Signs and Symptoms of Viral Hepatitis
Viral hepatitis commonly presents with fatigue, poor appetite, nausea, vomiting, abdominal pain, low-grade fever, jaundice, dark urine, and light-colored stools, though many cases (especially in children under 6 years) can be asymptomatic. 1
Clinical Manifestations by Stage
Prodromal (Pre-icteric) Stage
- Fatigue and malaise
- Anorexia (loss of appetite)
- Nausea and vomiting
- Abdominal pain (typically in right upper quadrant)
- Low-grade fever
- Muscle and joint pain
- Dark urine (bilirubinuria) - often one of the first noticeable signs 1
Icteric Stage
- Jaundice (yellowing of skin and sclera)
- Clay-colored/light stools
- Hepatomegaly (enlarged liver)
- Possible splenomegaly
- Liver tenderness on examination 1
Typically, fatigue and loss of appetite precede jaundice by 1-2 weeks. The icteric phase usually lasts 2-4 weeks, with the entire acute illness lasting 2-4 months. 1
Key Differences by Age Group
- Children under 6 years: Over 90% of hepatitis A infections are asymptomatic 1
- Children under 5 years and immunosuppressed adults: Typically asymptomatic with newly acquired HBV infection 1
- Older children and adults: 30-50% have clinical signs of acute disease with HBV infection; more than two-thirds develop jaundice with HAV infection 1
- Adults over 60: Highest case-fatality rates (approximately 1.8% for acute HBV) 1
Differences by Hepatitis Virus Type
While clinical presentations are similar across viral hepatitis types, there are some distinctions:
Hepatitis A
- Incubation period: Average 28 days (range: 15-50 days) 1
- Self-limiting acute infection
- No chronic infection
- 10-15% may have relapsing disease lasting up to 6 months 1
Hepatitis B
- Incubation period: 2-3 months (range: 6 weeks-6 months) 1
- Can cause both acute and chronic infection
- Risk of chronicity is age-dependent:
90% in infants
- 25-50% in children aged 1-5 years
- <5% in older children and adults 1
Hepatitis C
- Most acute infections (70-80%) are asymptomatic 1
- When symptomatic: flu-like symptoms, fatigue, nausea, RUQ pain
- 50-80% progress to chronic infection 1
- Chronic infection often asymptomatic until advanced liver disease develops
Laboratory Findings
- Elevated liver enzymes (ALT, AST)
- Elevated bilirubin (direct and total)
- Specific serologic markers depending on virus type:
- HAV: IgM anti-HAV (acute infection)
- HBV: HBsAg, IgM anti-HBc (acute infection)
- HCV: Anti-HCV antibodies, HCV RNA
Complications
- Fulminant hepatitis (rare but more common in adults >50 years and those with underlying liver disease) 1
- Cholestatic hepatitis with prolonged jaundice
- Progression to chronic infection (HBV, HCV)
- Cirrhosis and hepatocellular carcinoma (in chronic infection)
Important Clinical Pearls
Peak infectivity for hepatitis A occurs during the 2 weeks before onset of jaundice or elevation of liver enzymes 1
Asymptomatic cases can still transmit the virus, particularly important in children who often have subclinical infections 1
Immunosuppressed patients are at higher risk for chronic HBV infection and may experience reactivation of previously resolved infections 1
Pregnant women with hepatitis generally don't have more severe disease, but vertical transmission can occur 1
Case-fatality rates increase with age, with the highest rates in adults over 60 years 1