Chronic Hepatitis

Chronic hepatitis is inflammation of the liver that lasts at least 6 months.

• Common causes are hepatitis B and C viruses and drugs.

• Many people have no symptoms until the liver has become severely scarred.
• Chronic hepatitis can result in cirrhosis, with an enlarged spleen, fluid accumulation in
the abdominal cavity, and deterioration of brain function.
• A biopsy is done to confirm the diagnosis.
• Drugs, such as antiviral drugs or corticosteroids, may be used, and for advanced disease,
liver transplantation may be needed.

Chronic hepatitis, although much less common than acute hepatitis, can persist for years, even
decades. In most people, it is quite mild and does not cause significant liver damage. However,
in some people, continued inflammation slowly damages the liver, eventually resulting in
cirrhosis (severe scarring of the liver), liver failure, and sometimes liver cancer.

Causes

Chronic hepatitis is usually caused by one of the hepatitis viruses (see Hepatitis:Introduction ).
Hepatitis C virus causes about 60 to 70% of cases, and at least 75% of acute hepatitis C cases
become chronic. About 5 to 7% of hepatitis B cases, sometimes with hepatitis D co-infection,
become chronic. Hepatitis A and E viruses do not cause chronic hepatitis.

Certain drugs can cause chronic hepatitis, particularly when they are taken for a long time. They
include isoniazid, methyldopa, nitrofurantoin Some Trade Names
FURADANTINMACRODANTIN
, and, rarely, acetaminophen Some Trade Names
TYLENOL
. Wilson's disease, a rare hereditary disorder involving abnormal retention of copper in the liver
(see Causes of Hyponatremia ), may cause chronic hepatitis in children and young adults. Other
causes include alcoholic hepatitis, fatty liver not due to alcohol use (nonalcoholic
steatohepatitis), and alpha1-antitrypsin deficiency (a hereditary disorder).

No one knows exactly why a particular virus or drug causes chronic hepatitis in some people but
not in others or why the degree of severity varies. In many people with chronic hepatitis, no
obvious cause can be found. In some of these people, the chronic inflammation resembles
inflammation caused by the body attacking its own tissues (an autoimmune reaction (see
Autoimmune Disorders), but this connection has not been proven. This type of
inflammation called autoimmune hepatitis, is more common among women than
men.

Did You Know...

• Chronic hepatitis may not be
diagnosed until after cirrhosis
develops.

Symptoms
In about two thirds of people, chronic hepatitis develops gradually without causing any obvious
symptoms until cirrhosis occurs. In the remaining one third, it develops after a bout of acute viral
hepatitis that persists or returns (often several weeks later).

Symptoms often include a vague feeling of illness (malaise), poor appetite, and fatigue.
Sometimes affected people also have a low-grade fever and some upper abdominal discomfort.
Jaundice is rare. Complications of chronic liver disease and cirrhosis may eventually develop.
They can include an enlarged spleen, spiderlike blood vessels in the skin, redness of the palms,
and accumulation of fluid in the abdominal cavity (ascites—see Manifestations of Liver Disease:
Ascites). Liver malfunction may lead to deterioration of brain function (hepatic encephalopathy),
particularly in people with cirrhosis due to hepatitis C (see Manifestations of Liver Disease:
Hepatic Encephalopathy).

Autoimmune hepatitis may cause other symptoms that can involve virtually any body system,
especially in young women. Such symptoms include acne, cessation of menstrual periods, joint
pain, lung scarring, inflammation of the thyroid gland and kidneys, and anemia.

In many people, chronic hepatitis does not progress for years. In others, it gradually worsens.
The outlook depends partly on which virus is the cause:

• Chronic hepatitis C leads to cirrhosis, which develops over a period of years, in about 15
to 25% of people. The risk of liver cancer is increased but only if cirrhosis is present.
• Chronic hepatitis B tends to worsen, sometimes rapidly, and increases the risk of liver
cancer.
• Chronic co-infection with hepatitis B and D causes cirrhosis in up to 70%.
• Autoimmune hepatitis can be effectively treated in most people, but some develop
cirrhosis, with or without liver failure.
• Chronic hepatitis caused by a drug may completely resolve once the drug is stopped.

Diagnosis

Doctors may suspect hepatitis C when people have typical symptoms, when blood tests to
evaluate liver function are abnormal, or when people have had hepatitis C before. Blood tests are
done and may help establish the diagnosis, identify the cause, and determine the severity of liver
damage. However, a liver biopsy (see Diagnostic Tests for Liver, Gallbladder, and Biliary
Disorders: Biopsy of the Liver) is essential for a definite diagnosis. The liver biopsy also enables
a doctor to determine how severe the inflammation is and whether any scarring or cirrhosis has
developed. The biopsy may help identify the cause of hepatitis. Occasionally, a biopsy needs to
be done more than once.

If people have chronic hepatitis B, ultrasonography and blood tests to measure alpha–fetoprotein
levels are done annually to screen for liver cancer. Levels of alpha–fetoprotein—a protein
normally produced by immature liver cells in fetuses—usually increase when liver cancer is
present. People with chronic hepatitis C are screened similarly, but only if they have cirrhosis.

Treatment

If a drug is the cause, the drug is stopped. If another disorder is the cause, it is treated.

Hepatitis B and C: People with progressive chronic hepatitis B or C are usually given antiviral
drugs. For hepatitis B, entecavir Some Trade Names
BARACLUDE
, adefovir Some Trade Names
HEPSERA
, or lamivudine is usually used. These drugs are taken by mouth, as is telbivudine Some Trade
Names
TYZEKA
, a new drug for which little information is available. Interferon-alpha or pegylated interferon-
alpha, given by injection under the skin, may be used instead of an oral drug. Hepatitis B tends to
recur once drug treatment is stopped and may be even more severe. Thus, an antiviral drug may
need to be taken indefinitely.

For hepatitis C, pegylated interferon-alpha plus ribavirin Some Trade Names

VIRAZOLE
is most effective. This combination may stop the inflammation. After taking these drugs for 6
months to 1 year, 45 to 75% of people improve and have no further problems.

Antiviral drugs used to treat chronic hepatitis commonly cause side effects. Lamivudine may
have fewer side effects than the others. These drugs should not be taken by people who have
certain conditions:

• Advanced cirrhosis due to hepatitis B

• A transplanted organ
• A reduced number of blood cells (cytopenia), such as red blood cells (anemia)
• Substance abuse.

If family members and close contacts of people with chronic hepatitis B have not been
vaccinated, they should be. They are also given hepatitis B immune globulin. Such measures are
not necessary for chronic hepatitis C.

Autoimmune Hepatitis: Usually, corticosteroids (such as prednisone) are used, sometimes with
azathioprine Some Trade Names
IMURAN
, a drug used to suppress the immune system. These drugs suppress the inflammation, relieve
symptoms, and improve long-term survival. Nevertheless, scarring in the liver may gradually
worsen. Stopping these drugs usually leads to recurrence of the inflammation, so most people
have to take the drugs indefinitely.

Complications: Regardless of the cause or type of chronic hepatitis, complications require

treatment. For example, treating ascites involves restriction of salt consumption, bed rest, and
sometimes drugs. If brain function deteriorates, eliminating protein from the diet can help.

Liver Transplantation: Transplantation (see Transplantation: Liver Transplantation) may be

considered for people with severe liver failure. However, in people who have hepatitis B or
hepatitis C, the virus tends to infect the transplanted liver. In people with hepatitis B, the virus
tends to severely damage the transplanted liver over months or a few years, but taking
lamivudine may improve the outcome. In people with hepatitis C, the virus virtually always
recurs in the transplanted liver, but the infection is usually so mild that people are likely to
survive for many years.