Hepatitis B Clinical Presentation

Updated: Aug 01, 2018
  • Author: Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP, AGAF; Chief Editor: BS Anand, MD  more...
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Presentation

History

The spectrum of the symptomatology of hepatitis B disease varies from subclinical hepatitis to icteric hepatitis to fulminant, acute, and subacute hepatitis during the acute phase, and from an asymptomatic chronic infection state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) during the chronic phase.

Papular acrodermatitis, also recognized as Gianotti-Crosti syndrome, has been associated with hepatitis B, most commonly in children with acute infection. [36]

The following multisystem manifestations may occur in hepatitis B virus (HBV) infection:

  • Pleural effusion and hepatopulmonary and portopulmonary syndrome may occur in patients with cirrhosis

  • Diffuse intravascular coagulation may occur in patients with fulminant hepatitis

  • Myocarditis, pericarditis, and arrhythmia occur primarily in patients with fulminant hepatitis

  • Arthralgias and arthritic (serum sickness) subcutaneous nodules may also occur, but these are rare

  • Guillain-Barre syndrome, encephalitis, aseptic meningitis, and mononeuritis multiplex may occur in patients with acute hepatitis B

  • Pancreatitis may develop

  • Aplastic anemia is uncommon, and agranulocytosis is extremely uncommon

A variety of cutaneous manifestations have been recognized during the early course of viral hepatitis, including hives and a fleeting maculopapular rash. These various lesions are episodic, palpable, and, at times, pruritic. A discoloration of the skin can be identified after the resolution of the exanthem, particularly on the lower extremities. Women are more prone to developing cutaneous manifestations.

Acute phase

The incubation period is 1-6 months in the acute phase of hepatitis B infection. Anicteric hepatitis is the predominant form of expression for this disease. The majority of the patients are asymptomatic, but patients with anicteric hepatitis have a greater tendency to develop chronic hepatitis. Patients with symptomatology have the same symptoms as patients who develop icteric hepatitis.

Icteric hepatitis is associated with a prodromal period, during which a serum sickness –like syndrome can occur. The symptomatology is more constitutional and includes the following:

  • Anorexia

  • Nausea

  • Vomiting

  • Low-grade fever

  • Myalgia

  • Fatigability

  • Disordered gustatory acuity and smell sensations (aversion to food and cigarettes)

  • Right upper quadrant and epigastric pain (intermittent, mild to moderate)

Patients with fulminant and subfulminant hepatitis may present with the following:

  • Hepatic encephalopathy

  • Somnolence

  • Disturbances in sleep pattern

  • Mental confusion

  • Coma

  • Ascites

  • Gastrointestinal (GI) bleeding

  • Coagulopathy

Chronic phase

Patients with chronic hepatitis B disease can be immune tolerant or have an inactive chronic infection without any evidence of active disease; they are also asymptomatic.

Patients with chronic active hepatitis, especially during the replicative state, may complain of symptomatology such as the following:

  • Symptoms similar to those of acute hepatitis

  • Fatigue

  • Anorexia

  • Nausea

  • Mild upper quadrant pain or discomfort

If progressive liver disease is present, the following symptomatology may appear:

  • Hepatic decompensation

  • Hepatic encephalopathy

  • Somnolence

  • Disturbances in sleep pattern

  • Mental confusion

  • Coma

  • Ascites

  • GI bleeding

  • Coagulopathy

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Physical Examination

The physical examination findings in hepatitis B disease vary from minimal to impressive (in patients with hepatic decompensation), according to the stage of disease.

Patients with acute hepatitis usually do not have any clinical findings, but the physical examination can reveal the following:

  • Low-grade fever

  • Jaundice (10 days after appearance of constitutional symptomatology, lasting for 1-3 mo)

  • Hepatomegaly (mildly enlarged, soft liver)

  • Splenomegaly (5-15%)

  • Palmar erythema (rarely)

  • Spider nevi (rarely)

The physical examination of patients with chronic hepatitis B virus (HBV) infection can reveal stigmata of chronic liver disease such as the following:

  • Hepatomegaly

  • Splenomegaly

  • Muscle wasting

  • Palmar erythema

  • Spider angioma

  • Vasculitis (rarely)

Patients with cirrhosis may have the following findings:

  • Jaundice

  • History of variceal bleeding

  • Peripheral edema

  • Gynecomastia

  • Testicular atrophy

  • Abdominal collateral veins (caput medusa)

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