Liver Diseases - Hepatitis

"Hepatitis" means inflammation of the liver. Functionally, it means dysfunction of the liver--usually from infection, although toxic substances such as chlorine can cause it, too. Hepatic dysfunction is a serious condition because of the important things the liver does, from detoxifying substances in preparation for elimination to participating in the immune system, the clotting cascade, the turnover of bilirubin, and myriad other functions. A sick liver means a very sick person.

The Infectious Hepatitides

The infectious hepatitides (plural of hepatitis) are characterized by one of six strains--A, B, C, D, E, and G.

Each causes liver damage via the inflammatory process. These letter assignments are an ongoing process, as there haven't always been so many letters, and we can be assured that more letters are yet to come. Currently, we're up to the letter "G."

HEPATITIS A and B: Hepatitis A (formerly called "infectious hepatitis") and Hepatitis B (formerly called "serum hepatitis") are both ancient diseases. (Hepatitis B has been identified in a 3,000-year-old mummy.)

There are vaccinations that protect from Hep A and Hep B.

• A: Hepatitis A is an acquired acute disease contracted via a fecal-oral route (person-to-person or consuming contaminated food or water). It is similar to Hep E in that both Hep A and Hep E are acute infections and are contracted from the fecal-oral route. (The others are from bodily fluids.)

Hep A usually runs its course and resolves spontaneously.

Treatment is supportive.

• B: Hepatitis B. is contracted via contamination with infected bodily fluids. Although Hep B is an ancient disease, the first identified Hep B epidemic was in the 19th Century.

Hepatitis B has two forms:

1. acute and
2. chronic.

The acute form can progress--rarely--to "fulminant" hepatitis, which has a high mortality.

Persons who recover from Hep B do not eliminate all of the virus, such that they remain carriers and are considered still infectious. Depending on when a person gets it, the likelihood of converting from acute hepatitis to chronic hepatitis goes up the younger the person is at the time of contracting it.

It is associated with hepatitis D. [SEE BELOW]

Treatment is supportive.

 

 

HEPATITIS C: Hepatitis C, although discovered in 1988, is now a major cause of liver cirrhosis, liver cancer, and the most common cause of both liver-related death and the need for liver transplantation.

It is usually transmitted by exposure to infected blood. It can also be transmitted via the perinatal route in expectant mothers.

It has an acute as well as a chronic form. The acute form is self-limited but leads to chronic infection, which progresses to cirrhosis, liver cancer, and the need for a transplant.

Most patients with Hep C complain of fatigue.

It is treated with antiviral medication.

HEPATITIS D, E, G: The hepatitides D through G were all discovered around the same time as the discovery of Hep C, over a time span of 20 years.

• Hep D is a defective virus closely related to the Hep B virus. It cannot replicate without the presence of Hep B, so anyone with Hep D is always dually infected with both Hep B and Hep D. The course of Hep D ranges from inactive carrier state to acute liver failure. It can be transmitted by poor hygiene with exposure through the mucosa or insignificant breaks in the skin.

Like its co-morbidity, Hep B, treatment is supportive.

• Hep E is a cause of acute hepatitis with a significant mortality rate in the third world, where it is endemic. Besides liver complications, it also can present with blood disorders, thyroiditis, kidney and pancreatic disease, and neurological abnormalities. It can persist as a chronic Hep E infection in immunocompromised patients. Unless there was travel or residency outside of the USA, such as in Asia, India, or North Africa, Hep E is not one of the frequent hepatitides encountered.

Management is mainly supportive.

• Hep G is related to Hep C and its proof of causing hepatitis is elusive. Anguishing over Hep F and G is probably not warranted in the field. (The same goes for Hep E unless there was travel or residency outside of the USA, such as Asia, India, or North Africa.)

Is there a Hep F? This is a hypothetical virus still being pursued. It is also called Toga virus.

Associated Hepatitides:

A and E are both from fecal-oral route.

All others are from contamination of bodily fluids.

B and D: D needs B to replicate.

IMMUNIZATION AGAINST HEPATITIS

There are vaccines that can prevent hepatitis A and B and also a combination vaccine that guards against hep A and B, but not for types C, D, or E.

 

Signs and Symptoms of Hepatitis

• Fever
• Jaundice
• Scleral icterus
• Hepatomegaly
• RUQ abdominal pain (possible referred pain to right shoulder)
• Fatigue and malaise
• Arthritis
• Angioedema

 

In the Field

In the field, you won't be able to tell one hepatitis letter from another, but will focus on support of ABC (airway, breathing, and circulation), patient comfort, and transport.

►Call to Action: PROTECT YOURSELF:

In the field, the mainstay protocol in dealing with persons with possible hepatitis is personal protective equipment (PPE) to separate you from bodily fluids (Hep B, C, D, E, G).

Also, in some cases of hepatitis, the buildup of toxins from the disease can cause violent, combative, and bizarre behavior, so one must be vigilant of unexpected physical injury that risks exposure their bodily fluids.

►Call to Action: TRANSPORT. Regarding the patient, the mainstay of dealing with someone suspected of having hepatitis is transported, because these persons are extremely sick and it is impossible to know which hepatitis is being encountered without appropriate laboratory investigation.

In the field, any RUQ pain associated with jaundice requires transport to address complications of acute disease.

Certainly, jaundice, bleeding, right upper quadrant abdominal pain, or cognitive impairments can include hepatitis in the differential diagnoses, but these are all transport-worthy conditions better served by evaluation, diagnosis, and management at an appropriate facility. When in doubt, transport!