Viral Hepatitis

Overview

Viral hepatitis is inflammation of the liver caused by infection with one of several hepatitis viruses. These viruses are designated by letters A through E, with each type having different modes of transmission, clinical features, and outcomes. Hepatitis can be acute (short-term) or chronic (long-lasting), and while some forms resolve on their own, others can lead to serious complications including cirrhosis, liver failure, and liver cancer.

The liver is a vital organ that performs hundreds of essential functions, including filtering toxins from blood, producing bile for digestion, storing vitamins and minerals, and manufacturing proteins necessary for blood clotting. When hepatitis viruses infect liver cells, they cause inflammation that disrupts these crucial functions. The severity and duration of this disruption vary greatly depending on the virus type and individual factors.

Globally, viral hepatitis is a major public health concern, affecting hundreds of millions of people. The World Health Organization estimates that 354 million people worldwide live with chronic hepatitis B or C, and most are unaware of their infection. Despite the availability of effective vaccines for hepatitis A and B, and curative treatments for hepatitis C, viral hepatitis still causes approximately 1.1 million deaths annually, comparable to tuberculosis and HIV.

Understanding the different types of viral hepatitis is crucial for prevention, early detection, and appropriate treatment. Each type has unique characteristics, but they all share the common feature of causing liver inflammation that can significantly impact health and quality of life.

Types of Hepatitis

There are five main types of viral hepatitis, each caused by a different virus with distinct characteristics:

Hepatitis A (HAV)

• Transmission: Fecal-oral route through contaminated food or water
• Duration: Always acute, never becomes chronic
• Prognosis: Usually mild, complete recovery expected
• Prevention: Vaccine available, good sanitation
• Prevalence: Common in areas with poor sanitation

Hepatitis B (HBV)

• Transmission: Blood, sexual contact, mother to child
• Duration: Can be acute or chronic
• Prognosis: 90% of adults clear infection; higher chronicity risk in children
• Prevention: Vaccine available
• Prevalence: 296 million people living with chronic HBV globally

Hepatitis C (HCV)

• Transmission: Primarily blood-to-blood contact
• Duration: Often becomes chronic (75-85% of cases)
• Prognosis: Can be cured with antiviral medications
• Prevention: No vaccine available
• Prevalence: 58 million people with chronic HCV globally

Hepatitis D (HDV)

• Transmission: Same as HBV; requires HBV to replicate
• Duration: Can be acute or chronic
• Prognosis: Most severe form; accelerates liver damage
• Prevention: HBV vaccination prevents HDV
• Prevalence: Affects 5% of people with chronic HBV

Hepatitis E (HEV)

• Transmission: Fecal-oral route, similar to HAV
• Duration: Usually acute, chronic in immunocompromised
• Prognosis: Generally self-limiting; dangerous in pregnancy
• Prevention: Vaccine available in some countries
• Prevalence: Common in developing countries

Symptoms

Viral hepatitis symptoms vary depending on whether the infection is acute or chronic, and many people with chronic hepatitis have no symptoms until significant liver damage occurs.

Additional Symptoms

• Clay-colored or pale stools
• Joint pain and muscle aches
• Loss of appetite
• Itchy skin (pruritus)
• Abdominal swelling (ascites) in advanced cases
• Confusion or mental changes (hepatic encephalopathy)
• Easy bruising or bleeding

Acute vs. Chronic Symptoms

Transmission

Understanding how each type of hepatitis spreads is crucial for prevention and risk assessment.

Fecal-Oral Transmission (Hepatitis A & E)

• Contaminated food or water
• Close personal contact with infected person
• Poor hand hygiene after using bathroom
• Sexual contact (especially oral-anal)
• Travel to endemic areas

Blood-Borne Transmission (Hepatitis B, C, D)

• Hepatitis B:
  • Unprotected sexual contact
  • Sharing needles or drug equipment
  • Mother to child during birth
  • Needlestick injuries
  • Sharing personal items (razors, toothbrushes)
• Hepatitis C:
  • Sharing needles or drug equipment (most common)
  • Blood transfusions before 1992
  • Needlestick injuries
  • Mother to child (less common)
  • Sexual transmission (rare but possible)
• Hepatitis D:
  • Only occurs with HBV infection
  • Same transmission routes as HBV

What Does NOT Transmit Hepatitis

• Casual contact (hugging, kissing on cheek)
• Sharing food or drinks (except HAV/HEV)
• Coughing or sneezing
• Breastfeeding (unless nipples are cracked/bleeding)
• Using same toilet

Risk Factors

Certain groups have higher risk for viral hepatitis infection:

Geographic and Demographic Factors

• Travel to endemic areas: HAV and HEV risk
• Born to infected mothers: HBV vertical transmission
• Born in high-prevalence countries: HBV and HCV
• Baby boomers (born 1945-1965): Higher HCV prevalence
• Household contact: With infected individuals

Diagnosis

Diagnosing viral hepatitis requires specific blood tests to identify the virus and assess liver damage.

Initial Evaluation

• Medical history: Risk factors, symptoms, travel
• Physical examination: Jaundice, liver enlargement, abdominal tenderness
• Liver function tests:
  • ALT and AST (liver enzymes)
  • Bilirubin levels
  • Albumin and total protein
  • Prothrombin time (PT/INR)

Virus-Specific Tests

Additional Testing

• Liver biopsy: Assesses degree of liver damage
• FibroScan: Non-invasive assessment of liver fibrosis
• Ultrasound: Evaluates liver structure
• AFP: Screens for liver cancer in chronic cases

Treatment

Treatment varies significantly depending on the type of hepatitis, whether it's acute or chronic, and the degree of liver damage.

Hepatitis A Treatment

• No specific antiviral treatment
• Supportive care: rest, hydration, nutrition
• Avoid alcohol and hepatotoxic medications
• Monitor for rare fulminant hepatitis
• Most recover completely within 2-6 months

Hepatitis B Treatment

Hepatitis C Treatment

Revolutionary direct-acting antivirals (DAAs) can cure HCV in 95% of cases:

• Sofosbuvir/Velpatasvir: Pan-genotypic, 12 weeks
• Glecaprevir/Pibrentasvir: 8-16 weeks depending on cirrhosis
• Sofosbuvir/Ledipasvir: For genotype 1
• Treatment duration: Usually 8-12 weeks
• Cure definition: Undetectable virus 12 weeks after treatment (SVR12)

Hepatitis D Treatment

• Pegylated interferon alpha (limited effectiveness)
• Bulevirtide: Recently approved entry inhibitor
• Manage underlying HBV infection
• Liver transplant for end-stage disease

Hepatitis E Treatment

• Usually self-limiting; supportive care
• Ribavirin for chronic HEV in immunocompromised
• Reduce immunosuppression if possible
• Monitor pregnant women closely (20% mortality risk)

General Management

• Lifestyle modifications: No alcohol, healthy diet, maintain healthy weight
• Monitor for complications: Regular blood tests, imaging
• Vaccinations: HAV and HBV vaccines for those not immune
• Avoid hepatotoxic drugs: Including acetaminophen in high doses

Complications

Untreated or chronic viral hepatitis can lead to serious liver complications:

Acute Complications

• Fulminant hepatic failure: Rare but life-threatening, requires urgent transplant
• Cholestatic hepatitis: Prolonged jaundice and itching
• Relapsing hepatitis: Symptoms return after initial improvement

Chronic Complications

Extrahepatic Manifestations

• Glomerulonephritis (kidney inflammation)
• Cryoglobulinemia (abnormal blood proteins)
• Polyarteritis nodosa (blood vessel inflammation)
• Thyroid disorders
• Diabetes mellitus
• Arthritis and joint pain

Prevention

Prevention strategies vary by hepatitis type but include vaccination, safe practices, and screening.

General Prevention Measures

• Hand hygiene: Wash hands thoroughly, especially after bathroom use
• Safe sex practices: Use barrier protection
• Don't share personal items: Razors, toothbrushes, nail clippers
• Safe injection practices: Never share needles or drug equipment
• Blood safety: Ensure sterile equipment for tattoos, piercings

Type-Specific Prevention

Harm Reduction

• Needle exchange programs
• Opioid substitution therapy
• Safe injection sites
• Education and counseling

Vaccines

Effective vaccines are available for hepatitis A and B, providing long-lasting protection.

Hepatitis A Vaccine

• Schedule: 2 doses, 6-12 months apart
• Effectiveness: Nearly 100% protection
• Duration: At least 20 years, possibly lifelong
• Who should get it:
  • All children at age 1
  • Travelers to endemic areas
  • Men who have sex with men
  • People who use drugs
  • Those with chronic liver disease

Hepatitis B Vaccine

• Schedule: 3 doses over 6 months (or 2-dose series available)
• Effectiveness: 90-95% protection
• Duration: At least 20 years, likely lifelong
• Who should get it:
  • All infants at birth
  • Unvaccinated children and adolescents
  • High-risk adults
  • Healthcare workers
  • Diabetics under 60

Combination Vaccines

• Twinrix: Combined HAV/HBV vaccine
• Schedule: 3 doses over 6 months
• Accelerated schedule: Available for travelers

No Vaccines Available

• Hepatitis C: No vaccine; prevention through safe practices
• Hepatitis D: Prevented by HBV vaccination
• Hepatitis E: Vaccine exists but not widely available

When to See a Doctor

Prompt medical attention is important for proper diagnosis and treatment of viral hepatitis.

Seek Medical Care For

• Jaundice (yellowing of skin or eyes)
• Dark urine and pale stools
• Persistent fatigue lasting more than 2 weeks
• Unexplained abdominal pain or swelling
• Loss of appetite and unintentional weight loss
• Persistent nausea or vomiting
• Known exposure to hepatitis

Get Tested If You

• Were born between 1945-1965 (HCV screening)
• Have ever injected drugs
• Received blood transfusion before 1992
• Have HIV infection
• Are on hemodialysis
• Have elevated liver enzymes
• Were born to mother with HBV or HCV

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