hepatitis

Hepatitis refers to an inflammatory condition of the liver. Its commonly

caused by a viral infection, but there are other possible causes of
hepatitis. These include autoimmune hepatitis and hepatitis that occurs as
a secondary result of medications, drugs, toxins, and
alcohol. Autoimmune hepatitis is a disease that occurs when your body
makes antibodies against your liver tissue.

Your liver is located in the right upper area of your abdomen. It performs
many critical functions that affect metabolism throughout your body,
including:

bile production, which is essential to digestion

filtering of toxins from your body
excretion of bilirubin (a product of broken-down red blood cells),
cholesterol, hormones, and drugs
breakdown of carbohydrates, fats, and proteins
activation of enzymes, which are specialized proteins essential to
body functions
storage of glycogen (a form of sugar), minerals, and vitamins (A,
D, E, and K)
synthesis of blood proteins, such as albumin
synthesis of clotting factors

According to the Centers for Disease Control and Prevention (CDC),

approximately 4.4 million Americans are currently living with chronic
hepatitis B and C. Many more people dont even know that they have
hepatitis.

Treatment options vary depending on which type of hepatitis you have.

You can prevent some forms of hepatitis through immunizations and
lifestyle precautions.

TYPES of viral hepatitis

Viral infections of the liver that are classified as hepatitis include

hepatitis A, B, C, D, and E. A different virus is responsible for each type
of virally transmitted hepatitis.
Hepatitis A is always an acute, short-term disease, while hepatitis B, C,
and D are most likely to become ongoing and chronic. Hepatitis E is
usually acute but can be particularly dangerous in pregnant women.

Hepatitis A

Hepatitis A is caused by an infection with the hepatitis A virus (HAV).

This type of hepatitis is most commonly transmitted by consuming food
or water contaminated by feces from a person infected with hepatitis A.

Hepatitis B

Hepatitis B is transmitted through contact with infectious body fluids,

such as blood, vaginal secretions, or semen, containing the hepatitis B
virus (HBV). Injection drug use, having sex with an infected partner, or
sharing razors with an infected person increase your risk of getting
hepatitis B.

Its estimated by the CDC that 1.2 million people in the United States and
350 million people worldwide live with this chronic disease.

Hepatitis C

Hepatitis C comes from the hepatitis C virus (HCV). Hepatitis C is

transmitted through direct contact with infected body fluids, typically
through injection drug use and sexual contact. HCV is among the most
common bloodborne viral infections in the United States. Approximately
2.7 to 3.9 million Americans are currently living with a chronic form of
this infection.

Hepatitis D

Also called delta hepatitis, hepatitis D is a serious liver disease caused by

the hepatitis D virus (HDV). HDV is contracted through direct contact
with infected blood. Hepatitis D is a rare form of hepatitis that only
occurs in conjunction with hepatitis B infection. The hepatitis D virus
cant multiply without the presence of hepatitis B. Its very uncommon in
the United States.

Hepatitis E
Hepatitis E is a waterborne disease caused by the hepatitis E virus (HEV).
Hepatitis E is mainly found in areas with poor sanitation and typically
results from ingesting fecal matter that contaminates the water supply.
This disease is uncommon in the United States. However, cases of
hepatitis E have been reported in the Middle East, Asia, Central America,
and Africa, according to the CDC.

Causes of noninfectious hepatitis

Alcohol and other toxins

Excessive alcohol consumption can cause liver damage and

inflammation. This is sometimes referred to as alcoholic hepatitis. The
alcohol directly injures the cells of your liver. Over time, it can cause
permanent damage and lead to liver failure and cirrhosis, a thickening and
scarring of the liver.

Other toxic causes of hepatitis include overuse or overdose of

medications and exposure to poisons.

Autoimmune system response

In some cases, the immune system mistakes the liver as a harmful object
and begins to attack it. It causes ongoing inflammation that can range
from mild to severe, often hindering liver function. Its three times more
common in women than in men.

Acute hepatitis

Viral Hepatitis: Hepatitis A to E (more than 95% of viral

cause), Herpes simplex, Cytomegalovirus, Epstein-Barr, yellow
fever virus, adenoviruses.
Non viral infection: toxoplasma, Leptospira, Q fever,[2] rocky
mountain spotted fever[3]
Alcohol
Toxins: Amanita toxin in mushrooms, Carbon tetrachloride,
asafetida
 Drugs: Paracetamol, amoxycillin, anti tuberculosis
medicines, minocycline and many others (see longer list
below).
Circulatory insufficiency
Pregnancy
Auto immune conditions e.g. Systemic Lupus Erythematosus
(SLE)
Metabolic diseases e.g. Wilson's disease
Chronic hepatitis

Viral Hepatitis: Hepatitis B with or without hepatitis D,

Hepatitis C (Hepatitis A and E do not lead to chronic disease)
Autoimmune: Autoimmune hepatitis
Alcohol
Drugs: methyl-dopa, nitrofurantoin, isoniazide, ketoconazole
Non-alcoholic steatohepatitis
Heredity: Wilson's disease, alpha 1-antitrypsin deficiency
Primary biliary cirrhosis and primary sclerosing cholangitis
occasionally mimic chronic hepatitis

symptoms of hepatitis

If you have infectious forms of hepatitis that are chronic, like hepatitis B
and C, you may not have symptoms in the beginning. Symptoms may not
occur until the damage affects liver function.

Signs and symptoms of acute hepatitis appear quickly. They include:

fatigue
flu-like symptoms
dark urine
pale stool
abdominal pain
 loss of appetite
unexplained weight loss
yellow skin and eyes, which may be signs of jaundice

Chronic hepatitis develops slowly, so these signs and symptoms may be

too subtle to notice.

DIAGNOSIS

History and physical exam

To diagnose hepatitis, first your doctor will take your history to determine
any risk factors you may have for infectious or noninfectious hepatitis.

During a physical examination, your doctor may press down gently on

your abdomen to see if theres pain or tenderness. Your doctor may also
feel to see if your liver is enlarged. If your skin or eyes are yellow, your
doctor will note this during the exam.

Liver function tests

Liver function tests use blood samples to determine how efficiently your
liver works. Abnormal results of these tests may be the first indication
that there is a problem, especially if you dont show any signs on a
physical exam of liver disease. High liver enzyme levels may indicate
that your liver is stressed, damaged, or not functioning properly.

Other blood tests

If your liver function tests are abnormal, your doctor will likely order
other bloodtests to detect the source of the problem. These tests can check
for the viruses that cause hepatitis. They can also be used to check for
antibodies that are common in conditions like autoimmune hepatitis.

Ultrasound

An abdominal ultrasound uses ultrasound waves to create an image of the

organs within your abdomen. This test allows your doctor to take a close
at your liver and nearby organs. It can reveal:

fluid in your abdomen

 liver damage or enlargement
liver tumors
abnormalities of your gallbladder

Sometimes the pancreas shows up on ultrasound images as well. This can

be a useful test in determining the cause of your abnormal liver function.

Liver biopsy

A liver biopsy is an invasive procedure that involves your doctor taking a

sample of tissue from your liver. It can be done through your skin with a
needle and doesnt require surgery. Typically, an ultrasound is used to
guide your doctor when taking the biopsy sample.

This test allows your doctor to determine how infection or inflammation

has affected your liver. It can also be used to sample any areas in your
liver that appear abnormal.

TREATMENT

Treatment options are determined by which type of hepatitis you have

and whether the infection is acute or chronic.

Hepatitis A

Hepatitis A usually doesnt require treatment because its a short-term

illness. Bed rest may be recommended if symptoms cause a great deal of
discomfort. If you experience vomiting or diarrhea, follow your doctors
orders for hydration and nutrition.

The hepatitis A vaccine is available to prevent this infection. Most

children begin vaccination between ages 12 and 18 months. Its a series
of two vaccines. Vaccination for hepatitis A is also available for adults
and can be combined with the hepatitis B vaccine.

Hepatitis B

Acute hepatitis B doesnt require specific treatment.

Chronic hepatitis B is treated with antiviral medications. This form of

treatment can be costly because it must be continued for several months
or years. Treatment for chronic hepatitis B also requires regular medical
evaluations and monitoring to determine if the virus is responding to
treatment.

Hepatitis B can be prevented with vaccination. The CDC recommends

hepatitis B vaccinations for all newborns. The series of three vaccines is
typically completed over the first six months of childhood. The vaccine is
also recommended for all healthcare and medical personnel.

Hepatitis C

Antiviral medications are used to treat both acute and chronic forms of
hepatitis C. People who develop chronic hepatitis C are typically treated
with a combination of antiviral drug therapies. They may also need
further testing to determine the best form of treatment.

People who develop cirrhosis (scarring of the liver) or liver disease as a

result of chronic hepatitis C may be candidates for a liver transplant.

Currently, there is no vaccination for hepatitis C.

Hepatitis D

No antiviral medications exist for the treatment of hepatitis D at this time.

According to a 2013 study, a drug called alpha interferon can be used to
treat hepatitis D, but it only shows improvement in about 25 to 30 percent
of people.

Hepatitis D can be prevented by getting the vaccination for hepatitis B, as

infection with hepatitis B is necessary for hepatitis D to develop.

Hepatitis E

Currently, no specific medical therapies are available to treat hepatitis E.

Because the infection is often acute, it typically resolves on its own.
People with this type of infection are often advised to get adequate rest,
drink plenty of fluids, get enough nutrients, and avoid alcohol. However,
pregnant women who develop this infection require close monitoring and
care.

Autoimmune hepatitis
Corticosteroids, like prednisone or budesonide, are extremely important
in the early treatment of autoimmune hepatitis. Theyre effective in
about 80 percent of people with this condition.

Azothioprine (Imuran), a drug that suppresses the immune system, is

often included in treatment. It can be used with or without steroids.

Other immune suppressing drugs like mycophenolate (CellCept),

tacrolimus (Prograf) and cyclosporine (Neoral) can also be used as
alternatives to azathioprine for treatment.

PREVENTION

Hygiene

Practicing good hygiene is one key way to avoid contracting hepatitis A

and E. If youre traveling to a developing country, you should avoid:

local water
ice
raw or undercooked shellfish and oysters
raw fruit and vegetables

Hepatitis B, C, and D contracted through contaminated blood can be

prevented by:

not sharing drug needles

not sharing razors
not using someone elses toothbrush
not touching spilled blood

Hepatitis B and C can also be contracted through sexual intercourse and

intimate sexual contact. Practicing safe sex by using condoms and dental
dams can help decrease the risk of infection.

Vaccines

The use of vaccines is an important key to preventing

hepatitis. Vaccinations are available to prevent the development of
hepatitis A and B. Experts are currently developing vaccines against
hepatitis C. A vaccination for hepatitis E exists in China, but it isnt
available in the United States.
Complications of hepatitis

Chronic hepatitis B or C can often lead to more serious health problems.

Because the virus affects the liver, people with chronic hepatitis B or C
are at risk for:

chronic liver disease

cirrhosis
liver cancer

When your liver stops functioning normally, liver failure can occur.
Complications of liver failure include:

bleeding disorders
a buildup of fluid in your abdomen, known as ascites
increased blood pressure in portal veins that enter your liver,
known as portal hypertension
kidney failure
hepatic encephalopathy, which can involve fatigue, memory loss,
and diminished mental abilities due to the buildup of toxins, like
ammonia, that affect brain function
hepatocellular carcinoma, which is a form of liver cancer
death

People with chronic hepatitis B and C are encouraged to avoid alcohol

because it can accelerate liver disease and failure. Certain supplements
and medications can also affect liver function. If you have chronic
hepatitis B or C, check with your doctor before taking any new
medications.

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:
Allopurinol
Amitriptyline (antidepressant)
Amiodarone (antiarrhythmic)
Azathioprine[11][12]
Halothane (a specific type of anesthetic gas)
 Hormonal contraceptives
Ibuprofen and indomethacin (NSAIDs)
Isoniazid (INH), rifampicin, and pyrazinamide (tuberculosis-
specific antibiotics)
Ketoconazole (antifungal)
Methyldopa (antihypertensive)
Minocycline (tetracycline antibiotic)
Nifedipine (antihypertensive)
Nitrofurantoin (antibiotic)
Phenytoin and valproic acid (antiepileptics)
Zidovudine (antiretroviral i.e. against HIV)
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 -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).
Cylindrospermopsin, a toxin from the cyanobacterium
Cylindrospermopsis raciborskii and other cyanobacteria.
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 hepatocytespossibly due to genetic predisposition or
acute liver infectioncauses 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 hyaline) 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.