Click here to view next page of this article

Acute and Chronic Hepatitis

Acute hepatitis is an acute inflammation of the liver marked by hepatocyte degeneration and necrosis. By definition the time course should be less than six months. Interestingly, it is a spectrum of disease, all the way from completely asymptomatic infection to fulminant liver failure, which is of course the most dreaded complication of any form of acute hepatitis.

Now first let’s look at the neonatal period. Obviously, this is acute hepatitis within the first one month of life, by this definition. Far and away the most important reason is infectious etiologies. Of those infections, the viruses are preeminent. The TORCH viruses, you are very familiar what this stands for, generally present in the neonatal period with a slightly more chronic presentation, although these children can look acutely sick. The ones that you think about in a baby, and infant.

Now, how do these infants look? Well, they present either at birth - particularly in the case of the TORCH infections - or within the first few days of life. Very often these babies are SGA and that may be one of your first tip-offs, and they present often as the generic septic infant. You have to put your thinking cap.

So what are the clues? Well the first thing that might tip you off is on good old fashioned physical exam you may note that the liver is quite large as is the spleen, and these infants may have a variety of unusual rashes. Characteristically, on the laboratory findings, you are going to find an elevated AST and ALT, sometimes into the 5-600 range.

Now what about hepatitis B? A very different kind of virus in all respects. First of all, it’s a DNA virus. The incubation period is much longer. It’s in the order of 2-3 months, not 2-3 weeks. And the spread is generally by blood, saliva, sexual contact but there is also an incidence of intrafamily spread, particularly when there are small children in the family, and of course.

Presentation; again, all the way from anicteric asymptomatic disease to fulminant liver failure. The chronic carrier state is very often completely asymptomatic. So particularly in parts of the world where health care may not be as sophisticated as here, very often people don’t even know that they’ve got the virus and can transmit it.

Symptoms; the same scenario. Malaise, low grade fever, maybe some right upper quadrant pain. But different to hepatitis A and may be a tip-off in terms of differentiating them is that there are more extrahepatic symptoms with hepatitis B, particularly arthralgias, myalgias.

The clinical course; a very interesting difference in the clinical course depending on age. If you are a neonate and you are infected with hepatitis B from your mother, 90% of these infants will not be able to clear hepatitis B. However, for you and I as healthy adults, if we acquire hepatitis B we have a 90% chance of clearing the virus. Only 10% of us will become chronic carriers. The chronic carrier state of course is something you don’t want to have because it leads to all kinds of unfortunate.

Treatment for hepatitis C is again symptomatic. But more and more interest is being placed on the use of interferon, particularly combined with new antiviral agents such as ribavirin. But even with the most sophisticated combination therapy, which I should add has not been tested in children, the chances of being able to overcome the virus are probably well less than 20%.

Moving along the alphabet, delta hepatitis. The only thing you really have to remember about delta hepatitis is that it’s a funny little virus. It’s really like a parasite. It only exists in company with hepatitis B. So if you don’t have hepatitis B you can’t have

What about hepatitis E? You’ll be glad that we are coming to the end of this. We are not going to go all the way through to Z. Hepatitis E, if you have to remember anything about it, it’s a lot like hepatitis A in terms of its presentation. It’s an RNA virus, short incubation, spread by contaminated water, sometimes in epidemics, particularly in third world countries, there may be an

Now having gone through the alphabet soup, A, B, C, D, E, and I’m sure there are a whole lot of others out there, you should also keep in mind that some other viruses that we know quite a lot about can also infect the liver. By far and away the herpes viruses are the most important here. CMV, EBV, type I and type II and varicella. Remember, EBV virus can cause a big liver,

What about some of the other causes of hepatitis in children? Well, there is a variety of toxic and metabolic diseases and I’m going to try to run through these to give you a vignette. This is not designed to be an exhaustive list or we’d be here all afternoon. Well, what about drug toxicities? Well, the one that we worry the most about because it is so commonly available is acetaminophen. There are basically two kinds of acetaminophen overdose in children. One is the teenager who takes a whole

What about environmental toxins? Well this is kind of difficult because it seems like we are surrounded by environmental toxins, but certainly liver failure and hepatitis have been associated with glue sniffing, polyvinyl alcohol, carbon tetrachloride. Again, presentation very variable. Some may even develop fulminant liver failure. Others many have just a little bit of elevated transaminases with some cholestasis. Of the ingestion’s, the one that always stands out in our minds in a referral center is the family that goes on a little picnic, to do some mushroom gathering, and they decide that Amanita phylloides is such a pretty

Now I put up Reye’s syndrome, although maybe next year I really have to leave it off this slide because we’ve seen so little of it. But Reye’s syndrome causes a fulminant liver failure-type picture. It’s probably a mitochondrial defect. We are not really sure of its etiology. It also causes massive cerebral edema. We have associated it in the past with the use of aspirin in varicella. Since 

Okay, what about chronic hepatitis in childhood? We are leaving behind acute and now we are going to chronic. And surprise, surprise, the definition is more than six months of duration and this chronic inflammation of the liver. Of the infections, again, the most common B and C are the ones to think about. The clinical features are very similar. The onset is often quite gradual and the histology may vary all the way from a relatively benign picture under the microscope, to full-blown cirrhosis. 

The way these present is with the features of chronic liver disease, which are pretty generic. Patients are tired, they are usually jaundiced, they may not think so clearly, they may have already developed ascites with portal hypertension, maybe variceal bleeding, they lose weight. They often feel very lousy. However, having said all of that, you can have full-blown cirrhosis on a liver biopsy and no symptoms at all. Sometimes your patients, maybe in the older age group - the 17 or 18-year-old who was perhaps infected with hepatitis B at birth - may only be picked up because someone did liver tests because they had some other kind of illness and noticed they were elevated. So it can be a great masquerader. When you do do the laboratory tests you see the AST and the ALT are elevated but they are not super-high numbers. They are generally under 500 IU/ml. When the bilirubin is elevated it will be a conjugated type of bilirubinemia. And as I’ve said, even with full-blown cirrhosis not only can you be asymptomatic, you may have a completely normal bilirubin and you may have actually almost normal transaminases. But what you note, if you are astute, is that the serum albumin is on the low side and the pro-time may already be starting to prolong. These are the indicators of poor synthetic function. So in chronic liver disease you are really very interested in synthetic function rather than numbers, like what’s the AST?

Serology; well, we’ve gone through all of that with hepatitis B and C. What about the physical exam? These people in general have very small shrunken up livers, and you may only appreciate it if you take the time to percuss the liver span and you might

The management is largely symptomatic. You are going to restrict fluids and sodium. And you are going to treat encephalopathy, but generally you are often … these children may come all the way to needing transplant in their teen years, or sometimes even sooner. We have transplanted children with chronic hepatitis B who have