Acute Hepatitis A - Clinicals, Diagnosis, and Management

Gastroenterology

Clinicals - History

Fact Explanation
Low grade fever Inflammation in the liver release cytokines which reset the temperature set point in the hypothalamus at a higher level causing fever. Low grade fever
Inflammation in the liver release cytokines which reset the temperature set point in the hypothalamus at a higher level causing fever.
Yellowish discoloration of skin, sclera and mucous membranes Yellowish staining of the skin, sclera, and mucous membranes by bilirubin, a yellow-orange bile pigment due to dysfunction of the intra hepatic phase of bilirubin metabolism. Often manifest when the serum bilirubin level is greater than 2.5 to 3 mg per dL. Yellowish discoloration of skin, sclera and mucous membranes
Yellowish staining of the skin, sclera, and mucous membranes by bilirubin, a yellow-orange bile pigment due to dysfunction of the intra hepatic phase of bilirubin metabolism. Often manifest when the serum bilirubin level is greater than 2.5 to 3 mg per dL.
Dark colored urine Due to excessive passage of conjugated bilirubin and urobilinogen in urine which makes urine dark. Dark colored urine
Due to excessive passage of conjugated bilirubin and urobilinogen in urine which makes urine dark.
Pale stools Due to intra hepatic cholestasis which decreases the passage of bile into the gastrointestinal tract and which in turn reduces the level of stercobilin which is necessary to give normal color to the stools. Pale stools
Due to intra hepatic cholestasis which decreases the passage of bile into the gastrointestinal tract and which in turn reduces the level of stercobilin which is necessary to give normal color to the stools.
Pruritus Elevated levels of bile salts in the skin act as pruritogens. Pruritus
Elevated levels of bile salts in the skin act as pruritogens.
Anorexia Associated viremia and action of cytokines make the patient anorexic. (Characteristically smokers develops distaste for cigarettes). Anorexia
Associated viremia and action of cytokines make the patient anorexic. (Characteristically smokers develops distaste for cigarettes).
Fatigue/malaise The viremia causes the patient to feel unwell with non specific symptoms. Fatigue/malaise
The viremia causes the patient to feel unwell with non specific symptoms.
Nausea and vomiting Inflammatory mediators stimulate vomiting center in brain. So patients feel nausea and also vomit. Nausea and vomiting
Inflammatory mediators stimulate vomiting center in brain. So patients feel nausea and also vomit.
Right sided abdominal pain Inflammation of the liver will cause liver enlargement, which stretches the liver capsule generating pain. Right sided abdominal pain
Inflammation of the liver will cause liver enlargement, which stretches the liver capsule generating pain.
History of ingestion of food or water from an unsafe source. Hepatitis A virus is shed in the stool and is primarily spread by food or water contaminated with fecal matter. History of ingestion of food or water from an unsafe source.
Hepatitis A virus is shed in the stool and is primarily spread by food or water contaminated with fecal matter.

Clinicals - Examination

Fact Explanation
Increased body temperature Inflammation in the liver release cytokines which reset the temperature set point in the hypothalamus at a higher level causing increased body temperature. Increased body temperature
Inflammation in the liver release cytokines which reset the temperature set point in the hypothalamus at a higher level causing increased body temperature.
Jaundice/scleral icterus Due to deposition of bilirubin in the skin, sclera and mucous membranes. Jaundice/scleral icterus
Due to deposition of bilirubin in the skin, sclera and mucous membranes.
Tender hepatomegaly Diffuse inflammation of the liver causes moderate enlargement of the liver with smooth edges and stretching of the liver capsule producing tender hepatomegaly. Tender hepatomegaly
Diffuse inflammation of the liver causes moderate enlargement of the liver with smooth edges and stretching of the liver capsule producing tender hepatomegaly.
Mild splenomegaly Because of the immune hyperplasia as a response to viral infection. Mild splenomegaly
Because of the immune hyperplasia as a response to viral infection.

Investigations - Diagnosis

Fact Explanation
Serological tests - antibodies Anti hepatitis A virus IgM or four fold rise IgG in two different serum samples taken in the acute stage and convalescent phase of the illness will indicate presence of an acute hepatitis A virus infection. Serological tests - antibodies
Anti hepatitis A virus IgM or four fold rise IgG in two different serum samples taken in the acute stage and convalescent phase of the illness will indicate presence of an acute hepatitis A virus infection.
Liver enzymes - Aspartate transaminase (AST), Alanine transaminase (ALT), Alkaline phosphatase (ALP) Usually all these enzymes levels are elevated which indicates hepatocellular injury and precedes the appearance of jaundice. AST and ALT rise >500IU/L and ALT level will be higher than AST. Liver enzymes - Aspartate transaminase (AST), Alanine transaminase (ALT), Alkaline phosphatase (ALP)
Usually all these enzymes levels are elevated which indicates hepatocellular injury and precedes the appearance of jaundice. AST and ALT rise >500IU/L and ALT level will be higher than AST.
Serum bilirubin, Bilirubin in urine and urinary urobilinogen Usually bilirubin levels are normal during prodomal stage. Then it start to increase producing hyperbilirubinaemia and bilirubinuria. Serum bilirubin, Bilirubin in urine and urinary urobilinogen
Usually bilirubin levels are normal during prodomal stage. Then it start to increase producing hyperbilirubinaemia and bilirubinuria.
Full Blood Count Will show leucopenia with relative lymphocytosis. Full Blood Count
Will show leucopenia with relative lymphocytosis.
Hepatitis A virus RNA in blood or faeces Hepatitis A virus is a 27nm picornavirus with single stranded RNA genome. It replicates in the liver, excreted in bile and found in feces thereafter. During initial viremic phase it can be found in blood. Though it is not done routinely it helps definitive diagnosis when there is diagnostic uncertainty. Hepatitis A virus RNA in blood or faeces
Hepatitis A virus is a 27nm picornavirus with single stranded RNA genome. It replicates in the liver, excreted in bile and found in feces thereafter. During initial viremic phase it can be found in blood. Though it is not done routinely it helps definitive diagnosis when there is diagnostic uncertainty.
Liver biopsy Perform only when there is an uncertainty about the diagnosis. Liver biopsy
Perform only when there is an uncertainty about the diagnosis.

Investigations - Management

Fact Explanation
Prothrombin time Prolonged in sever cases such as fulminant hepatic failure. Prothrombin time
Prolonged in sever cases such as fulminant hepatic failure.

Management - Supportive

Fact Explanation
Bed rest Hepatitis A acute illness period usually doesnot last more than 2 months, therefore hospital admission is also not necessary but bed rest is usually advised. When the fever and jaundice have subsided patient can return to work or school. Bed rest
Hepatitis A acute illness period usually doesnot last more than 2 months, therefore hospital admission is also not necessary but bed rest is usually advised. When the fever and jaundice have subsided patient can return to work or school.
Antipyretics For fever. Paracetamol must use cautiously. Antipyretics
For fever. Paracetamol must use cautiously.
Analgesics To relieve pain. Analgesics
To relieve pain.
Antiemetics - metoclopromide For nausea and vomiting. Antiemetics - metoclopromide
For nausea and vomiting.
Cholestyramine For pruritus. Cholestyramine
For pruritus.

Management - Specific

Fact Explanation
Prevention 1)Practice proper hand washing techniques and maintaining good personal hygeine to stop faeco-oral transmissoion of the virus.
2) Using boiled water for drinking as the virus is killed by boiling water.
3) Immunization - inactivated hepatitis A virus vaccine for high risk groups(eg: travelers to endemic areas)
4) Post exposure prophylaxis - immunoglobulins within 2 weeks of exposure to household and institutional contacts.
5) Notification and contact tracing to prevent the spread of the disease.
Prevention
1)Practice proper hand washing techniques and maintaining good personal hygeine to stop faeco-oral transmissoion of the virus.
2) Using boiled water for drinking as the virus is killed by boiling water.
3) Immunization - inactivated hepatitis A virus vaccine for high risk groups(eg: travelers to endemic areas)
4) Post exposure prophylaxis - immunoglobulins within 2 weeks of exposure to household and institutional contacts.
5) Notification and contact tracing to prevent the spread of the disease.
Liver transplantation For patients who have developed fulminant hepatic failure. Liver transplantation
For patients who have developed fulminant hepatic failure.

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