Hepatitis is a condition in which the liver is inflamed (remember “itis” means inflammation). This inflammation can occur for a variety of reasons. In some cases, the inflammation is acute and the patient has a full recovery. In other cases, the condition is chronic and can even advance to serious liver disease. 

When we think of hepatitis, we generally think of hepatitis caused by a virus, which includes hepatitis A, B, C, D, and E. Each type is caused by a different virus and transmission varies. This lesson provides an overview of the different types of viral hepatitis as well as some general information about hepatitis, signs & symptoms, and patient education.

Functions of the liver

The liver has many functions, which is why liver disease and liver failure can have such widespread effects.

  1. Bile production – Bile aids in the digestion and absorption of fats
  2. Drug metabolism – Many drugs are metabolized in the liver
  3. Storage of fat-soluble vitamins and some minerals such as copper and iron
  4. Bilirubin metabolism – The breakdown of heme produces bilirubin, which is metabolized by the liver
  5. Synthesis of plasma proteins including albumin and clotting factors
  6. The conversion of T4 to T3  – recall that T3 is the “active” form of thyroid hormone

Basic hepatitis pathophysiology

The hepatitis viruses infect hepatocytes, causing inflammation and swelling of the liver. This swelling interferes with liver function, causing the patient to experience symptoms such as nausea, jaundice or joint pain. As the disease progresses, the organ hardens (fibrosis) and undergoes scarring (cirrhosis) that drastically affects the liver’s ability to function properly. Eventually, the organ can no longer meet the body’s demands and liver failure results. 

Signs and symptoms of hepatitis

Many cases of hepatitis are mild and patients may have no symptoms or simply show signs of a new infection such as fever and fatigue. However, more prominent symptoms can appear and may be associated with advanced liver disease.

  • Fever – Temperature increases in response to the viral infection
  • Fatigue – Fatigue occurs as the body works hard to fight the virus
  • Nausea and vomiting – N/V occur as the liver’s ability to remove toxins from the body decreases, leading to GI upset
  • Abdominal pain – Liver inflammation can cause abdominal pain, as can ascites and splenomegaly which occur as the disease progresses
  • Loss of appetite – Loss of appetite can occur due to GI upset and abnormal levels of ghrelin and leptin, which are hunger hormones
  • Dark urine – Dark urine occurs due to the buildup of bilirubin
  • Clay-colored stools – Light or clay-colored stools occur due to the liver’s inability to produce or drain bile adequately
  • Jaundice – A yellowish discoloration of the skin and sclera is due to the buildup of bilirubin in the system
  • Generalized pain and joint pain – Inflammatory cytokines associated with cirrhosis also cause generalized pain as well as joint pain
  • Bruising – Individuals with liver disease bruise easily due to the reduced production of clotting factors by the liver
  • Edema in the legs – Edema occurs due to third-spacing of fluids secondary to low albumin levels (remember, the liver produces albumin)
  • Bloated abdomen – Ascites, a condition in which fluid builds up in the abdomen, is due to portal hypertension and decreased oncotic pressure secondary to low albumin levels
  • Cognitive changes – Liver disease can cause ammonia levels to build up, leading to confusion and hepatic encephalopathy

Abnormal lab values in hepatitis

In addition to testing for specific antigens and antibodies when diagnosing hepatitis, LFTs (liver function tests) will be elevated, with the degree of abnormality correlating with the extent of liver damage. Key labs to evaluate include AST, ALT, alkaline phosphatase, and bilirubin.

Hepatitis A

Hepatitis A is a form of acute hepatitis that primarily occurs when someone ingests the hepatitis A virus (HAV). This can occur from ingesting contaminated food or water as well as through the fecal-oral route. For example, if someone with hepatitis A doesn’t wash their hands thoroughly after going to the bathroom and then shakes your hand, you could contract hepatitis A if your hand (or something it touches) enters your mouth. Hepatitis A can also be spread through close, personal contact (including sexual activity) and when sharing needles with an infected individual. Hepatitis A is highly contagious and accounts for 20 to 25 percent of hepatitis cases in developed countries. The good news is, hepatitis A can be prevented with a vaccine. Additionally, most cases resolve in about two months without causing long-term illness. 

Hepatitis B

Hepatitis B can be acute or chronic and is spread through contact with infected body fluids such as blood, saliva, vaginal fluids and semen. The acute form usually occurs within three to five months of exposure to the hepatitis B virus (HBV), and severity can vary widely. Some individuals have no symptoms or very mild symptoms while others will have severe illness requiring hospitalization. When an individual is unable to recover from acute hepatitis B, they develop chronic hepatitis B, which can cause serious liver disease such as cirrhosis and even liver cancer.

Hepatitis B is a global health problem, with the highest incidence of cases in the WHO Western Pacific Region (which includes China, Mongolia, Vietnam, Malaysia, Japan, New Zealand and Australia) and the WHO African Region. 

Memory aid for viral hepatitis: A - Anus, B - Body fluids, C - CBC, D - Double, E - Easy

Hepatitis C

Hepatitis C is caused by a bloodborne virus that is transmitted through exposure to infected blood. This can occur due to sharing needles, needlestick injury in healthcare, unscreened blood transfusions, and sexual activity. In about 30% of individuals, the virus causes acute asymptomatic illness that typically resolves within six months. Other cases of hepatitis C virus (HCV) infection cause chronic illness that leads to liver cirrhosis and/or liver cancer. While there is no vaccine for hepatitis C, it can be treated with antiviral medications such as sofosbuvir and daclatasvir. Hepatitis C is a leading cause of liver failure and liver transplant in the United States.

Hepatitis D

Hepatitis D is known as an “incomplete virus” because it can only infect individuals who are already infected with hepatitis B. Like the other forms of hepatitis, infection with hepatitis D virus (HDV) can be acute or chronic. A key difference is that the acute form causes more severe symptoms than other types of viral hepatitis. An individual who progresses to the chronic form of hepatitis D will have more severe and rapid disease progression than someone who just has hepatitis B. Treatment for HDV in most countries is pegylated interferon, though it is only effective in about 30% of cases. There is no specific vaccine against hepatitis D, so the only way to prevent it is to get the hepatitis B vaccine.

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Hepatitis E

Hepatitis E is the most uncommon type of viral hepatitis in developed countries and in most people only causes mild illness that resolves on its own. The HEV virus is usually spread by the fecal-oral route, and in developing countries the most common source is contaminated drinking water. Other sources that have been identified include undercooked pork and shellfish. For that reason, you may also see it referred to as a foodborne illness. There is no specific treatment for HEV, nor is there a vaccine available in the United States (in 2012, China approved a vaccine for use in that country).

TransmissionAcute or ChronicTreatmentVaccine
Hepatitis AMainly fecal-oral route, can be transmitted through contaminated food or water, and through person-to-person contactAcute – symptoms last up to two monthsNo treatment, resolves on its ownYes (2 doses)
Hepatitis BContact with infected body fluids such as blood, saliva, vaginal fluids and semen (including transmission from mother to child at birth)Acute or chronic – acute symptoms usually last several weeks but can persist for up to six monthsAcute – no treatment, resolves on its own

Chronic – antiviral medications, interferon, liver transplant in severe disease
Yes (3 doses)
Hepatitis CExposure to infected bloodAcute or chronicAntiviral medication, liver transplant in severe diseaseNo
Hepatitis DCo-infection with hepatitis BAcute or chronicPegylated interferon, liver transplant in severe diseaseNo
Hepatitis EMainly fecal-oral route, can be transmitted through contaminated drinking water, undercooked pork and shellfishAcuteNo treatment, resolves on its ownNo

Patient education for hepatitis

Key things to teach your patient with hepatitis include:

  • Patients should be vaccinated against other forms of hepatitis
  • Individuals with hepatitis B should be tested for hepatitis D if their condition worsens or they notice signs of new infection such as fever
  • Avoid alcohol as this can be damaging to the liver
  • Avoid medications that can harm the liver further – this includes acetaminophen, NSAIDs, statins, sulfa antibiotics, some anti seizure medications, and herbs such as black cohosh and kava
  • Patients with hepatitis A or E should wash their hands after any exposure to stool that contains the virus (i.e. after using the bathroom or changing a diaper) and before preparing food
  • Several forms of hepatitis can be transmitted through person to person contact, including sexual activity so individuals should take measures to prevent the spread of infection
  • Avoid transmission of bloodborne viruses by not sharing needles
  • Follow a healthy diet that includes a variety of fruits, vegetables and whole grains
  • Avoid foods high in salt, sugar and fat as well as undercooked foods and raw shellfish
  • Maintain optimal body weight

Great job reviewing viral hepatitis…you’re going to do great on that exam! Want to review viral hepatitis again? Listen to episode 352 of the Straight A Nursing podcast while you’re on the go. Listen from any podcast platform, or straight from the website here.

Looking for more ways to study on-the-go? Review the key things to know for nursing school and NCLEX with audio-based flashcards in Study Sesh.

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References:

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American Liver Foundation. (2022b, June 10). Treatment for Hepatitis C (HCV). American Liver Foundation. https://liverfoundation.org/liver-diseases/viral-hepatitis/hepatitis-c/treating-hepatitis-c/

American Liver Foundation. (2022c, June 15). Liver Disease Diets: Fatty Liver Diet and More. American Liver Foundation. https://liverfoundation.org/health-and-wellness/healthy-lifestyle/liver-disease-diets/

CDC. (2020, October 27). Hepatitis E Questions and Answers for Health Professionals. CDC. https://www.cdc.gov/hepatitis/hev/hevfaq.htm

CDC. (2022, March 30). Hepatitis B FAQs | CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hbv/bfaq.htm

CDC. (2023a, August 29). Hepatitis A – FAQs, Statistics, Data, & Guidelines. CDC. https://www.cdc.gov/hepatitis/hav/index.htm

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Hawaii Pacific Health. (2016, April 26). Love Your Liver: Look for These 8 Signs of Organ Damage. Hawaii Pacific Health. https://www.hawaiipacifichealth.org/healthier-hawaii/be-healthy/love-your-liver-look-for-these-8-signs-of-organ-damage/

Johns Hopkins Medicine. (n.d.). Hepatitis. Johns Hopkins Medicine. Retrieved April 25, 2024, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/hepatitis

Kalra, A., Yetiskul, E., Wehrle, C. J., & Tuma, F. (2024). Physiology, Liver. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK535438/

Kingston, H. (n.d.). What are the Symptoms of Liver Dysfunction? 9 Common Signs. LetsGetChecked. Retrieved April 25, 2024, from https://www.letsgetchecked.com/articles/what-are-the-symptoms-of-liver-dysfunction/

Klinge, M., Coppler, T., Liebschutz, J. M., Dugum, M., Wassan, A., DiMartini, A., & Rogal, S. (2018). The assessment and management of pain in cirrhosis. Current Hepatology Reports, 17(1), 42–51. https://doi.org/10.1007/s11901-018-0389-7

Mayo Clinic. (n.d.). Hepatitis B – Diagnosis and treatment. Mayo Clinic. Retrieved April 25, 2024, from https://www.mayoclinic.org/diseases-conditions/hepatitis-b/diagnosis-treatment/drc-20366821

Waqar, S., Sharma, B., & Koirala, J. (2024). Hepatitis E. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532278/

WHO. (n.d.). Where we work. WHO. https://www.who.int/westernpacific/about/where-we-work

World Health Organization. (2024a, April 9). Hepatitis B. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

World Health Organization. (2024b, April 9). Hepatitis C. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c