Acute Hepatitis E

Gastroenterology

Clinicals - History

Fact Explanation
Outbreak of similar acute symptoms. Hepatitis E is commonly transmitted by the feco-oral route, often through contaminated water. As a result it's usually noticed in epidemics of varying population sizes. Outbreaks are more common in areas with poor sanitation. Outbreak of similar acute symptoms.
Hepatitis E is commonly transmitted by the feco-oral route, often through contaminated water. As a result it's usually noticed in epidemics of varying population sizes. Outbreaks are more common in areas with poor sanitation.
Maternal infection of Hepatitis E during pregnancy The pregnant women who are infected during the third trimester are at risk of lifelong chronic infection, and there is a risk of fetal transmission, fetal death and neonatal symptomatic or asymptomatic hepatitis as well. The risk of mortality in HEV infections in late pregnancy is very high. Maternal infection of Hepatitis E during pregnancy
The pregnant women who are infected during the third trimester are at risk of lifelong chronic infection, and there is a risk of fetal transmission, fetal death and neonatal symptomatic or asymptomatic hepatitis as well. The risk of mortality in HEV infections in late pregnancy is very high.
History of solid organ transplantation from a Hepatitis E antibody positive person. It has been reported that the recipients of solid organ transplantation are at risk of Hepatitis E infection. The recipients are managed with induced immunosuppression, so re-infection is an important contributing factor in chronic HEV state. History of solid organ transplantation from a Hepatitis E antibody positive person.
It has been reported that the recipients of solid organ transplantation are at risk of Hepatitis E infection. The recipients are managed with induced immunosuppression, so re-infection is an important contributing factor in chronic HEV state.
History of immunosuppression. i.e. HIV infection, Hematological diseases such as lymphomas. Re-activation of HEV and progress to chronicity is observed in immunosuppressed patients. Extra-hepatic manifestations also have been seen in immunocompromised individuals. History of immunosuppression.
i.e. HIV infection, Hematological diseases such as lymphomas. Re-activation of HEV and progress to chronicity is observed in immunosuppressed patients. Extra-hepatic manifestations also have been seen in immunocompromised individuals.
Asymptomatic incubation period Just like any other hepatotrophic viruses, HEV has an incubation period, and in this case ranging 15–60 days, with a mean of 40 days. Asymptomatic incubation period
Just like any other hepatotrophic viruses, HEV has an incubation period, and in this case ranging 15–60 days, with a mean of 40 days.
Flu-like prodrome The typical viral hepatitis have a non-distinctive flu-like prodrome before the onset of icteric phase. The common symptoms are malaise, fever, arthralgia, nausea and vomiting. Flu-like prodrome
The typical viral hepatitis have a non-distinctive flu-like prodrome before the onset of icteric phase. The common symptoms are malaise, fever, arthralgia, nausea and vomiting.
Jaundice Yellow discoloration of the skin and sclera is due to cholestasis following acute necro-inflammation of the liver. Jaundice
Yellow discoloration of the skin and sclera is due to cholestasis following acute necro-inflammation of the liver.
Dark urine Due to filtering of bilirubin into urine in cholestasis. Dark urine
Due to filtering of bilirubin into urine in cholestasis.
Pale stools Reduced levels of stercobilinogen in stools due to cholestasis. Pale stools
Reduced levels of stercobilinogen in stools due to cholestasis.
Abdominal pain. Most patients complain of epigastric pain. It's an acute, dull pain due to stretching of the liver capsule. Abdominal pain.
Most patients complain of epigastric pain. It's an acute, dull pain due to stretching of the liver capsule.
Generalized itching Pruritus is a common and disabling complication of cholestasis, There have been various theories proposed for the cause, deposition of bile salts in skin, and role of serotonin. Generalized itching
Pruritus is a common and disabling complication of cholestasis, There have been various theories proposed for the cause, deposition of bile salts in skin, and role of serotonin.
Acute polyarthritis or arthralgia. It's a systemic extrahepatic manifestation of HEV infection, and can be the initial presentation. Acute polyarthritis or arthralgia.
It's a systemic extrahepatic manifestation of HEV infection, and can be the initial presentation.
Acute epigastric pain that radiates to back, relieved by bending forward, shortness of breath or abdominal swelling, probably associated with mild fever and nausea/ vomiting. Features of acute necrotizing pancreatitis: Pancreatitis is a rare but life threatening extra-hepatic complication of HEV infection. This happens in the early stage of infection and since it occurs in non-fulminant infection, the prognosis is favorable. Acute epigastric pain that radiates to back, relieved by bending forward, shortness of breath or abdominal swelling, probably associated with mild fever and nausea/ vomiting.
Features of acute necrotizing pancreatitis: Pancreatitis is a rare but life threatening extra-hepatic complication of HEV infection. This happens in the early stage of infection and since it occurs in non-fulminant infection, the prognosis is favorable.
Purpuric rash Due to thrombocytopenia as a result of virus associated hemo-phagocytic syndrome. It is proposed that there is an immunological basis for it. Purpuric rash
Due to thrombocytopenia as a result of virus associated hemo-phagocytic syndrome. It is proposed that there is an immunological basis for it.
Neurological features. There have been reported combination of various neurological symptoms i.e. inflammatory polyradiculopathy ,Guillain-Barre syndrome, mononeuritis, encephalitis, proximal myopathy and amyotrophy . These are consequences of extra-hepatic manifestations of the infection. Some patients improve completely, some partially and some don't improve at all. Neurological features.
There have been reported combination of various neurological symptoms i.e. inflammatory polyradiculopathy ,Guillain-Barre syndrome, mononeuritis, encephalitis, proximal myopathy and amyotrophy . These are consequences of extra-hepatic manifestations of the infection. Some patients improve completely, some partially and some don't improve at all.
Asymptomatic Asymptomatic and anicteric infections have been reported. Asymptomatic
Asymptomatic and anicteric infections have been reported.

Clinicals - Examination

Fact Explanation
Mild fever Milder fever with other features is usually present since it causes an inflammation; hepatitis. Mild fever
Milder fever with other features is usually present since it causes an inflammation; hepatitis.
Yellow discolouration of sclera and skin. It is due to cholestasis following acute necro-inflammation of the liver. Yellow discolouration of sclera and skin.
It is due to cholestasis following acute necro-inflammation of the liver.
Peripheral stigmata of chronic liver disease The deviation from the usual self-limiting milder acute hepatitis, HEV infection progresses to chronic hepatitis in immunodeficient patients. The expected peripheral stigmata are liver palms, spider nevi, Dupuytren's contractures, ecchymosis, parotid swelling. Peripheral stigmata of chronic liver disease
The deviation from the usual self-limiting milder acute hepatitis, HEV infection progresses to chronic hepatitis in immunodeficient patients. The expected peripheral stigmata are liver palms, spider nevi, Dupuytren's contractures, ecchymosis, parotid swelling.
Tender hepatomegaly Due to the inflammation of liver parenchyma and it produces pain when liver capsule is stretched. Tender hepatomegaly
Due to the inflammation of liver parenchyma and it produces pain when liver capsule is stretched.
Blood pressure Systemic complications, more commonly autonomic in nature are associated with HEV infections. Blood pressure
Systemic complications, more commonly autonomic in nature are associated with HEV infections.

Investigations - Diagnosis

Fact Explanation
Liver enzyme profile Transaminases are elevated in acute hepatitis ,due to necro-inflammation of hepatocytes. Usually like in other viral hepatitis types, it can be markedly elevated above the upper limit of normal. Serum Alkaline phosphatase can also be mildly elevated. Liver enzyme profile
Transaminases are elevated in acute hepatitis ,due to necro-inflammation of hepatocytes. Usually like in other viral hepatitis types, it can be markedly elevated above the upper limit of normal. Serum Alkaline phosphatase can also be mildly elevated.
Serum bilirubin level. Bilirubin is markedly elevated, usually above >20 mg/ dl. It peaks at 2-3 weeks. Serum bilirubin level.
Bilirubin is markedly elevated, usually above >20 mg/ dl. It peaks at 2-3 weeks.
Anti-HEV immunoglobulin M In the acute infection, enzyme immunoassay shows that anti-HEV immunoglobulin M becomes detectable days before the onset of symptoms and disappears during a 4–6 month period. Anti-HEV immunoglobulin M
In the acute infection, enzyme immunoassay shows that anti-HEV immunoglobulin M becomes detectable days before the onset of symptoms and disappears during a 4–6 month period.
Anti-HEV immunoglobin G The IgG response for Hepatitis E (Anti-HEV IgG) appears soon after the IgM response and may persist up to 12 years after infection. Anti-HEV immunoglobin G
The IgG response for Hepatitis E (Anti-HEV IgG) appears soon after the IgM response and may persist up to 12 years after infection.
HEV RNA Nucleic acid amplification tests for detection of viral RNA in serum and stool samples can be used to identify HEV RNA in infected individuals. It's detectable in blood at the peak of abnormal liver function tests starting from 2 weeks before to 1 week after onset of jaundice. HEV RNA appeared in stool later than in blood and disappeared from stool 2 weeks after it became undetectable in blood. Testing for antigen (RNA) together with anti-HEV IgM is the best tool for diagnosis. HEV RNA
Nucleic acid amplification tests for detection of viral RNA in serum and stool samples can be used to identify HEV RNA in infected individuals. It's detectable in blood at the peak of abnormal liver function tests starting from 2 weeks before to 1 week after onset of jaundice. HEV RNA appeared in stool later than in blood and disappeared from stool 2 weeks after it became undetectable in blood. Testing for antigen (RNA) together with anti-HEV IgM is the best tool for diagnosis.

Management - Supportive

Fact Explanation
Primary prevention. There is no specific treatment option for acute hepatitis E as it's a self-limiting condition. However prevention by ensuring that the water and food sources are clean, can reduce the incidence. Primary prevention.
There is no specific treatment option for acute hepatitis E as it's a self-limiting condition. However prevention by ensuring that the water and food sources are clean, can reduce the incidence.

Management - Specific

Fact Explanation
Hepatitis E vaccine A recombinant subunit vaccine has been formed though there are contradictions for it's use. The length of protected time is still not defined. Some studies have proven good outcomes from the vaccine. Vaccination in the time of epidemics are known to reduce mortality. Hepatitis E vaccine
A recombinant subunit vaccine has been formed though there are contradictions for it's use. The length of protected time is still not defined. Some studies have proven good outcomes from the vaccine. Vaccination in the time of epidemics are known to reduce mortality.
Ribavirin therapy The antiviral Ribavarin is proven in treatment of both acute and chronic hepatitis E. 21 days have been proved to be enough for recovery. Ribavirin should be considered in immunosuppressed patients when the immuno-suppressive drugs cannot be lowered. Ribavirin therapy
The antiviral Ribavarin is proven in treatment of both acute and chronic hepatitis E. 21 days have been proved to be enough for recovery. Ribavirin should be considered in immunosuppressed patients when the immuno-suppressive drugs cannot be lowered.

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