Open Access
Feature Article

Nonviral hepatitis: common causes and their management

Open Access
Feature Article

Nonviral hepatitis: common causes and their management

RACHAEL JACOB, Simone Strasser

Figures

© dr_microbe/istockphoto.com
© dr_microbe/istockphoto.com
Dr Jacob is a Hepatology Fellow at AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney. Associate Professor Strasser is a Senior Staff Specialist at AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW.

Abstract

The proportion of hepatitis cases due to nonviral causes is increasing, given therapeutic advances for chronic viral hepatitis in recent years. Initial assessment can lead to a positive diagnosis and early management, and many patients can be safely and effectively managed in primary care.

Key Points

  • The most common causes of nonviral liver disease that may present as a hepatitis include metabolic-associated fatty liver disease (MAFLD), alcohol-related liver disease (ALD) and drug-induced liver injury (DILI).
  • A thorough medication history should be taken for patients with hepatitis, including prescription and over-the-counter medications as well as herbal and dietary supplements.
  • Targeted blood tests may reveal causes of nonviral hepatitis.
  • Patients with features of severe liver injury, liver failure or cirrhosis should be referred for urgent hepatology assessment and, in appropriate cases, hospitalisation.

Hepatitis refers to liver inflammation, usually brought to attention by asymptomatic elevation of serum ­aminotransferases (aspartate aminotransferase [AST] or alanine aminotransferase [ALT]) or by symptoms, such as nausea, fatigue, abdominal discomfort or jaundice. Acute or chronic viral hepatitis can be readily excluded through serological testing, but the evaluation of nonviral causes may be more complex. Nonviral liver disorders that should be considered include, but are not limited to, alcohol-related liver disease (ALD), metabolic-associated fatty liver disease (MAFLD), drug- or toxin-induced liver injury (DILI), biliary or pancreatic disorders and, less commonly, autoimmune disorders, genetic disorders and Budd-Chiari syndrome. Hepatitis can be acute or chronic (arbitrarily defined as lasting more than six months), with prolonged inflammation resulting in fibrosis and cirrhosis in some individuals. Given the significant therapeutic advances for chronic viral hepatitis in recent years, the proportion of nonviral liver disease as a cause of hepatitis is increasing, as is the prevalence. This article presents an approach to the investigation and management of the common causes of nonviral hepatitis.

Assessing nonviral hepatitis

A diagnostic approach can be used to assess patients with nonviral hepatitis, as discussed below and presented in the Flowchart. The indications for specialist involvement and the red flags for urgent referral are listed in Box 1 and Box 2.

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Symptoms and presenting features

Patients with hepatitis are frequently asymptomatic, with elevated liver enzymes levels being found on routine blood tests. Some patients present with nonspecific symptoms, such as lethargy, nausea and/or vomiting, anorexia, abdominal pain, fevers and jaundice, which prompt further investigation.

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Marked elevation of serum AST and ALT levels (greater then 500 U/L) may reflect severe liver injury and can be associated with acute liver failure marked by ­coagulopathy and encephalopathy. This a medical emergency and patients require immediate ­hospitalisation. Nonviral ­conditions to ­consider are severe autoimmune hepatitis, DILI and ischaemic hepatitis. 

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