What is the management for a 3-year-old child with viral hepatitis, marked elevations in liver enzymes, elevated alkaline phosphatase, hyperbilirubinemia, and pruritus?

Management of Viral Hepatitis in a 3-Year-Old with Elevated Liver Enzymes and Pruritus

Supportive care with fluid restriction to 50-60% of maintenance volume is the primary management for this child with viral hepatitis presenting with markedly elevated liver enzymes, hyperbilirubinemia, and pruritus. 1

Initial Assessment and Management

• Restrict fluid therapy to 50-60% of maintenance volume calculated by the Holliday-Segar formula to prevent fluid overload and worsening of edematous states 1
• Use isotonic maintenance fluids to reduce the risk of hyponatremia 1
• Avoid lactate buffer solutions in children with severe liver dysfunction to prevent lactic acidosis 1
• Monitor fluid balance, electrolytes (especially sodium), and glucose levels daily 1

Specific Management for Pruritus

• Ursodeoxycholic acid can be considered for cholestatic pruritus, though it should be used with caution and with monitoring of liver enzymes 2
• Regular monitoring of SGOT (AST) and SGPT (ALT) should be performed if ursodeoxycholic acid is initiated 2
• Avoid bile acid sequestering agents like cholestyramine as they may interfere with ursodeoxycholic acid absorption if used concurrently 2

Monitoring Parameters

• Monitor liver function tests (ALT, AST, alkaline phosphatase, bilirubin) every 3 months during the acute phase 3
• Perform full blood count and liver function tests at least yearly during follow-up 3
• Regular ultrasound surveillance is recommended every 6-12 months depending on disease severity 3

Treatment Decision Algorithm

1. Determine disease phase:

   • This child is likely in the immune active phase based on markedly elevated transaminases 3

2. Assess need for antiviral therapy:

   • Antivirals should be considered for children with elevated ALT levels for at least 6 months 3
   • Current presentation with ALT/AST of 1000 IU/L exceeds the threshold of 1.5 times ULN or 60 IU/L 3

3. Determine if immediate antiviral therapy is warranted:

   • For most children with acute viral hepatitis, supportive care is sufficient as the condition is typically self-limited 4
   • Antiviral therapy should be reserved for children with evidence of chronic infection (>6 months) or specific complications 3

Special Considerations

• Evaluate for complications of severe hepatitis including coagulopathy and encephalopathy 5
• Consider liver biopsy if etiology remains unclear or if there is concern for autoimmune hepatitis 3
• Assess for family history of hepatocellular carcinoma, which may warrant more aggressive management even with mild histological changes 3
• Be alert for signs of fulminant hepatic failure, which would necessitate referral to a liver transplant center 6, 5

Pitfalls to Avoid

• Avoid NSAIDs and aspirin due to bleeding risk 1
• Do not use hypotonic fluids which increase the risk of hyponatremia 1
• Avoid fluid overload which can exacerbate ascites and edematous states 1
• Do not initiate antiviral therapy without determining chronicity (>6 months) of infection, as most acute viral hepatitis in children resolves spontaneously 3
• Avoid unnecessary interventions during the acute phase, as most cases of viral hepatitis in children are self-limited 4, 5

Follow-up Plan

• Schedule follow-up in 2-4 weeks to reassess liver function tests 3
• If liver enzymes remain elevated after 3-6 months, consider further evaluation for chronic hepatitis 3
• Monitor for resolution of pruritus and jaundice as indicators of clinical improvement 4