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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