Hepatitis is inflammation of the liver that can be caused by several viruses. This document focuses on hepatitis A, hepatitis B, hepatitis C, and hepatitis E viruses. It describes the transmission, clinical features, diagnosis, treatment, and prevention of each. The key points are that hepatitis A and E are usually transmitted by the fecal-oral route, while hepatitis B and C are transmitted through blood or body fluids. Hepatitis B and C tend to cause chronic liver disease more often than hepatitis A and E. Prevention involves vaccination, safe needle practices, and hygiene.

1. HEPATITIS
DR SARAH KISUSANGE

2. INTRODUCTION
Viral hepatitis: Means inflammation of the liver caused by
viruses.
• There are several different viruses that in one way or the
other cause hepatitis.
• Hepatitis D virus does not cause infection on its own but
is accompanied with hepatitis B virus.
• Non-viral causes of hepatitis will be covered in the Internal
Medicine Module.
• The modes of transmission do differ among the viruses.
• Hepatitis A (HAV) and E (HEV) are transmitted by faecal-
oral or food borne route while hepatitis B (HBV) and C
(HCV) are spread mainly by exposure to infected blood or
body secretions.

3. Cont…
• In infected individuals, the virus can be found
in the blood, semen, vaginal discharge, breast
milk, and saliva.
• The clinical features of all viral hepatitis are
similar except that HBV and HCV have
tendency to chronic diseases.

4. Hepatitis A (HAV)
Epidemiology of HAV
• Hepatitis A occurs in the form of slowly spreading epidemics within
families and institutions.
• The epidemics can be traced to contaminated food, water and milk.
• Poor personal hygiene, overcrowding and poor sanitation increase
the transmission which is mainly via faecal-oral route.
• Most children in African countries are infected at a young age.
• The disease is very mild in children with gastroenteritis, without
jaundice resulting is long lasting immunity.
• When children acquire the infection later in life, they are more likely
to develop jaundice and more severe infection.
• Most cases of infectious hepatitis are therefore diagnosed in older
children and young adults
• The disease is maximally infectious just before the onset of jaundice

5. Clinical Features
• The incubation period is 1 – 4 weeks
• In the pre-icteric phase, the diseases present like
gastroenteritis with sudden outset of
 Fever
 Malaise
 Anorexia
 Nausea and abdominal discomfort
Stools are usually pale and urine is dark
The liver is moderately enlarged and the spleen is palpable in
about 10% of patients
Occasionally, tender lymphadenopathy is seen, with a transient
rash in some cases

6. • Children often do not progress to the next phase of
illness
• In the icteric phase, after few days jaundice appears
• The jaundice is partly hepatocellular type and partly
obstructive because the swollen liver cells block bile
flow in the bile capillaries
• Itching is usually not present
• Complete recovery phase in about 2 weeks is the rule
• Long period of extreme tiredness with depression may
occur after jaundice has disappeared
• A chronic carrier state does not occur

7. Diagnosis
Liver biochemistry ( Liver function test)
– Elevated serum bilirubin
– A raised serum AST or ALT
The erythrocyte sedimentation rate (ESR) is raised
Viral markers: antibodies to HAV
– IgG antibodies are common in the general population over
the age of 50 years
– Anti-HAV IgM means an acute infection
Presence of urobilinogen in urine analysis

8. Differential Diagnosis of Hepatitis A
• Yellow fever
• Relapsing fever
• Malaria
• Medication toxicity

9. Treatment
• No specific treatment is available; therefore there is no strict
reason for admission to hospital unless patient is unable to
maintain adequate fluid hydration.
• Bed rest at home is best and will prevent spread of the
disease.
• If admission for one or other reason is indicated, the patient
should be isolated and careful disposal of excreta.
• Patient should be advised to eat a high calories diet.
• Alcohol should be avoided for at least 6 months.
• Prevention can be obtained by giving the Hepatitis A
vaccination if available (2 shots recommended at least 6 -12
months apart)

10. Prognosis
• The prognosis is excellent, with most patients making a complete
recovery
• The mortality in young adults is 0.1% but it increases with age
• Death is due to fulminant hepatic necrosis
• During recovery, 5–15% of patients may have relapse of the
hepatitis but this settles spontaneously
• Occasionally a more severe jaundice with cholestasis will run a
prolonged course of 7–20 weeks and is called ‘cholestatic viral
hepatitis’
• Pts may complain of physical weakness for several months
following resolution of the symptoms and biochemical parameters.
This is known as the post-hepatitis syndrome; it is a functional
illness

11. Prevention and Prophylaxis
Active immunization
• HAV vaccine can be given to people travelling frequently to
endemic areas, patients with chronic liver disease, people
with haemophilia, and workers in frequent contact with
hepatitis cases
• Community outbreaks can be interrupted by vaccination
• A single dose produces antibodies that persist for at least 1
year, with immunity lasting beyond 10 years
Passive immunization
• Normal human immunoglobulin (0.02 mL/kg i.m.) is used if
exposure to HAV is < 2 weeks
Hygiene
• Proper disposal of feaces
• Proper water and food treatment to avoid contamination

12. Hepatitis E
Definition
• • Hepatitis E: A disease of the liver caused
by hepatitis E virus and is transmitted via
faecal-oral route.
• Causes outbreaks of hepatitis with similar
symptoms and signs to hepatitis A.

13. Epidemiology of HEV
• It is a water borne disease
• Contaminated water or food supplies have been
implicated in major outbreaks
• Symptomatic infection is more common in young
adults aged 15-40 years
• Children have a lower rate of infection
• High fatality rate in pregnant women (5-25%) because
of acute hepatic failure.
• Most people with hepatitis E recover fully, and there is
no progression to chronic liver disease.

14. Clinical Features
• The incubation period of hepatitis E is longer (3-
12 weeks).
• Typical signs and symptoms include:
Jaundice
Loss of appetite
Enlarged and tender liver
Abdominal pain
Nausea
Vomiting
Fever

15. Management
Diagnosis of Hepatitis E
• Hepatitis E should be suspected in outbreaks of
water-borne hepatitis, especially if the disease is
more severe in pregnant women, or if hepatitis A
has been excluded.
• Confirmatory diagnosis is made by blood tests
which detect elevated antibody levels specific to
hepatitis E in the body.
• However, such tests are not widely available and
patients need to be referred if at all confirmatory
diagnosis is required.

16. Treatment
• No specific treatment to alter the course of infection
• Treatment is mainly supportive
• Antibiotics have no role
• Prevention remains the effective approach against the
disease
• Hospitalization is required for fulminant hepatitis and
should be considered for infected pregnant women
• These patients need to be referred to hospitals for
proper management

17. Prevention and Control of HAV and
HEV
• Improvement of sanitation will diminish transmission of hepatitis A
• In most industrialized countries gamma globulin is now rarely given
• The hepatitis A vaccine is what is recommended for travelers (2
shots 6-12 months apart, no booster is needed) Other actions are:
 Isolation of admitted patients with hepatitis
 Improve food hygiene and water supplies
 Improve sanitation facilities
 Provision of health education on proper hand washing and excreta
disposal
 Improve food and water hygiene.

18. Hepatitis B (HBV)
• An infection of the liver caused by the hepatitis B virus
(HBV).
• It is estimated that 350 million individuals worldwide
are infected with the virus, which causes 620,000
deaths worldwide each year.
• Hepatitis B is found throughout the world.
• When a person first gets hepatitis B, they are said to
have an 'acute' infection.
• Most people are able to eliminate the virus and are
cured of the infection.
• Some are not able to clear the virus and have 'chronic'
infection with hepatitis B that is usually life-long.

19. Cont…
• The hepatitis B virus reproduces in liver cells,
but the virus itself is not the direct cause of
damage to the liver.
• Rather, the presence of the virus triggers an
immune response from the body as the body
tries to eliminate the virus and recover from
the infection.
• This immune response causes inflammation
and may seriously injure liver cells

20. Transmission
• Hepatitis B is spread mainly by exposure to infected blood or body
secretions.
• In infected individuals, the virus can be found in the blood, semen,
vaginal discharge, breast milk, and saliva.
• Sexual contact is the most common means of transmission, followed
by using contaminated needles for injecting illicit drugs, tattooing,
body piercing, or acupuncture.
• Additionally, hepatitis B can be transmitted through sharing
toothbrushes and razors contaminated with infected fluids or blood.
• Hepatitis B may also be spread from infected mothers to their babies
at birth (so-called 'vertical' transmission).
• Hepatitis B can be transmitted through transfused blood products,
donated livers and other organs.

21. Clinical Features
There are two types of Clinical features of HBV
which are:
• Acute hepatitis
• Chronic hepatitis

22. Cont…
Acute Hepatitis
• The period of illness that occurs during the first 1-6 months after
acquiring the virus.
• Only 30% to 50% of adults develop significant symptoms during
acute infection.
• Early symptoms may be non-specific, including fever, a flu-like
illness, and joint pains.
• Symptoms of acute hepatitis may include:
 Fatigue,
 Loss of appetite,
 Nausea,
 Jaundice
 Pain in the upper right abdomen (due to the inflamed liver).

23. Cont…
• Rarely, acute hepatitis damages the liver so badly leading to liver
failure.
• This life-threatening condition is called ‘fulminant hepatitis.’
• Patients with fulminant hepatitis are at risk of developing bleeding
problems and coma resulting from the failure of the liver.
• The body's immune response is the major determinant of the
outcome in acute hepatitis B.
• Individuals who develop a strong immune response to the infection
are more likely to clear the virus and recover.
• However, these patients also are more likely to develop more severe
liver injury and symptoms due to the strong immune response that is
trying to eliminate the virus.
• On the other hand, a weaker immune response results in less liver
injury and fewer symptoms but a higher risk of developing chronic
hepatitis B.

24. • People who recover and eliminate the virus
will develop life-long immunity.
• Most infants and children who acquire acute
hepatitis B viral infection have no symptoms
• In these individuals, the immune system fails
to mount a vigorous response to the virus.
• The risk of an infected infant developing
chronic hepatitis B is greater than 95%.

25. Cont…
Chronic Hepatitis
• Patients with chronic hepatitis B develop symptoms in proportion to the degree of
abnormalities in liver functions.
• The signs and symptoms of chronic hepatitis B vary widely depending on the
severity of the liver damage.
• Most signs and symptoms of chronic hepatitis are due to complications which
include Liver cirrhosis. This is caused by severe scarring of the liver leading to
dysfunction
Symptoms may include:
 Weakness
 Fatigue
 Loss of appetite
 Weight loss
 Breast enlargement in men
 Rash on the palms
 Difficulty with blood clotting
 Spider-like blood vessels on the skin

26. Cont…
• Patients with liver cirrhosis also are at risk of infections because the liver
plays an important role in the immune system
Several complications occur in advanced cirrhosis:
 Confusion and even coma (encephalopathy) results from the inability of the
liver to detoxify certain toxic substances.
 Increased pressure in the blood vessels of the liver (portal hypertension)
causes fluid to build up in the abdominal cavity (ascites) and may result in
engorged veins in the swallowing tube (esophageal varices) that tear easily
and may cause massive upper gastrointestinal bleeding.
 Portal hypertension can also cause kidney failure or an enlarged spleen
resulting in a decrease of blood cells and the development of anemia,
increased risk of infection and bleeding.
 Decreased production of clotting factors. This causes abnormalities in
blood clotting and sometimes spontaneous bleeding.
 Development of jaundice because the damaged liver is unable to eliminate
bilirubin

27. Cont…
• Liver cancer (hepatocellular carcinoma)
Patients with chronic hepatitis B are at risk of developing liver cancer
The way in which the cancer develops is not fully understood. Symptoms of
liver cancer are nonspecific
Patients may have no symptoms, or they may experience
 Abdominal pain and swelling
 Enlarged liver
 Weight loss
 Fever
• Extra-hepatic complications such as:
 Polyarteritis nodosa: a disease characterized by inflammation of the small
blood vessels throughout the body. This condition can cause a wide range
of symptoms, including:
• Muscle weakness
• Nerve damage

28. Cont..
Deep skin ulcers
Kidney problems
High blood pressure
Unexplained fevers
Abdominal pain
• Glomerulonephritis

29. Management
Diagnosis
• Infection with hepatitis B is suspected when the medical history and the physical examination reveal
risk factors for the infection or symptoms and signs that are suggestive of hepatitis B
• All the investigations for HBV are done at hospital levels, therefore patients have to be referred for
investigation as well as treatment.
• These investigations may include:
 Viral antigens
 Antibodies against the virus
 Liver function test
 RFT, FBP, HIV,
 Alfa Feto Protein (AFP)
 Colour Doppler ultrasonography or duplex Doppler ultrasonography or real time
 ultrasonography.
 CT scan
 Viral genetic materials (DNA PCR)
 Liver biopsy especially when hepatocellular carcinoma is suspected

30. Cont…
Treatment of Acute Viral Hepatitis B
• No specific antiviral treatment is required.
• Offer supportive management and counselling.
• Offer a follow up plan at 4 or 6 weeks’ intervals
for a clinical and laboratory re assessment for
evidence of symptoms recovery and biochemical
remission.
• Re-test at 6 months to assess sero conversion
status or progression to chronicity

31. • Treatment of chronic hepatitis B
Tenofovir (TDF) (PO) 300mg 24hourly; for at
least 48weeks;
and
Entecavir can be used

32. Prevention and Control of HBV
• A recombinant hepatitis B vaccine is available
to special people at risk (this would include
health care workers, HIV+ individuals and IV
drug users).
• This produces active immunization in 95% of
normal individuals but ineffective in people
already infected with HBV.

33. Cont…
Other important preventive measures include:
• Sterilization of reusable hospital instruments
• Screening of blood and blood products for HBV will
prevent transmission from blood transfusion
• Health education to at risk population e.g. IDU and sex
workers
• Change of behavior e.g. abstinence, faithfulness and use of
condoms will also reduce the risk of transmission
• Avoidance of needle stick injuries in health care workers
• Properly dispose of contaminated needles and instruments
• Persons with HBV should not share razors or toothbrushes

34. Hepatitis C
• Hepatitis C is an infection of the liver caused by
the hepatitis C virus (HCV).
• It is difficult for the human immune system to
eliminate the virus from the body, and infection
with HCV usually becomes chronic.
• Chronic infection with HCV damages the liver
and can cause liver failure in some people.
• HCV is spread (transmitted) most efficiently
through inadvertent exposure to infected blood.

35. Transmission
• The different ways in which HCV can be
transmitted include:
Needles shared among users of illicit drugs.
Accidental needle-sticks in healthcare workers.
Transfusions of blood or blood products.
From mother to unborn child (vertical
transmission)
Re-use of sharp tool have to patients without
appropriate cleaning

36. Clinical Features of HCV
• About 75% of people have no symptoms when they first
acquire HCV infection.
• The remaining 25% may complain of:
 Fatigue
 Loss of appetite
 Muscle aches
 Fever
 Jaundice is rare at the early stage of infection
• In the chronic infection the signs and symptoms of liver
cirrhosis are similar to those in HBV chronic infection,
however complications outside the liver do differ as
outlined below:

37. Cont…
• Two skin conditions, lichen planus and
porphyria cutanea tarda, have been associated
with chronic infection with HCV.
• Low platelet counts may occur as a result of
antibody-mediated platelet destruction.
• HCV also is associated with B-cell lymphoma,
a cancer of the lymph system

38. Management
Diagnosis
• The diagnosis of HCV may be done in some
hospitals and patients suspected of having
HCV have to be referred.
• In hospitals several investigations can be done
including:
Antibodies against the virus
Viral genetic material (RNA)

39. Cont…
Treatment
• Patients suspected of having need to be
referred to hospitals for evaluation and
possible treatment.
• This includes the use of some drugs such as
ledipasvir, interferon and ribavirin.
• These drugs may not be readily available.

40. Prevention and Control of HCV
• Avoiding needle sharing especially among drug addicts.
• Safe needle-usage techniques for health care workers to reduce
accidental needle-sticks injuries.
• There is no clear way to prevent transmission of the HCV from
mother to child.
• Persons with multiple sexual partners should use barrier precautions
such as condoms to limit the risk of HCV as well as other sexually-
transmitted diseases.
• Screening tests for blood and blood products to reduce the risk of
transmission through transfusion.
• People with HCV should not share razors or toothbrushes with
others.
• Sterilizing/cleaning reusable hospital instruments and disposable
sharp instruments should be discarded properly.

41. Hepatitis D (HDV)
• Incomplete RNA particle enclosed in a shell of HbsAg
• It is unable to replicate on its own but is activated by
the presence of HBV
• It is particularly seen in intravenous drug users but can
affect all risk groups for HBV infection
• Co-infection of HDV and HBV is clinically
indistinguishable from an acute icteric HBV infection
• Dx is confirmed by finding serum IgM anti-HDV in the
presence of IgM anti-HBc
• The HDV RNA is an early marker of infection

42. Cont…
• The infection may be transient but the clinical
course is variable
• Spontaneous resolution is rare
• Between 60% and 70% of patients will develop
cirrhosis, and more rapidly than with HBV
infection alone
• In 15% the disease is rapidly progressive with
development of cirrhosis in only a few years
• Lamivudine and adefovir appear to be unhelpful

43. KEY POINTS
• Viral hepatitis can either be transmitted by faeco-oral route or via
blood and blood products or sexual contact.
• HAV and HEV are self limiting diseases and have no tendency to
chronic infection.
• HBV and HCV can cause chronic infections.
• Diagnosis and management of all types of hepatitis are challenging
and most of the time requires referral to hospitals.
• Prevention of HAV and HEV is similar to other faeco-oral disease
i.e. hygiene and improvement of sanitation.
• A vaccine is available for Hepatitis A and HBV but others have no
approved vaccines.
• Prevention of HBV and HCV are similar and comprises all efforts of
avoiding contact with infected blood and blood products and safe
sexual behavior.

44. QUESTIONS
1. Write an assay on Viral hepatitis with inclusion of the following
• Viral hepatitis: Means inflammation of the liver caused by viruses(2 mark)
• causes of Viral hepatitis(2 marks)
• Hepatitis A, B, C and E viruses.
• modes of transmission of each cause (2 marks)
• Hepatitis A (HAV) and E (HEV) are transmitted by faecal-oral or foodborne route
• hepatitis B (HBV) and C (HCV) are spread mainly by exposure to infected blood or body
secretions
• Clinical Features of Viral hepatitis(3 marks)
• In the pre-icteric phase, the diseases present like gastroenteritis with sudden outset of:
• Fever
• Malaise
• Anorexia
• Nausea and abdominal discomfort
• jaundice is partly hepatocellular type and partly obstructive because the swollen liver cells block
bile flow in the bile capillaries

45. Management of Viral hepatitis
• Investigations(2 marks)
• LFT (AST and ALT) can be markedly elevate
• Blood slide to exclude causes of jaundice i.e malaria
and relapsing fever.
• both direct and indirect bilirubins are raised
• Stools are usually pale and urine is dark
• WBC total and differential are normal
• Treatment(2 marks)
• No specific treatment is available
• Conclusion (2 marks)

46. 2.Mention five (5) symptoms of acute hepatitis.
(5 Marks)
• ……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……

47. 3. Pertaining to Hepatitis
A. There are now only three types of viruses that cause
Hepatitis (Hep A virus, Hep B virus and Hep C virus)
B. Hepatitis C is the most recently discovered hepatitis
virus
C.The major route of transmission of Hepatitis C virus is
through oral - fecal route.
D.Hepatitis C is the most likely to progress to chronic
infection
E The jaundice in Hepatitis is predominantly obstructive