Treatment of Hepatitis A
Hepatitis A requires only supportive care, as it is a self-limited infection that does not progress to chronic liver disease or require antiviral therapy. 1
Primary Management Strategy
The cornerstone of hepatitis A management is supportive care with expectant recovery:
- No specific antiviral medications are indicated for hepatitis A infection, as the disease resolves spontaneously in the vast majority of cases 1, 2
- Avoid hepatotoxic medications and drugs metabolized by the liver during the acute illness to prevent additional hepatic injury 1, 2
- Abstinence from alcohol is essential during the acute phase 2
- No dietary restrictions are necessary for patients with hepatitis A 1
- No activity restrictions are required, though bedrest may provide symptomatic relief if the patient is very symptomatic 1, 2
Expected Clinical Course
Understanding the natural history helps guide patient counseling:
- Most patients recover within 3-4 weeks with complete resolution of elevated liver enzymes 1
- Peak infectivity occurs 2 weeks before jaundice onset, so patients are often past peak infectiousness when diagnosed 1
- Discoloration of stool typically resolves within 2-3 weeks, indicating disease resolution 1
- 10-15% of patients experience relapsing disease lasting up to 6 months, with approximately 20% of those having multiple relapses 1
- Even with relapses, overall outcomes remain very good 1
Outpatient vs. Inpatient Management
Most patients can be managed as outpatients with close monitoring 1, 2. However, hospitalization is necessary in specific circumstances:
Indications for Hospitalization:
- Severe nausea and vomiting causing dehydration that prevents adequate oral intake 1, 3
- Signs of fulminant hepatitis A with acute liver failure, including prolonged INR and hepatic encephalopathy 1, 3
- Inability to maintain adequate oral hydration requiring intravenous rehydration 2
- Any alteration of mental status suggesting evolving fulminant hepatic failure 2
Monitoring for High-Risk Patients
Certain populations require closer surveillance:
- Patients >50 years old have a case fatality rate of 1.8% (compared to 0.3% overall) 1
- Patients with chronic liver disease are at significantly increased risk for fulminant hepatitis A 1
- Monitor liver function tests closely in patients with severe jaundice, particularly ALT, AST, bilirubin, and INR 3
Signs of Fulminant Disease:
- Worsening jaundice 1
- Deteriorating liver function 1
- Coagulopathy (prolonged INR) 1, 3
- Encephalopathy 1, 3
Liver transplantation may be required for fulminant hepatitis A, though spontaneous recovery occurs in 30-60% of cases 1. Transplantation is especially required in older patients (>40 years) and those who are jaundiced for >7 days before the onset of encephalopathy 4
Special Considerations
Cholestatic Hepatitis:
- For prolonged jaundice with cholestatic features, a short course of rapidly tapered corticosteroids can reduce symptoms 1
Pediatric Patients:
- Children can shed virus for up to 10 weeks after illness onset, requiring extended precautions 1
Post-Exposure Prophylaxis for Contacts
Contacts exposed to the same source should receive post-exposure prophylaxis within 2 weeks of exposure 1, 3:
- For healthy persons, hepatitis A vaccine alone is now preferred 1, 3
- Immune globulin (IG) should be used for:
- Hepatitis A vaccine can be administered simultaneously with IG at different injection sites 3
Infection Control
Proper handwashing is critical, as hepatitis A is transmitted via the fecal-oral route 3, 5. However, maximal viral excretion occurs before the onset of jaundice, so patients are often past peak infectiousness at diagnosis 6. People are most infectious 14 days before and seven days after the development of jaundice 5