Hepatitis A, B, C

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Original Editors - Emily Schmidt & Allyson Simmonds from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Hepatitis A is a contagious liver infection cause by the hepatitis A virus. It causes inflammation that affects your livers ability to function. It is the most common of the two hepatitis viruses enterically transmitted hepatitis viruses in the US and one of the two that is vaccine preventable.

Hepatitis C is an infection caused by a virus that attacks the liver and leads to inflammation. Most people who have the infection often do not know that they have the disease, and are often asymptomatic. It is considered to be among the most serious of the hepatitis viruses. About 80% of people who have the virus develop chronic hepatitis, and many people also can develop cirrhosis or even liver cancer.

Prevalence

About 3,600 cases of Hepatitis A are reported each year. However, since not all people are symptomatic, more people are infected than are diagnosed and reported.

Estimates for the prevalence of the Hepatitis B virus claim that more than one third of the world's population has been infected with 5% of the population being chronic carriers. Approximately 25% of all carriers will develop a serious liver diease, while there are over one million deaths due to the infection of the Hepatitis B virus.  According to the CDC, there were an estimated 43,000 new Hepatitis B infections in the United States 2007, with the number of actue infections significantly declining.  For chronic infections, estimates range from 800,000-1.4 million people in the United States.

Every year around 3-4 million people are infected with the Hepatitis C virus. About 150 million people are chronically infected and at risk of developing liver cirrhosis and even liver cancer. More than 350,000 people die from hepatitis C-related liver disease every year.

Characteristics/Clinical Presentation

Hepatitis A symptoms usually do not appear until 2-6 weeks after you have been exposed to the virus. They are usually mild, but can last up to several months (2-6 months), especially in adults. The symptoms include:
1. Dark urine
2. Fatigue
3. Itching
4. Loss of appetite
5. Low-grade fever
6. Nausea and vomiting
7. Pale or clay-colored stools
8. Jaundice
9. Abdominal pain
10. Headache
11. Diarrhea
12. Muscle Pain
It is important to note that not everyone will develop signs and symptoms of the virus.
A vaccination is recommended for children age 12-23 months and for adults who are at high risk for the infection.

Early on, Hepatitis C usually is asymptomatic. When signs and symptoms begin to set in, they are generally mild and flu-like. Associated signs and symptoms of hepatitis C include:
1. Fatigue
2. Fever
3. Nausea or poor appetite
4. Muscle and joint pains
5. Tenderness of your liver
6. Abdominal pain
7. Dark urine
8. Grey-coloured feces
9. Jaundice
10. Abdominal swelling
11. Itching
About 75-85% of recently infected people develop chronic disease and 60-70% of chronically infected people develop chronic liver disease. Also 5-20% develop cirrhosis and 1-5% die from cirrhosis or liver cancer.

Associated Co-morbidities

Some co-morbidities that may be associated with Hepatitis C include:
1. Diabetes
2. Obesity
3. HIV
4. ESRD
5. Maladaptive lifestyle habits
6. Poor quality of life
7. Liver Disease
8. Disorders of Lipid Metabolism
9. Non-traumatic joint Disorders
10. Non-specific chest pain
11. GI Disorders

Medications

There is no specific treatment for Hepatitis A. Rest is recommended when the symptoms are most severe. When in the acute stages it is recommended that you avoid any toxic substances to the live, including Tylenol.

Since HCV infects the blood and can lead to cirrhosis of the liver or liver cancer, the goal of medication is to prevent this from happening. Many patients with hepatitis C benefit from treatment with medications. The most common medication include antiviral medications including pegylated interferon alfa and ribavirin. Typically pegylated interferon alfa is receivied weekly through injections. Ribavirin is a capsule taken twice daily. Treatments are given fro 24-48 weeks. Two newer drugs that may be available for use for patients with genotype 1 are Telaprevir and Boceprevir. These medications do have several side effects, and therefore, patients need to be watched closely. Some of the side effects of the medications can include depression and flu-like symptoms. If patients develop cirrhosis or liver cancer, the patient may be a candidate for a liver transplant.

Diagnostic Tests/Lab Tests/Lab Values

A primary care physician will conduct a physical exam when looking for Hepatitis A Virus. During the physical exam, they may find that you have an enlarged and tender liver. Also, they will have you partake in blood tests. The blood tests will look at IgM and IgG antibody levels as well as liver enzymes. In both cases the antibody and enzyme levels will be raised. 

Blood tests are done to check for the Hepatitis C Virus. They specifically look at EIA assay to detect the hepatitis C antibody and the hepatitis C RNA assay to measure virus levels. Genetic testing can be done to check for the hepatitis C genotype. Six different genotypes exist. Most people have genotype 1 infection, which is the hardest to treat. Genotypes 2 and 3 are also common, but typically respond better to treatment. Tests can also be done to monior the amount of liver damage: albumin levels, liver function tests, and prothrombin time. A liver biopsy can also be done to assess liver damage.

Etiology/Causes

Hepatitis A is found mostly in the stools and blood of an infected person. It is spread primarily by person-to-person contact. You can contract this disease if:
1. You eat or drink food or water that has been contaminated by stools containing the hepatitis a virus
2. You come into contact with the stool or blood of a person who currently has the disease
3. A person with the disease does not wash his or her hands properly after using the restroom and touch other objects or foods
4. You participate in sexual practices that involve oral-anal contact
People who are at an increased risk for contracting the disease are
1. Travelers
2. Native people of America
3. Restaurant workers and food handlers
4. Children living in communities that have high rates of hepatitis
5. Children and workers in day care centers
6. People engaging in anal/oral sex with STDs or HIV
7. People with chronic liver disease
8. If you eat raw shellfish frequently
9. Laboratory workers who handle the live hepatitis a virus

Hepatits C is caused by the hepatitis C virus. It is spread when you come into contact with contaminated blood. It can be spread by:
1. Blood transfusions and organ transplants before 1992
2. Shared needles – injection drug use or those given with contaminated syringes and needle-stick injuries in health-care settings
3. Childbirth- it can be passed to the child by the mother
4. Sexual contact1- unprotected with a person who has hepatitis C
5. Long-term kidney dialysis
6. Have regular contact with blood-work
7. Share personal items such as toothbrushes and razoes with someone who has hepatitis C

Systemic Involvement

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Medical Management (current best evidence)

There is no specific treatment for Hepatitis A. Rest is recommended when the symptoms are most severe. People with acute hepatitis should avoid alcohol and any substances that are toxic to the liver such as Tylenol. Fatty foods that can cause vomiting should also be avoided during the acute phase. It is important to maintain comfort and an adequate nutritional balance as recovery can take several weeks up to a month. It is also important to constantly replaced fluids that you may be losing.
It is also important to try to prevent yourself from contracting the disease, if you do not have it, or prevent others from contracting the disease in any way possible. In order to do this you should avoid sexual activities if you have the disease, and avoid sexual activities with an individual who has Hepatitis A, as a condom does not offer adequate protection. Also, wash your hands thoroughly after using the toilet, whether you are infected or not. Refrain from preparing food for others while you are infected, as this is a way to pass the disease on. Also avoid unclean food or water, especially if traveling.
If you have been exposed to the disease and have not had it before or have not received the vaccine, ask your doctor or nurse about receiving either immune globulin or the Hepatitis A vaccine. Vaccines that protect against the virus are available and begin to protect you four weeks after receiving the initial dose. The 6-12 month booster is required for long-term protection. It is especially important that children age 12-23 months or adults at a high risk for contracting the virus get a vaccineii Also it is important for anyone one year of age and older traveling to or working in countries with high or intermediate prevalence of Hepatitis A (central or south America, Mexico, Asia), children and adolescents 2-18 who live in states or communities where routine vaccination has been implanted because of high disease prevalence, men who have sex with men, people who use street drugs, people with chronic liver disease, people who are treated with clotting factors, and people who work in HAV laboratories to get vaccinated for safety reasons.

Hepatitis C does not always require treatment. There are 6 genotypes of hepatitis C and they all respond differently to treatment. A good screening is required before starting the treatment to determine the most appropriate approach. Combination of antiviral therapy with interferon and ribavirin has been the most common form of treatment for hepatitis C. Interferon is not widely available globally and is not well tolerated depending on the genotype the patient presents with. Therefore, not all patients finish their interferon treatment. Although hepatitis C is considered to be curable, it is not always the case. Two new drugs have been developed that may be better tolerated and they are: telaprevir and boceprevir. However, mor etesting needs to be done to ensure that these new drugs lead to greater access and treatment globally.
If your liver has been severly damaged, a liver transplant may be an option. It is important to realize that a liver transplant is not the cure and the use of antiviral medications continues after the liver transplant takes place.
It is also recommended that people be careful not to take vitamins, nutritional supplements, or new over-the-counter medications without first discussing it with their primary care physician. It is important to avoid any substances that are toxic to the liver such as alcohol, as it can speed up the progression of the disease. It is also recommended that you receive a vaccination against hepatitis A and B.
Also, prevention can help avoid passing on the disease or contracting the illness. The risk of infection can be reduced by:
1. Unnesscessary and unsafe injections
2. Unsafe blood products
3. Unsafe sharps and waste collection and disposal
4. Use of illicit drugs and sharing injection equipment
5. Unprotected sex with hepatitis c infected people
6. Sharing of sharp personal items that may be contaminated with infected blood
7. Tattoos, piercings, and acupuncture performed with contaminated equipment

Physical Therapy Management (current best evidence)

A multifaceted approach is needed in the treatment of hepatitis A. No specific physical therapy is needed, as bed rest is the recommended form of treatment. Supportive therapy is also used to ensure the patient is comfortable and has an adequate nutritional balance. It is also important to remind the patient to refrain from the use of alcohol or intake of fatty substances.

With any other medical condition, it is important to teach people who have Hepatitis C the importance of stretching in order to stay flexible and it could help relieve some of the symptoms of muscle pain. It is also important for the patient to remain physically active in order to maintain the healthiest lifestyle possible and prevent the patient from developing secondary co-morbidities due to inactivity. During physical activity it is important to monitor the patient for signs and symptoms of fatigue.

Alternative/Holistic Management (current best evidence)

No alternative medicines have been proven to be helpful in preventing or treating the Hepatitis A Virus. One item of interest to researchers is milk thistle. Proponents of milk thistle, which is a herb, is used to treat jaundice and other liver disorders. Due to the lack of well-designed research studies, it is difficult to draw conclusions on the usefulness of this herb.

No alternative medicines have been proven to be helpful in preventing or treating the Hepatitis C Virus. One item of interest in the research is milk thistle. Proponents of milk thistle, which is a herb, can be used to treat jaundice and other liver disorders. Due to the lack of well-designed research studies, it is difficult to draw conclusions on the usefulness of this herb.

Differential Diagnosis

Some alternate diagnoses for Hepatitis A that could be made based on the presenting signs and symptoms could be:
1. Budd-Chiari Syndrome: uncommon condition induced by thrombotic or nonthrombotic obstruction to hepatic venous outflow. Hepatomegaly, ascites, and abdominal pain are characteristics of the disorder
2. Cytomegalovirus: resulting in fever of unknown origin, pneumonia, hepatitis, encephalitis, myelitis, colitis, uveitis, retinitis, and neuropathy
3. Other Hepatitis Virus'

Some differential diagnosis that may be associated with hepatitis C are:
1. Alcohol Liver Disease: Complications such as oesophageal or gastric variceal bleeding, ascites, coagulopathy, hepatic encephalopathy, and liver cancer are associated with the disease.
2. Hepatic Steatosis: Non-alcoholic hepatic steatosis, or non-alcoholic fatty liver disease, is the most common cause of chronic liver disease.
3. Haemochromatosis: An autosomal-recessive disorder of inappropriately increased dietary iron absorption and increased iron release from erythrophagocytosis; Presenting features include fatigue, arthralgias, and diabetes mellitus
4. Other Chronic Liver Dieases
5. Autoimmune Hepatitis: Autoimmune hepatitis is a chronic disease of unknown cause, characterized by continuing hepatocellular inflammation and necrosis and tending to progress to cirrhosis.
6. Cholangitis: an infection of the biliary tract with the potential to cause significant morbidity and mortality.
7. Viral Hepitis

Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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