Acute Infectious Hepatitis

Diagnosis

Complicated cases

Management of uncomplicated cases

Complicated cases (indications for further investigations)

Common causes are hepatitis viruses A and B and less commonly C, D and E. Hepatitis A is spread via the faecal-oral route and is often mild or asymptomatic. Hepatitis B is transmitted parenterally, peri-natally or by sexual contact. Symptomatic disease occurs in 10-20% of cases and fulminant hepatitis in 1% of cases. A chronic carrier state may occur, putting the patient at risk for hepatocellular carcinoma and cirrhosis. 

Diagnosis 

Hepatitis A is the commonest cause of acute onset jaundice in children > 1 year and a clinical diagnosis can be made. There is a prodrome of anorexia, vomiting, malaise then new onset jaundice with dark urine. A tender liver may be palpable. There is bilirubin detectable in the urine. There may be a history of contact with a person with jaundice. 

Complicated cases: 

• Signs of chronic liver disease or portal hypertension: Clubbing, pale nails, palmar erythema, Hard liver, Spleen palpable, Ascites/prominent abdominal veins. 
• Signs of liver failure / decompensating: Bleeding tendency, Altered level of consciousness/change in behaviour/ataxia, Hypoglycaemia, dehydration. 

Management of Uncomplicated Cases: 

• Urine dipstix to confirm bilirubin present and Hgt. 
• Do baseline investigations: LFTs, HGT and Hep A serology. 
• Consider offering passive prophylaxis with Human normal immunoglobulin for intramuscular injection (INTRAGAM ®) to young (<5yrs) household contacts (0,02ml/kg IMI). Max dose 3ml infants and small children, 5ml large children and adults. Children with chronic illness and persons over 60 also qualify. Must be given within 2 weeks of exposure. 
• Consider HAV in all exposed >2 year (can give with IG). IG not always available at Paarl (has to be fetched from TBH). 
• Avoid use of paracetamol or other liver toxic substances. 
• Manage at home with reassurance to parents. 
• Isolation not required from other family members, virus shedding usually ceases at onset of jaundice. 
• Bed rest may be indicated due to low energy levels but does not change course of illness. 
• High energy diet, fat often poorly tolerated. 
• Regular fluid intake especially if still vomiting. 
• Can return to school once jaundice has cleared and feeling less apathetic. 
• Return immediately if there is persistent vomiting, drowsiness, decreased arousability (very urgent!), bleeding, pallor or if jaundice lasts longer than 3 weeks or is recurrent. 
• Notify as Viral Hepatitis(See notification page in back of book) 

Complicated cases (Indications for further investigations) 

• Dehydration / severe persistent vomiting. 
• Any signs to suggest liver failure: bleeding, confusion/drowsiness, hypoglycaemia, ataxia or chronic liver disease. Refer to TBH for ICU care! 
• Jaundice persisting beyond 3 weeks. 

Investigations with complicated Cases: 

• Dextrostix/Hgt – Dextrose containing bolus and continuous infusion immediately if low 
• Electrolytes (+/- blood gas depending on degree of dehydration) 
• Liver function tests (ALT, AST, LDH,GGT, Bili – total and conjugated, Albumin) 
• FBC, clotting profile 
• Blood culture 
• Virology: Hepatitis A IgM, HBsAg and HBsAb, Hepatitis C 
• Consider cross-match for blood products if suspect clotting abnormality 
• Further investigations (ammonia, other virology). Note: For ammonia, phone lab to arrange, has to go to Green Point. Dark green top, heparinised tube on ice, to lab within 15 min of being drawn. 

If investigations and clinical picture suggestive of diagnosis of liver failure, institute management for acute liver failure and refer to GIT service Tygerberg Hospital: 

• Treat shock/dehydration. If in renal failure then catheterize and review fluid and electrolyte balance closely. 
• Test for and manage hypoglycaemia: if low glucose(<2,6mmol/l) 2-5ml/kg bolus 10%dextrose then 5%dextrose containing solution(PMS) or10% dextrose solution (NNL or cocktail 100ml PMS + 10ml 50% dextrose) iv infusion depending on blood glucose at usual maintenance volume for the age group. NBM initially (reduce protein load) 
• Cover with broad spectrum antibiotics (Cefotaxime) for possible gram-negative sepsis 
• Decontaminate gut: Lactulose (5-10ml tds) and Gentamicin 50mg/kg/day (max dose 360mg) 4hourly PO 
• Fungal prophylaxis: Mycostatin 1ml QID 
• Prophylaxis against GIT bleed: Sucralfate 0,5g 6hrly po 
• Trial of Mannitol if depressed LOC, features of encephalopathy and intravascularly replete (Dose:0,5g/kg/dose) 
• Vitamin K 5-10mg IVI stat, FFP, Cryoprecipitate depending on results and clinical status 
• N-acetylcysteine infusion: load 150mg/kg in 5%D/W over 1 hour then 10mg/kg/hour continuously