What is the management approach for acute hepatitis?

Management of Acute Hepatitis

The management of acute hepatitis should focus on identifying the etiology, providing appropriate supportive care, and considering specific antiviral therapy only in select cases with severe disease or risk of progression to liver failure. 1, 2

Diagnostic Approach

Initial Assessment

• Measure prothrombin time/INR and assess mental status to evaluate for acute liver failure (ALF) 1
• ALF is defined as INR ≥1.5 with any degree of mental alteration (encephalopathy) in a patient without preexisting cirrhosis and with illness duration ≤26 weeks 1
• Obtain comprehensive laboratory testing:
  • Prothrombin time/INR, complete blood count, comprehensive metabolic panel
  • AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin
  • Arterial blood gases with lactate
  • Arterial ammonia levels 1, 2

Etiologic Investigation

• Acetaminophen level and toxicology screen
• Viral hepatitis serologies (HAV IgM, HBsAg, HBc IgM, HEV, HCV)
• Autoimmune markers
• Ceruloplasmin level (Wilson disease)
• Hepatic Doppler ultrasound to evaluate vascular patency 1, 2

Management Based on Etiology

Viral Hepatitis

1. Hepatitis A and E:

   • Primarily supportive care as most cases are self-limited 3
   • Monitor for progression to severe disease

2. Acute Hepatitis B:

   • Most cases (>95%) recover spontaneously without antiviral therapy 1
   • Oral antiviral therapy should be considered only in cases of persistent serious hepatitis or acute liver failure 1
   • When indicated, nucleos(t)ide analogues (entecavir or tenofovir) are preferred 2

3. Acute Hepatitis C:

   • Confirm diagnosis by measuring HCV RNA in serum 1
   • For symptomatic acute hepatitis C, delay treatment for 2-4 months to allow for potential spontaneous resolution 1
   • If treatment is initiated, consider peginterferon due to its improved ease of administration 1
   • Treatment duration of at least 6 months is reasonable 1

4. Herpes Virus Hepatitis:

   • Administer acyclovir immediately 1, 2
   • Consider liver transplant evaluation 2

Drug-Induced Hepatitis

1. Acetaminophen Overdose:

   • Administer N-acetylcysteine (NAC) immediately: loading dose of 140 mg/kg orally or 150 mg/kg IV, followed by maintenance doses 2
   • For patients presenting within 4 hours of ingestion, administer activated charcoal (1g/kg) prior to NAC 2

2. Other Drug-Induced Hepatitis:

   • Discontinue all but essential medications 1
   • For mushroom poisoning, consider penicillin G and silymarin 1

Supportive Care

General Measures

• Bedrest for symptomatic patients
• High-calorie diet
• Avoid hepatotoxic medications and alcohol 3
• IV rehydration if unable to maintain adequate oral intake 3

For Patients with Severe Disease or Encephalopathy

• Monitor encephalopathy frequently
• Maintain serum sodium between 140-145 mmol/L
• Monitor blood glucose at least every 2 hours
• Consider tracheal intubation for progressive hepatic encephalopathy (Glasgow <8)
• Assess volume status and cardiac function
• Use crystalloid fluids for initial volume expansion and norepinephrine for refractory hypotension 2

Infection Control

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 2

Liver Transplantation Considerations

• Early contact with a transplant center is essential for all patients with acute liver failure 2
• Specific indications for urgent transplantation include:
  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Severe drug-induced liver injury with poor prognostic factors 2

Important Cautions

• Avoid benzodiazepines, psychotropic drugs, treatments aimed at lowering ammonia levels (lactulose, rifaximin), nephrotoxic drugs including NSAIDs, and routine correction of coagulation abnormalities 2
• For patients with HCV/HBV coinfection, test for evidence of current or prior HBV infection before initiating HCV treatment, as HBV reactivation can occur during or after HCV treatment 4
• Early initiation of antiviral therapy for acute hepatitis B may interfere with normal protective immune response and potentially increase the risk of chronic hepatitis 1

Most cases of acute viral hepatitis are self-limited and resolve spontaneously with supportive care. Specific antiviral therapy should be reserved for severe cases or those at risk of progression to liver failure.