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Hepatitis

Jul 25, 2019

Hepatitis is inflammation of liver tissue which usually presents with jaundice, abdominal pain, nausea, vomiting, dark urine, loss of appetite or itching. It is often caused by viral infection but it is important to consider non infective pathologies such as alcoholic hepatitis, steatohepatitis and drug induced hepatitis.

Medications:

Symptomatic management

  • For nausea in adult – tab. Avomine  (Promethazine 25 mg) 1 tablet 4 times a day.
  • For nausea in children – syp. Phenergan  (Promethazine 5 mg/5ml) 1 mg/kg orally every 6 hours (maximum dose – 25 mg).
  • For nausea in pregnancy – tab. Doxinate OD (Doxylamine 20 mg, Vitamin B6 20 mg) – 1 tablet at bedtime.
  • Lotion Lactocalamine (contains Zinc Oxide) – apply locally over itchy areas as needed.
  • Tab. Levalon (Ursodeoxycholic acid 300 mg) 1 tablet twice a day for itching.
  • Tab. Sinosam (S-adenosyl methionine 200 mg) 1 tablet orally every 8 hours (contraindicated in pregnancy).
  • Tab. Liv 52 DS (herbal remedy) 1 tablet thrice a day.

Specific management depending on the type of hepatitis

Hepatitis A / Hepatitis E-

  • Offer symptomatic management. Most cases follow a benign, self-limited course.
  • Advice rest – Avoid return to work or school until fever and jaundice resolve.

Acute hepatitis B-

  • Offer symptomatic management.
  • Spontaneously resolves in 90% of cases within 3 – 6 months
  • Recheck HBsAg at 6 months

Chronic hepatitis B carrier – if HBsAg positive at 6 months

  • Cap. Liv 52 HB (herbal remedy) – two capsules thrice a day for upto 6 months.
  • Hepatitis B serology testing for all susceptible exposures (sexual partners, blood transmission) and vaccinate if non-immune

Chronic hepatitis B infection – refer to gastroenterologist.

Hepatitis C

  • Tab. Velpacruz S 400mg/100 mg (Sofosbuvir 400 mg, Velpatasvir 100 mg) – one tablet once a day for 12 weeks.
  • Refer to gastroenterologist.

Hepatitis D

  • Requires hepatitis B virus for replication.
  • Management is similar to chronic hepatitis B infection.

Non infective hepatitis (alcoholic hepatitis, steatohepatitis, drug induced hepatitis) – This is mainly treated with symptomatic treatment:

  • Avoid hepatotoxins – Alcohol, hepatotoxic drugs and chemicals.
  • Steatohepatitis – Treat the underlying condition (diabetes, obesity, hyperlipidaemia).

Supportive treatment :

For hepatitis to prevent disease progression –

  • Administer relevant vaccine or immunoglobulin within 2 weeks after exposure.
  • For Hepatitis A in children – Inj. Havrix 720 Junior Monodose Vaccine (Freeze-dried Live Attenuated Hepatitis A Vaccine – 720ELISA) i.m.
  • For Hepatitis A in adults – Inj. Havrix 1440 (Freeze-dried Live Attenuated Hepatitis A Vaccine – 1440ELISA) i.m.
  • For Hepatitis B – Inj. Biovac B 100mcg (Hepatitis B vaccine – rDNA) i.m.
  • Avoid hepatotoxic medications.
  • Avoid iron supplements.
General advice:
  • Advice bed rest.
  • Avoid fried and fatty food.
  • Stop alcohol intake.
  • For nausea: sweet lime juice, sugarcane juice, coconut water, skimmed milk.
  • Ensure good hygiene, washing hands and clean drinking and cooking water.
  • Patient should be symptom-free and have normal serum bilirubin and aminotransferases before resuming work.

Investigations:

  • Liver function test – to assess the liver impairment.
  • Serum immunoassay – Hepatitis A (IgG and IgM), Hepatitis B (HBsAg), Hepatitis C (IgM and Hep C antibody).
  • White cell count – raised in active infection
  • Coagulation tests 〈 INR/Prothrombin time (PT), Partial thromboplastin time (APTT) 〉 – may be deranged in hepatic failure
  • Serum ammonia (if altered level of consciousness) – raised in hepatic encephalopathy
  • Serum electrolytes – low sodium due to dilutional causes, low potassium due to urinary loss
  • Renal function test – to rule out renal impairment

Alcoholic hepatitis can be diagnosed by following:

  • Aspartate aminotransferase (AST) is increased upto 300 units/L
  • AST: ALT = 2:1.
  • Gamma glutamyl transferase (GGT) markedly elevated.
  • Elevated mean corpuscular volume (MCV).

Hospitalize if-

  • Persistent vomiting
  • Prolongation of Prothrombin Time and INR
  • Changes in personality or sleep behavior
  • Evidence of ascites or excessive bruising

Referral:

Consider referral to gastroenterologist if patient fails to respond to the above treatments or presents with other complications.