Editing Hepatitis (section)

== Signs and symptoms ==
[[File:Jaundice eye.jpg|thumb|upright=1.3|Jaundiced eyes]]
Hepatitis has a broad spectrum of presentations that range from a complete lack of symptoms to severe&nbsp;[[liver failure]].<ref name="Harrison's Principles, chapter 360 (Acute Viral)">{{Cite book|title=Harrison's Principles of Internal Medicine, 19e|last=Dienstag|first=JL|publisher=McGraw-Hill|year=2015|isbn=978-0-07-180215-4|editor-last=Kasper|editor-first=D|location=New York, NY|chapter=Chapter 360: Acute Viral Hepatitis|editor-last2=Fauci|editor-first2=A|editor-last3=Hauser|editor-first3=S|editor-last4=Longo|editor-first4=D|editor-last5=Jameson|editor-first5=J|editor-last6=Loscalzo|editor-first6=J}}</ref><ref name="CURRENT Diagnosis & Treatment">{{Cite book|title=CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 3e|last1=Rutherford|first1=A|last2=Dienstag|first2=JL|publisher=McGraw-Hill|year=2016|isbn=978-0-07-183772-9|editor-last=Greenberger|editor-first=NJ|location=New York, NY|chapter=Chapter 40: Viral Hepatitis|editor-last2=Blumberg|editor-first2=RS|editor-last3=Burakoff|editor-first3=R}}</ref><ref name="Khalili & Burman">{{Cite book|title=Pathophysiology of Disease: An Introduction to Clinical Medicine, 7e|last1=Khalili|first1=M|last2=Burman|first2=B|publisher=McGraw-Hill|year=2013|isbn=978-1-25-925144-3|editor-last=Hammer|editor-first=GD|chapter=Chapter 14: Liver Disease|editor-last2=McPhee|editor-first2=SJ}}</ref> The acute form of hepatitis, generally caused by viral infection, is characterized by&nbsp;[[constitutional symptoms]]&nbsp;that are typically self-limiting.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" /> Chronic hepatitis presents similarly, but can manifest [[medical sign|signs]] and symptoms specific to liver dysfunction with long-standing inflammation and damage to the organ.<ref name="Khalili & Burman" /><ref name="Harrison's Principles, chapter 362 (Chronic)">{{Cite book|title=Harrison's Principles of Internal Medicine, 19e|last=Dienstag|first=JL|publisher=McGraw-Hill|year=2015|isbn=978-0-07-180215-4|editor-last=Kasper|editor-first=D|location=New York, NY|chapter=Chapter 362: Chronic Hepatitis|editor-last2=Fauci|editor-first2=A|editor-last3=Hauser|editor-first3=S|editor-last4=Longo|editor-first4=D|editor-last5=Jameson|editor-first5=J|editor-last6=Loscalzo|editor-first6=J}}</ref>

=== Acute hepatitis ===
Acute viral hepatitis follows three distinct phases:
# The initial [[Prodrome|prodromal phase]] (preceding symptoms) involves [[non-specific]] and [[flu-like]] symptoms common to many acute viral infections. These include [[Fatigue (medical)|fatigue]], [[nausea]], [[vomiting]], poor appetite, joint pain, and headaches.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" /> Fever, when present, is most common in cases of hepatitis A and E.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /> Late in this phase, people can experience liver-specific symptoms, including [[choluria]] (dark urine) and clay-colored stools.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" />
# [[Jaundice|Yellowing of the skin and whites of the eyes]] follow the prodrome after about 1–2 weeks and can last for up to 4 weeks.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" /> The non-specific symptoms seen in the prodromal typically resolve by this time, but people will develop an [[hepatomegaly|enlarged liver]] and right upper abdominal pain or discomfort.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /> 10–20% of people will also experience an [[Splenomegaly|enlarged spleen]], while some people will also experience a mild unintentional weight loss.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="Khalili & Burman" />
# The recovery phase is characterized by resolution of the clinical symptoms of hepatitis with persistent elevations in [[Liver function tests|liver lab values]] and potentially a persistently enlarged liver.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /> All cases of hepatitis A and E are expected to fully resolve after 1–2 months.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /> Most hepatitis B cases are also self-limiting and will resolve in 3–4 months.  Few cases of hepatitis C will resolve completely.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" />

Occasionally, however, acute hepatitis can cause [[liver failure]]. Liver failure can be life threatening and may lead to a [[coma]] or even death.<ref>{{cite book| title = Exploring Life Sciences| volume = 6|pages = 412-413|ISBN = 0-7614-7141-3|publisher = Marshall Cavendish}}</ref>

Both [[drug-induced hepatitis]] and [[autoimmune hepatitis]] can present very similarly to acute viral hepatitis, with slight variations in symptoms depending on the cause.<ref name="Fontana & Hayashi">{{Cite journal|last1=Fontana|first1=Robert|last2=Hayashi|first2=Paul|date=2014-05-01|title=Clinical Features, Diagnosis, and Natural History of Drug-Induced Liver Injury|journal=Seminars in Liver Disease|language=en|volume=34|issue=2|pages=134–144|doi=10.1055/s-0034-1375955|pmid=24879979|doi-access=free}}</ref><ref name="Manns Lohse Vergani">{{Cite journal|last1=Manns|first1=Michael P.|last2=Lohse|first2=Ansgar W.|last3=Vergani|first3=Diego|title=Autoimmune hepatitis – Update 2015|journal=Journal of Hepatology|volume=62|issue=1|pages=S100–S111|doi=10.1016/j.jhep.2015.03.005|pmid=25920079|year=2015|doi-access=free}}</ref> Cases of drug-induced hepatitis can manifest with systemic signs of an allergic reaction including rash, fever, [[serositis]] (inflammation of membranes lining certain organs), elevated [[Eosinophil granulocyte|eosinophils]] (a type of white blood cell), and [[Bone marrow suppression|suppression of bone marrow activity]].<ref name="Fontana & Hayashi" />

=== Fulminant hepatitis ===
Fulminant hepatitis, or massive hepatic [[necrosis|cell death]], is a rare and life-threatening complication of acute hepatitis that can occur in cases of hepatitis B, D, and E, in addition to drug-induced and autoimmune hepatitis.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="Fontana & Hayashi" /><ref name="Manns Lohse Vergani" /> The complication more frequently occurs in instances of hepatitis B and D co-infection at a rate of 2–20% and in pregnant women with hepatitis E at rate of 15–20% of cases.<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" /> In addition to the signs of acute hepatitis, people can also demonstrate signs of [[coagulopathy]] (abnormal coagulation studies with easy bruising and bleeding) and [[encephalopathy]] (confusion, disorientation, and [[somnolence|sleepiness]]).<ref name="Harrison's Principles, chapter 360 (Acute Viral)" /><ref name="CURRENT Diagnosis & Treatment" /> Mortality due to fulminant hepatitis is typically the result of various complications including [[cerebral edema]], [[gastrointestinal bleeding]], [[sepsis]], [[respiratory failure]], or [[kidney failure]].<ref name="Harrison's Principles, chapter 360 (Acute Viral)" />

=== Chronic hepatitis ===
Acute cases of hepatitis are seen to be resolved well within a six-month period. When hepatitis is continued for more than six months it is termed chronic hepatitis.<ref>{{cite book|last1=Munjal|first1=Y. P.|last2=Sharm|first2=Surendra K.|title=API Textbook of Medicine, Ninth Edition, Two Volume Set|date=2012|publisher=JP Medical Ltd|isbn=9789350250747|page=870|url=https://books.google.com/books?id=L7pW3yGjj7kC&pg=PA870|language=en|url-status=live|archive-url=https://web.archive.org/web/20170910162730/https://books.google.com/books?id=L7pW3yGjj7kC&pg=PA870|archive-date=2017-09-10}}</ref> Chronic hepatitis is often asymptomatic early in its course and is detected only by liver laboratory studies for [[Screening (medicine)|screening]] purposes or to evaluate non-specific symptoms.<ref name="Khalili & Burman" /><ref name="Harrison's Principles, chapter 362 (Chronic)" /> As the inflammation progresses, patients can develop constitutional symptoms similar to acute hepatitis, including fatigue, nausea, vomiting, poor appetite, and joint pain.<ref name="Harrison's Principles, chapter 362 (Chronic)" /> Jaundice can occur as well, but much later in the disease process and is typically a sign of advanced disease.<ref name="Harrison's Principles, chapter 362 (Chronic)" /> Chronic hepatitis interferes with hormonal functions of the liver which can result in acne, [[hirsutism]] (abnormal hair growth), and [[Amenorrhoea|amenorrhea]] (lack of menstrual period) in women.<ref name="Harrison's Principles, chapter 362 (Chronic)" /> Extensive damage and scarring of the liver over time defines [[cirrhosis]], a condition in which the liver's ability to function is permanently impeded.<ref name="Khalili & Burman" /> This results in jaundice, weight loss, coagulopathy, [[ascites]] (abdominal fluid collection), and [[peripheral edema]] (leg swelling).<ref name="Harrison's Principles, chapter 362 (Chronic)" /> Cirrhosis can lead to other life-threatening complications such as [[hepatic encephalopathy]], [[esophageal varices]],  [[hepatorenal syndrome]], and [[Hepatocellular carcinoma|liver cancer]].<ref name="Khalili & Burman" />