What is the management approach for acute hepatitis?

Management of Acute Hepatitis

The management of acute hepatitis should focus on identifying the specific etiology and providing appropriate supportive care, with etiology-specific treatments initiated only when indicated by evidence-based guidelines. 1, 2

Initial Assessment and Diagnosis

• Obtain comprehensive laboratory evaluation including liver enzymes, prothrombin time/INR, complete blood count, comprehensive metabolic panel, and viral hepatitis serologies 2
• Perform hepatitis serological testing to identify acute viral infection even when another etiology is suspected 1
• Consider HCV RNA testing when acute hepatitis C is suspected due to exposure, clinical presentation, or elevated aminotransferase levels 1
• Obtain detailed medication history including all prescription and non-prescription drugs, herbs, and dietary supplements taken over the past year 1

Etiology-Specific Management

Viral Hepatitis

• For acute viral hepatitis A and B, provide supportive care as no virus-specific treatments have proven effective 1, 2
• For suspected herpes virus hepatitis, initiate acyclovir treatment immediately 1, 2
• For acute hepatitis C:
  • Monitor HCV RNA for at least 12-16 weeks to detect potential spontaneous clearance before starting treatment 1
  • If treatment is indicated, pegylated IFN-α monotherapy for 24 weeks can achieve viral eradication in >90% of patients 1
  • Regular laboratory monitoring (every 4-8 weeks for 6-12 months) is recommended until ALT normalizes and HCV RNA becomes repeatedly undetectable 1

Drug-Induced Hepatotoxicity

• Discontinue all but essential medications in the setting of acute liver failure due to possible drug hepatotoxicity 1, 2
• Determine ingredients of non-prescription medications whenever possible 1

Autoimmune Hepatitis

• Consider liver biopsy to establish diagnosis when autoimmune hepatitis is suspected 1
• Treat with corticosteroids (prednisone, 40-60 mg/day) 1
• Place patients with acute liver failure due to autoimmune hepatitis on the transplantation list even while administering corticosteroids 1, 3

Mushroom Poisoning

• Administer penicillin G and silymarin (30-40 mg/kg/day for 3-4 days) 1, 2
• List patients for transplantation, as this procedure is often the only lifesaving option 1, 2

General Supportive Care

• Provide bedrest if the patient is very symptomatic 4
• Ensure adequate hydration and nutritional support with a high-calorie diet 4
• Advise abstinence from alcohol 1, 4
• Avoid hepatotoxic medications 4
• For patients with severe symptoms, consider hospitalization for intravenous rehydration 4

Management of Acute Liver Failure

• Transfer patients with signs of acute liver failure (coagulopathy and any degree of mental alteration) to ICU immediately 2
• Administer N-acetylcysteine regardless of suspected etiology 2
• Contact liver transplant unit early for all patients with acute liver failure 2
• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L 2
• Perform tracheal intubation and sedation for progressive hepatic encephalopathy 2
• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 2
• Provide stress ulcer prophylaxis with H2 blockers or proton pump inhibitors 2

Follow-up

• For untreated patients with chronic hepatitis C and non-sustained responders, regular follow-up is recommended 1
• Assess untreated patients every 1-2 years with a non-invasive method 1
• Continue HCC screening indefinitely in patients with cirrhosis 1

Special Populations

Pregnant Patients

• For acute fatty liver of pregnancy or HELLP syndrome, consult obstetrical services and expedite delivery 1
• Be aware that pregnancy (especially third trimester) increases the risk of ALF due to herpes virus 1

Active Substance Users

• Treatment of patients with active illicit drug abuse should be decided on an individual basis in an interdisciplinary team with addiction specialists 1
• Treatment of patients on stable maintenance substitution therapy can be safely performed with only slightly reduced SVR rates compared to conventional HCV patients 1

Common Pitfalls to Avoid

• Delaying transfer to a transplant center for patients with acute liver failure 2
• Failing to identify specific etiologies that might influence treatment 2
• Using benzodiazepines for sedation in patients with liver failure 2
• Administering nephrotoxic agents 2
• Routinely correcting coagulation abnormalities without active bleeding 2
• Delaying corticosteroid treatment in suspected autoimmune hepatitis 2, 3