How should acute hepatitis A be managed?

Management of Acute Hepatitis A

Acute hepatitis A requires only supportive care, as no specific antiviral therapy has proven effective for this self-limited infection. 1, 2, 3

Diagnosis

• Confirm acute hepatitis A infection by detecting IgM anti-HAV antibodies, as clinical features alone cannot reliably differentiate hepatitis A from other viral hepatitides 1, 2
• Serologic testing is essential because hepatitis A cannot be distinguished from other forms of viral hepatitis based on clinical presentation alone 1

Primary Treatment Approach

Supportive care is the sole treatment for acute hepatitis A, with management focused on symptom relief and monitoring for complications. 1, 2, 3, 4

• Provide rest, maintain hydration, and offer symptomatic relief for nausea, anorexia, and malaise 1
• Avoid all hepatotoxic medications, particularly acetaminophen, and ensure complete alcohol abstinence during the acute illness 2, 3
• No dietary restrictions are necessary, though patients often have reduced appetite during the acute phase 1

Monitoring Strategy

• Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution 2
• Watch closely for signs of acute liver failure, including coagulopathy (INR ≥1.5), mental status changes, and rising bilirubin 2, 3
• Hospitalization is necessary for patients who become dehydrated from nausea and vomiting, and is critical for those with signs of acute liver failure 1

Expected Clinical Course

• The majority of patients recover completely within approximately 2 months without specific intervention 2, 4
• Be aware that 10-15% of patients may experience a relapsing illness during the first 6 months after onset 1, 2
• Patients with pre-existing chronic liver disease are at higher risk for progression to acute liver failure 2
• Chronic infection or chronic liver disease does not occur with hepatitis A 4

Management of Severe or Atypical Presentations

Fulminant Hepatic Failure

• Transfer immediately to ICU if INR is prolonged by 4-6 seconds or more (INR ≥1.5) with any alteration in mental status 2
• Contact liver transplant center early for all patients with acute liver failure 2
• Emergency liver transplantation may be required, particularly in older patients (>40 years) and those jaundiced for >7 days before encephalopathy onset 5

Prolonged Cholestasis

• For patients with markedly elevated bilirubin and intense pruritus, consider ursodeoxycholic acid for symptomatic relief 6
• Corticosteroid therapy may be justified in markedly symptomatic patients with relapsing or cholestatic variants, though evidence is limited to case reports 6

Post-Exposure Prophylaxis for Contacts

Administer hepatitis A immune globulin (IG) to unvaccinated contacts within 14 days of exposure, as it provides >85% protection against infection. 1, 2

• Target IG to household members, co-habitants, sexual partners, and any persons with ongoing close personal contact with the index case 1, 2
• Do not postpone IG administration while awaiting anti-HAV testing, as delays reduce prophylactic effectiveness 2
• Hepatitis A vaccine should be offered subsequently to eligible individuals who receive IG 2

Critical Pitfalls to Avoid

• Do not use acetaminophen or allow alcohol consumption during acute hepatitis, as these are hepatotoxic and can worsen liver injury 2, 3
• Do not delay ICU transfer for patients with coagulopathy and mental status changes, as this represents acute liver failure requiring immediate intensive management 2
• Do not assume all cases will be uncomplicated—patients with chronic liver disease require closer monitoring due to higher risk of severe outcomes 2
• Do not use medications metabolized by the liver without careful consideration, as hepatic clearance is impaired during acute infection 1