Q. 1. An 8-year-old child presented with
jaundice and passage of dark colored urine of 10 days duration.
What other questions should be asked to specify diagnosis of acute
viral hepatitis (AVH)?
A1. History of (a) prodrome that
includes anorexia (highly specific), fever and vomiting; (b)
upper abdominal discomfort; (c) improvement in ano-rexia
and decrease or disappearance of fever following onset of jaundice
(d) similar history in the family or in the vicinity or
Q. 2. What other differential diagnosis
should be considered in such a child? How can we clinically
A2. (i) Continuation of fever after
the onset of jaundice suggests other differential diagnosis:
(a) Salmonella hepatitis - high fever,
mild jaundice; (b) Malaria hepatopathy: high fever with
chills/ rigors, usually mild jaundice and anemia; (c)
Lepto-spirosis: geographical predisposition (common in Western and
Southern parts of India), seasonal variation: high temperature
with excessive rainfall, biphasic illness of initial phase of
fever, myalgia followed by jaundice, azotemia and edema; (d)
Dengue: fever, seasonal variation and bleeding manifestations; (e)
Liver abscess: Fever, right upper quadrant pain, tender
hepatomegaly, and jaundice is uncommon; ( f ) Cholangitis
due to choledochal cyst, biliary stones or worms: may have biliary
(ii) Drug induced hepatitis:
Administration of hepatotoxic drugs including
isoniazid rifampicin; valproic acid, carbamazepine; erythromycin,
amoxi-cillin with clavulanic acid, and diclofenac.
Q. 3. What are the causes of acute viral
hepatitis in India?
A3. Pooled Indian data of children (N =
588) has shown AVH due to hepatitis A virus (HAV) to be the
commonest cause (53%), acute hepatitis E virus (HEV) 13%, acute
hepatitis B virus (HBV) 11%, mixed infections 10%, non A-E 13%.
Pooled data of 519 children revealed multiple virus infection in
14% cases (80% due to viral hepatitis A + E).
Q. 4. Can you distinguish viral hepatitis A
from viral hepatitis E or acute hepatitis B by history or by liver
A4. Viral hepatitis A and E cannot be
differentiated either by history or by liver function tests.
However, history of similar illness in other children during this
period in the family may be a clue to HAV rather than HEV. This is
due to the fact that person to person spread is rare with HEV
infection. However. other children may also suffer in HEV
infection in case of a common source of infection e.g.,
water. In case of acute HBV infection there may be (a)
history of recent injections (in India commonest cause of HBV
infection is intramuscular injections), blood or blood product
transfusion; (b) family history of HBV infection (c)
immuno-suppressed host (e.g., Downís syndrome, on
chemotherapy and others). Liver function tests are not
Q. 5. What minimum investigations should be
ordered in acute viral hepatitis? What parameters in liver
function tests will be helpful to support the diagnosis of acute
viral hepatitis? What is the role of prothrombin time?
A5. Liver function tests: Serum
bilirubin (total), serum alanine aminotransferase (ALT) and
albumin if available and affordable. There is no need to do viral
markers for hepatitis A and E. However, one should preferably do
HBsAg. Marked elevation in trans-aminases and normal serum albumin
support the diagnosis of AVH. Prothrombin time (PT) or
international normalized ratio (INR) is the most sensitive
laboratory marker of liver function. This test is easy, cheap and
widely available in our country. In a clinical setting of AVH most
important complication is that of acute liver failure (ALF). PT
gets deranged in ALF and thus serves as a useful marker to guide
early diagnosis and therapy.
Q. 6. Once diagnosed what advice would you
give to the patient and the family?
A6. Patient is advised high calorie
diet. There should be no restriction of fat, proteins and other
normally used food items. Consumption of high, dense and frequent
sugar solutions is not recommended. These may aggravate the
symptoms of nausea and vomiting. Isolation is not required once
the patient is in icteric phase and no drugs including so-called
hepatoprotective agents be prescribed. Ursodeoxycholic acid (UDCA)
has been found to be useful in cholestatic form (pruritus as a
symptom affecting quality of life) that constitutes a small
proportion of AVH cases. Pediatricians should explain natural
history of the disease to reassure the patient and parents
recovery of disease.
Q. 7. Would you repeat LFT in a child
diagnosed to have acute viral hepatitis? If yes when?
A7. In an uncomplicated case of AVH
repeat LFT should be done after 3-6 months of onset of disease to
document biochemical recovery. In order to assess recovery of AVH
clinical monitoring is sufficient. There is no correlation between
the severity of hepatitis and the level of transaminases. Recovery
can be adequately assessed by clinical features of disappearance
of fever and pain/tenderness in the region of liver, improvement
in appetite, gradual normalization of urine color and decreasing
jaundice. Repeat LFT in patients with alarm symptoms, irrespective
of duration of disease.
Q. 8. What are the alarm symptoms in acute
viral hepatitis and why is it important to monitor these features?
A8. Alarm symptoms are as follows: (a)
Altered sensorium indicates ALF but dehydration and
dyselectrolytemia due to persisting vomiting or reduced intake may
also result in altered sensorium without ALF; (b)
Persisting fever after the onset of jaundice is indicative of
other infective conditions; (c) Cola color urine with
anemia and deep jaundice suggest intravenous hemolysis that may be
due to G6PD deficiency or as the manifestation of Wilsonís disease
or autoimmune liver disease; (d) Increasing intensity of
jaundice; (e) Ascites: chronic liver disease, acute on
chronic liver disease or acute hepatitis alone; (f )
Persistent jaundice >12 weeks; (g) Prolongation of
pro-thrombin time >3 seconds; (h) Bleeding manifestations
Q. 9. A 5-year-old child presented with
jaundice and passage of dark colored urine of 14 days duration. He
was found to be HBsAg positive by investigations?
(a) Can this be acute hepatitis B
infection? (b) Can this be chronic hepatitis B infection?
A9 Yes, this could be either acute or
chronic. HBsAg positive child in the above clinical setting may
have (i) acute HBV infection or (ii) acute HBV
infection on a pre-existing chronic liver disease due to other
etiology e.g., Wilsonís disease or (iii) the child
has chronic HBV infection with a superimposed AVH due to hepatitis
A or E or (iv) reactivation of HBV. In this patient
component of acute hepatitis can be substantiated by marked
elevation of ALT. Evidence of chronic liver disease will come from
clinical examination and low serum albumin. IgM-anti-HBc should be
done to differ-entiate between acute HBV infection versus chronic
HBV infection. In acute hepatitis B infection, IgM-anti-HBc is
positive. If IgM-anti-HBc is positive this suggests possibility I
or II as above. In such a situation one would repeat HBsAg after 6
months to look for clearance. However, IgM- anti-HBc may also be
positive during HBV reactivation. In case of negative IgM- anti-HBc
this child has most likely chronic HBV infection.
Experts contributing to above replies are:
Surender K. Yachha,
Department of Gastroenterology
Sanjay Gandhi Postgraduate Institute
of Medical Sciences,
Lucknow, India 226 014.