Hepatitis A and E: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:31

Hepatitis A and E viruses are RNA viruses typically transmitted by the fecal-oral route that infect hepatocytes, causing inflammation of the liver.
Acute infection with both viruses usually causes a mild, self-limiting illness, although manifestations can range from asymptomatic infection to severe, life-threatening disease.
Hepatitis E can also persist in the body and progress into a chronic infection. Now, if your patient presents with a chief concern suggesting Hepatitis A or E infection, perform an ABCDE assessment to determine if they are unstable or stable.

Unstable patient0:31–1:38

If the patient is unstable, first stabilize their airway, breathing, and circulation. Next, obtain IV access and put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry.
Finally, if needed, don’t forget to provide supplemental oxygen!Now here’s a clinical pearl to keep in mind! In rare cases, acute Hepatitis A or E infection can lead to fulminant hepatic failure, causing an unstable presentation that requires acute management.
Patients may present with manifestations of hepatic encephalopathy, like impaired mental status and asterixis; coagulopathy, with INR greater than or equal to 1.5; and elevated AST, ALT, and bilirubin.
In addition to stabilization efforts, you should consult the surgical team, since these patients need rapid transfer to a liver transplant center!Okay, now let’s go back to the ABCDE assessment and focus on stable patients.

Stable patient 1:38–2:42

If your patient is stable, first obtain a focused history and physical examination, and order labs, including CMP, CBC, and INR.
History typically reveals symptoms, such as malaise, loss of appetite, nausea, vomiting, and right upper quadrant pain. Your patient will also likely report a risk factor for fecal-oral transmission, such as exposure to contaminated food or water; travel to areas with poor hygiene and sanitation; and direct contact with an infected person.
Next, the physical exam will typically reveal elevated temperature, jaundice, and hepatomegaly, sometimes with tenderness to palpation of the liver.
Finally, labs will usually show elevated ALT, AST, and bilirubin. In some individuals, you might even notice elevated INR and thrombocytopenia.
With these findings, you should suspect acute Hepatitis A or E infection!Now, once you suspect hepatitis A or E infection, your next step is to order additional labs to detect the infection.

Antibody/PCR testing2:42–3:13

First, you could check whether or not your patient has IgM antibodies against hepatitis A and E viruses, which is the first type of antibody to appear during an acute infection.
Alternatively, you could order a reverse-transcriptase polymerase chain reaction, or RT-PCR, to detect viral RNA of hepatitis A and E viruses in the blood.
Okay, now, if both IgM antibody tests and both RT-PCR tests are negative, consider an alternative diagnosis! Remember that several other viruses can present similarly, including hepatitis B, C, and D, as well as cytomegalovirus and Epstein-Barr virus!

Alternative Diagnosis3:13–3:33

On the flip side, if your patient has positive anti-Hepatitis A Virus IgM and positive Hepatitis A Virus RT-PCR, diagnose acute hepatitis A Infection!

Acute Hepatitis A3:33–4:46

Hepatitis A infection is generally a self-limited condition, with full clinical recovery and clearance of lab markers within 3 to 6 months.
So, in this case, management primarily relies on supportive care with oral or IV fluids, as well as nutritional support.
If needed, offer symptomatic treatment with medications for nausea and vomiting. Next, counsel your patient on lifestyle modifications, such as avoidance of hepatotoxins, including acetaminophen and alcohol.
Your patient should also receive the Hepatitis B vaccine series once recovered from acute Hepatitis A infection. Finally, don’t forget to offer post-exposure prophylaxis for unvaccinated contacts!
For unvaccinated contacts who are immunocompetent, you should give the HepA vaccine and may consider giving immune globulin; while unvaccinated contacts who are immunocompromised or have chronic liver disease should receive both immune globulin and HepA vaccine simultaneously in different anatomic sites.On the flip side, if your patient has positive anti-Hepatitis E Virus IgM and positive Hepatitis E Virus RT-PCR, diagnose acute hepatitis E infection!

Acute Hepatitis E4:46–5:35

Generally, hepatitis E virus infection is also a self-limited condition, with symptoms resolving within 2 to 6 weeks, but keep in mind that jaundice and elevated bilirubin might persist for more than 3 months!
Again, the management primarily relies on supportive treatment with oral or IV fluids and nutritional support. Again, if needed, you can provide symptomatic treatment for nausea and vomiting.
These individuals should also avoid hepatotoxins, such as acetaminophen and alcohol, and receive vaccinations for Hepatitis A and B once recovered.
After diagnosing acute hepatitis E and initiating treatment, your next step is to assess your patient for immunocompromised status.

Assess for Immunocompromised Status5:35–6:15

This is because patients with compromised immune systems are less likely to clear the hepatitis E virus effectively. While organ transplant recipients are most commonly affected, you should also assess for other conditions associated with immune compromise, such as HIV infection.
If your patient is not immunocompromised, then continue current management until the acute infection resolves. On the other hand, if they are immunocompromised, monitor for persistent infection by rechecking Hepatitis E Virus RT-PCR at 6 months.
If Hepatitis E Virus RT-PCR is negative, the Acute Hepatitis E infection has resolved, and no further treatment is necessary.On the other hand, if the Hepatitis E Virus RT-PCR is positive at 6 months, diagnose chronic Hepatitis E infection, which could progress to cirrhosis if untreated.

Acute Hepatitis E infection Resolved6:15–7:05

Treatment of chronic hepatitis E infection starts by reducing the dose of immunosuppressive medications. In some cases, this alone may allow the immune system to clear the virus, but many patients will also require treatment with the antiviral medication ribavirin.
Additionally, don’t forget to order periodic labs, such as CMP, to monitor hepatic function; and Hepatitis E Virus RT-PCR, to monitor viral RNA levels until evidence of the virus is undetectable.Alright, as a quick recap… Hepatitis A and E are RNA viruses transmitted by the fecal-oral route that infect hepatocytes, causing liver inflammation.

Review7:05–7:51

Hepatitis A Virus is diagnosed with a positive IgM and RT-PCR. Management includes supportive treatment, lifestyle modifications, and vaccination.
On the other hand, if Hepatitis E Virus IgM and RT-PCR are positive, diagnose acute Hepatitis E infection, and initiate the same treatment measures.
In addition, assess whether your patient is immunocompromised and at risk for progression to chronic Hepatitis E infection.
For immunocompromised patients, repeat Hepatitis E Virus RT-PCR at 6 months, and if positive, diagnose chronic hepatitis E.