What is the initial management approach for a patient presenting with acute viral hepatitis?

Management of Acute Viral Hepatitis

For acute viral hepatitis, provide supportive care as the primary treatment, avoid hepatotoxic substances (especially acetaminophen and alcohol), monitor for acute liver failure, and initiate immediate antiviral therapy only for acute hepatitis C (with DAAs) and herpes virus hepatitis (with acyclovir). 1, 2

Initial Assessment and Diagnosis

When evaluating suspected acute viral hepatitis, obtain comprehensive laboratory testing including:

• Prothrombin time/INR to assess for coagulopathy indicating potential acute liver failure 3, 2
• Liver enzymes (AST, ALT, alkaline phosphatase, bilirubin, albumin) 3, 2
• Complete blood count, comprehensive metabolic panel (including sodium, potassium, glucose, creatinine) 3
• Viral hepatitis serologies: anti-HAV IgM, HBsAg, anti-HBc IgM, anti-HCV, HCV RNA, anti-HEV 3, 2
• Acetaminophen level and toxicology screen to exclude drug-induced hepatotoxicity 3
• Arterial blood gas, arterial lactate, and ammonia if acute liver failure is suspected 3

If prothrombin time is prolonged by 4-6 seconds or more (INR ≥1.5) AND there is any alteration in mental status, diagnose acute liver failure and admit to ICU immediately. 3

Virus-Specific Management

Hepatitis A

• Provide supportive care only - no specific antiviral therapy is effective 1, 4
• Most cases are self-limited and managed in the community 5
• Hospitalize only if severe nausea/vomiting prevents adequate oral intake or if mental status changes occur 4
• Monitor coagulation factors (prothrombin time, factor V) to detect progression to fulminant hepatic failure, which occurs in 0.14-0.35% of cases 5

Hepatitis B

• For uncomplicated acute hepatitis B, provide supportive care without antivirals - this allows natural immunity to develop 1, 2
• Initiate nucleoside analogs (entecavir or tenofovir preferred) only if: 2
  • Persistent severe hepatitis develops
  • Signs of acute liver failure appear (coagulopathy, encephalopathy)
• Lamivudine 100 mg/day orally may be beneficial in severe cases 4
• Most cases (>95% in adults) resolve spontaneously without chronic infection 1

Hepatitis C

This represents a major shift from older guidelines:

• Initiate direct-acting antiviral (DAA) therapy immediately upon diagnosis of acute HCV with detectable RNA - do not wait for spontaneous clearance 3, 2
• This "test and treat" strategy is newly recommended (2020 AASLD-IDSA guidelines) based on real-world data showing reduced HCV transmission and prevention of loss to follow-up 3
• Use the same DAA regimens recommended for chronic HCV infection 3, 1

The older approach (2015 guidelines) recommended monitoring for 6+ months for spontaneous clearance, but this is now superseded. 3 The rationale for immediate treatment includes:

• Reducing onward transmission, especially in high-risk populations (MSM, PWID) 3
• Preventing loss to follow-up during observation periods 3
• High efficacy (>90%) and safety of modern DAA therapy 3

Alternative (historical): Pegylated interferon-α monotherapy for 24 weeks achieved >90% sustained virologic response in older studies, but DAAs are now preferred 1, 2

Hepatitis E

• Provide supportive care - no specific antiviral therapy 1
• Pregnant women require close monitoring, especially in second and third trimesters, as they face higher risk of fulminant hepatic failure (particularly with genotype 1) 1, 2

Herpes Virus Hepatitis

• Initiate acyclovir immediately when herpes virus hepatitis is suspected or documented 1, 2
• Immediately list for liver transplantation if herpes virus or varicella zoster causes acute liver failure 1, 2
• Pregnancy (especially third trimester) increases risk of herpes-related acute liver failure 2

General Supportive Care Measures

All patients with acute viral hepatitis should:

• Avoid all hepatotoxic medications, particularly acetaminophen 3, 2
• Abstain completely from alcohol 3, 4
• Rest if very symptomatic 4
• Maintain high-calorie diet 4
• Receive intravenous rehydration if unable to maintain oral intake 4

Monitoring and Follow-Up

• Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution 3, 2
• For acute hepatitis C specifically, regular laboratory monitoring every 4-8 weeks for 6-12 months was recommended historically until ALT normalizes and HCV RNA becomes undetectable 3
• Watch for signs of acute liver failure: increasing bilirubin, prolonged INR, mental status changes 3, 2

Transmission Prevention and Counseling

For acute hepatitis C patients:

• Counsel to avoid sharing injection equipment 3, 2
• Consider barrier precautions during sex, even in monogamous relationships during acute phase due to higher transmission risk 3
• Refer patients with injection drug use history to addiction medicine specialists 3, 2

When to Consider Liver Transplantation

Immediately refer to transplant center if:

• INR >1.5 with any signs of hepatic encephalopathy 3
• Known or suspected herpes virus or varicella zoster causing acute liver failure 1, 2
• Progression to grade 4 encephalopathy (though hepatitis A has better prognosis with medical management - up to 67% survival) 5
• Older patients (>40 years) with jaundice >7 days before encephalopathy onset 5

Critical Pitfalls to Avoid

• Do not delay ICU transfer for patients with coagulopathy and mental status changes 3, 2
• Do not use benzodiazepines for sedation in liver failure patients 2
• Do not routinely correct coagulation abnormalities without active bleeding 2
• Do not administer nephrotoxic agents 2
• For acute hepatitis C: do not wait for spontaneous clearance - treat immediately 3, 2
• For uncomplicated acute hepatitis B: do not routinely treat with antivirals as this may impair natural immunity 1, 2
• Do not use acetaminophen or alcohol during acute hepatitis 3, 2