What is the appropriate management for a 60‑year‑old man presenting with jaundice, scleral icterus, pruritus, markedly elevated transaminases and a positive hepatitis A virus test?

Management of Acute Hepatitis A with Jaundice and Elevated Transaminases

For a 60-year-old man with acute hepatitis A presenting with jaundice, scleral icterus, pruritus, and markedly elevated transaminases, the cornerstone of management is supportive care with close monitoring for signs of hepatic decompensation—no specific antiviral therapy exists for hepatitis A, and the focus must be on recognizing and managing potential complications, particularly fulminant hepatic failure, which carries higher risk in patients over 50 years of age. 1

Immediate Clinical Assessment

Assess for signs of acute liver failure immediately, including:

• Coagulopathy (check INR/PT) – a critical marker of hepatic synthetic dysfunction 2
• Encephalopathy – altered mental status, confusion, or asterixis 3
• Serum albumin – declining levels indicate impaired synthetic function 4
• Rising bilirubin – progressive jaundice suggests worsening hepatocellular injury 4

Age over 50 years is a significant risk factor for fulminant hepatitis A, with case fatality rates ranging from 0.01% to 2%, and fulminant disease being more common in this age group. 1 Spontaneous recovery occurs in only 30-60% of patients with fulminant hepatitis A. 1

Severity Grading and Monitoring Strategy

Grade the transaminase elevation using the Common Terminology Criteria for Adverse Events (CTCAE):

• Grade 1: AST/ALT >ULN to 3× ULN
• Grade 2: AST/ALT >3× to 5× ULN
• Grade 3: AST/ALT >5× to 20× ULN
• Grade 4: AST/ALT >20× ULN 3

For Grade 1-2 elevation (which is typical in acute hepatitis A):

• Monitor liver function tests 1-2 times weekly 3, 4
• Focus on functional hepatic indicators (INR, albumin, bilirubin) rather than transaminase magnitude alone, as transaminase levels correlate poorly with disease severity 4
• Continue supportive care with adequate hydration and nutrition 3

For Grade 3 elevation or any signs of decompensation:

• Urgent hepatology consultation 3
• Consider hospitalization for observation 3
• Monitor for acute liver failure development 3

Critical Monitoring Parameters

Do not rely solely on transaminase trends, as hepatitis A characteristically demonstrates fluctuating transaminase levels during its natural course—the biphasic or fluctuating pattern does not indicate worsening disease or treatment failure, but rather reflects the dynamic nature of viral hepatitis and hepatocellular recovery. 4

Instead, monitor these functional indicators:

• INR/PT – the most sensitive early marker of hepatic synthetic dysfunction 2, 4
• Serum bilirubin – assess excretory function; levels can rise dramatically in cholestatic variants 4, 5
• Serum albumin – marker of hepatic synthetic capacity 4
• Clinical symptoms – worsening jaundice, confusion, bleeding 3

Approximately 50% of patients with viral hepatitis can have normal transaminase values despite ongoing liver disease, making isolated enzyme trends unreliable markers of disease progression. 4

Management of Cholestatic Variant

If bilirubin rises disproportionately (>10 mg/dL) with intense pruritus, this suggests the cholestatic variant of hepatitis A, which occurs in approximately 10-15% of cases. 1, 5

For markedly symptomatic cholestatic hepatitis A:

• Consider ursodeoxycholic acid for symptomatic relief 5
• A short course of rapidly tapered corticosteroids can reduce symptoms and hasten resolution of disease in patients with prolonged jaundice and cholestatic features 1
• This approach is justified in markedly symptomatic patients with relapsing or cholestatic hepatitis 5

Relapsing Disease Recognition

Approximately 10-15% of patients with hepatitis A have relapsing disease lasting up to 6 months, with approximately 20% of these patients experiencing multiple relapses. 1

Relapsing hepatitis A presents as:

• Recurrence of symptoms and jaundice after initial improvement 1, 5
• Re-elevation of transaminases after normalization 1
• Hepatitis A virus can be detected in stool during relapse 1

Even with relapsing disease, overall outcomes are very good, and complete resolution is expected. 1

Supportive Care Measures

Ensure adequate nutrition and hydration:

• Maintain caloric intake of 30-40 kcal/kg body weight 1
• Protein intake of 1-1.5 g/kg body weight 1
• If unable to eat due to anorexia or altered mental status, consider enteral feeding 1

Avoid hepatotoxic substances:

• Complete alcohol abstinence 1, 3
• Discontinue all potentially hepatotoxic medications including NSAIDs, acetaminophen, and herbal supplements 3
• Avoid or use diuretics sparingly, as acute kidney injury is an early manifestation of multi-organ failure 1

Expected Resolution Timeline

Most patients are significantly better within 3-4 weeks, including resolution of elevated hepatocellular enzyme concentrations. 1

Reassess at 12 weeks or later following symptom onset to confirm transaminase normalization and complete resolution. 4 If transaminases remain elevated beyond this timeframe, investigate alternative or concurrent causes of liver disease (chronic hepatitis B or C, autoimmune hepatitis, drug-induced liver injury). 4

Hospitalization Criteria

Admit to hospital if:

• Age >50 years with severe symptoms (higher risk of fulminant hepatitis) 1
• INR >1.5 or rising 2, 3
• Any signs of encephalopathy 3
• Bilirubin >20 mg/dL (severe cholestasis) 5
• Inability to maintain oral hydration 1
• Inadequate social support for outpatient monitoring 1

Common Pitfalls to Avoid

Do not assume worsening disease based on rising transaminases alone—hepatitis A characteristically shows fluctuating enzyme levels, and a biphasic pattern is common and does not indicate treatment failure. 4

Do not delay repeat testing if initial anti-HAV IgM is negative—rare cases present with undetectable anti-HAV IgM levels at symptom onset despite active infection; repeat testing may be warranted if clinical suspicion remains high. 6

Do not overlook extrahepatic manifestations—uncommon presentations include maculopapular rash, polyarthralgia, and delayed antibody appearance. 6

Do not routinely order liver biopsy—diagnosis is serologic (anti-HAV IgM), and biopsy is not required for acute hepatitis A management. 1

Do not prescribe antiviral therapy—no specific antiviral treatment exists for hepatitis A; management is entirely supportive. 1

Prognosis and Follow-Up

Spontaneous recovery occurs in the majority of patients, with full liver function restoration expected. 1 However, prognosis in fulminant cases is influenced by age, clotting-factor levels, stage of coma, and presence of renal disease. 1

For this 60-year-old patient specifically, close monitoring is essential given the higher risk of fulminant hepatitis in patients over 50 years, particularly if chronic liver disease (including chronic hepatitis B or C) coexists. 1