Gastroenterology & Nutrition

Viral Hepatitis

Infection and inflammation of the liver caused by hepatitis A, B, C, D or E, ranging from self-limiting acute illness to chronic infection with cirrhosis, liver failure and hepatocellular carcinoma.

In a nutshell

Hepatitis A and E are mainly enteric and usually acute; B, C and D are blood-borne, with B and C able to become chronic and D requiring B. Confirm the virus with targeted serology and nucleic-acid testing. Refer HBsAg-positive people for specialist assessment; chronic B is usually suppressed with long-term specialist therapy, whereas chronic C is usually cured with direct-acting antivirals. Always assess severity, pregnancy, cirrhosis, transmission risk and public-health follow-up.

Classic presentation

A person with malaise, anorexia, dark urine and jaundice has a hepatitic liver-test pattern. Start with severity assessment and targeted viral testing; anti-HCV alone shows exposure, so HCV RNA or core antigen is needed to confirm current infection.

Key points

A and E are mainly enteric; B, C and D are blood-borne, and D requires hepatitis B.
HBsAg means current hepatitis B infection; persistence for at least 6 months indicates chronic infection.
Anti-HCV means exposure; HCV RNA or core antigen confirms current infection and RNA is needed for reinfection testing.
Chronic hepatitis B needs specialist assessment using HBV DNA, ALT and fibrosis; cirrhosis with detectable HBV DNA is a treatment indication in NICE CG165.
Direct-acting antivirals cure most chronic hepatitis C, but the regimen depends on cirrhosis, previous treatment, interactions and local specialist protocol.
Screen every pregnancy for hepatitis B and follow the current antenatal and selective neonatal immunisation pathway.
Hepatitis E in pregnancy, acute liver-failure features and decompensated cirrhosis require urgent specialist escalation.
There is no hepatitis C vaccine; cure does not prevent reinfection.

First-line investigation

Liver tests, glucose, renal function, full blood count and coagulation to assess severity, plus targeted viral serology: HAV/HEV IgM when indicated, an HBV panel with HBV DNA if HBsAg positive, and anti-HCV followed by HCV RNA or core antigen.

Management

Assess severity and escalate

Check coagulation, glucose, renal function and mental state; urgently involve hepatology or critical care for encephalopathy, coagulopathy, hypoglycaemia, haemodynamic instability or rapidly worsening jaundice.^5,2
Notify the appropriate UKHSA pathway and give transmission-reduction and contact advice.^13,12

Confirm the virus and link to care

Use targeted serology and nucleic-acid testing; refer all HBsAg-positive adults and all people with current HCV infection to specialist care.^5,6,3

Treat chronic B and cure chronic C

Use HBV DNA, ALT and fibrosis to guide specialist hepatitis B treatment; use current NICE technology appraisals, BNF and the local operational delivery network for hepatitis C DAA selection.^{5,7,8,9,14,15}

Protect pregnancy and prevent transmission

Screen every pregnancy for hepatitis B; high maternal HBV DNA requires specialist antiviral and neonatal immunisation pathway coordination. Offer risk-based hepatitis A and B vaccination and harm-reduction interventions.^11,4,1

Confirm cure and monitor chronic liver disease

Confirm HCV response with RNA or core antigen, test RNA rather than antibody for reinfection, and maintain hepatology follow-up and cancer surveillance when advanced fibrosis or cirrhosis is present.^6,3,5

Exam traps

Anti-HBs alone with negative anti-HBc is consistent with vaccine immunity; anti-HBc indicates natural exposure.
A positive HCV antibody does not prove current infection and does not confer immunity.
Hepatitis D cannot occur without hepatitis B.
Hepatitis E is not always benign: pregnancy and immunosuppression change the risk and escalation pathway.
Do not let a normal or mildly abnormal ALT exclude chronic hepatitis B or C.
A jaundiced patient with encephalopathy or coagulopathy has possible acute liver failure, not routine viral hepatitis.

Illustrations

Cirrhosis on liver histologyTrichrome-stained liver showing broad fibrous septa surrounding regenerative nodules, illustrating the architectural distortion that follows chronic viral hepatitis.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.