Introduction to Chronic Hepatitis

by Abraham Mathew Saji

Hepatitis, or commonly known as inflammation of the liver, is a silent killer that shows up late in its lifecycle. It can be caused by viruses, lifestyle, medication and/or inherited metabolic disorders. When infected for a prolonged duration, it is referred to as chronic hepatitis which can lead to liver cirrhosis, followed by liver cancer. Depending on the severity, hepatitis manifests itself with varying symptoms, which can provide valuable leads into an appropriate diagnosis and treatment regimen. Like all other ailments, there are means and methods to prevent hepatitis.

What Is Hepatitis?

Hepatitis is an inflammation of the liver. In chronic hepatitis, liver inflammation continues for at least six months. This condition may be mild and result in relatively little damage, or may be more serious, causing resulting in destruction of many liver cells. Some severe cases lead to cirrhosis¹ and eventually liver failure.

Viruses are the most common cause of hepatitis (according to the “World Health Organization, Hepatitis” report dated 25 November 2013). Viruses that cause hepatitis include:

• Hepatitis B and C: These viruses cause two-thirds of all cases of chronic hepatitis. Both these viruses usually begin with mild symptoms. Over time, perhaps a decade or more, both may lead to serious complication of cirrhosis due to ongoing destruction of liver cells and resultant scarring, eventually leading to liver cancer.
• Hepatitis D: Infects only patients already infected with hepatitis B, and it generally results in a flare of active hepatitis.

These viruses are primarily passed from one person to another through sexual contact, blood or other body fluids during blood transfusions or using shared needles. Treatment for some types of viral chronic hepatitis can eliminate active infection. However, the virus can remain dormant in cells, causing a recurrence of liver inflammation when the infection gets active. The common diagnosed causes of non-infectious chronic hepatitis include:

• Alcohol: Alcohol is considered to be the main cause of non-infectious chronic hepatitis. Also, even moderate intake of alcohol can worsen pre-existing chronic hepatitis(especially hepatitis C), with an increased risk of advancing to cirrhosis.
• Non-alcoholic steatohepatitis (NASH): NASH has become a relatively common cause of persistent liver inflammation. “Steato” means fat and the hallmark of NASH is fat accumulation in the liver and active on-going liver damage. Most people do not display symptoms. Asymptomatic patients are usually discovered when a routine blood test is performed and the level of liver enzymes are found to be elevated.
• 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 is a progressive disease that can lead to cirrhosis. It may occur in autoimmune diseases such as Sjögren’s syndrome² and autoimmune hemolytic anaemia.

Some medications can also lead to chronic hepatitis. These medications include:

• Isoniazid for tuberculosis.
• Methyldopa for hypertension.
• Phenytoin for seizure disorders.
• Nitrofurantoin for urinary tract infections.

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.

Several rare inherited metabolic disorders also can lead to chronic hepatitis. They include:

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

Symptoms

At first, chronic hepatitis often does not display 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 abdominal discomfort
• Loss of appetite
• Nausea
• Body aches

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

• Jaundice (yellowing of the skin and eyes)
• Abdominal swelling
• Weight loss
• Muscle weakness
• Dark urine
• Easy bruisability and spontaneous bleeding

Diagnosis

Because chronic hepatitis often does not have any early symptoms, the disorder is frequently discovered during a routine blood test. If chronic hepatitis is suspected, the patient is usually examined 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 are done to measure the levels of:

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

If these tests show signs of liver inflammation or liver failure, further tests for hepatitis B and C as well as antibodies that signal autoimmune hepatitis are recommended. The suspected roles of medications taken concomitantly are also considered to determine the case, as long-term administration of some medication have adverse effects on the liver. If the cause is still unknown, further blood tests are performed to check for uncommon causes. An ultrasound or computed tomography (CT) test may be done to assess the size of the liver to assess the magnitude of liver damage. A small liver that appears shrunk and scarred is suspected to be cirrhosis.

In this case, a liver biopsy may be recommended. A small piece of tissue removed from the liver will be examined  to determine:

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

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

Prevention

The best way to protect against chronic hepatitis is to protect against the viruses. Vaccinations for hepatitis B are recommended for health care practitioners and people who travel to certain countries. Infants are now routinely vaccinated against hepatitis B.

Needles should never be shared. Avoid getting a tattoo or any body piercing done. If needed, ensure choice of an establishment where all equipment is sterilised adequately.

The best way to protect against chronic hepatitis is to protect against the viruses

Non-alcoholic steatohepatitis (NASH) is commonly seen in people who are overweight, especially if they accumulate excessive fat around the midsection. Women with a waist circumference of =35 inches and men with a waist circumference of =40 inches are at high risk of developing this type of chronic hepatitis. Maintaining a healthy weight and regular exercise are keys to preventing NASH.

Regular blood tests are warranted when taking medications with potential to damage the liver to avoid development of chronic hepatitis.

Treatment

The treatment goals for chronic hepatitis are to prevent the disease from getting worse and to prevent cirrhosis and liver failure. In mild cases of chronic hepatitis from hepatitis B or C, treatment may not be necessary, and the condition may not get worse. With active infection, or if a liver biopsy shows early signs of damage, treatment is more likely to be recommended to eliminate active infection.

Viral hepatitis is treated with antiviral medications. Drugs used to treat hepatitis C include alpha interferon, ribavirin, boceprevir and telaprevir. For hepatitis B, the drugs used include lamivudine, adefovir, tenofovir and entecavir. Clinical trials are under way to determine the best treatment regimen to improve response and lower the chances of relapse of the disease.

Common side effects with antiviral medication include:

• Fatigue
• Muscle aches
• Headaches
• Nausea and vomiting
• Fevers
• Weight loss
• Irritability and depression

Treatment of alcoholic hepatitis is complete abstinence from alcohol.

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

Corticosteroids and other medications, such as azathioprine, that 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. For example, medication-related chronic hepatitis requires stopping or changing the drug. If cirrhosis or liver failure develops, a liver transplant may be needed.

Supportive care is important in coping with chronic hepatitis. A well-balanced diet and good physical fitness can help battle fatigue and improve overall health.

Summary

The hepatitis causing viruses can progress slowly and silently within the liver to cause varying types and extents of liver damage. In its most severe stages, it can lead to cirrhosis, liver failure and death unless a liver transplant is done. Other factors that affect the prognosis include age, other medical illnesses, subtype of virus and alcohol use. The diagnosis would be aided by pathological and radiological tests, which can assist the medical practitioner to prescribe the appropriate dosage regimen of medications along with lifestyle changes.

About the Author

ABRAHAM MATHEW SAJI is a pharmacist who engages extensively in research and development of modern medicine and its implications on the human body. He hold a Masters Degree in Pharmacy with 20 years of industrial experience in the field of Pharmaceutical Research and Development. He is actively involved in the formulation and development of various pharmaceutical dosage forms with a local pharmaceutical manufacturing company. He holds memberships with reputable international professional bodies. He is an ardent reader with a passion for writing. He works closely with medical and paramedical practitioners to get a better insight into certain areas before publishing articles on the subject of interest. Find out more about Abraham by visiting his Scientific Malaysian profile at http://www.scientificmalaysian.com/members/abraham/

1 Cirrhosis is a chronic liver disease marked by cellular degeneration, inflammation, and thickening of fibrous tissue. The latter leads to scarring of the liver;

2 Sjögren’s syndrome is a chronic autoimmune condition characterized by degeneration of the salivary and lachrymal glands, which results in dryness of the mouth and eyes.