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Chapter: Clinical Cases in Anesthesia : Liver Disease

What are the concerns associated with viral hepatitis?

Hepatitis is an inflammatory process of the liver. The major causes of hepatitis in this country are viral, alcoholic, and drug-induced.

What are the concerns associated with viral hepatitis?

 

Hepatitis is an inflammatory process of the liver. The major causes of hepatitis in this country are viral, alcoholic, and drug-induced. Its natural history is highly variable and depends on numerous factors including age, coexisting liver disease, alcohol consumption, and obesity. The pro-gression of viral hepatitis to cirrhosis and ultimately to ESLD has been a tremendous burden to society.

 

Anesthesiologists are commonly called on to care for these individuals either in advance consultation or as part of scheduled anesthetics. Two major concerns are associ-ated with viral hepatitis. The first is the risk to the patient and the second is the risk to all health care personnel. Viral hepatitis is a significant source of occupational illness that frequently leads to a carrier state.

 

Hepatitis A is the most common hepatic viral infection, accounting for approximately 40% of all cases of hepatitis in the United States. It is usually transmitted by fecal-oral routes and is commonly acquired by consumption of con-taminated seafood. Its incubation period is approximately 15–45 days and generally produces a mild illness. It is com-monly subclinical and very rarely causes hepatic failure via massive liver necrosis. The disease is usually benign, acute, self-limited and, unlike hepatitis B, does not lead to chronicity or a carrier state. Recovery is usually complete at 1–2 months. Diagnosis may be aided by the detection of hepatitis A antigen (HAsAg) during the acute phase or of the immunoglobulin G (IgG) or M (IgM) antibodies later.

 

Hepatitis B causes much more morbidity and mortality, is variable in presentation, and requires a complex sero-logic diagnosis. Fortunately, its incidence is decreasing with improved detection and vaccination of individuals per-ceived to be at risk. In New York State, hepatitis B vaccina-tion is mandatory for all children. The incubation period of hepatitis B ranges from 45 days to 6 months. Initially, the disease presents with nonspecific symptoms such as malaise, nausea, vomiting, anorexia, and headaches. Upper quadrant pain and hepatic enlargement may be present. The symp-toms may subside or progress to an icteric phase character-ized by jaundice, pruritus, hepatomegaly, or other gastrointestinal symptoms. This phase may develop into ful-minant hepatic failure or a convalescent period. Full recovery from hepatitis B occurs in 90% of patients within 3 months. Approximately 10% of individuals remain in a carrier state, develop chronic hepatitis (either active or persistent), mani-fest cirrhosis, or present with hepatocellular carcinoma.

Hepatitis B persisting for more than 6 months following an attack of acute viral hepatitis is considered to have become chronic. Chronic persistent hepatitis differs from chronic active hepatitis in that it has an excellent prognosis for eventual recovery. Transaminase levels may fluctuate but eventually return to normal. Biopsy results show inflammation without fibrosis. On the other hand, chronic active hepatitis carries a poor prognosis, varies widely in presentation, and often leads to cirrhosis, hepatocellular carcinoma, and death.

 

The majority of non-A, non-B viral hepatitis is now known to be caused by hepatitis C. The clinical spectrum of hepatitis C spans the entire gamut from asymptomatic to acute fulminant disease. Compared with hepatitis B, the early hepatitis caused by the hepatitis C viruses is mild, but it has a much higher propensity (approximately 40%) for transition to chronicity. The most common presentation of hepatitis C is a mild increase in transaminase levels on routine blood screening.

 

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