Signs and symptoms of hepatitis

Infection begins with an incubation period during which the virus multiples and spreads without symptoms. The prodromal or pre-icteric phase follows, causing nonspecific symptoms such as profound anorexia, malaise, nausea and vomiting and often fever or right upper quadrant abdominal pain. Urticaria (hives) and arthralgias (pain in the joints) occasionally occur, specially in HBV infection. After 3 to 10 days, the urine darkens, followed by jaundice (the icteric phase). Systemic (whole body) symptoms often regress, and the patients feels better despite worsening jaundice. During the icteric phase, the liver is usally enlarged and tender, but the edge of the liver remains soft and smooth. Mild splenomegaly(enlargement of the spleen) occurs in 15 to 20% of patients. Jaundice usually peaks within 1 to 2 weeks and then fades during a two to four week recovery phase. Appetite usually returns after the first week. Acute viral hepatitis resolves spontaneously within 4 to 8 weeks after symptoms onset.

Sometimes anicteric(without jaundice) hepatitis, a minor flulike illness without jaundice is the only manifestation. It occurs more often that icteric(of or relating to jaundice) hepatitis in patients with HCV infection and in children with HAV infection.

Recrudescent hepatitis occurs in a few patients and is characterized by recurrent manifestations during the recovery phase. Manifestations of cholestasis(a checking or failure of bile flow) may develop during the icteric phase (called cholestatic  hepatitis) but usually resolve. When they persist, they cause prolonged jaundice, elevated alkaline phosphatases, and pruritus (itch) despite general regression of inflammation.

HAV often does not cause jaundice and may not cause any symptoms. It almost invariably resolves after the acute infection, although there can be early recrudescence (increased severity after remission).

HBV cause a wide spectrum of liver diseases, from a subclinical carrier state to severe fulminant acute hepatitis, particularly in the elderly, in whom mortality can reach 10% to 15%. Five to 10% of all patients with HBV develop chronic hepatitis or become inactive carriers. Cirrhosis can develop. Hepatocellular carcinoma can ultimately develop in chronic HBV infection, even without being preceded by cirrhosis.

HCV may be asymptomatic during the acute infection. Its severity often fluctuates, sometimes with recredescent (increased severity after remission) hepatitis and roller-coaster aminotransferase levels for many years or even decades. HCV has the highest rate of chronicity (about 75%). The resultant chronic hepatitis is usually asymptomatic or benign but progresses to cirrhosis in 20% to 30% of patients; cirrhosis often takes decades to appear. Hepatocellular carcinoma can results from HCV-induced cirrhosis but results only rarely from chronic infection without cirrhosis (unlike HBV infection).

Acute HDV infection typically manifests as unusually severe acute HBV infection (co-infection), an acute exacerbation in chronic HBV carriers (superinfection), or a relatively aggressive course of chronic HBV infection.

HEV may be severe, especially in pregnant women.


Justin L. Kaplan MD, Robert S. Porter MD, eds. 2011. Merck Manual Of Diagnosis and Therapy, The – 19th Ed. Whitehouse Station, NJ. Merck Sharp & Dohme Corp., A Subsidiary of Merck & Co., Inc. ISBN-10: 0-911910-19-0, ISBN-13: 978-0-911910-19-3. ISSN: 0076-6526. STAT!Ref Online Electronic Medical Library. 8/5/2012 7:20:26 PM CDT (UTC -05:00).