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Chronic Hepatitis

Chronic hepatitis is defined as inflammation of the liver lasting for more than six months. It can be caused by viruses, steatosis, alcohol, autoimmune diseases, hemochromatosis, alpha-1-antitrypsin deficiency and long-standing use of drugs like isoniazid, methyldopa, and nitrofurantoin). A majority of the patients have elevated liver enzymes without symptoms. A liver biopsy is a gold standard for diagnosis, prognosis, and management of the condition.


Presentation

Chronic hepatitis is a condition characterized by inflammation of the liver parenchyma lasting for more than six months. It has variable clinical features ranging from no symptoms to fulminant liver failure irrespective of the cause of chronic hepatitis. Several viruses (hepatitis B, C, D, and E ) are known to cause chronic active hepatitis with progression to cirrhosis [1] [2] as well as hepatocellular carcinoma. Chronic hepatitis develops over several years [1]. Other causes of chronic hepatitis include autoimmune hepatitis, drugs like isoniazid, nitrofurantoin and methyldopa (long-standing use), alcohol, non-alcoholic steatohepatitis, deficiency of alpha -1-antitrypsin, Wilson's disease, and hemochromatosis.

Non-specific symptoms of anorexia, easy fatigability, malaise with low-grade fever and upper quadrant abdominal discomfort may be seen in cases of chronic hepatitis although, many patients are asymptomatic and diagnosed incidentally due to elevated liver enzymes. In advanced stages of chronic hepatitis, features of cirrhosis like hepatosplenomegaly, palmar erythema, parotid enlargement, spider nevi, gynecomastia and even ascites, portal hypertension and hepatic encephalopathy may be present. Cholestasis can produce symptoms of jaundice, acholic stools, pruritus, and steatorrhoea. In women with autoimmune chronic hepatitis, features of other organ involvement such as arthralgias, menstrual irregularities, ulcerative colitis, thyroiditis, pulmonary fibrosis, nephritis and hemolytic anemia are seen. Extra-hepatic manifestation like lichen planus, vasculitis, porphyria cutanea tarda, glomerulonephritis, cryoglobulinemia and even lymphomas are noted in chronic hepatitis secondary to hepatitis C while ataxia with other neurological manifestation has been reported in chronic hepatitis E [3] [4].

Pain
  • OUTCOMES: Positive outcome by medication and operation demonstrates that his phosphorus and serum calcium levels were maintained within normal range and pain in the right thigh region was improved from visual analogue pain score (VAS) 7 before surgery[ncbi.nlm.nih.gov]
  • […] patients.Here the authors report a case of a 40 year-old male, with a CHB monoinfection, that, three years after TDF therapy, developed a progressive chronic kidney disease with a serious hypophosphatemia and a secondary osteomalacia that was manifested by bone pain[ncbi.nlm.nih.gov]
  • RESULTS: The most prevalent problems related to HRQOL were anxiety/depression and pain/discomfort.[ncbi.nlm.nih.gov]
  • Tell your health care provider right away if you have stomach area pain that may be a symptom of this type of blood clot New or worsened cataracts (a clouding of the lens in the eye).[us.promacta.com]
  • Dengue can provoke alterations in hepatic functions and typical symptoms of acute hepatitis, such as pain in the right hypochondrium, hepatomegaly, jaundice and elevated transaminase levels.[scielo.br]
Fatigue
  • Except for reduced motivation other dimensions of fatigue were significantly higher among those with CHB compared to healthy controls (p CONCLUSIONS: Poor HRQOL and fatigue are widespread among patients with CHB.[ncbi.nlm.nih.gov]
  • Symptoms can include: fatigue muscle aches loss of appetite Most symptoms of chronic hepatitis C don’t appear until cirrhosis develops and the liver begins to fail.[healthline.com]
  • The resolution of liver test abnormalities and symptoms of fatigue after stopping nitrofurantoin supported the diagnosis of drug induced liver disease.[livertox.nih.gov]
  • People with symptoms most commonly complain of fatigue. Fatigue worsens throughout the day and may even be debilitating.[drugs.com]
Chronic Fatigue Syndrome
  • Alleged link between hepatitis B vaccine and chronic fatigue syndrome. Can Dis Wkly Rep 1991;17:215--6. Herroelen L, de Keyser J, Ebinger G. Central-nervous-system demyelination after immunisation with recombinant hepatitis B vaccine.[cdc.gov]
  • In rare instances, other illnesses have been reported after hepatitis B vaccination, including GBS, chronic fatigue syndrome, neurologic disorders (e.g. leukoencephalitis, optic neuritis, and transverse myelitis), rheumatoid arthritis, type 1 diabetes[cdc.gov]
Down Syndrome
  • First- and second-trimester evaluation of risk for Down syndrome. Obstet Gynecol 2007;110:10--7. CDC. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(No. RR-2).[cdc.gov]
  • He found a higher prevalence of the protein in the blood of patients from developing countries, compared to those from developed ones, and noted associations of the antigen with other diseases like leukemia and Down Syndrome.[en.wikipedia.org]
Abdominal Pain
  • But over time, they can experience the following: tiredness weight loss nausea abdominal pain severe itching jaundice (yellow discoloration of the skin and eyes) Eventually, people can have complications such as fluid in the abdomen and difficulty thinking[hepc.liverfoundation.org]
  • Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.[web.archive.org]
  • Blood clots in the liver's main artery may cause abdominal pain. The following tests will be done: Blood tests to check liver function ( AST and ALT ). These readings can be very high with ischemia. Doppler ultrasound of the blood vessels of liver.[nlm.nih.gov]
  • Blood clots in the liver's main artery may cause abdominal pain.[web.archive.org]
  • Symptoms include an enlarged liver, fever, nausea, vomiting, abdominal pain, and dark urine Disease of the liver causing inflammation. Symptoms include an enlarged liver, fever, nausea, vomiting, abdominal pain, and dark urine Hepatitis.[icd9data.com]
Diplopia
  • INTRODUCTION: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids is a brainstem disorder characterized by perivascular pathologic reaction with lymphocyte infiltration and leading to diplopia, facial palsy, dysarthria[ncbi.nlm.nih.gov]
Joint Effusion
  • A 21-year-old African (Ghanaian) man with chronic hepatitis B infection was referred to our Endocrine unit as having acromegaly with changing facial features, enlarging hands and feet, and large knee joint effusions which affected activities of daily[ncbi.nlm.nih.gov]
Palmar Erythema
  • In advanced stages of chronic hepatitis, features of cirrhosis like hepatosplenomegaly, palmar erythema, parotid enlargement, spider nevi, gynecomastia and even ascites, portal hypertension and hepatic encephalopathy may be present.[symptoma.com]
  • erythema Patients with advanced cirrhosis may develop ascites or esophageal varices Serum enzyme levels usually fluctuate but may be elevated 2x to 10x Many patients with mild chronic hepatitis C have persistently normal serum aminotransferase levels[pathologyoutlines.com]
  • Palmar erythema. Jaundice. Clubbing. Dupuytren's contracture (alcoholic cirrhosis). Xanthomas: palmar creases or above the eyes in primary biliary cirrhosis. Initial hepatomegaly may be followed by a small liver in well-established cirrhosis.[patient.info]
  • Often, particularly with HCV, the first findings are Signs of chronic liver disease (eg, splenomegaly, spider nevi, palmar erythema) Complications of cirrhosis (eg, portal hypertension, ascites, encephalopathy) A few patients with chronic hepatitis develop[merckmanuals.com]
Hirsutism
  • Hirsutism. Investigation of chronic hepatitis Urinalysis : bilirubin and urobilinogen. Blood tests: FBC (associated anaemia, thrombocytopenia, raised MCV with alcohol abuse), clotting studies (clotting impairment with hepatic dysfunction).[patient.info]
  • Chronic hepatitis interferes with hormonal functions of the liver which can result in acne, hirsutism (abnormal hair growth), and amenorrhea (lack of menstrual period) in women.[en.wikipedia.org]
Dysarthria
  • INTRODUCTION: Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids is a brainstem disorder characterized by perivascular pathologic reaction with lymphocyte infiltration and leading to diplopia, facial palsy, dysarthria[ncbi.nlm.nih.gov]

Workup

The workup in all cases should begin with a detailed history and physical examination. As the etiology of chronic hepatitis can be variable like congenital alpha-1-antitrypsin deficiency, viral, autoimmune or long-standing usage of drugs and alcohol, the workup should specifically note previous history of hepatitis, high risk behavior (drug /alcohol abuse, multiple sexual partners), tattoos /piercings, history of incarceration, blood/ blood product transfusion, surgery, autoimmune diseases etc). Needle tracks, features of icterus, cirrhosis, and cholestasis should be looked for during physical examination.

Routine laboratory tests like complete blood count, urinalysis, stool analysis, liver enzymes, serum proteins and, coagulation profile are obtained. If hepatitis is confirmed on laboratory tests then specific tests to detect etiology of the chronic hepatitis are performed. These include viral serology, autoantibodies, alpha-1-antitrypsin levels, immunoglobulins, ceruloplasmin levels (in children to rule out Wilson's disease). Serum iron, ferritin, and total iron-binding capacity levels can help detect hemochromatosis as the cause of chronic hepatitis.

If an asymptomatic patient is detected with elevated liver enzymes and if they were born between 1945 and 1965, they should be evaluated for hepatitis C. Cryoglobulin and rheumatoid factor levels are assessed in patients with chronic hepatitis secondary to hepatitis C.

Liver biopsy is the gold standard for the diagnosis of chronic hepatitis and provides information about the extent of cellular necrosis, parenchymal fibrosis and inflammation [5] [6]. Histopathology can also detect steatohepatitis and iron deposition and helps to plan further disease management and prognosis [7]. Fibroscan, an ultrasound-based procedure can detect liver fibrosis in advanced cases while blood tests like FIBROSpect II, HepaScore, and HCV FIBROSURE are used to detect mild and severe stages of liver fibrosis.

Treatment

  • , care and treatment of infection due to the hepatitis C virus (HCV).[who.int]
  • During the 3-year study, NA treatment history including the incidence, the type of treatment modification, reasons for the modification, and overall complete virologic response (CVR) rate were retrospectively evaluated using the patients' medical records[ncbi.nlm.nih.gov]
  • He was given tenofovir alone as antiviral treatment instead. After hemodialysis and 4 weeks treatment of corticosteroids, his symptoms recovered, and blood lactate gradually returned to a normal range.[ncbi.nlm.nih.gov]

Prognosis

  • AIMS: We aimed to elucidate whether coexistence of MS and CHB affects the long-term prognosis of CHB patients with oral NUCs treatment.[ncbi.nlm.nih.gov]
  • However if patients recieved valid management and effective treatment, they were able to maintain their health and benign prognosis.[ncbi.nlm.nih.gov]
  • Prognosis was good after adjustment of the ADV dose and supplemental administration of phosphate and calcitriol.[ncbi.nlm.nih.gov]
  • Histopathology can also detect steatohepatitis and iron deposition and helps to plan further disease management and prognosis.[symptoma.com]
  • BACKGROUND: Evaluation of liver fibrosis is important to assess prognosis and guide the treatment for chronic hepatitis B.[ncbi.nlm.nih.gov]

Etiology

  • For a transitional period and to facilitate relearning, the terms CAH, CPH, and CLH can be reported in parentheses behind the etiologic diagnosis.[ncbi.nlm.nih.gov]
  • If hepatitis is confirmed on laboratory tests then specific tests to detect etiology of the chronic hepatitis are performed.[symptoma.com]
  • BACKGROUND/AIMS: Chronic hepatitis B virus (HBV) infection (CHB) plays a central role in the etiology of hepatocellular carcinoma (HCC).[ncbi.nlm.nih.gov]
  • Unless these tests indicate viral etiology, further testing is required.[merckmanuals.com]
  • […] geographic regions with HBsAg prevalence of 2% US born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of 8% injection-drug users men who have sex with men persons with elevated ALT/AST of unknown etiology[cdc.gov]

Epidemiology

  • Changes of estimated glomerular filtration rate (eGFR), which was computed with both the Chronic Kidney Disease Epidemiology Collaboration and the Modification of Diet in Renal Disease formulas, were tested by repeated measures One-way analysis of variance[ncbi.nlm.nih.gov]
  • Glomerular filtration rates (GFRs) were calculated by Cockcroft-Gault (CG), abbreviated Modification of Diet in Renal Disease (MDRD) study, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and were tested by repeated-measures[ncbi.nlm.nih.gov]
  • Jian‐Gao Fan, Epidemiology of alcoholic and nonalcoholic fatty liver disease in China, Journal of Gastroenterology and Hepatology, 28, (11-17), (2013).[doi.org]
  • Improvements in socioeconomic and hygienic conditions have led to a change in its epidemiology worldwide.[doi.org]
  • Box 47840 Olympia, WA 98504-7840 Additional Resources Washington State Hepatitis C Epidemiologic Profile (PDF) Washington State Hepatitis C Mortality Fact Sheet (PDF) Hepatitis Notifiable Conditions in Washington State Hepatitis Reporting Form - (Notifiable[doh.wa.gov]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology may be mitochondrial toxicity, for the NAs inhibit not only hepatitis B virus (HBV) polymerase, but also the host mitochondrial DNA polymerase γ.[ncbi.nlm.nih.gov]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 79. Updated by: Michael M.[nlm.nih.gov]
  • Hepatic Disorders, Jaundice, and Hepatic Failure Sections: Hepatic Disorders, Jaundice, and Hepatic Failure: Introduction, Epidemiology, Pathophysiology, Clinical Features, Diagnosis of Specific Entities, Laboratory Evaluation, Imaging, Treatment, Disposition[web.archive.org]
  • Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test Hepatitis B virus (HBV) is a DNA virus that is endemic throughout the world.[mayomedicallaboratories.com]

Prevention

  • Authors : WHO Overview These are the first World Health Organization (WHO) guidelines for the prevention, care and treatment of persons living with chronic hepatitis B (CHB) infection, and complement similar recently published guidance by WHO on the prevention[who.int]
  • 326,000-686,000) and cost per HCC prevented (range: US 654,000-1,380,000) over 10-year horizon using data from REVEAL study, cost per end point complication prevented in cirrhotics (US 9,630/year), and cost per HCC prevented in cirrhotics (US 27,600[ncbi.nlm.nih.gov]
  • Chinese medicine has its unique advantages in the clinical prevention and treatment, while the syndrome of Chinese medicine lacks the understanding at the micro level.[ncbi.nlm.nih.gov]
  • […] the perinatal hepatitis B prevention program.[cdc.gov]

References

Article

  1. Previsani N, Lavanchy D. World Health Organization. Hepatitis D. (WHO/CDS/CSR/NCS/2001.1). 2001. Accessed January 24,2017.
  2. Adhami T, Levinthal G. Hepatitis D. The Cleveland Clinic Disease Management Project. May 29, 2002.
  3. Kamar N, Bendall RP, Peron JM, et al. Hepatitis E virus and neurologic disorders. Emerg Infect Dis. 2011;17:173–179.
  4. Kamar N, Weclawiak H, Guilbeau-Frugier C, et al. Hepatitis E virus and the kidney in solid-organ transplant patients. Transplantation. 2012;93:617–623.
  5. European Association for Study of Liver. EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol. 2014;60:392–420.
  6. Dienstag JL. The role of liver biopsy in chronic hepatitis C. Hepatology. 2002;36:S152–S160.
  7. Bedossa P, Moucari R, Chelbi E, et al. Evidence for a role of nonalcoholic steatohepatitis in hepatitis C: a prospective study. Hepatology. 2007;46:380–387.

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Last updated: 2019-07-11 21:37