What Is It?
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.
Viruses are the most common cause of chronic hepatitis. Viruses that cause hepatitis include:
- Hepatitis B and C. These viruses cause two-thirds of all cases of chronic hepatitis. People infected with hepatitis C have the greatest risk of developing chronic hepatitis. Both of these viruses usually begin with mild symptoms. Over time, perhaps a decade or more, both 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 Sjogren'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 medications also can lead to chronic hepatitis. These medications include:
- Isoniazid (Laniazid, Nydrazid) for tuberculosis
- Methyldopa (Aldomet, Amodopa) for high blood pressure (hypertension)
- Phenytoin (Dilantin) for seizure disorders
- Macrodantin 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.
Some rare, inherited metabolic disorders also can lead to chronic hepatitis. They include:
- Wilson's disease, a condition in which the body has difficulty metabolizing copper
- Hemochromatosis, a condition of excessive iron deposits in many of the body organs that can lead to chronic hepatitis and cirrhosis
- Sarcoidosis, an inflammatory disease that can affect the liver
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
- Aching joints
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
- Confusion that may progress to coma
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 or liver failure, you will undergo 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 amount of scarring and the extent and type of liver damage. This information helps to determine the best treatment and to assess your chances 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.
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.
Usually, chronic hepatitis is 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 is to protect yourself against the hepatitis B and C viruses. Vaccinations for hepatitis B are recommended for health care workers and people traveling to certain countries. 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.
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.
There is no way to prevent autoimmune chronic hepatitis because the cause is unknown.
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.
The goals of treatment 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 hepatitis 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. Treatment isn't recommended for everyone because of the side effects and the risk that active infection may return.
Viral hepatitis is treated with antiviral medications, such as interferon alpha (Roferon-A, Intron A), ribavirin (Copegus, Rebetol, Virazole) for hepatitis C and lamivudine (Epivir), adefovir, tenofovir, entecavir for hepatitis B. Clinical trials are under way to determine the best combination of medications, dosage and length of treatment to improve response and lower the chance that the condition will return.
Common side effects with interferon include:
- Muscle aches
- Nausea and vomiting
- Weight loss
- Irritability and depression
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 serious infection 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.
Supportive care is key in coping 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.
In its most severe stages, 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.
Anyone with cirrhosis also has an increased risk of developing liver cancer and must be screened regularly with a blood test and ultrasound examination of the liver.
The risk of developing cirrhosis depends on the cause of the hepatitis and the degree of inflammation. Symptoms and signs of cirrhosis may develop in 15% to 30% of people who have had chronic hepatitis infection for more than 20 years.
American College of Gastroenterology (ACG)
P.O. Box 342260
Bethesda, MD 20827-2260
American Autoimmune Related Diseases Association (AARDA)
22100 Gratiot Ave.
East Detroit, MI 48021
American Liver Foundation
75 Maiden Lane
New York, NY 10038
National Institute of Diabetes & Digestive & Kidney Disorders
Office of Communications and Public Liaison
Building 31, Room 9A06
31 Center Drive, MSC 2560
Bethesda, MD 20892-2560