What is Hepatitis?
Acute hepatitis describes numerous conditions that involve sudden inflammation or damage to the liver tissue, leading to increased liver functionality. Hepatitis can be divided into two categories based on how long the inflammation or damage lasts. When the inflammation or liver injury lasts less than six months and the liver function tests normalize, it’s referred to as acute hepatitis. But if the inflammation or liver damage continues for more than six months, it’s known as chronic hepatitis.
The most common cause of acute hepatitis is a viral infection. However, there are many non-infectious causes as well that can lead to acute hepatitis. These can include reactions to certain medications (drug-induced hepatitis), heavy alcohol drinking (alcoholic hepatitis), immune system issues (autoimmune hepatitis, primary biliary cholangitis), problems with the bile duct (cholestatic hepatitis), liver issues related to pregnancy, shock, or spread of disease from another part of the body.
What Causes Hepatitis?
Several issues, both infectious and noninfectious, can lead to acute liver inflammation. The most common triggers are viral infections or drugs that inadvertently harm the liver. Here are some typical reasons for acute liver inflammation and failure:
Infectious causes include viruses that specially target the liver, called hepatotropic viruses. These are Hepatitis A, B, C, D, and E Viruses. Non-hepatotropic viruses, which don’t specialize in the liver but can still affect it, include Epstein-Barr virus, Cytomegalovirus, Herpes simplex virus, Coxsackievirus, Adenovirus, Dengue virus, and Coronavirus-19. Bacteria, fungi, and parasites can also cause acute liver inflammation.
Then there are inflammation triggers related to toxins and substances. Alcohol can lead to fatty liver disease, acute alcoholic hepatitis, or alcoholic cirrhosis. Drugs and toxins also make the list, with some causing liver damage in large doses, such as acetaminophen, commonly known as paracetamol. Others can cause harm regardless of the dose, which is a rare reaction typically related to antibiotics and anticonvulsants as well as other drugs and substances like statins, NSAIDs, herbal supplements, along with toxins from mushrooms, carbon tetrachloride, and sea anemone stings.
The list of causes also includes immune or inflammatory conditions like autoimmune hepatitis and bile duct diseases such as primary biliary cholangitis or primary sclerosing cholangitis.
There are metabolic or inherited conditions like nonalcoholic fatty liver disease, hemochromatosis, and Wilson’s disease.
Pregnancy can cause issues such as preeclampsia, acute fatty liver of pregnancy, and HELLP syndrome.
Conditions related to blood supply and blood vessels can cause liver inflammation too. These include shock from heart failure or widespread infection, low blood pressure, heatstroke, drug use like cocaine or methamphetamines, the rare Budd-Chiari syndrome where veins of the liver get blocked, and sinusoidal obstruction syndrome, another rare condition where the small veins inside the liver are blocked.
Your liver could also be under duress from miscellaneous causes such as cancer, eclampsia, HELLP syndrome, Reye’s syndrome, or complications from a liver transplant.
Risk Factors and Frequency for Hepatitis
Acute hepatitis, inflammation of the liver, can be caused by a variety of factors. Some of these include certain viruses like Hepatitis A, B, C, D and E, some other viral infections, lifestyle choices such as drug misuse, and diseases including autoimmune conditions. It’s found that viral infections and drug-induced liver damage are the most common causes of acute hepatitis and acute liver failure.
Rates of these viral hepatitis cases usually vary based on the region’s income level, with fewer cases reported in high-income areas and more in low-resource areas. Since the introduction of vaccines for Hepatitis A and B, the number of cases has significantly decreased. However, we’ve seen a number of Hepatitis A cases come up from isolated food-related outbreaks, drug misuse, and among the homeless population. While for Hepatitis B, although less, it’s more common among those aged 40 and over due to factors such as drug misuse, multiple sex partners, and lack of prior vaccination.
In the last decade, cases of Hepatitis C have been on the rise, especially among those aged 20 to 40. This increase is believed to be due to drug misuse related to the opioid crisis and better disease monitoring strategies.
According to estimates from the World Health Organization, almost one in three people globally have been infected with either Hepatitis B or C. Additionally, in areas with high rates of hepatitis, over 90% of the children are found to be affected by Hepatitis A by the time they reach the age of 10. Most of these cases are reported in regions with less income.
Acute hepatitis can sometimes turn severe, leading to acute liver failure. This condition may require a liver transplant and is rarely reported. As most data comes from liver transplant centers, the cases could be underreported. For instance, patients who recover without any special treatment or do not have access to specialized centers might not be included.
In countries like the UK, US, and Australia, liver damage caused by over the counter pain-reliever acetaminophen accounts for 39 to 50% of acute liver failure cases, while viral hepatitis accounts for 7 to 15% of cases. However, in many parts of the world, especially in Japan, India, and Bangladesh, Hepatitis A, B, and E are significant contributors to acute liver failure cases.
Signs and Symptoms of Hepatitis
Acute hepatitis is a liver condition that can arise from different causes. It can present in various ways, from unnoticed changes in liver tests to severe liver failure that could need a liver transplant. Understanding the cause of acute hepatitis is crucial for managing it effectively. This involves looking into the patient’s illness duration and any recent travels. It’s also important to assess if the patient is involved in risk-increasing behaviors or habits, such as IV drug use, alcohol consumption, and sexual history. The patient’s history of receiving blood products and recent food intake should also be considered. When reviewing any medication use, it’s essential to include prescription drugs, over-the-counter drugs, common remedies that contain acetaminophen, multivitamins, and herbal supplements.
Patients with acute viral hepatitis usually have symptoms like fever, feeling unwell, fatigue, loss of appetite, vomiting, diarrhea, and abdominal pain. Some patients could notice a yellow tint in their eyes (icterus) and/or skin (jaundice), dark urine, and pale stools.
The physical signs observed in a patient with acute hepatitis depend on the cause of the condition. They can range from signs like icterus and jaundice to severe symptoms like seizures, bleeding problems, low blood pressure, and symptoms linked with the failure of multiple organs. Long-standing liver disease symptoms, like varicose veins around the naval, red blotches on skin, reddened palms, fluid-filled abdomen, hand contraction, breast enlargement in men, and liver-related mental illness, can appear in patients where an acute liver problem develops on underlying chronic liver disease.
Common symptoms of acute hepatitis include:
- Fever
- Feeling unwell
- Fatigue
- Loss of appetite
- Vomiting
- Diarrhea
- Abdominal pain
- Yellow coloration of the eyes and/or skin
- Dark urine
- Pale stools
Testing for Hepatitis
When checking for acute hepatitis, doctors need to tell it apart from chronic hepatitis. They use biochemical tests like AST, ALT, alkaline phosphatase, GGT, lactate dehydrogenase, bilirubin, PT/INR, and albumin to see how your liver is working. If these tests show any abnormalities, it means there’s damage to liver cells from either an infection or other causes. The results of these tests can give clues about the cause and severity of the liver damage.
Other conditions that could cause abnormal liver function tests include pregnancy, lactic acidosis, sepsis, cardiac dysfunction, and other non-liver related conditions. In testing, doctors are also looking for markers, signs in the body that could suggest problems. Here are some of these markers:
- An increase in serum bilirubin could suggest liver diseases because damaged liver cells or bile ducts can’t process it properly.
- A higher ammonia level usually means the liver isn’t functioning well enough to break it down. There are also markers for liver cell damage:
- Raised levels of certain enzymes like aminotransferases, AST, and ALT, suggest liver cell damage.
- If these enzymes are over five times the upper normal limit or more than 500 IU/L, it means there’s a lot of damage to liver cells. This is common in cases like acute hepatitis, severe liver damage from drugs like an overdose of acetaminophen, intense lack of blood supply to the liver, liver death, or very severe autoimmune hepatitis.
Slightly elevated enzyme levels could be a result of variety of liver damages or disorder. It also could be due to chronic hepatitis or non-liver related conditions.
- An increase in enzyme levels like alkaline phosphatase (AP) and gamma-glutamyl transferase (GGT) could mean the liver isn’t secreting bile properly, which is called cholestasis. This could be because of problems inside or outside the liver.
As for markers of liver function:
- Increased Prothrombin time (PT): If liver injury decreases vitamin K-dependent coagulation factors (II, VII, IX, X), PT goes up. A high PT/INR (more than 1.5) is a bad sign and might lead to an acute liver failure diagnosis.
- Decreased albumin: This isn’t specific to liver injury, but a lower level indicates an issue with liver function.
Though liver function tests give doctors a better idea about the cause and severity of any liver damage, further diagnostic tests may be necessary. The American College of Gastroenterology (ACG) has issued guidelines based on the degree of elevation of the ALT and AST. They recommend a series of tests and in the case of severe elevation an ultrasound examination could be useful.
In some cases, additional tests are recommended and even a liver biopsy might be necessary if the diagnosis isn’t clear.
Treatment Options for Hepatitis
The process of treating acute hepatitis relies heavily on identifying what specifically is causing damage to the liver cells. The most common infections leading to acute hepatitis are Hepatitis A and E. These often resolve themselves within 2 to 4 weeks with the right supportive care, which includes treatments like IV fluids and medications for nausea or other symptoms. Patients should also steer clear of alcohol and some medications and supplements that could harm the liver even more. Additionally, patients should learn how to reduce the risk of passing their infection to others.
On the other hand, a frequent non-infectious cause of acute hepatitis is due to over-consuming the pain reliever acetaminophen, which can lead to severe liver damage. It’s critical for patients showing signs of severe liver damage to be treated with N-acetylcysteine, a medication that can counteract acetaminophen poisoning, as soon as possible. This medication can be taken orally or through an IV, with specific dosages and timing.
It’s also suggested for patients with severe liver failure, excluding those caused by ischemia (restricted blood flow), to be treated with N-acetylcysteine, even if there’s no indication of acetaminophen overdose. Patients showing minor symptoms, unusual liver function tests, but normal liver production can generally be evaluated in an outpatient setting or referred to a liver specialist. If liver function remains abnormal but no cause is identified, a liver biopsy, a procedure to remove a small piece of liver tissue for examination, may be necessary.
Rarely, patients with acute hepatitis who also experience severe liver failure, characterized by confusion and blood clotting issues, should be assessed by a liver specialist for possible relocation to a liver transplant center. Certain evaluation tools, such as the King’s College Criteria, can help decide if a referral for a liver transplant is needed.
What else can Hepatitis be?
Aside from the previously mentioned causes of acute hepatitis, which result from direct damage to the liver cells, doctors should also consider other conditions that could cause secondary damage. These conditions could originate outside the liver or are not related to the liver at all. They include:
- Gallstones (medically known as choledocholithiasis)
- Cancer in the gallbladder or pancreas
- Cancer spreading to the liver from other parts of the body (liver metastases)
- Systemic infections that affect the whole body (sepsis)
- Low blood pressure throughout the body (systemic hypotension)
- Blood clot in the liver artery (hepatic artery thrombosis)
- Heart failure
It’s crucial for the physician to consider these possibilities to ensure an accurate diagnosis is made.
What to expect with Hepatitis
The outlook for acute hepatitis varies greatly and depends on what’s causing harm to the liver cells. Recognizing the cause of the acute hepatitis quickly and managing it appropriately is crucial to reduce the severity and risk of death.
Possible Complications When Diagnosed with Hepatitis
Acute hepatitis is a condition that can be very serious, although complications are rare. One of the most severe complications is called acute liver failure (ALF). This complication can lead to a significant increase in liver enzymes, excessive bilirubin in the blood, abnormal blood clotting, and a sudden onset of brain complications due to liver disease in patients who have never had liver issues before.
The chance of acute hepatitis turning into acute liver failure depends on the reason behind the person’s hepatitis. Estimates show that less than 1% of patients with acute hepatitis A and about 1% of patients with acute hepatitis B will develop ALF. On the other hand, 20 to 40% of patients with acute hepatitis E in developing countries and about 69% of patients with serious autoimmune hepatitis may progress to ALF. In rare conditions like Wilson’s disease, it causes only about 2% of acute liver failure cases.
In the US and much of Europe, most cases of ALF result from either the toxic effects of an over-the-counter drug called acetaminophen, or unpredictable drug reactions. These causes account for about 40 to 50% of cases. In less wealthy countries, viral infections are more often the cause. But, it’s not all bad news. Approximately 45 to 55% of people with ALF recover without any intervention, and 25% may need a liver transplant. Unfortunately, about 25% do not recover.
The specific reason behind the acute liver failure can also predict if the person will recover on their own. For example, patients who have liver failure due to an overdose of acetaminophen have a better chance of recovery, as about 75% of these patients recover spontaneously. But, if ALF is because of other causes, only about 40% recover on their own.
If a person has acute liver failure, it’s essential to think about the possibility of needing a liver transplant and getting them transferred to a transplant center. Doctors use various tools to determine the need for a liver transplant, such as the King’s College Criteria and the Model for End-Stage Liver Disease (MELD) Score.
Preventing Hepatitis
Vaccines for both hepatitis A and B have been around since the 1990s. These vaccines have significantly reduced the number of people getting these infections. Hepatitis A usually spreads through contact with infected feces and can be prevented by better food handling, purifying water, and improving cleanliness. To reduce the risk of catching hepatitis B and C, avoid injecting drugs and always practice safe sex.
Accidental swallowing of too much acetaminophen by kids can be prevented by storing the drug safely where kids can’t get to it and using packages designed to keep children from opening them. Also, for adults, understanding that many over-the-counter drugs contain acetaminophen can help prevent accidental overdoses.
If doctors can’t find out why a patient with mild symptoms and stable condition has acute hepatitis at first, they will need to monitor the patient to see if the liver tests return to normal or carry out further checks if the test results keep showing problems.