Management of Hepatitis A
Hepatitis A is a self-limited viral infection that primarily requires supportive care, as most cases resolve without specific antiviral treatment. 1
Clinical Presentation and Diagnosis
Hepatitis A presents with:
- Abrupt onset of fever, malaise, anorexia, nausea, abdominal discomfort
- Dark urine and jaundice (in >70% of adults, but only 30% of children under 6 years)
- Symptoms typically last <2 months, though 10-15% may have prolonged or relapsing disease lasting up to 6 months 1
Diagnosis requires:
- Positive serologic test for IgM antibody to HAV (IgM anti-HAV) in a person with symptoms of acute viral hepatitis
- Clinical presentation alone cannot differentiate hepatitis A from other viral hepatitis forms 1
Treatment Approach
Supportive Care
- Supportive care is the mainstay of treatment for hepatitis A 2
- Bedrest for symptomatic patients
- High-calorie diet
- Adequate hydration (IV fluids if unable to maintain oral intake)
- Avoidance of hepatotoxic medications
- Complete abstinence from alcohol 2
Hospitalization Criteria
Hospitalization may be necessary for:
- Patients with severe dehydration due to nausea and vomiting
- Patients with altered mental status suggesting evolving fulminant hepatic failure
- Elderly patients (>49 years) who have higher mortality rates (1.8% vs. overall 0.3%) 1, 2
Monitoring
- Monitor liver enzymes and coagulation factors
- Prothrombin time and factor V levels are important for monitoring risk of fulminant hepatic failure 3
- Watch for signs of hepatic encephalopathy
Special Considerations
Fulminant Hepatitis
- Fulminant hepatic failure is rare (0.1-0.35% of cases) but more common in adults >40 years 1, 3
- Monitor for encephalopathy, cerebral edema, renal and respiratory failure
- Liver transplantation may be required in severe cases, particularly in older patients or those jaundiced for >7 days before encephalopathy onset 3
Relapsing Disease
- 10-15% of patients may experience relapsing illness within the first 6 months
- Recurrent viral shedding can occur during relapses 1
Prevention and Post-Exposure Management
Vaccination
- Hepatitis A vaccine is the most effective prevention method
- Recommended for:
Post-Exposure Prophylaxis
- For recent exposure (within 2 weeks):
- Immune globulin (IG) is >85% effective in preventing hepatitis A
- Hepatitis A vaccine can also be used for post-exposure prophylaxis 1
Contact Tracing
- Cases should be reported to public health authorities
- Contact investigation should identify persons who would benefit from post-exposure prophylaxis
- Cellmates, sexual contacts, and close personal contacts should receive IG 1
Common Pitfalls to Avoid
Failure to recognize severe disease in older adults: Mortality is significantly higher (1.8%) in adults over 49 years compared to the overall rate (0.3%) 1
Inappropriate use of hepatotoxic medications: Avoid medications that might cause liver damage or are metabolized by the liver 1
Inadequate contact tracing: Failure to identify and provide prophylaxis to close contacts can lead to outbreaks, especially in institutional settings 1
Overlooking the need for vaccination of vulnerable populations: High-risk groups remain insufficiently protected in many countries 5
Missing relapsing disease: Up to 15% of patients may experience relapse within 6 months and require continued monitoring 6