Hepatitis A
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.General: Inflammation of the liver.
B.Acute: Clinical or biochemical evidence of liver disease less than 6 months.
C.Vaccine preventable, communicable disease of the liver caused by the hepatitis A virus.
D.Self-limited disease that does not result in chronic infection.
Incidence
A.Most common form of acute viral hepatitis in the world.
B.In the United States, the estimated number of new infections in 2015 was 2,800 people.
Pathogenesis
A.Transmitted person-to-person by the fecal–oral route or consumption of contaminated food or water.
Predisposing Factors
A.International travel to developing countries.
B.Day-care employees and children.
C.Poor hygiene practices at restaurants/cafeterias.
D.Living with an infected person.
E.Men who have sex with men.
Subjective Data
A.Common complaints/symptoms.
1.Fatigue.
2.Fever.
3.Malaise.
4.Headache.
5.Nausea.
6.Right upper quadrant pain.
7.Loss of appetite.
8.Itching.
9.Myalgia.
B.Common/typical scenario.
1.Onset of symptoms.
2.Vaccination history.
3.Recent travel.
4.Food history.
C.Family and social history.
1.Living situation.
2.Sexual practices/preferences.
D.Review of systems.
1.Dark urine.
2.Light-colored stool.
3.Jaundice.
Physical Examination
A.Jaundice.
B.Scleral icterus.
C.Fever up to 104°F.
D.Right upper quadrant (RUQ) tenderness.
E.Hepatomegaly.
Diagnostic Tests
A.Workup includes: Complete blood count (CBC), comprehensive metabolic panel (CMP), international normalized ratio (INR), hepatitis A IgM and IgG antibodies, hepatitis B serologies (Hep B surface antibody, Hep B surface antigen, Hep B core antibody), hepatitis C antibody screen, hepatitis E antibody.
B.Lab abnormalities include: Elevations of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) often greater than 1,000 IU-L, followed by elevations of bilirubin up to 10 mg/dL.
C.Ultrasound of the abdomen.
Differential Diagnosis
A.Hepatitis E.
B.Alcoholic hepatitis.
C.Autoimmune hepatitis.
D.Acute drug-induced liver injury (DILI)
E.Acute HIV infection.
F.Cytomegalovirus (CMV) infection.
G.Epstein–Barr virus (EBV).
H.Herpes simplex virus (HSV).
Evaluation and Management Plan
A.General plan.
1.Supportive care.
a.Intravenous (IV) fluids.
b.Antiemetic medications.
B.Patient/family teaching points.
1.Vaccination of close contacts.
2.Safe sex practices.
3.Good hand hygiene.
C.Pharmacotherapy.
1.Acetaminophen may be cautiously administered but limited to 2 g per day.
2.Administration of immunoglobulin within 14 days of exposure to achieve passive immunization and reduce severity of illness.
D.Discharge instructions.
1.Rest.
2.Return to work should be delayed for 10 days after the onset of jaundice.
3.Follow-up with primary care physician.
Follow-Up
A.Primary care doctor visit: Repeat liver tests.
B.Vaccination for hepatitis B, if not immune.
C.Most people have a full recovery; infection confers lifelong immunity (positive hepatitis A antibody).
D.Up to 10% of patients experience a relapse of symptoms during the 6 months following acute illness.
Consultation/Referral
A.Hepatologist for chronic elevated liver tests post infection.
Special/Geriatric Considerations
A.Liver transplant should be considered in fulminant disease.
B.This occurs in less than 1% of patients and is most common in individuals over 50, or with any other chronic liver disease.
Bibliography
Centers for Disease Control and Prevention. (n.d.). Hepatitis A questions and answers for health professionals. Retrieved from https://www.cdc.gov/hepatitis/hav/havfaq.htm
Gilroy, R. K. (2017, October 16). Hepatitis A. In B. S. Anand (Ed.), Medscape. Retrieved from https://emedicine.medscape.com/article/177484-overview
Lai, M., & Chopra, S. (2018, December 17). Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis. In E. L. Baron (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/hepatitis-a-virus-infection-in-adults-an-overview
Mayo Clinic. (n.d.). Hepatitis A. Retrieved from https://www.mayoclinic.org/diseases-conditions/hepatitis-a/symptoms-causes/syc-20367007.