What is the recommended management for acute hepatitis A?

Hepatitis A Treatment

Acute hepatitis A requires only supportive care, as no antiviral therapy has proven effective for this self-limited infection. 1, 2

Core Management Principles

Supportive Care Only

• Provide supportive care exclusively—no antiviral agents have demonstrated efficacy against hepatitis A virus 1
• Expect complete recovery in the majority of patients within approximately 2 months, though 10-15% may experience relapsing illness during the first 6 months 1
• Avoid all hepatotoxic medications, particularly acetaminophen (even in therapeutic doses), and mandate complete alcohol abstinence 2

Monitoring Strategy

• Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution 2
• Watch closely for the rare development of acute liver failure, which occurs in only 0.14-0.35% of hospitalized cases 3
• Immediately assess for acute liver failure by checking INR—if INR ≥1.5 with any mental status change, transfer to ICU and contact transplant center urgently 2

Risk Stratification

High-Risk Populations

• Patients with pre-existing chronic liver disease face significantly higher risk of progression to acute liver failure 1
• Older patients (>40 years) and those jaundiced for >7 days before encephalopathy onset have worse prognosis and may require emergency liver transplantation 3
• Pregnant women (especially third trimester) are at increased risk for severe complications 2

Prognostic Indicators

• Use prothrombin time and factor V levels as the most favored coagulation assays to monitor risk of fulminant hepatic failure 3
• Rising bilirubin, prolonging INR, and mental status changes signal potential progression to acute liver failure 2

Management of Acute Liver Failure

If acute liver failure develops (INR ≥1.5 with any mental status alteration), take immediate action:

• Transfer to ICU immediately 2
• Contact liver transplant center early 2
• Administer N-acetylcysteine regardless of etiology 2
• Patients progressing to grade 4 encephalopathy have reasonably good prognosis compared to other etiologies, with survival rates up to 67% with medical management alone 3

Post-Exposure Prophylaxis for Contacts

Immune Globulin Administration

• Administer hepatitis A immune globulin (IG) to unvaccinated contacts within 14 days of exposure—this provides >85% protection against infection 1
• Target IG to household members, co-habitants, sexual partners, and persons with ongoing close personal contact 1
• Do not postpone IG administration while awaiting anti-HAV testing, as delays reduce prophylactic effectiveness 1
• Hepatitis A vaccine alone is not recommended for post-exposure prophylaxis 1

Special Considerations in Pregnancy

• In pregnant women with acute hepatitis A, caesarean section is not recommended unless there is an obstetric indication 4
• Breastfeeding should not be discouraged in women with acute hepatitis A 4
• Active or passive immunization of newborns is not routinely suggested 4

Diagnostic Pitfalls to Avoid

• Be aware that anti-HAV IgM antibodies may be undetectable at initial symptom onset in rare cases—repeat viral hepatitis testing if clinical suspicion remains high 5
• Recognize that uncommon extrahepatic manifestations (maculopapular rash, polyarthralgia) can occur and may delay diagnosis 5
• Confirm diagnosis by detecting IgM anti-HAV antibodies, as clinical features alone cannot reliably differentiate hepatitis A from other viral hepatitides 1

Critical Management Pitfalls

• Do not delay ICU transfer for patients with coagulopathy and mental status changes 2
• Avoid using benzodiazepines for sedation in patients with liver failure 2
• Do not administer nephrotoxic agents 2
• Do not routinely correct coagulation abnormalities without active bleeding 2