Hepatitis

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Overview
Classification Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Alcoholic Hepatitis Autoimmune Hepatitis
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2], Usama Talib, BSc, MD [3]

Overview

Hepatitis refers to any injury to the liver that may result in inflammation. The etiologic agent could be infectious (almost always viral) or non-infectious. Depending on the disease course they could be classified as acute or chronic. Acute viral hepatitis are a spectrum of systemic inflammatory conditions that predominantly involve the liver. Hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), the HBV-associated delta agent or hepatitis D virus (HDV), and hepatitis E virus (HEV) are the most common viruses that may cause acute viral hepatitis. Alcoholic hepatitis and and non alcoholic steatohepatitis (NASH) are the most common non-infectious hepatitis. Many drugs and toxins may also result in hepatic injury. The common manifestation among hepatitis patients are, fever, jaundice, fatigue, abdominal pain, and hepatomegaly. Diagnosis is based on clinical manifestation and laboratory findings. In rare conditions liver biopsy is required for either diagnosis or treatment plan. In some cases disease may progress to chronic course and result in multiple complications such as, hepatocellular carcinoma (HCC), cirrhosis, or hepatorenal syndrome. In such conditions liver transplantation is the best treatment.

Classification

Hepatitis may be classified based on etiology in to two major category.

• Infectious causes
• Non-infectious causes

Infectious Causes

Infectious hepatitis classified according to viral agent in to 7 major category.

Viral Hepatitis                                                                                                                                                                                                                                                                                         Hepatitis A   Hepatitis B   Hepatitis C   Hepatitis D   Hepatitis E   Hepatitis F   Hepatitis G   Other                                                                                                                             • EBV hepatitis • CMV hepatitis • HSV hepatitis • Coxsackie B virus hepatitis

Non-Infectious Hepatitis

Non-infectious Hepatitis

Alcoholic hepatitis

Non-alcoholic steatohepatitis (NASH)

Alpha 1 antitrypsin deficiency

Autoimmune hepatitis

Obstructive hepatitis

Drug related hepatitis

Toxin related hepatitis

Ischemic hepatitis

•Gallstones •Tumors

•Isoniazid •NSAIDs •Beta-lactam antibiotics •Sulfa-containing drugs •HAART

Chemicals

Another classification scheme for hepatitis is based on duration of disease which may classified as Acute vs Chronic.

Differential diagnosis

Hepatitis must be differentiated from other conditions that may cause fever, fatigue, nausea and vomiting, and elevated liver enzymes.

Disease		Clinical manifestations					Laboratory findings			Additional findings
		Symptoms			Signs		Transaminitis (elevated AST and ALT)	Viral markers	Autoimmune markers
		Nausea & vomiting	Abdominal pain	Arthralgia	Jaundice	Hepatomegaly
Acute viral hepatitis	Hepatitis A	+++	++	+	+++	+	+++	HAV Ab	---	Fecal-oral transmission Usually acute and self limit Fever is usually present.
	Hepatitis B	+++	++	++	+++	+	+++	HBs Ag, HBc Ab, HBe Ag	---	Percutaneous transmission is the most common way. May cause acute hepatic failure or becomes chronic Fever is usually present.
	Hepatitis C	+++	++	++	+++	+	+++	HCV Ab	---	Percutaneous transmission is the most common way. Higher rate of chronic progression Associated with extra hepatic manifestation such as, cryoglobulinemia and membranoproliferative glomerulonephritis. Fever is usually present.
	Hepatitis E	++	++	+/-	++	+	+++	HEV Ab	---	Fecal-oral transmission May cause fulminant disease in pregnant women. Fever is usually present.
	CMV hepatitis	+/-	++	-	+	+	++	CMV-specific immunoglobulin (Ig)M antibody	--	Usually manifests as mononucleosis syndrome, fever is usually present.
	EBV hepatitis	+/-	++	-	+/-	+	++	Heterophile antibody test, monospot test	--	Systemic manifestations as mononucleosis syndrome, fever is usually present.
Autoimmune hepatitis		-	+	+/-	++	+	+++	---	ANA, ASMA, anti SLA/LP, ANCA, ALKM-1 antibodies	Liver biopsy may be required for diagnosis
Alcoholic hepatitis		+/-	+	-	+	-	AST>ALT	---	---	History of alcohol intake
Drug induced hepatitis		+/-	+	-	+	+	++	---	---	May cause either cholestatic or hepatocellular injury.