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Gastrointestinal & Hepatic System

Viral Hepatitis (Overview)

Inflammation of the liver caused by viral infection. Hepatitis A, B, C, D, and E viruses are the primary causes. Presentation ranges from asymptomatic infection to acute fulminant hepatitis or chronic infection leading to cirrhosis and liver cancer (HBV, HCV, HDV).

Also known as: Hepatitis, Liver Inflammation

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Referral and warning signs

When to refer

Refer to specialist (Gastroenterologist/Hepatologist/Infectious Diseases) for: Fulminant hepatitis/acute liver failure (URGENT). Chronic Hepatitis B or C diagnosis for assessment and treatment initiation/monitoring. Complications of cirrhosis (varices, ascites, encephalopathy, HCC screening). Diagnostic uncertainty.

Red flags

  • Signs of acute liver failure (jaundice with confusion/encephalopathy, coagulopathy - prolonged INR)
  • Signs of decompensated cirrhosis (ascites, variceal bleeding, hepatic encephalopathy)
  • Severe symptoms (persistent vomiting, dehydration)
  • Suspicion of hepatocellular carcinoma (e.g., weight loss, new liver mass)

Signs and symptoms

  • Acute Hepatitis (Many cases asymptomatic, esp. HAV/HEV in children, HBV/HCV):
  • - Prodrome (pre-icteric phase): Fatigue, malaise, anorexia, nausea, vomiting, low-grade fever, RUQ discomfort, myalgia, arthralgia.
  • - Icteric Phase: Jaundice (yellowing of skin/sclera), dark urine, pale stools, pruritus (itching). Prodromal symptoms may improve as jaundice appears.
  • - Recovery Phase: Gradual resolution of symptoms and LFT abnormalities (weeks to months).
  • Fulminant Hepatitis (Acute Liver Failure): Rapid onset severe liver injury with impaired synthetic function (INR >1.5) and hepatic encephalopathy in patient without pre-existing cirrhosis. High mortality.
  • Chronic Hepatitis (HBV, HCV, HDV): Often asymptomatic for years/decades. May have non-specific fatigue, malaise. May present later with complications of cirrhosis (ascites, variceal bleeding, encephalopathy, jaundice) or hepatocellular carcinoma (HCC).

Risk factors

  • Hepatitis A/E (Faecal-oral): Poor sanitation, contaminated food/water, travel to endemic areas, close personal contact.
  • Hepatitis B/C/D (Parenteral/Sexual/Perinatal):
  • - Unprotected sexual intercourse, multiple partners.
  • - Injecting drug use (sharing needles).
  • - Mother-to-child transmission (perinatal - esp. HBV).
  • - Receipt of unscreened blood/blood products (historical risk).
  • - Needlestick injuries / Occupational exposure.
  • - Household contact with infected person.
  • - Haemodialysis.
  • - Tattoos, body piercing with non-sterile equipment.
  • - Hepatitis D requires co-infection or superinfection with Hepatitis B.

Diagnosis

Clinical assessment

Suspect acute hepatitis with jaundice, dark urine, RUQ pain, prodromal symptoms. Suspect chronic hepatitis with risk factors, abnormal LFTs, or complications of cirrhosis. Differentiate viral hepatitis from other causes of jaundice/liver injury (drugs/toxins, alcohol, autoimmune hepatitis, Wilson's disease, haemochromatosis, biliary obstruction).

Investigations

  • Liver Function Tests (LFTs): ALT/AST markedly elevated in acute hepatitis (>10x ULN common). Bilirubin elevated (conjugated & unconjugated). ALP, may be mildly elevated. Albumin, INR/PT usually normal in acute uncomplicated hepatitis, but low Albumin/prolonged INR indicate severe liver dysfunction/failure.
  • Viral Hepatitis Serology (Specific tests for each virus):
  • - Hepatitis A: Anti-HAV IgM (acute infection), Anti-HAV IgG (past infection/immunity).
  • - Hepatitis B: HBsAg (surface antigen - indicates infection, acute or chronic), Anti-HBc IgM (core antibody IgM - acute infection), Anti-HBc Total (total core antibody - current or past infection), HBeAg (e antigen - marker of high replication), Anti-HBe (e antibody - marker of lower replication), Anti-HBs (surface antibody - immunity from vaccination or resolved infection), HBV DNA (viral load - quantification).
  • - Hepatitis C: Anti-HCV (antibody - indicates exposure, doesn't distinguish acute/chronic/resolved). HCV RNA (viral load - confirms active infection).
  • - Hepatitis D: Anti-HDV or HDV RNA (only relevant if HBsAg positive).
  • - Hepatitis E: Anti-HEV IgM (acute infection), Anti-HEV IgG (past infection). HEV RNA.
  • Abdominal Ultrasound: Assess liver size/texture, rule out biliary obstruction, detect cirrhosis/HCC.
  • Liver Biopsy: Rarely needed for acute hepatitis. May be used in chronic hepatitis to assess grade (inflammation) and stage (fibrosis/cirrhosis), though non-invasive fibrosis assessment (e.g., FibroScan, APRI score) increasingly used.

Diagnostic criteria

Diagnosis based on clinical presentation, elevated LFTs, and specific positive viral serology/RNA tests.

Management

Non-pharmacological management

  • Acute Viral Hepatitis (HAV, HBV, HCV, HEV):
  • - Supportive care: Rest, adequate hydration, nutrition.
  • - Avoid alcohol and hepatotoxic medications (including herbal remedies).
  • - Hospitalization if severe symptoms, dehydration, signs of liver failure (encephalopathy, coagulopathy).
  • Chronic Viral Hepatitis (HBV, HCV, HDV):
  • - Lifestyle: Avoid alcohol, maintain healthy weight, manage co-morbidities.
  • - Regular monitoring for disease progression/complications.
  • - Vaccination against other hepatitis viruses (e.g., HAV and HBV vaccine for HCV patients).
  • - Counselling on transmission prevention.

Pharmacological treatment

  • Acute Hepatitis A/E: Supportive care only, usually self-limiting.
  • Acute Hepatitis B: Supportive care. Antiviral therapy rarely indicated unless severe/fulminant.
  • Acute Hepatitis C: Monitor for spontaneous clearance vs chronicity. Antiviral treatment may be considered early by specialists to prevent chronicity.
  • Fulminant Hepatitis / Acute Liver Failure: Urgent referral to specialist/transplant centre. Management includes supportive care (ICU), managing complications (cerebral oedema, coagulopathy, infection, renal failure).
  • Chronic Hepatitis B: See specific section (GI018). Antiviral therapy (e.g., Tenofovir, Entecavir) indicated based on viral load, LFTs, fibrosis stage, HBeAg status.
  • Chronic Hepatitis C: See specific section (GI019). Highly effective Direct-Acting Antiviral (DAA) regimens available, aim for cure.
  • Chronic Hepatitis D: Interferon-based therapy (Peg-IFN) or newer agents (specialist care).

Monitoring

  • Acute Hepatitis: Monitor symptoms, LFTs (ALT/AST, Bilirubin, INR) until resolution.
  • Chronic Hepatitis B/C: Regular monitoring of LFTs, viral load (HBV DNA / HCV RNA), fibrosis stage (non-invasive tests or biopsy), screening for Hepatocellular Carcinoma (Ultrasound +/- AFP every 6 months if cirrhotic or high risk). Monitor response to antiviral therapy.

Complications

  • Acute: Fulminant liver failure, Aplastic anaemia (rare, post-hepatitis).
  • Chronic (HBV/HCV/HDV): Liver Cirrhosis, Portal Hypertension (varices, ascites, encephalopathy), Hepatocellular Carcinoma (HCC), Extrahepatic manifestations (e.g., cryoglobulinemia, glomerulonephritis - esp HCV).

Prevention

  • Vaccination: Hepatitis A, Hepatitis B vaccines available and highly effective.
  • Hygiene and Sanitation: For HAV/HEV (safe water, handwashing, proper food handling).
  • Safe Sex Practices (Condoms): For HBV/HCV/HDV.
  • Blood Safety: Screening of blood products.
  • Safe Injection Practices: Avoid sharing needles/syringes, sterile medical/tattooing equipment.
  • Harm Reduction for IVDU.
  • Perinatal Transmission Prevention (HBV): Screening pregnant women, timely infant vaccination + HBIG (Hepatitis B Immunoglobulin) if indicated.
  • Post-exposure Prophylaxis (HBV): Vaccination +/- HBIG after exposure.

Patient education

  • Type of hepatitis virus and mode of transmission.
  • Natural history (acute vs chronic potential).
  • Importance of avoiding alcohol and hepatotoxic drugs.
  • Transmission prevention measures (hygiene, safe sex, avoid sharing sharps).
  • Need for vaccination against other hepatitis viruses.
  • Importance of long-term monitoring/treatment for chronic hepatitis.
  • Screening for complications (cirrhosis, HCC).
  • Contact tracing/screening recommendations for family/partners.

Uganda-specific notes

High prevalence of HBV, significant burden of HCV co-infection with HIV often. HAV/HEV outbreaks occur related to sanitation. Access to diagnostics (viral load, genotype) and treatment (DAAs for HCV, Tenofovir/Entecavir for HBV) improving but still limited. Universal HBV vaccination for infants is key.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.5.1, 6.5.2, 6.5.3 (Integrates information)

  • National Hepatitis B Guidelines, MOH Uganda

    (Refer to specific MOH guidelines)

  • National Hepatitis C Guidelines, MOH Uganda

    (Refer to specific MOH guidelines)

For learning and professional reference. Use current local guidance and clinical judgement.

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