Hepatitis

           

If pregnant — see Hepatitis in pregnancy
Causes of hepatitis
  • Viral hepatitis (A, B, C) —  Table 7.11
  • Syphilis
  • Alcohol or kava
  • Fatty liver from alcohol, high blood fats, diabetes, obesity
  • Medicines — oral contraceptives, TB medicines, epilepsy medicines, paracetamol overdose, statins
  • Plants or herbal medicines, eg St John’s wort, echinacea, mushrooms
  • Other — autoimmune, too much iron or copper in body

Table 7.11  Main types of viral hepatitis  

* Contact with blood includes sharing needles, razors, toothbrushes OR knives, sticks, stones for ‘sorry cuts’, ceremonial business OR backyard tattoos, piercings

** Many people who acquire viral hepatitis remain asymptomatic

Symptoms

  • Caused by new acute hepatitis or worsening of chronic hepatitis
    • Feel unwell, no appetite
    • Confusion, drowsiness
    • Dark urine — colour of strong tea
    • Pale faeces
    • Nausea and/or vomiting
    • Jaundice (yellow skin or eyes)
    • Upper abdominal pain, tender liver
    • Smokers go off their cigarettes
  • If underlying chronic liver disease — may also have signs of cirrhosis
  • Children may not be sick at all
  • Common to have abnormal LFT without being sick or having any significant liver disease

Acute hepatitis

Liver inflammation — measured by raised ALT (liver function test)

Ask

  • About symptoms
  • Faeces — pale or melena (blood, black and tarry)
  • Alcohol use — recent binge
  • IV drug use, unprotected sex
  • Medicines — prescribed or over the counter

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A, pregnancy test

Do

  • If hepatitis status unknown or not immune — blood as needed
    • Hepatitis A — HAV IgG, HAV IgM
    • Hepatitis B — HBsAg, anti-HBc IgG, anti-HBc IgM, anti-HBs — write in clinical notes on pathology form 'query Hepatitis B' so that pathology company can complete all tests
    • Hepatitis C — anti-HCV
  • Blood for LFT, AST,  INR, FBC, UEC
  • Medical consult
  • Advise person — careful hand washing, separate eating utensils, safer sex, blood precautions, eg don't share razors, toothbrush, needles
  • Food and fluids as tolerated
  • No alcohol until fully well and LFT normal — several months
  • May need further blood tests to monitor — LFTs, INR
  • If hepatitis A or hepatitis B — close contacts may need immunisation

Follow-up

  • Review regularly — based on symptoms and blood test results. Doctor will advise frequency
  • Check serology results — may show viral cause of hepatitis
  • Work out if person already has chronic viral hepatitis
  • Put on recall for 6 month review — to see if problem has become chronic

Chronic hepatitis

  • Hepatitis (inflamed liver) or viral hepatitis infection for more than 6 months
  • ALT is raised if more than 30 units/L in men or 19 units/L in women
  • All Aboriginal Australians should be tested for Hepatitis B (HBsAg, Anti-HBs, Anti-HBc) at least once due to the high rate of chronic Hepatitis B in Aboriginal people
  • Alcohol, fatty liver and hepatitis B infection are the most common causes of chronic liver disease in remote Aboriginal communities. Hepatitis C is an increasing problem

Classification of hepatitis B status

Understanding hepatitis serology (blood tests) is hard — contact PHU if you need help

Table 7.12 Classification of hepatitis B status

  • If person has had 3 documented immunisations starting at birth and complies with the recommended schedule — no further testing for hepatitis B is needed unless
    • They are Aboriginal and/or Torres Strait Islander
    • There is a clinical reason to think they have active hepatitis
    • It is part of routine antenatal testing in pregnancy — see Hepatitis in pregnancy

Person has chronic viral hepatitis if

  • HBsAg positive for more than 6 months — chronic hepatitis B
  • Anti-HCV positive and hepatitis C PCR positive for more than 6 months — chronic hepatitis C

Look in file notes

Check

6 months after first acute presentation OR if reoccurrence of symptoms

  • Blood for FBC, UEC, LFT, coagulation studies, HIV
  • If hepatitis B
    • Take blood for HBsAg, hepatitis B viral load, HBeAg, anti-HBe. If result not known — ADD HAV IgG, Anti-HCV
    • Write on pathology form — 'If HBsAg positive, please do hepatitis B viral load, HBeAg, anti-HBe'
  • If hepatitis C
    • Take blood for HCV genotype and viral load
    • HBsAg, anti-HBs, anti-HBc, HAV IgG (if results not known)

Do

  • Medical consult about results, care plan and follow-up
  • Discuss preventive measures — Table 7.13
  • For all new diagnoses of chronic liver disease
  • If not hepatitis B or hepatitis C — may also need tests for antinuclear, anti-smooth muscle, anti-mitochondrial, anti-LKM antibodies, alpha1 anti-trypsin, caeruloplasmin, copper studies, iron studies, HbA1c and non-fasting lipids, immunoglobulins

Table 7.13  Preventive measures for chronic viral hepatitis  

* Check file notes, immunisation registers

Management of chronic viral hepatitis

Aim to

  • Prevent further liver damage, eg cirrhosis (scarred liver), liver cancer
  • Prevent passing infection to others
  • Minimise alcohol use — see Brief interventions
    • Shouldn't drink alcohol at all
    • If drinking — advise less than 7 standard drinks week and at least 3 alcohol-free days a week

Do — chronic hepatitis B infection

HBsAg positive for more than 6 months

  • Adult Health Check
  • If at high risk of liver cancer — offer 6 monthly AFP, LFT, liver ultrasound
  • 12 monthly hepatitis B viral load, HBsAg, HBeAg
    • May need antiviral treatment if ALT is raised (more than 30 units/L for men, more than 19 units/L for women) and viral load greater than 2000 international units/mL
    • Oral antiviral treatment for hepatitis B can prevent or reverse cirrhosis and prevent cancer. Treatment for most people will be lifelong
  • Medical follow-up to consider if specialist consult is required

Do — chronic hepatitis C infection

Anti-HCV and HCV PCR positive for more than 6 months

  • Oral antiviral treatment can cure hepatitis C infection
  • Most people can be treated with in 8–12 weeks with easy to take tablet medicine
  • All patients should have treatment and monitoring discussed with specialist
  • If evidence of cirrhosis — urgent referral to specialist

Do — chronic non-viral hepatitis

Continuing abnormal LFTs where no cause identified and serology negative for hepatitis B and hepatitis C

  • Medical consult to discuss other blood tests before referral to specialist

Cirrhosis

Fibrosis (liver scarring) — some people have normal liver function tests and no symptoms or signs of liver disease

More likely if abnormal findings on any of the following 

  • Clinical signs of chronic liver disease — encephalopathy (altered mental state), spider naevi (red spots on chest wall that go pale with pressure), palmar erythema (red palms), gynaecomastia (breast enlargement in males), palpable spleen, ascites (swollen abdomen), oedema (swollen legs)
  • Abnormal blood test results — low platelets, low albumin, high bilirubin, high INR
    • APRI (AST to platelet ratio index) score more than 1 may indicate fibrosis — see APRI online calculator 
  • Imaging — liver ultrasound and Fibroscan
  • If any of the above — medical/specialist consult

Monitoring for liver cancer

Liver cancer can be treated and possibly cured if diagnosed early — when tumour small and no symptoms

People at high risk

  • All Aboriginal people over 50 years with hepatitis B or hepatitis C
  • Chronic hepatitis B or hepatitis C AND family history of liver cancer in first degree relative
  • All persons with proven or suspected cirrhosis

Do

  • Explain screening and treatment so person can decide if they want screening
  • People at high risk should be screened every 6 months with
    • Blood for alpha-fetoprotein (AFP)
    • Liver ultrasound

Supporting resources

  • APRI (AST to Platelet Ratio Index) online calculator
  • Menzies Hep B Story app
  • Menzies Hep B PAST — Hep B hub website