Hepatitis

Hepatitis
Hepatitis is inflammation of the liver. The clinical signs, prognosis, and treatment depend on the cause.
Signs and symptoms
Symptoms include malaise, joint aches, abdominal pain, vomiting 2-3 times per day for the first 5 days, defecation, loss of appetite, dark urine, fever, hepatomegaly (enlarged liver) and jaundice (icterus, yellowing of the eyes and skin). Some chronic forms of hepatitis show very few of these signs and are only present when the longstanding inflammation has led to the replacement of liver cells by connective tissue; this disease process is referred to as cirrhosis of the liver. Certain liver function tests can also indicate hepatitis.
Types of hepatitis
Viral
Most cases of acute hepatitis are due to viral infections:
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis B with D
• Hepatitis E
• Hepatitis F (discredited)
• Hepatitis G
• In addition to the hepatitis viruses (please note that the hepatitis viruses are not all related). Other viruses can also cause hepatitis, including cytomegalovirus, Epstein-Barr virus, yellow fever, etc.
Please see the respective articles for more detailed information.
See also infectious canine hepatitis.
Hepatitis A
Hepatitis A or infectious jaundice is caused by a picornovirus. It is transmitted by the orofecal route, transmitted to humans through methods such as contaminated food. It causes an acute form of hepatitis and does not have a chronic stage. The patient's immune system makes antibodies against hepatitis A that confer immunity against future infection. People with hepatitis A are advised to rest, stay hydrated and avoid alcohol. A vaccine is available that will prevent infection from hepatitis A for life. Hepatitis A can be spread through personal contact, consumption of raw sea food or drinking contaminated water. This occurs primarily in third world countries. Strict personal hygiene and the avoidance of raw and unpeeled foods can help prevent an infection. Infected persons already begin excreting the hepatitis A virus with their stool two weeks after the appearance of the first symptoms. The time between the infection and the start of the illness can run from 15 to 45 days, and approximately 15% of sufferers may experience relapsing symptoms from six months to a year following initial diagnosis.
Hepatitis B
Hepatitis B is caused by a hepadnavirus, which can cause both acute and chronic hepatitis. Chronic hepatitis develops in the 15% of patients who are unable to eliminate the virus after an initial infection. Identified methods of transmission include blood (blood transfusion, now rare), tattoos (both amateur and professionally done), sexually (through sexual intercourse or through contact with blood or bodily fluids), or in utero (from mother to her unborn child, as the virus can cross the placenta). However, in about half of cases the source of infection cannot be determined. Blood contact can occur by sharing syringes in intravenous drug use, shaving accessories such as razor blades, or touching wounds on infected persons. Needle-exchange programmes have been created in many countries as a form of prevention. In the United States, 95% of patients clear their infection and develop antibodies against hepatitis B virus. 5% of patients do not clear the infection and develop chronic infection; only these people are at risk of long term complications of hepatitis B.
Patients with chronic hepatitis B have antibodies against hepatitis B, but these antibodies are not enough to clear the infection that establishes itself in the DNA of the affected liver cells. The continued production of virus combined with antibodies is a likely cause of immune complex disease seen in these patients. A vaccine is available that will prevent infection from hepatitis B for life. Hepatitis B infections result in 500,000 to 1,200,000 deaths per year worldwide due to the complications of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Hepatitis B is endemic in a number of (mainly South-East Asian) countries, making cirrhosis and hepatocellular carcinoma big killers. There are three FDA-approved treatment options available for persons with a chronic hepatitis B infection: alpha-interferon, adefovir and lamivudine. About 45% of persons on treatment achieve a sustained response.
Hepatitis C
Hepatitis C (originally "non-A non-B hepatitis") can be transmitted through contact with blood (including through sexual contact where the two parties' blood is mixed). Hepatitis C may lead to a chronic form of hepatitis, culminating in cirrhosis. It can remain asymptomatic for 10-20 years. No vaccine is available for hepatitis C, although in January 2007 researchers at the University of Washington announced a breakthrough which they predict will lead to a vaccine within five years. Patients with hepatitis C are prone to severe hepatitis if they contract either hepatitis A or B, so all hepatitis C patients should be immunized against hepatitis A and hepatitis B if they are not already immune. However, hepatitis C itself is a very lethal virus, and it can result in death; most people who have gotten hepatitis C have died. The virus can cause cirrhosis of the liver. The virus, if detected early on, can be treated by a combination of interferon and the antiviral drug ribavirin. The genotype of the virus determines the rate of response to this treatment regimen.
Hepatitis E
Hepatitis E produces symptoms similar to hepatitis A, although it can take a fulminant course in some patients, particularly pregnant women; it is more prevalent in the Indian subcontinent.
Hepatitis G
Another type of hepatitis, hepatitis G, has been identified, and is probably spread by blood and sexual contact. There is, however, doubt about whether it causes hepatitis, or is just associated with hepatitis, as it does not appear to be primarily replicated in the liver.
Other viruses can cause infectious hepatitis:
• Mumps virus
• Rubella virus
• Cytomegalovirus
• Epstein-Barr virus
• Other herpes viruses
Alcoholic Hepatitis
Ethanol, mostly in alcoholic beverages, is an important cause of hepatitis. Usually alcoholic hepatitis comes after a period of increased alcohol consumption. Alcoholic hepatitis is characterized by a variable constellation of symptoms, which may include feeling unwell, enlargement of the liver, development of fluid in the abdomen ascites, and modest elevation of liver blood tests. Alcoholic hepatitis can vary from mild with only liver test elevation to severe liver inflammation with development of jaundice, prolonged prothrombin time, and liver failure. Severe cases are characterized by either obtundation (dulled consciousness) or the combination of elevated bilirubin levels and prolonged prothrombin time; the mortality rate in both categories is 50% within 30 days of onset.
Alcoholic hepatitis is distinct from cirrhosis caused by long term alcohol consumption. Alcoholic hepatitis can occur in patients with chronic alcoholic liver disease and alcoholic cirrhosis. Alcoholic hepatitis by itself does not lead to cirrhosis, but cirrhosis is more common in patients with long term alcohol consumption. Patients who drink alcohol to excess are also more often than others found to have hepatitis C. The combination of hepatitis C and alcohol consumption accelerates the development of cirrhosis in Western countries.
Drug induced hepatitis
A large number of drugs can cause hepatitis. The anti-diabetic drug troglitazone was withdrawn in 2000 for causing hepatitis. Other drugs associated with hepatitis:
• Halothane (a specific type of anesthetic gas)
• Methyldopa (antihypertensive)
• Minocycline (tetracycline anitbiotic)
• Isoniazid (INH), rifampicin, and pyrazinamide (tuberculosis-specific antibiotics)
• Phenytoin and valproic acid (antiepileptics)
• Zidovudine (antiretroviral i.e. against AIDS)
• Ketoconazole (antifungal)
• Nifedipine (antihypertensive)
• Ibuprofen and indometacin (NSAIDs)
• Amitriptyline (antidepressant)
• Amiodarone (antiarrhythmic)
• Nitrofurantoin (antibiotic)
• Hormonal contraceptives
• Allopurinol
• Azathioprine
• Some herbs and nutritional supplements
The clinical course of drug-induced hepatitis is quite variable, depending on the drug and the patient's tendency to react to the drug. For example, halothane hepatitis can range from mild to fatal as can INH-induced hepatitis. Hormonal contraception can cause structural changes in the liver. Amiodarone hepatitis can be untreatable since the long half life of the drug (up to 60 days) means that there is no effective way to stop exposure to the drug. Statins can cause elevations of liver function blood tests normally without indicating an underlying hepatitis. Lastly, human variability is such that any drug can be a cause of hepatitis.
Other toxins that cause hepatitis
Toxins and drugs can cause hepatitis:
• Amatoxin-containing mushrooms, including the Death Cap (Amanita phalloides), the Destroying Angel (Amanita ocreata), and some species of Galerina. A portion of a single mushroom can be enough to be lethal (10 mg or less of α-amanitin).
• White phosphorus, an industrial toxin.
• Paracetamol (acetaminophen in the United States) can cause hepatitis when taken in an overdose. The severity of liver damage can be limited by prompt administration of acetylcysteine.
• Carbon tetrachloride ("tetra", a dry cleaning agent), chloroform, and trichloroethylene, all chlorinated hydrocarbons, cause steatohepatitis (hepatitis with fatty liver).
Metabolic disorders
Some metabolic disorders cause different forms of hepatitis. Hemochromatosis (due to iron accumulation) and Wilson's disease (copper accumulation) can cause liver inflammation and necrosis.
See below for non-alcoholic steatohepatitis (NASH), effectively a consequence of metabolic syndrome.
Obstructive
"Obstructive jaundice" is the term used to describe jaundice due to obstruction of the bile duct (by gallstones or external obstruction by cancer). If longstanding it leads to destruction and inflammation of liver tissue.
Autoimmune
Anomalous presentation of human leukocyte antigen (HLA) class II on the surface of hepatocytes—possibly due to genetic predisposition or acute liver infection—causes a cell-mediated immune response against the body's own liver, resulting in autoimmune hepatitis.
Autoimmune hepatitis has an incidence of 1-2 per 100,000 per year, and a prevalence of 15-20/100,000. As with most other autoimmune diseases, it affects women much more often than men (8:1). Liver enzymes are elevated, as is bilirubin. Autoimmune hepatitis can progress to cirrhosis. Treatment is with steroids and disease-modifying antirheumatic drugs (DMARDs).
The diagnosis of autoimmune hepatitis is best achieved with a combination of clinical and laboratory findings. A number of specific antibodies found in the blood (antinuclear antibody (ANA), smooth muscle antibody (SMA), Liver/kidney microsomal antibody (LKM-1) and anti-mitochondrial antibody (AMA)) are of use, as is finding an increased Immunoglobulin G level. However, the diagnosis of autoimmune hepatitis always requires a liver biopsy. In complex cases a scoring system can be used to help determine if a patient has autoimmune hepatitis, which combines clinical and laboratory features of a given case.
Four subtypes are recognised, but the clinical utility of distinguishing subtypes is limited.
1. Positive ANA and SMA, raised immunoglobulin G (classic form, responds well to low dose steroids)
2. Positive LKM-1 (typically female children and teenagers; disease can be severe)
3. All antibodies negative, positive antibodies against soluble liver antigen (SLA)(now designated SLP/LP). This group behaves like group 1.
4. No autoantibodies detected (~13%)
Alpha 1-antitrypsin deficiency
In severe cases of alpha 1-antitrypsin deficiency (A1AD), the accumulated protein in the endoplasmic reticulum causes liver cell damage and inflammation.
Nonalcoholic steatohepatitis
Non-alcoholic steatohepatitis (NASH) is a type of hepatitis which resembles alcoholic hepatitis on liver biopsy (fat droplets, inflammatory cells, but usually no Mallory's hyalin) but occurs in patients who have no known history of alcohol abuse. NASH is more common in women and the most common cause is obesity or the metabolic syndrome. A related but less serious condition is called "fatty liver" (steatosis hepatis), which occurs in up to 80% of all clinically obese people. A liver biopsy for fatty liver shows fat droplets throughout the liver, but no signs of inflammation or Mallory's hyalin.
The diagnosis depends on history, physical exam, blood tests, radiological imaging and sometimes a liver biopsy. The initial evaluation to identify the presence of fatty infiltration of the liver is radiologic imaging including ultrasound, computed tomographic imaging, or magnetic resonance imaging. However, radiologic imaging cannot readily identify inflammation in the liver. Therefore, the differentiation between steatosis and NASH often requires a liver biopsy. It can also be difficult to distinguish NASH from alcoholic hepatitis when the patient has a history of alcohol consumption. Sometimes in such cases a trial of abstinence from alcohol along with follow -up blood tests and a repeat liver biopsy are required.
NASH is becoming recognized as the most important cause of liver disease second only to Hepatitis C in numbers of patients going on to cirrhosis.
Hepatitis awareness
World Hepatitis Awareness Day is an annual event organised by several mondial hepatitis advocacy groups to raise awareness of infectious hepatitis and demand action to curb the spread of the disease and treat people who are infected.

Dr Abdul Aziz Awan

HEPATITIS
The word hepatitis simply means an inflammation of the liver without pinpointing a specific cause. Someone with hepatitis may:
• have one of several disorders, including viral or bacterial infection of the liver
• have a liver injury caused by a toxin (poison)
• have liver damage caused by interruption of the organ's normal blood supply
• be experiencing an attack by his or her own immune system through an autoimmune disorder
• have experienced trauma to the abdomen in the area of the liver
Hepatitis is most commonly caused by one of three viruses:
• the hepatitis A virus
• the hepatitis B virus
• the hepatitis C virus
In
some rare cases, the Epstein Barr Virus (which causes mononucleosis)
can also result in hepatitis because it can cause inflammation of the
liver. Other viruses and bacteria that also can cause hepatitis include
hepatitis D and E, varicella (chickenpox), and cytomegalovirus (CMV).
Hepatitis A
In
children, the most common form of hepatitis is hepatitis A (also called
infectious hepatitis). This form is caused by the hepatitis A virus
(HAV), which lives in the stools (feces or poop) of infected
individuals. Infected stool can be present in small amounts in food and
on objects (from doorknobs to diapers).
The hepatitis A virus is spread:
•
when someone ingests anything that's contaminated with HAV-infected
stool (this makes it easy for the virus to spread in overcrowded,
unsanitary living conditions)
• in water, milk, and foods, especially in shellfish
Because
hepatitis A can be a mild infection, particularly in children, it's
possible for some people to be unaware that they have had the illness.
In fact, although medical tests show that about 40% of urban Americans
have had hepatitis A, only about 5% recall being sick. Although the
hepatitis A virus can cause prolonged illness up to 6 months, it
typically only causes short-lived illnesses and it does not cause
chronic liver disease.
Hepatitis B
Hepatitis
B (also called serum hepatitis) is caused by the hepatitis B virus
(HBV). HBV can cause a wide spectrum of symptoms ranging from general
malaise to chronic liver disease that can lead to liver cancer.
The hepatitis B virus spreads through:
• infected body fluids, such as blood, saliva, semen, vaginal fluids, tears, and urine
• a contaminated blood transfusion (uncommon in the United States)
• shared contaminated needles or syringes for injecting drugs
• sexual activity with an HBV-infected person
• transmission from HBV-infected mothers to their newborn babies
Hepatitis C
The
hepatitis C virus (HCV) is spread by direct contact with an infected
person's blood. The symptoms of the hepatitis C virus can be very
similar to those of the hepatitis A and B viruses. However, infection
with the hepatitis C virus can lead to chronic liver disease and is the
leading reason for liver transplant in the United States.
The hepatitis C virus can be spread by:
• sharing drug needles
• getting a tattoo or body piercing with unsterilized tools
•
blood transfusions (especially ones that occurred before 1992; since
then the U.S. blood supply has been routinely screened for the disease)

• transmission from mother to newborn
• sexual contact (although this is less common)
Hepatitis
C is also a common threat in kidney dialysis centers. Rarely, people
living with an infected person can contract the disease by sharing
items that might contain that person's blood, such as razors or
toothbrushes.
Diagnosis
All of these viral hepatitis conditions can be diagnosed and followed through the use of readily available blood tests.
Signs and Symptoms
Hepatitis, in its early stages, may cause flu-like symptoms, including:
• malaise (a general ill feeling)
• fever
• muscle aches
• loss of appetite
• nausea
• vomiting
• diarrhea
• jaundice (a yellowing of the skin and whites of the eyes)
But
some people with hepatitis may have no symptoms at all and may not even
know they're infected. Children with hepatitis A, for example, usually
have mild symptoms or have no symptoms.
If hepatitis progresses, its
symptoms begin to point to the liver as the source of illness.
Chemicals normally secreted by the liver begin to build up in the
blood, which causes:
• jaundice
• foul breath
• a bitter taste in the mouth
• dark or "tea-colored" urine
• white, light, or "clay-colored" stools
There
can also be abdominal pain, which may be centered below the right ribs
(over a tender, swollen liver) or below the left ribs (over a tender
spleen).
Contagiousness
Hepatitis A, hepatitis B, and hepatitis C are all contagious.
The
hepatitis A virus can be spread in contaminated food or water, as well
as in unsanitary conditions in child-care facilities or schools.
Toilets and sinks used by an infected person should be cleaned with
antiseptic cleansers. People who live with or care for someone with
hepatitis should wash their hands after contact with the infected
person. In addition, when traveling to countries where hepatitis A is
prevalent, your child should be vaccinated with at least two doses of
the hepatitis A vaccine.
The hepatitis B virus can be found in
virtually all body fluids, though its main routes of infection are
through sexual contact, contaminated blood transfusions, and shared
needles for drug injections. Household contact with adults with
hepatitis B can put people at risk for contracting hepatitis. But
frequent hand washing and good hygiene practices can reduce this risk.
All children in the United States are routinely vaccinated against
hepatitis B at birth and use of the hepatitis B vaccine can greatly
decrease the incidence of this infection. Ask your child's doctor about
this vaccine. Even adults can be vaccinated if they feel they're at
risk.
The hepatitis C virus can be spread through shared drug
needles, contaminated blood products, and, less commonly, through
sexual contact. Although hepatitis C can be spread from a mother to her
fetus during pregnancy, the risk of passing hepatitis C to the fetus
isn't very high (about 5%). If you're pregnant, contact your doctor if
you think you may have been exposed to hepatitis C.
Over the past
several years, improved medical technology has almost eliminated the
risk of catching hepatitis from contaminated blood products and blood
transfusions. But as tattoos and acupuncture have become more popular,
the risk of developing hepatitis from improperly sterilized equipment
used in these procedures has increased. Shared needles in drug use and
shared straws in cocaine use are two very common ways for hepatitis C
to spread.
Prevention
In general, to prevent viral hepatitis you should:
• Follow good hygiene and avoid crowded, unhealthy living conditions.
•
Take extra care, particularly when drinking and swimming, if you travel
to areas of the world where sanitation is poor and water quality is
uncertain.
• Never eat shellfish from waters contaminated by sewage.
• Remind everyone in your family to wash their hands thoroughly after using the toilet and before eating.
•
Use antiseptic cleansers to clean any toilet, sink, potty-chair, or
bedpan used by someone in the family who develops hepatitis.
Because
contaminated needles and syringes are a major source of hepatitis
infection, it's a good idea to encourage drug awareness programs in
your community and schools. At home, speak to your child frankly and
frequently about the dangers of drug use. It's also important to
encourage abstinence and safe sex for teens, in order to eliminate
their risk of hepatitis infection through sexual contact.
A hepatitis A vaccine is available, and is especially recommended for those who:
• travel abroad
• have other forms of liver disease
• have many sexual partners
• are in high-risk occupations, such as health-care and child-care personnel
If
you're planning to travel abroad, consult your doctor in advance so you
and your family have enough time to complete the required
immunizations. The vaccine is especially useful for staff of child-care
facilities or schools where they may be at risk of exposure.
There's also a hepatitis B vaccine, which should be given to both children and adults as part of routine immunization.
Unfortunately,
there's no vaccine for hepatitis C - animal studies indicate that it
may not be possible because the virus doesn't cause the kind of
response that would be needed for a vaccine to be successful.
Duration
For
viral hepatitis, the incubation period (the time it takes for a person
to become infected after being exposed) varies depending on which
hepatitis virus causes the disease:
• For hepatitis A, the incubation period is 2 to 6 weeks.
• For hepatitis B, the incubation period is between 4 and 20 weeks.
• For hepatitis C, it's estimated that the incubation period is 2 to 26 weeks.
Hepatitis
A is usually active for a short period of time and once a person
recovers, he or she can no longer pass the virus to other people. It's
practically unheard for people to become chronic carriers of hepatitis
A. Almost all previously healthy persons who develop hepatitis A will
completely recover from their illness in a few weeks or months without
long-term complications.
With hepatitis B, 85% to 90% of patients recover from their illness completely within 6 months, without long-term complications.
However,
75% to 85% of those who are infected with hepatitis C do not recover
completely and are more likely to continue to have a long-term
infection. People with hepatitis B (the percentage who don't recover
completely) or hepatitis C who continue to be infected can go on to
develop chronic hepatitis and cirrhosis of the liver (the chronic
degeneration and disruption of the structure of the liver). Some people
with hepatitis B or C may also become lifelong carriers of these
viruses and can spread them to other people.
Treatment
When
symptoms are severe or laboratory tests show liver damage, it's
sometimes necessary for hepatitis to be treated in the hospital. Here's
a quick look at the treatments available for the various hepatitis
viruses:
• There are no medications used to treat hepatitis A because it's a short-term infection that goes away on its own.
•
Hepatitis B can sometimes be treated using medications. Four drugs are
approved for use in adults with hepatitis B, but there hasn't been
enough research yet on their use in children. However, you can talk to
your child's doctor about a drug that may be available in some centers
on a research basis for children.
• The treatment of hepatitis C
has improved significantly with the use of two medications, only one of
which is approved for use in children. Another more effective drug
isn't approved for children yet but is available for kids in some
centers on a research basis. In those adults who've just been infected
with hepatitis C (by accidental needle injury, for example),
combination therapy with the two drugs is the treatment of choice and
can eliminate the virus in about 50% of the people infected.
Children
with mild hepatitis may be treated at home. Except for using the
bathroom, they should rest in bed until the fever and jaundice are gone
and their appetite is normal. Kids with a lack of appetite should try
smaller, more frequent meals and fluids that are high in calories (like
milkshakes). They should also eat healthy foods rich in protein and
carbohydrates and drink plenty of water.
When to Call Your Child's Doctor
Call the doctor if your child:
• has symptoms of hepatitis
• attends a school or child-care facility where someone has hepatitis
• has been exposed to a friend or relative with the illness
If
you have an older child who volunteers at a first-aid station,
hospital, or nursing home, be sure that he or she is aware of proper
safety procedures for preventing contact with blood or body fluids. You
may also want to have your child immunized against the hepatitis B
virus. Call your child's doctor if you believe your child may have been
exposed to a patient with hepatitis.
If you already know your child
has hepatitis, call your child's doctor if you notice any of the
following symptoms, which may be signs of their liver condition
worsening:
• confusion or extreme drowsiness
• skin rash
• itching
Also,
monitor your child's appetite and digestive functions, and call the
doctor if your child's appetite decreases, or if nausea, vomiting,
diarrhea, or jaundice increase.

Dr Abdul Aziz Awan