Page 24 of 42

PE23.13 | Acute Hepatitis — SDL Guide (Part 2)

Management

The management approach for acute hepatitis is stratified into two distinct pathways determined by the severity of illness at presentation and on sequential clinical reassessment. The majority of children with acute viral hepatitis (HAV, HEV in non-pregnant patients) follow the supportive care pathway: rest, hydration, nutrition, avoidance of hepatotoxins, and close monitoring for the emergence of any feature suggesting progression toward acute liver failure. This is not passive management — the clinician's role is active vigilance, specifically watching the INR trajectory and mental status at every contact. The minority who develop ALF enter the emergency pathway, which is characterised by intensive monitoring, organ-support interventions, and time-critical transfer to a specialised centre. Knowing which management pathway applies — and being willing to escalate rapidly when the clinical picture changes — is the essential skill that distinguishes safe from unsafe management of acute hepatitis.

Uncomplicated acute viral hepatitis (HAV, HEV in non-pregnant patients):
The cornerstone of management is supportive care:
- Rest: bed rest during the icteric phase; resuming activity as tolerated once jaundice fades.
- Hydration and nutrition: oral rehydration to maintain fluid balance. Small, frequent, palatable meals. High-carbohydrate, low-fat diet is traditional (fat avoidance reduces nausea); there is no evidence that restriction of fat is necessary but it is often better tolerated. Maintain adequate caloric intake; prolonged fasting is harmful.
- Avoid hepatotoxins: strict avoidance of alcohol, and review all medications to discontinue any potential hepatotoxin (including certain traditional/herbal medicines). Paracetamol should be used cautiously and at weight-appropriate doses — avoid in the presence of significant liver dysfunction.
- Isolation precautions: for HAV/HEV, strict handwashing, separate utensils, and contact precautions until 1 week after onset of jaundice (faecal shedding period).

Indications for hospitalisation depend on severity:

Feature	Outpatient	Hospitalise
Oral intake	Adequate	Poor/vomiting
INR	<1.5	>1.5
Bilirubin	Moderate	Rapidly rising or >10 mg/dL
Mental status	Normal	Any change
Blood glucose	Normal	Hypoglycaemia
Clinical assessment	Stable	Signs of ALF

Acute Liver Failure (ALF) — emergency management:
ALF is a medical emergency. Management priorities:
1. Admit to a paediatric intensive care unit (PICU) — ideally at a liver transplant centre.
2. Monitor closely: BP, heart rate, urine output, blood glucose (hourly in severe ALF), neurological status, INR, ammonia.
3. Prevent and treat hepatic encephalopathy: lactulose (reduces gut ammonia production), protein restriction (temporarily), avoid sedatives.
4. Correct coagulopathy only if active bleeding or before invasive procedures — do not prophylactically transfuse FFP/platelets as it makes INR unreliable as a disease marker.
5. Treat hypoglycaemia: IV dextrose infusion.
6. Prevent infections: broad-spectrum antibiotics if sepsis suspected (ALF patients are immunocompromised).
7. Manage raised intracranial pressure (cerebral oedema in ALF): elevate head of bed, hypertonic saline if needed, avoid fluid overload.
8. Liver transplantation evaluation: ALF with King's College criteria or PELD score indicating poor prognosis requires urgent transplant evaluation — timing is critical.

Specific antiviral therapy:
- HAV and HEV: No antiviral therapy; management is supportive.
- HBV: For acute HBV in adults/older children with severe acute hepatitis or ALF, short-course nucleoside analogues (tenofovir, entecavir) may be given to reduce viral load; evidence is limited.
- Drug-induced (paracetamol): N-acetylcysteine (NAC) is the specific antidote — most effective when given within 8–10 hours of overdose but beneficial up to 24 hours. Dose: 150 mg/kg in 200 mL 5% dextrose IV over 60 minutes, then maintenance infusion.

Prevention:
- Hepatitis A: 2-dose inactivated vaccine (IAP-recommended at 12–18 months + booster at 24 months or 2 years later); improved sanitation and safe water. Handwashing is essential.
- Hepatitis B: Covered by universal vaccination in the NIS (Hep-B birth dose + pentavalent at 6/10/14 weeks). Safe injection practices, blood product screening, PPTCT (Prevention of Parent-to-Child Transmission) — HBsAg-positive mothers' infants receive Hep-B immunoglobulin + vaccine at birth.

Self-Assessment

This self-assessment section focuses on the three highest-yield clinical skills in acute hepatitis: (1) interpreting viral serology accurately to identify the causative agent; (2) recognising early acute liver failure and acting on it urgently; and (3) communicating the special danger of Hepatitis E in pregnant women. Work through the questions below and review the answers only after you have committed to a response — the act of deciding before checking is where learning consolidates.

Unlike many medical topics where there is a spectrum of 'acceptable' answers, acute hepatitis serology interpretation is binary and high-stakes: either you know that IgM anti-HAV = acute infection and anti-HBs = immunity/vaccination (not disease), or you don't. These are the facts that separate a safe graduation from one where a diagnostic error causes harm to a patient. Use the key recall questions below as a self-audit.

Key recall questions:
1. Which serological marker confirms ACUTE Hepatitis A infection?
2. What two markers distinguish acute HBV from chronic HBV infection?
3. Define acute liver failure (ALF) — name the three components.
4. What is the specific antidote for paracetamol-induced ALF and within what timeframe is it most effective?
5. Who has the highest mortality risk from Hepatitis E infection?

Answers: 1. IgM anti-HAV (IgG anti-HAV = past infection/vaccination). 2. Acute = HBsAg + IgM anti-HBc; chronic = HBsAg + IgG anti-HBc (IgM anti-HBc becomes negative after 6 months). 3. ALF = hepatic encephalopathy + coagulopathy (INR >1.5) + within 8 weeks of onset in a child without prior liver disease. 4. N-acetylcysteine (NAC), most effective within 8–10 hours of overdose. 5. Pregnant women in the third trimester — case-fatality rate up to 20–25% in endemic settings.