Chronic hepatitis

What is chronic hepatitis?

Hepatitis is an inflammation of the liver. In chronic hepatitis, liver inflammation continues for at least six months. This condition may be mild, causing relatively little damage, or more serious, causing many liver cells to be destroyed. Some cases lead to cirrhosis and liver failure.

Chronic hepatitis from infection is most often caused by these viruses:

Hepatitis B and C. Often the person infected is unaware of any initial symptoms. Or the symptoms were so mild that the person did not seek medical attention. This is especially true for chronic hepatitis C. Over time, perhaps a decade or more, both types may lead to the serious complication of cirrhosis due to ongoing destruction of liver cells and resultant scarring. A minority of patients with cirrhosis develop liver cancer over time.

Hepatitis D. Hepatitis D infects only patients already infected with hepatitis B, and it generally results in a flare of active hepatitis.

The three more commonly diagnosed causes of non-infectious chronic hepatitis include:

Alcohol. Alcohol can cause a chronic hepatitis, especially if associated with inadequate nutrition. Also, even moderate intake of alcohol can make chronic hepatitis from any other cause (especially hepatitis C) worse, with an increased risk of advancing to cirrhosis.

Non-alcoholic steatohepatitis (NASH). Nonalcoholic steatohepatitis or NASH has become a relatively common cause of persistent liver inflammation. "Steato" means fat and the hallmark of NASH is fat in the liver AND active on-going liver damage. Most people have no symptoms. They are usually discovered when a routine blood test is performed and the level of liver enzymes are found to be above normal.

Autoimmune hepatitis. In this form of chronic hepatitis, the immune system mistakenly destroys the body's own liver cells. What triggers autoimmune chronic hepatitis is unknown. If left untreated, it's a progressive disease that can lead to cirrhosis. It may appear with other autoimmune diseases, such as Sjögren's syndrome and autoimmune hemolytic anemia. Autoimmune hepatitis most often is found in young women, but it can affect women and men of all ages.

Some rare, inherited metabolic disorders also can lead to chronic hepatitis, such as:

• Wilson's disease, a condition in which the body has difficulty metabolizing copper
• Hemochromatosis, a condition of excessive iron deposits in the liver and many other parts of the body.

Some medications also can lead to chronic hepatitis. However, chronic hepatitis caused by medications is relatively uncommon. Periodic blood tests are warranted when patients are placed on drugs known to cause hepatitis. Discontinuing the medication usually reverses early liver inflammation.

Symptoms of chronic hepatitis

At first, chronic hepatitis often does not cause any symptoms. People with symptoms most commonly complain of fatigue. Fatigue worsens throughout the day and may even be debilitating. Other common symptoms include:

• Mild upper abdomen discomfort
• Loss of appetite
• Nausea
• Body aches.

If chronic hepatitis becomes more severe, people may experience additional symptoms, including:

• Dark urine
• Jaundice (yellowing of the skin and eyes)
• Easy bruisability and spontaneous bleeding
• Abdominal swelling
• Muscle weakness
• Confusion that may progress to coma.

Diagnosing chronic hepatitis

Because chronic hepatitis often does not cause any early symptoms, the disorder frequently is discovered during a routine blood test.

If your doctor suspects you may have chronic hepatitis, he or she may examine you for jaundice, tenderness in the abdomen (especially the right upper corner where the liver is located) and signs of fluid that fills the abdomen during liver failure.

Blood tests may be done to measure:

• Liver enzymes, which are released when liver cells become inflamed or damaged
• Bile duct enzymes
• Levels of bilirubin, a pigment produced by the breakdown of red blood cells. High levels of bilirubin cause jaundice
• Protein levels and clotting factors to assess how the liver is functioning.

If these tests show signs of liver inflammation, you will undergo blood tests for hepatitis B and C and for antibodies that signal autoimmune hepatitis. Your doctor will review medications you take now or have taken recently to determine if they could be causing your chronic hepatitis. If the cause still is not known, further blood tests will be ordered to check for uncommon causes. An ultrasound or computed tomography (CT) test may be done to assess the size of the liver. A small liver that appears scarred suggests cirrhosis.

A liver biopsy may be recommended. In a biopsy, a small piece of tissue will be removed from your liver and will be examined under a microscope to help determine:

• The cause of chronic hepatitis
• The severity of inflammation
• The amount of scarring
• The extent and type of liver damage.

This information helps to determine the best treatment and to assess your risk of developing cirrhosis and liver failure. A liver biopsy also can help to check for other disorders, such as alcoholic liver injury or fatty liver.

Expected duration of chronic hepatitis

By definition, chronic hepatitis is inflammation that continues for more than six months. With mild or nonexistent symptoms, you may have chronic hepatitis for some time before it is discovered. Treatment for some types of viral chronic hepatitis can eliminate active infection. However, the virus can remain dormant in cells, so the condition can return.

Preventing chronic hepatitis

Until recently, most cases of chronic hepatitis were caused by infection with the hepatitis B or C virus. These viruses primarily are passed from person to person through sexual contact or through contact with blood or other bodily fluids when needles are shared or during blood transfusions. The reason some cases of viral hepatitis become chronic hepatitis and others do not remains unknown.

The best way to protect against chronic hepatitis from hepatitis B and C viruses is vaccination. Vaccinations for hepatitis B are recommended for health care workers, people traveling to certain countries and those who are concerned about acquiring hepatitis B through sexual contact or drug use. Infants are now routinely vaccinated against hepatitis B. Condoms always should be used during sexual contact to help prevent infection. Needles should never be shared. When getting a tattoo or any body piercing done, make sure to choose an establishment where all equipment is sterilized adequately.

Because of effective therapy to eradicate hepatitis C and improved therapies for hepatitis B, persistent liver inflammation due to fatty liver is now the more cause of chronic hepatitis in developed countries. Non-alcoholic liver disease with inflammation is called non-alcoholic steatohepatitis (NASH).

Non-alcoholic steatohepatitis (NASH) is seen most often in people who are overweight, especially if they accumulate excessive fat around the midsection. Women with waist size 35 inches or greater and men with waist size 40 inches or greater are at highest risk of developing this type of chronic hepatitis. Maintaining a healthy weight and exercising regularly give you the best chance of preventing NASH. Avoiding and even better eliminating alcohol use helps prevent both NASH and alcoholic hepatitis.

If you are taking a medication that could affect your liver, make sure to have your blood tested regularly to avoid the development of chronic hepatitis or liver damage.

Treating chronic hepatitis

The goals of treatment for chronic hepatitis are to prevent the disease from getting worse and to prevent cirrhosis and liver failure.

Chronic hepatitis B and C are treated with antiviral medications. The newest drugs have incredibly high success rates.

If you have hepatitis C, you should receive the vaccine for hepatitis A and B unless blood tests show that you are already immune to these viruses. You can develop more severe symptoms from hepatitis A or B than someone who does not have hepatitis C.

Treatment of alcoholic hepatitis is complete abstinence from alcohol.

People with NASH usually need to lose weight and always need to exercise more. In addition, many people with NASH have elevated blood sugars and frequently progress to type 2 diabetes. Good control of blood sugar can help to decrease the fatty accumulation and inflammation in the liver.

If you already have evidence of cirrhosis, you should have a test called endoscopy to look for esophageal varices, enlarged veins in the esophagus that can cause life-threatening bleeding. In an endoscopy, a flexible viewing tube is inserted through your mouth into your esophagus. You also should be screened periodically with a blood test (alpha fetoprotein) and an ultrasound study to search for an early liver cancer.

Corticosteroids and other medications such as azathioprine to suppress the immune system are the main treatment of autoimmune chronic hepatitis. These drugs usually decrease symptoms, reduce liver inflammation and prolong survival.

Treatment for the less common forms of chronic hepatitis focuses on the disease that is causing the condition. Medication-related chronic hepatitis requires stopping or changing the drug.

If cirrhosis or liver failure develops, a liver transplant may be needed.

If you have chronic hepatitis, you must avoid further liver damage from alcohol or acetaminophen (Tylenol). Discuss with your doctor how much acetaminophen you can take, if any. Remember that certain cold formulations and pain medications also contain acetaminophen.

A healthy lifestyle is so important for people with chronic hepatitis. A well-balanced diet and good physical fitness can help you battle fatigue and improve overall health. You may need to limit your salt intake if you tend to accumulate fluid as a consequence of cirrhosis. Also, always talk to your physician before taking any additional drugs, including prescription, nonprescription and alternative medications. Your injured liver may not be able to detoxify these.

When to call a professional

If you experience persistent fatigue, the most common symptom of chronic hepatitis, make an appointment to see your doctor. If you show signs that could come from chronic hepatitis or liver failure, such as jaundice, abdominal swelling or weight loss, you should call your doctor for an evaluation.

Prognosis

The prognosis for chronic hepatitis has improved dramatically over the last few years. In fact, for hepatitis C, many people can now be cured.

Despite treatment, some people will progress to cirrhosis. Advanced cirrhosis can lead to liver failure and death unless a liver transplant can be done.

The likelihood of developing cirrhosis depends on the severity of the disease and the response to treatment. When a biopsy shows more severe damage, treatment can be important to help decrease the risk of developing cirrhosis even if you do not have symptoms. Other factors that affect the prognosis include age, other medical illnesses, the subtype of virus and alcohol use.

Cirrhosis increases the risk of developing liver cancer. Periodic screening with a blood test and ultrasound examination of the liver improves the chance of early detection.

Additional info

American College of Gastroenterology (ACG)
https://gi.org/

American Liver Foundation
https://www.liverfoundation.org/

National Institute of Diabetes & Digestive & Kidney Disorders
https://www.niddk.nih.gov/