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.
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   as well as hepatocellular carcinoma. Chronic hepatitis develops over several years . 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  .
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  . Histopathology can also detect steatohepatitis and iron deposition and helps to plan further disease management and prognosis . 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.