Suspect viral hepatitis when a child presents with a combination of features comprising of jaundice, nausea, vomiting, and pain over right upper quadrant of abdomen.
- Common cause of acute hepatitis in our setting is acute viral hepatitis A, rarely hepatitis E, B.
- Risk of acute liver failure in hepatitis A and E is <0.1%, except in pregnant females where hepatitis E causes liver failure in around 20%.
History and examination
Important History: Vaccination history, family history of liver disease, exposure to infected individuals, travel history
| Symptoms | Signs |
| Prodromal illness (anorexia, nausea, vomiting, low-grade fever, pain right hypochondrium, and malaise) followed by jaundice Dark urine Pale stools Fatigue | Icterus Hepatomegaly |
Note: Also look for ascites, spleenomegaly, rashes, variceal bleed or encephalopathy.
*In Viral Hepatitis, fever susbside when jaundice is seen.
Differential diagnosis (D/D) & Complication
D/D
- Cholangitis (Pain abdomen, jaundice, fever), Cholecystitis (Pain abdomen, fever, Murphy’s sign), cholelithiasis. In all these cases, there will be disproportionagte ALP/GGT elevation
- Malaria (Jaundice within a week of fever, anemia, splenomegaly, AST/ALT- 3/4 times increased)
- Enteric fever (Continuous fever, anicteric hepatitis)
- Leptospirosis (Biphasic illness, jaundice beyond 2 weeks asssociated with renal involvement with or without bleeding manifestation)
- Rickettsial Infection/ Scrub typhus (Persistent fever, lymphadenopathy, Hepatosplenomegaly, ulcer in groin or axilla, feature of ARDS)
- Autoimmune hepatitis (chronic liver disease, autoantibodies, family history of autoimmune diseases)
- Drug-induced liver injury (History of recent medication use, elevated liver enzymes, no fever)
- Wilson Disease
Complications: Chronic liver disease, cirrhosis, liver failure, hepatocellular carcinoma (in chronic cases)
Acute Liver Failure in Pediatric
Biochemical evidence of acute liver injury with no known evidence of chronic liver disease, and hepatic based coagulopathy defined as PT >15 seconds or INR >1.5 not corrected by Vitamin K in the presence of clinical hepatic encephalopathy or PT >20 seconds or INR > 2.0 regardless of the presense of clinical HE.
Investigation
- Liver Function Test ( AST/ ALT ( increased 10-20 times) Total bilirubin, Direct bilirubin)
- PT/INR
- Serology ( IgM Hepatitis A, IgM Hepatitis B, HBsAg, IgM Anti-HBc)
- Complete Blood Count
- USG Abdomen and Pelvis (To evaluate liver size, texture, and presence of complications e.g., cirrhosis, portal hypertension)
- To rule out other cause in case of persistent fever ( Malarial Antigen, IgM Dengue, Blood Culture, Widal, IgM Leptospira, Antibody for scrub typhus)
Admission criteria
- Admission may be necessary for severe cases with high liver enzyme levels, coagulopathy, encephalopathy, persistent vomiting, poor oral intake, and bleeding.
Management
- Supportive care:
- Hydration and electrolyte balance
- Adequate nutrition and calorie intake, with a low-fat diet
- Avoid hepatotoxic medications (e.g., acetaminophen) and alcohol consumption
- Medical
No specific antiviral is currently available against Hepatitis A and E virus.
Rx:
- Syp Antacid 5ml PO TDS x 15 days
- Syp Vitamin B complex 5ml PO BD x 2 weeks
- Syp Lactulose 5ml PO HS x 2 weeks
Advices
- Improvement of sanitation, personal hygiene, avoidance of contaminated food and water (street side foods)
- Look for abnormal behaviour, irritability or sleepiness, alteration of sleep rhythm, abdominal distension, persistent fever or vomiting
- Icteric phase persists for a variable time (days to weeks)
- Give high fiber diet to avoid constipation.
- Give plenty of water.
Referral
- Refer to a pediatric hepatologist or gastroenterologist for further evaluation and management of complicated cases or cases not responding to treatment.
Follow up
- Follow up within 2-4 weeks after the acute episode to monitor liver function and assess for complications
- Longer-term follow-up may be necessary for chronic hepatitis or complications such as cirrhosis and liver failure