Viral Hepatitis - Hyperexcision

Last updated: November 9, 2024

Viral hepatitis is a viral infection of the liver. It is most commonly caused by the hepatitis virus, but other viruses e.g. CMV, EBV and Yellow Fever can cause hepatitis. There are 5 types of hepatitis virus: Hepatitis A Virus (HAV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Hepatitis D Virus (HDV), and Hepatitis E Virus (HEV). HAV and HEV are spread fecal-oral. HBV, HCV, and HDV are spread parenterally (all body fluids are potentially infective) and can cause chronic infection. HEV can only cause chronic infection in immunosuppressed individuals. Only HAV and HBV have effective vaccination. All chronic hepatitis (B, C and D) increase the risk of hepatocellular carcinoma.

	HAV	HBV	HCV	HDV	HEV
Group	Enterovirus	Hepadnavirus	Flavivirus	Incomplete virus	Calicivirus
Nucleic Acid	RNA	DNA	RNA	RNA	RNA
Incubation (weeks)	2-4	4-20	2-26	6-9	3-8
Spread	Fecal-oral	Parenteral	Parenteral	Parenteral	Fecal-oral
Acute or Chronic Hepatitis	Acute	Acute and Chronic	Acute and Chronic	Acute and Chronic (requires HBV)	Acute
Treatment	Support, self-limited	Support, Monotherapy if chronic, Follow-up for hepatocellular carcinoma	Combination therapy	Interferon alfa (limited success)	No specific treatment
Active immunization	Vaccine	Vaccine	No	Prevented by HBV Vaccine	No
Passive Immunization	Immune serum globulin	Hyperimmune serum globulin	No	–	No

Patient History
- Recent travel and other GI symptoms e.g. diarrhoea = Hepatitis A
- IV drug use and unprotected sexual contact = Hepatitis B and C
Signs and symptoms Prodromal symptoms usually precede jaundice
- Fever
- Malaise
- Anorexia
- Nausea
- Right Upper Quadrant pain
- Jaundice
- Dark urine (bilirubin is lost in urine)
- Light-colored stool (less bilirubin enters the intestines)
Differentials
- Alcohol or Drug-induced hepatitis: AST> ALT is usually alcohol or drug-induced hepatitis
Investigations
- Liver Function Tests
  - Elevated AST
  - Elevated ALT
  - ALT > AST
  - Elevated Bilirubin
- Complete Blood Count
  - Elevated WBC
- Hepatitis Serology (Hepatitis A, C, D, and E): best initial test to determine the etiology
- PCR-RNA for hepatitis C: represents activity level (viral load) for hepatitis C
- PCR-DNA for hepatitis D: represents viral load for hepatitis B
Treatment of acute hepatitis
- Supportive
- Avoid alcohol and elective surgery
- Immunize contacts
Treatment of chronic hepatitis B
- Monotherapy with Tenofovir, Lamivudine, Adefovir or Entecavir
  - Started > 6 months of postitive surface antigen
  - Long term monitoring of LFTs based on ALT, AST
  - Monitor for hepatocellular carcinoma via ultrasound
  - Interferon is falling out of favour
Treatment of chronic Hepatitic C
- Genotype → Combination therapy Sofosbuvir/velpatasvir or glecaprevir/pibrentasvir
- Long-term monitoring of HCV RNA which indicates response
  - Monitoring starts at diagnosis and is continued for 12 weeks
  - Treatment is discontinued at 12 weeks is cured or continued indefinitely if chronic (80% of patients)
Definitive cure of chronic hepatitis (cirrhosis)
- Transplantation
Vaccination
- HAV vaccine is given to travelers, those living in crowded areas, and oral-anal sexual contact
  - IM dose gives immunity for 1 year
  - 20 years immunity if a booster is given at 6-12 months
- HBV vaccine is given to everyone
Post-exposure prophylaxis
- HAV post-exposure prophylaxis
  - Vaccinate if > 12 mos
  - HAV immune globulin if immunocompromised or chronic liver disease
- HBV post-exposure prophylaxis
  - HBV immune globulin is given after high risk exposure

Interpretation of Hepatitis A Serology

Test	Interpretation
Anti-HAV positive	Acute Hepatitis A

Interpretation of Hepatitis C Serology

Antibody	RNA	Interpretation
Ab-	HCV RNA +	Infection
Ab+	HCV RNA +	Infection
Ab +	HCV RNA –	Immunity

Interpretation of Hepatitis B Serology

Test	Interpretation
HBsAg positive	Active Infection
HBeAb positive	Infectious
IgM HBc positive	Early infection
IgG HBc positive	Immune, Exposed
IgG HBs positive	Immune

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

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