

the abdominal cavity, beneath the diaphragm.

• The liver consists of 2 main lobes.

• Both are made up of 8 segments that consist of 1,000

lobules (small lobes).
• Small lobules are connected to small ducts that
connect with larger ducts to form the common
hepatic duct.

• The common hepatic duct transports the bile

made by the liver cells to the gallbladder and
duodenum via the common bile duct
 Blood Supply
• 2 distinct sources that supply blood to the
liver

• Recieves 70% of its Blood Supply and 40 %

of its oxygen from portal vein.

• 30% of its blood supply and 60% of its

oxygen from hepatic Artery
 Function Of Liver
• Production of bile, break down fats in the
small intestine during digestion.

• Production of certain proteins for blood

plasma.

• Production of cholesterol to help carry fats

through the body.
• Conversion of excess glucose into glycogen for
storage and to balance and make glucose as
needed.

• Conversion of poisonous ammonia to urea.

• Clearing drugs and other poisonous substances

from Blood.

• Regulating blood clotting

• Resisting infections by making immune factors.

 Hepatitis
Definition:
Term used to describe a wide variety of
conditions characterized by acute
inflammation of the hepatic parenchyma
or injury to hepatocytes resulting in
elevated liver function indices.
 Acute/Chronic Hepatitis
•Hepatitis is classified as

•Acute or chronic

•If the inflammation or hepatocellular injury lasts for less than six months,
characterized by normalization of the liver function tests, it is called Acute
hepatitis.

• If the inflammation or hepatocellular injury persists beyond six months, it is

termed
chronic hepatitis.
 Causes of Acute Hepatitis
• Infections (Viral )(Most Common)

• Non Infectious
Drug Induced
Alcohol
Autoimmune(PBC,PSC,Autoimmune Hepatitis)
Pregnancy Related
Metabolic( Hemochromatosis,wilson,NAFLD)
Metastatic
 Acute Viral Hepatitis
• Hepatotropic viruses:
– Hepatitis A Virus(HAV)
– Hepatitis B Virus (HBV)
– Hepatitis C Virus (HCV)
– Hepatitis D Virus (HDV)
– Hepatitis E Virus (HEV)

• Nonhepatotropic virus:
– Epstein-Barr virus (EBV)
– Cytomegalovirus (CMV)
– Herpes simplex virus (HSV)
• Nonhepatotropic virus:
– Epstein-Barr virus (EBV)
– Cytomegalovirus (CMV)
– Herpes simplex virus (HSV)
– Coxsackievirus
– Adenovirus
– Dengue virus
– Coronavirus-19(COVID-19
 Drugs and Toxins
–Acetaminophen (Paracetamol)

–Antibiotics, AntiTuberculous and Anticonvulsants

– Statins, NSAIDs, Herbal/Nutritional supplements

–Mushroom (Amanita phalloides), 

• Hepatitis A Is most common form of acute viral
Hepatitis worlwide.

• The incidence of Hepatitis A virus (HAV) has

significantly decreased by approximately 95% since
the introduction of the hepatitis A vaccine in 1995.

• The past five years have seen a small increase in

cases mostly from isolated food-related outbreaks,
persons who use drugs, and the homeless
population.
• Worldwide, the World Health Organization
estimates that 1 in 3 people have been infected
with either HBV or HCV.

• In high endemic areas, HAV has affected more than

90% of children by age 10.

• Again the majority of cases are in low-income

region
 Symptoms
• Depends on Underlying Cause.

• Symptoms ranging from

Asymptomatic elevated liver function tests

to Acute liver failure requiring liver
transplantation
 Common Symptoms
• Fever,
• Malaise or fatigue,
• Loss of appetite , vomiting,
• Diarrhea, and abdominal pain.
• Yellowish discoloration of sclera or skin
(jaundice),
• Dark-colored urine, and light-colored
stools
Jaundice
 Examination Findings
• Jaundice
• Signs of acute encephalopathy,
• seizures
• Bleeding Diathesis
• Hypotension and other
manifestations related to multiple
organ failure.
 Investigations
• Complete Blood Count

• Liver Function Tests

• Prothrombin Time

• Serum Albumin
 Investigations as per Specific Etiologies

• HAV IgM Antibodies

• HEV IgM Antibodies

• HBcIgM Antibodies

• Serum Ceruloplasmin
• ANA,AMA,ASMA

• Drug Levels

• Ultrasound Abdomen (for cholestasis)

• Doppler Ultrasound for Hepatic Veins and Portal

Vein

• Liver Biopsy
 Markers Suggestive of Hepatocellular
Injury
• Elevation of serum transaminases such as
• Aspartate aminotransferase (AST), also called serum
glutamic-oxaloacetic transaminase (SGOT)

• Alanine aminotransferase (ALT), also called serum

glutamic pyruvic transaminase (SGPT).
 Elevated Aminotransferses
• Acute Severe Elevation (ALT more than AST)
(greter than 1000u/l)
• Acute Viral Hepatitis
• Drug Induced
• Ischemic Hepatitis
• Acute Biliary Obstruction
• Acute Budd Chairi syndrome
• Autoimmune Hepatitis
 Elevated Aminotransferses

• Mild Elevation(ALT more than AST)(less

than 150u/l)
• Chronic Viral hepatitis
• Hemochromatosis
• Alpha 1 antitrypsin Deficiency
• Steatosis
Markers Suggestive of Cholestatic Injury

•  Elevation in alkaline phosphatase (AP)

and
• Gamma-glutamyl transferase (GGT)

• can be secondary to various intra-hepatic or

extrahepatic causes.
 Managment
• The management of acute hepatitis depends on the specific
etiological factor.

• Hepatitis A and E are the most common infectious causes of

acute hepatitis and usually have a self-limited clinical course,
resolving in 2 to 4 weeks with supportive treatment (that
includes IV fluids, antiemetics, and symptomatic treatment)
• Patients should avoid the use of alcohol and
other potentially hepatotoxic medications and
over the counter supplements

• They should also receive education about

reducing the risk of transmission of infection
to others.
 Acute Viral Hepatitis A
• Caused by Non Enveloped RNA Virus.

• Transmitted by Feco Oral Route .

• Risk Factors includes

• Travel to endemic areas ,

• Homosexuals,
• Those Inject Drugs,
• Household or Daycare Contacts
• Incubation Period is 30 days (4weeks).

• Symptoms
(Jaundice, fever, malaise,vomitings,Diarrhae)

• Prolonged Cholestatic Hepatitis

• Relapsing hepatitis

• Examination: Jaundice, Tender Hepatomegaly

• Diagnosis: HAV IgM Antibodies

• Treatment: Supportive
 Persons at High risk for HAV Infection
• Healthy person travelling to endemic areas
• Homosexuals
• IV Inject Users
• HIV Positive persons
• Persons with Chronic Liver Disease
• Those Infected with Family Members

These All High risk group persons should be vaccinated for

Hepatitis A
Vaccines for Hepatitis A are
HAVRIX (0,6-12 months) TWINRIX (0,7,21-30days)
VAQTA (0,6-18 moths)
 Acute Viral Hepatitis E
• Caused by Non Enveloped RNA Virus

• 8 Genotypes

• Zoonotic Transmission to Humans

through Wide Range Hosts (Swine,cats, rats, Pigs)

• Transmitted by feco oral route through contaminated

water.
• Incubation Period is 2 to 10 weeks

• Symptoms:

(Jaundice, fever, malaise,vomitings,Diarrhae)

• Examination: Jaundice, Tender Hepatomegaly

• Diagnosis: HEV IgM Antibodies

• HEV RNA PCR

• Treatment: Supportive
• Acute Hepatitis E infection in pregnancy can lead to acute Liver
failure with High Mortality .

• HEV Vaccine Useful for

• Traverlers to high endemic areas ,

• Persons with Chronic liver Disease
• Pregnant women
• Immunosupressed Persons
 Prevention
• Hepatitis A:
• Vaccinate for High Risk Groups.

• Drinking Clean Water

• Strict Attention to Sewage Disposal

 Prevention
• Hepatitis E:
• Vaccinate for High Risk Groups.

• Drinking Clean Water

• Strict Attention to Sewage Disposal

• Zoonotic Transmission Can be Avoided Thru proper

Cooking of pork and avoidance of undercooked
Meat
 Complication
• Although rare, the most serious complication of
acute hepatitis is progression to Acute Liver Failure
(ALF)

ALF is characterized by 2-3 times increase in

• Serum transaminases
• Hyperbilirubinemia
• Coagulopathy and
• Rapid onset of hepatic encephalopathy in patients
without any prior liver disease
• Approximately 45 to 55% of patients with ALF
recover spontaneously.

• About 25% need a referral for a liver

transplant

• The rest 25% succumb

• Patients with acute liver failure should be

considered for liver transplant and should be
promptly transferred to transplant centers.
• THANKS