Hepatitis B Initial Assessment

Clinical Presentation

Most acute viral hepatitis infections are asymptomatic, or they can cause an anicteric illness that may not be diagnosed as hepatitis.

Hepatitis A generally causes minor illness in childhood with >80% of infections being asymptomatic. Adults are more likely to produce clinical symptoms. Symptoms usually last for <2 months, however, some patients may suffer from prolonged infection or may experience disease relapse. 

Hepatitis B, C, and D may also be asymptomatic. Symptomatic hepatitis B will depend on the mode and time of transmission. Vertical transmission from mother to child is almost always asymptomatic while other routes of transmission are more likely to produce symptomatic disease (30% of cases transmitted by intravenous [IV] drug use are icteric). 

Hepatitis E is usually asymptomatic and patients with symptoms are usually older adolescents or young adults. The extrahepatic manifestations such as Guillain-Barré syndrome, Parsonage-Turner syndrome, neuralgic amyotrophy, bilateral brachial neuritis, peripheral neuropathy, encephalitis, membranoproliferative glomerulonephritis with or without cryoglobulinemia, membranous glomerulonephritis, acute pancreatitis, other autoimmune manifestations (eg myocarditis, arthritis, thyroiditis), and thrombocytopenia have been observed. Some patients may experience persistent hepatitis E virus replication and immunocompromised patients or those with chronic liver disease are at risk for chronic hepatitis E virus infection with prolonged viremia (>6 months).

During the preicteric phase, patients may manifest with nonspecific systemic symptoms (eg myalgia, nausea, vomiting, fatigue, malaise with discomfort in the right upper quadrant of the abdomen), altered sense of smell or taste, coryza, photophobia, headache, cough, diarrhea, dark urine, and serum sickness-like syndrome. Hepatomegaly, splenomegaly, and lymphadenopathy may be seen during physical examination. During the icteric phase, jaundice is usually noted after the onset of the fever or upon lysis of the fever.

If fulminant hepatitis ensues, the development of symptoms of hepatic encephalopathy (eg confusion, drowsiness within 8 weeks of symptoms or within 2 weeks of the onset of jaundice). Hypoglycemia and prolonged prothrombin time (PT) may also occur.

The routes of transmission of hepatitis differ according to type. Hepatitis A may be transmitted via the oral-fecal (eg ingestion of contaminated food or water) route, person-to-person contact, or sexual contact. Hepatitis B may be transmitted via the perinatal route, percutaneous route, sexual contact, or close person-to-person contact (ie by open cuts and sores). Hepatitis C may be transmitted via blood transfusions, organ transplants, percutaneous (especially intravenous drug use) route, sexual contact, or perinatal route. Hepatitis D is transmitted via sexual contact, percutaneous route especially intravenous drug use, or mucous membrane contact with infectious blood or body fluids. They may be found only in patients with hepatitis B since it requires the hepatitis B outer coat. Hepatitis E is transmitted via the oral-fecal route (ingestion of contaminated food or water), or by blood transfusion in endemic areas.

Hepatitis B_Initial Assessment 1

Hepatitis B_Initial Assessment 2

History

The following are important points in the clinical history of patients with suspected viral hepatitis: 

• Contacts with jaundiced patients
• Intravenous drug use
• History of blood transfusion
• Surgery or hospitalizations
• Family history of chronic liver disease
• Occupation
• Food and water sources
• Alcohol use
• Migration from a country with high hepatitis B or hepatitis D virus prevalence rates

Screening

Screening for chronic hepatitis B virus infection is recommended for household members, sex partners, and drug-sharing partners of a person with chronic hepatitis B virus infection, men who have sex with men (MSM), HIV-positive individuals, pregnant women, blood or plasma or organ or tissue or semen donors, infants born to HBsAg-positive mothers, patients on hemodialysis, chemotherapy, or immunosuppressive therapy, patients with elevated AST/ALT of unknown etiology, correctional facility inmates, and individuals born in countries with hepatitis B virus prevalence of ≥2%.