eMedicine Specialties > Emergency Medicine > Gastrointestinal

Viral Hepatitis: Follow-up

Author: Adrienne M Buggs, MD, FACEP, FAAEM,, Medical Director, Drug Enforcement Administration Training Academy Health Unit; Consulting Staff, Department of Emergency Medicine, Dewitt Army Hospital
Coauthor(s): Joseph K Lim, MD, Assistant Professor of Medicine, Director, Yale Viral Hepatitis Program, Section of Digestive Diseases, Yale University School of Medicine
Contributor Information and Disclosures

Updated: Jul 7, 2009

Follow-up

Further Inpatient Care

• Admit patients with hepatitis if they are showing any signs or symptoms suggestive of severe complications.
• Admit and evaluate for hepatic encephalopathy any patients with altered mental status, agitation, behavior or personality changes, or changes in sleep-wake cycle.
• Other admission criteria that are suggestive of severe disease include a PT prolonged greater than 3 seconds, bilirubin greater than 30 mg/dL, and hypoglycemia.
• Admit any patients with intractable vomiting, significant electrolyte or fluid disturbances, or significant comorbid illness; those who are immunocompromised; and those who are older than 50 years.

Further Outpatient Care

• Most patients with viral hepatitis can be monitored on an outpatient basis.
• Ensure that patients are able to maintain adequate hydration, and arrange close follow-up care with their primary care physicians.
• Instruct patients to refrain from using any potential hepatotoxins, such as ethanol or acetaminophen.
• Advise patients to avoid prolonged or vigorous physical exertion until their symptoms improve.
• Patients who are found subsequently to have hepatitis B virus or hepatitis C virus should be referred to a gastroenterologist or a hepatologist for further evaluation and treatment.

Deterrence/Prevention

• Hepatitis A
  • Improved sanitation, strict personal hygiene, and hand washing all may help to prevent transmission of HAV. The virus is inactivated by household bleach or by heating to 85°C for 1 minute.
  • Travelers to endemic areas should not drink untreated water or ingest raw seafood or shellfish. Fruits and vegetables should not be eaten unless they are cooked or can be peeled.
  • Certain inactivated viral vaccines have proven highly effective in preventing infection with HAV when given before exposure. These vaccines are not recommended for children younger than 2 years. In this age group, passively acquired maternal anti-HAV antibodies may decrease the immunogenicity of the vaccine.
  • Active immunization is recommended for health care workers, daycare personnel, and travelers to endemic areas. HAV vaccine also is recommended for sewage and wastewater workers and veterinarians working with imported nonhuman primates.
  • Passive postexposure immunization with immune globulin (dose 0.02 mL/kg) can protect persons exposed to HAV against clinical illness.¹⁰ Effectiveness is highest if given within 48 hours of exposure, but it may be helpful when given as far as 2 weeks into the incubation period. These patients also should receive active immunization with the HAV vaccine.
  • Immune globulin also is recommended before exposure for children younger than 2 years who are at risk of exposure to HAV.
• Hepatitis B
  • Active immunization with the 3-dose recombinant DNA HBV vaccine may prevent infection. Recommendations from the Centers for Disease Control and Prevention are available on hepatitis B vaccination.¹¹
  • Use of this vaccine has proven very successful in preventing infection among those at risk for HBV infection because of occupational exposure. Unfortunately, approximately 5-32% of those vaccinated do not develop an adequate antibody response to the HBV vaccine. Because of the nonresponse rate, many recommend that health care workers undergo postvaccination testing to confirm response within 1-2 months of receiving the vaccine. The duration of immunity conferred by the vaccine is not clearly known. Some authors recommend that a booster be given at 5-10 years.
  • This vaccine is recommended for all children as part of the usual immunization schedule as well as to infants born to mothers who are potentially infectious.
  • Nonimmunized persons who are close contacts of patients with acute HBV infection or who suffer percutaneous exposure to HBV, and infants born to potentially infectious mothers, should receive passive immunization with the HBV immune globulin in addition to active immunization.
  • Combined active and passive immunization in these settings is 80-95% effective in preventing transmission of HBV.
• Hepatitis C
  • No vaccine against HCV is available, and immune globulin is not proven to prevent transmission. In fact, immune globulin administration has been associated with HCV.
  • At the present time, the major means of preventing transmission is to prevent infected blood, organs, and semen from entering the donor pools.
• Hepatitis D
  • Since HDV can infect patients only when HBV is present, transmission of this disease can be decreased by effectively immunizing patients against HBV.
  • Unfortunately, at this time, no means is known of preventing HDV superinfection in patients with chronic HBV.
• Hepatitis E
  • No vaccine exists for prevention of HEV.
  • Administration of immune globulin does not prevent development of clinical disease.

Complications

• Acute/subacute hepatic necrosis
• Chronic active hepatitis
• Chronic hepatitis
• Cirrhosis
• Hepatic failure
• Hepatocellular carcinoma (HBV, HCV)

Prognosis

The prognosis varies with causative virus.

• Hepatitis A virus
  • Hepatitis A virus infection usually is mild and self-limited.
  • Infection confers lifelong immunity against hepatitis A virus.
  • Three rare complications include relapsing hepatitis, cholestatic hepatitis, and fulminant hepatic failure.
  • Mortality rate for hepatitis A virus hepatitis is 0.01%.
• Hepatitis B virus
  • Risk of chronic infection in infected older children and adults approaches 5-10%.
  • Patients with chronic hepatitis B virus infection are at risk for cirrhosis and hepatocellular cancer.
  • Fulminant hepatic failure develops in 0.5-1% of patients infected with hepatitis B virus; their case-fatality rate is 80%.
• Hepatitis C virus
  • Chronic infection develops in 50-60% of patients with hepatitis C virus.
  • Chronically infected patients are at risk for chronic active hepatitis, cirrhosis, and hepatocellular cancer.
  • Chronic hepatitis C virus infection is the leading indication for liver transplant in the United States.
  • Chronic hepatitis C virus infection is responsible for 10,000 deaths each year in the United States.
• Hepatitis D virus
  • Patients with chronic hepatitis B virus who are co-infected with hepatitis D virus also tend to develop chronic hepatitis D virus infection.
  • Chronic co-infection with hepatitis B virus and hepatitis D virus often leads to rapidly progressive subacute or chronic hepatitis with as many as 70-80% of these patients eventually developing cirrhosis.
• Hepatitis E virus
  • Hepatitis E virus infection usually is mild and self-limited.
  • Case-fatality rate reaches 15-20% in pregnant women.
  • Hepatitis E virus infection does not result in chronic disease.

Patient Education

• Refer patients with infectious hepatitis to their primary care providers for further counseling specific to their disease, as the specific etiologic virus is unlikely to be known at time of discharge from the ED.
• Counsel patients regarding the importance of follow-up care to monitor for evidence of disease progression or development of complications.
• Advise patients in general to exercise meticulous personal hygiene including strict hand washing.
• Instruct patients not to share any articles with potential for contamination with blood, semen, or saliva, including needles, toothbrushes, or razors.
• Inform food handlers suspected of having HAV not to return to work until their primary care physician can confirm that they are no longer shedding virus.
• Instruct patients to refrain from using any hepatotoxins, including ethanol and acetaminophen.
• For excellent patient education resources, visit eMedicine's Hepatitis Center; Liver, Gallbladder, and Pancreas Center; and Public Health Center. Also, see eMedicine's patient education articles Hepatitis A; Hepatitis B; Hepatitis C; Cirrhosis; Immunization Schedule, Children; and Immunization Schedule, Adults.

Miscellaneous

Special Concerns

• Pregnancy
  • In general, none of the hepatitis viruses are known to be teratogenic.
  • Except in the case of HEV, the disease courses of the various hepatitis viruses are no different in pregnancy.
  • Treatment usually consists of supportive care. Patients with significant vomiting or dehydration may require admission for hydration as well as monitoring for fetal well-being and preterm uterine irritability.
  • Nonimmunized patients who are pregnant and exposed to HAV or HBV should receive active and passive immunization with the appropriate immune globulin and viral vaccine. Immune globulin, HBV immune globulin, HAV vaccine, and HBV vaccine all currently are approved for use during pregnancy.
  • Hepatitis A: HAV has an incidence of less than 1 per 1000 in pregnancy. HAV is not transmitted to the fetus in utero but may be transmitted to the neonate during delivery or during the postpartum period (fecal-oral route). Infants born to women infected with HAV during the third trimester should receive postexposure prophylaxis with immunoglobulin.
  • Hepatitis B: Acute infection with HBV occurs at a rate of 1-2 per 1000 pregnancies. In addition, 0.5-1.5% of pregnant women are chronic carriers of HBV. No evidence exists of transplacental infection; perinatal infection of the neonate usually occurs during delivery. Infants born to mothers who are chronic carriers of HBV or who acquire acute HBV infection during the third trimester should receive active and passive immunization. When these neonates receive HBV vaccine and immune globulin within 12 hours of delivery, the rate of vertical transmission decreases so that fewer than 5% of exposed neonates become chronic carriers.
  • Hepatitis C: The most common risk factor for HCV infection in pregnancy is history of substance abuse. Vertical transmission does occur, but the exact frequency of this occurrence is unknown.
  • Hepatitis D: Perinatal transmission rarely occurs.
  • Hepatitis E: The disease course of HEV may be more severe during pregnancy, with a high case-fatality rate, especially when the disease is contracted during the second or third trimester. Perinatal transmission occurs but with undetermined frequency. When vertical transmission of HEV does occur, it is associated with significant perinatal morbidity and death.
  • Alternatively, acute hepatitis occurring during pregnancy may also be caused by certain disease states of pregnancy. These conditions include HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), acute fatty liver of pregnancy, ruptured liver hematoma, and intrahepatic cholestasis of pregnancy.
• Drug-induced hepatitis
  • A large number of prescription medicines, drugs, and chemical agents are known to cause hepatotoxicity. Some agents cause hepatic damage directly, while others induce an autoimmune response against the liver. Damage can occur acutely or from chronic exposure. Moreover, drug-induced hepatitis follows viral hepatitis as a leading cause of fulminant hepatic failure in the United States.
  • Prescription medications that have been associated with drug-induced hepatitis include acetaminophen, amiodarone, amoxicillin-clavulanate, minocycline, nitrofurantoin, telithromycin, trimethoprim-sulfa, and trovafloxacin. Hepatitis induced by medications accounts for up to 5% of hospitalizations for hepatitis in the United States.
  • Various herbal preparations and toxic plants have been implicated in causing hepatitis. Some products that have been associated with significant hepatotoxicity include Comfrey, Germander, Jin Bu Huan, Kava, Ma Huang, Pennyroyal, Senna, and Valerian.
  • Several drugs of abuse are known to cause hepatic injury, including cocaine, methylenedioxymethamphetamine (ecstasy), toluene, trichloroethylene, phencyclidine, and ethanol. Patients hospitalized with hepatitis induced by ethanol have a reported mortality rate of 20-65%.
  • Occupational exposure to a variety of industrial agents may produce liver injury.
  • Acute hepatitis can result from a single large exposure to one of the hepatotoxic agents. These substances may be ingested, inhaled as toxic fumes, or absorbed through the skin. In general, once significant exposure has occurred, a 3-phase clinical syndrome of acute hepatic injury occurs.
    • During phase 1, patients develop gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain. They also may exhibit delirium, seizures, or coma representing associated central nervous system toxicity.
    • Between 24-48 hours after exposure, patients enter phase 2; they often experience resolution of their symptoms.
    • Phase 3 occurs 48-72 hours after exposure with the development of fulminant hepatic failure, often accompanied by renal failure. Some of these patients may deteriorate to the point that they face death or require emergent liver transplantation.
• Autoimmune hepatitis
  • Autoimmune hepatitis is a progressive inflammatory disease of the liver that occurs more commonly in young women and girls. The etiology is not known, but indications are that a certain environmental trigger incites an autoimmune response directed against the liver. These triggers might be viruses, chemicals, or other unknown agents.
  • The resulting chronic hepatitis eventually leads to fibrosis and cirrhosis. Autoimmune hepatitis also is associated with progression to primary hepatocellular carcinoma but not with the same frequency as viral hepatitis.
  • As with other forms of hepatitis, the clinical presentation of autoimmune hepatitis may vary.
  • Patients may be asymptomatic, or they may present with insidious onset of constitutional symptoms and jaundice. Occasionally, patients may develop acute onset of symptoms, significant jaundice, and elevated transaminases mimicking severe viral hepatitis.
  • Patients with autoimmune hepatitis have circulating autoantibodies in their serum and often have elevated serum globulins, gamma globulins in particular.
  • Other autoimmune diseases that may affect these patients include Graves disease, idiopathic thrombocytopenic purpura, pulmonary fibrosis, vitiligo, ulcerative colitis, glomerulonephritis, insulin-dependent diabetes mellitus, and myasthenia gravis.

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