Acute: The most common etiology of acute hepatitis is viral infection. In North America, hepatitis A, hepatitis B and hepatitis C are the commonest causes of viral hepatitis.
Chronic: Hepatitis lasting > 6 mo is generally defined as chronic, although this duration is arbitrary. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are frequent causes of chronic hepatitis; 5 to 10% of cases of HBV infection, with or without hepatitis D virus (HDV) co-infection, and about 75% of cases of HCV infection become chronic. Hepatitis A and E viruses are not causes. Although the mechanism of chronicity is uncertain, liver injury is mostly determined by the patient's immune reaction to the infection.
-Hiram Lara

Acute: Acute infection tends to develop in predictable phases. Infection begins with an incubation period, during which the virus multiplies and spreads without symptoms. The prodromal, or pre-icteric, phase follows, producing nonspecific symptoms, such as profound anorexia, malaise, nausea and vomiting, and, often, fever or right upper quadrant abdominal pain. Urticaria and arthralgias occasionally occur, especially in HBV infection. After 3 to 10 days, the urine darkens, followed by jaundice. During this phase, the liver is usually enlarged and tender, but the edge of the liver remains soft and smooth. Sometimes anicteric hepatitis, a minor flu-like illness without jaundice, is the only manifestation. It occurs more often than icteric hepatitis in patients with HCV infection and in children with HAV infection.
Chronic: Clinical features vary widely. About a third of cases develop after acute hepatitis, but most develop insidiously de novo. Many patients are asymptomatic, especially in chronic HCV infection. However, malaise, anorexia, and fatigue are common, sometimes with low-grade fever and nonspecific upper abdominal discomfort. Often, particularly with HCV, the first findings are signs of chronic liver disease. A few patients with chronic hepatitis develop manifestations of cholestasis. In the autoimmune variant, especially in young women, manifestations may involve virtually any body system and can include acne, amenorrhea, arthralgia, ulcerative colitis, pulmonary fibrosis, thyroiditis, nephritis, and hemolytic anemia.
-Hiram Lara

Method of Diagnosis:
Acute: Acute hepatitis must first be differentiated from other disorders that cause similar symptoms. In the prodromal phase, hepatitis mimics various nonspecific viral illnesses and is difficult to diagnose. Anicteric patients suspected of having hepatitis based on risk factors are tested initially with nonspecific liver function tests, including aminotransferases, bilirubin, and alkaline phosphatase. Usually, acute hepatitis is suspected only during the icteric phase. Thus, acute hepatitis should be differentiated from other disorders causing jaundice.
Acute hepatitis can usually be differentiated from other causes of jaundice by its marked elevations of AST and ALT, typically ≥ 400 IU/L. ALT is typically higher than AST, but absolute levels correlate poorly with clinical severity. Values increase early in the prodromal phase, peak before jaundice is maximal, and fall slowly during the recovery phase. Urinary bilirubin usually precedes jaundice. Hyperbilirubinemia in acute viral hepatitis varies in severity, and fractionation has no clinical value. Alkaline phosphatase is usually only moderately elevated; marked elevation suggests extra hepatic cholestasis and prompts imaging tests. If laboratory results suggest acute hepatitis, particularly if ALT and AST are > 1000 IU/L, PT is measured.
Chronic: The diagnosis is suspected in patients with suggestive symptoms and signs, incidentally noted elevations in aminotransferase levels, or previously diagnosed acute hepatitis. Liver function tests are needed if not previously done and include serum ALT, AST, alkaline phosphatase, and bilirubin. Aminotransferase elevations are the most characteristic laboratory abnormalities. They are typically 100 to 500 IU/L. Aminotransferase levels can be normal during chronic hepatitis if the disease is quiescent, particularly with HCV. Alkaline phosphatase is usually normal or only slightly elevated but is occasionally markedly high. Bilirubin is usually normal unless the disease is severe or advanced. However, abnormalities in these laboratory tests are not specific and can result from other disorders, such as alcoholic liver disease, recrudescent acute viral hepatitis, and primary biliary cirrhosis.
If laboratory results are compatible with hepatitis, viral serologic tests are done to exclude HBV and HCV. Unless these tests indicate viral etiology, further testing is required. The first tests done include autoantibodies, immunoglobulins, and α1 antitrypsin level.
-Hiram Lara

Risk Factors:
People who are at risk for developing hepatitis are workers in the health care professions, people with multiple sexual partners, intravenous drug users, and hemophiliacs. Hepatitis is generally thought to be as much as ten times more common in the lower socioeconomic and poorly educated groups. About one third of all cases of hepatitis come from an unknown or unidentifiable source. This means that you don't have to be in a high risk group in order to be infected with the hepatitis virus.
-Hiram Lara

Because treatments have limited efficacy, prevention of viral hepatitis is very important. Good personal hygiene helps prevent transmission, particularly fecal-oral transmission, as occurs with HAV and HEV. Blood and other body fluids (eg, saliva, semen) of patients with acute HBV and HCV and stool of patients with HAV are considered infectious. Barrier protection is recommended, but isolation of patients does little to prevent spread of HAV and is of no value in HBV or HCV infection. Posttransfusion infection is minimized by avoiding unnecessary transfusions and screening all donors for HBsAg and anti-HCV. Screening has decreased the incidence of post transfusion hepatitis, probably to about 1/100,000 units of blood component transfused.
Immunoprophylaxis can involve active immunization using vaccines and passive immunization.
-Hiram Lara

Supplements Commonly Used:
Milk thistle (silymarin), Alpha-lipoic acid, Selenium
-Hiram Lara

**Labs Appropriate to Disease:
*Normal Values Range:ALT Males 4-40 U/L Females 4-31 U/L, ALP Adult 40- 120 U/L Child 60-530 U/L, Ammonia Adult 7-27 umol/dl Child 0-64 umol/dl
*Values in the Disease:ALT Males > 40 U/L Females > 31 U/L, Alp Adult > 120 U/L Child > 530 U/L, Ammonia Adult > 27 umol/dl Child > 64 umol/dl

*Nutritional Significance:** Obesity also raises ALT levels. Vitamin D deficiency also raises ALP levels. Malnutrition, Vitamin C deficiency, Zinc deficiency and excess Vitamin D all lower ALP levels. A high protein diet will also raise Ammonia levels.

General Dietary Prescription:Patients with acute and chronic hepatitis should be encouraged to consume a meal plan adequate in energy, protein and micronutrients with a regular meal schedule. 4 to 6 small, frequent meals ( or at least 3 meals and a bedtime snack) are suggested to promote adequate intake and minimize loss of muscle mass.

Specific Foods to Include: No specific diet improves signs or symptoms.

Specific Foods to Avoid: Food restrictions are not usually required for hepatitis. Alcohol should be avoided.

Recommended Prescription Drug Therapy: For hepatitis B drugs such as Entecavir, Interferferon, and Epivir HBV may be helpful. For Hepatitis C drugs such as Rebetron, Ribavirin, and Pegasys may be helpful.

Potential Food and Drug Interactions:Baraclude- Food lowers drug levels. May cause dyspepsia and diarrhea.
Interferon- Insure adequate hydration. May cause anorexia, a decrease in weight ad an increase in thrust.
Epivir HBV- May cause anorexia, abdominal cramps, diarrhea, vomiting and nausea.
Rebetron and Ribavirin- should be taken with a high fat meal. Anorexia, taste changes and dyspepsia may occur.
Pegasys- Insure adequate hydration. anorexia, weight loss and increased thrust may occur.
Many of these may result in Anorexia, so the patients should pay much attention to weight loss and eating habits. Diarrhea is also common so fluid levels should be monitored to decrease the risk of dehydration.

General Nutrition Education Objectives or Goals: Patients should be educated on the risks of alcohol and its effects on the liver. They should also be informed of the chances of their hepatitis turning into cirrhosis and how to control symptoms of end stage liver disease. The information in the general nutrition prescription will help with this. Other goals would include 2,000 mg sodium intake for fluid retention. Adequate protein intake (1.0 to 1.2 g/kg of body weight). Also, a low fat diet (<30% energy as fat) in case of steatorrhea.

Kevin Wyzgoski and Hiram Lara

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