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Acute Hepatitis
Aka: Acute Hepatitis, Acute Hepatitis Causes, Hepatitis Differential Diagnosis in Acute Cases, Acute Liver Disease, Acute Liver Disease in Pregnancy, Acute Hepatitis in Pregnancy- See Also
- History
- Travel history
- Undercooked food ingestion
- Hepatotoxin exposure
- IV Drug Abuse
- Sexual contacts
- Viral Hepatitis exposure
- Symptoms
- Signs
- Dehydration
- Jaundice
- Hepatomegaly
- Firm enlarged, palpable liver edge
- Labs
- See Viral Hepatitis
- See Liver Function Test Abnormality
- Serum Lipase
- Complete Blood Count
- Coagulation tests (INR/ProTime, Partial Thromboplastin Time)
- INR elevation in the absence of Warfarin is not equivalent to increased bleeding
- INR only reflects Factor VII levels, where as liver failure results in both pro and Anticoagulant factors
- Consider Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to evaluate Coagulopathy
- Direct Bilirubin (Conjugated Bilirubin, fractionated from liver tests)
- Serum Ammonia (if Altered Level of Consciousness)
- Comprehensive metabolic panel
- Electrolytes
- Renal Function tests
- Liver Function Tests
- Alkaline Phosphatase typically up to twice normal in Viral Hepatitis
- Serum Aminotransferases (AST, ALT) up to 10-20 fold above normal in Viral Hepatitis
- Viral Hepatitis (consider)
- Toxicology labs (consider)
- Urine Toxicology Screening
- Blood Alcohol level
- Acetaminophen level
- Salicylate level
- Imaging
- Head CT
- Indicated for Altered Level of Consciousness (e.g. Hepatic Encephalopathy)
- Ocular Ultrasound
- Optic Nerve Sheath Diameter >5mm is consistent with Increased Intracranial Pressure
- Head CT
- Differential Diagnosis: Infection
- Viral Hepatitis (most common)
- Typical acute Viral Hepatitis causes
- Mild Viral Hepatitis causes
- Cytomegalovirus (CMV)
- Mononucleosis (EBV)
- Coxsachievirus
- Potentially severe hepatitis (especially in immunocompromised patients)
- Herpes Simplex Virus (HSV)
- Varicella
- Bacterial hepatitis
- Leptospirosis
- Associated with animal or tick borne exposure
- Q Fever
- Relapsing Fever and myalgias
- Alkaline Phosphatase significantly increased out of proportion to transaminases
- Rocky Mountain Spotted Fever
- Jaundice is prominent
- Secondary Syphilis
- Typhoid Fever
- Overwhelming infection (Sepsis)
- Liver Abscess (esp. immunocompromised hosts or those with underlying cancer)
- Biliary tract source (Escherichia coli, KlebsiellaPneumoniae)
- Fitz-Hugh-Curtis Syndrome
- Perihepatic spread of Pelvic Inflammatory Disease
- Primarily NeisseriaGonorrhea and Chlamydia trachomatis
- Leptospirosis
- Parasite
- Entamoeba histolytica (Liver Abscess)
- Toxocariasis
- Associated with pneumonitis, Leukocytosis with Eosinophil predominance
- Liver Trematodes (liver flukes)
- Fungal causes
- Candida albicans (Liver Abscess)
- Seen in immunocompromised patients especially with prolonged antibiotic exposure
- Candida albicans (Liver Abscess)
- Viral Hepatitis (most common)
- Differential Diagnosis: Pregnancy related Acute Liver Disease
- Hyperemesis Gravidarum
- Liver transaminases (AST, ALT) may be over 200 IU/L
- Alkaline Phosphatase may be increased up to twice normal
- Serum Bilirubin may be increased enough to cause visible Jaundice
- HELLP Syndrome
- Often associated with Preeclampsia with Severe Hypertension and Proteinuria
- Most commonly occurs in third trimester and immediately postpartum
- Acute Fatty Liver of Pregnancy
- Associated with more severe liver failure and Renal Insufficiency
- May be difficult to distinguish with HELLP Syndrome
- Intrahepatic Cholestasis of Pregnancy
- Most common liver disease in pregnancy (second and third trimester)
- Significantly elevated Bilirubin levels risk fetal demise and preterm delivery
- Hyperemesis Gravidarum
- Differential Diagnosis: Miscellaneous
- Autoimmune Conditions
- Systemic Lupus Erythematosus (SLE)
- Autoimmune Hepatitis
- Women predominate in a bimodal distribution (ages 15 to 25 and 45 to 60 years old)
- Medications and drugs
- See Hepatotoxin
- Alcohol Abuse
- Carbon tetrachloride
- Autoimmune Conditions
- Precautions: Red Flags (admission criteria)
- Altered Mental Status
- Hypoglycemia
- Severe Hyperbilirubinemia
- Significant Renal Insufficiency
- Significantly abnormal coagulation studies
- Management
- See Fulminant Hepatitis (Acute Liver Failure)
- Supportive care
- Intravenous rehydration
- Antiemetics
- Specific management
- Disposition
- Admit patients with red flag findings (see above) to Intensive Care unit
- Most patients may be discharged to home with close interval follow-up with primary care
- Prevention
- See Viral Hepatitis
- References
- Swaminathan and Weingart in Herbert (2020) EM:Rap 20(10):1-2
- Swencki (2015) Crit Dec Emerg Med 29(11):2-10
- (2004) MMWR Recomm Rep 53(RR-4): 1-33 [PubMed]
- Matheny (2012) Am Fam Physician 86(11): 1027-34 [PubMed]