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]

  Always discuss pain with your medical provider, particularly when pain is constant, severe or interferes with your quality of life. Call your medical provider if you have severe or chronic stomach pain. [hepmag.com]

  Symptoms & Causes Common symptoms of autoimmune hepatitis include feeling tired, pain in your joints, nausea, poor appetite, pain over your liver, and jaundice. [niddk.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]

• 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]

  Mental fatigue can manifest as somnolence, lethargy, or directed attention fatigue.[4] Fatigue and 'feelings of fatigue' are sometimes confused.[5] Unlike weakness, fatigue usually can be alleviated by periods of rest. [en.wikipedia.org]

  Fatigue: In the acute phase, bed rest and low physical exertion may be advised. [hepmag.com]

  Usually minimal if present at all and include nonspecific symptoms of weakness, fatigue, intermittent nausea and abdominal discomfort. Serum Enzyme Elevations. [livertox.nih.gov]

  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]

• Anemia

  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. [symptoma.com]

  PROMACTA is a prescription medicine used to treat people with severe aplastic anemia (SAA) in combination with standard immunosuppressive therapy as the first treatment for adults and children 2 years of age and older. [us.promacta.com]

  The observed SAEs (eg, grade 3 anemia, gastroenteritis, respiratory symptoms) were not thought to be TDF-related [ 24 ]. [doi.org]

  The most common side effects of Zepatier with ribavirin were anemia and headache. [fda.gov]

• Swelling

  Tell your health care provider right away if you have signs and symptoms of a blood clot in the leg such as swelling, pain, or tenderness. People with chronic liver disease may be at risk for a type of blood clot in the stomach area. [us.promacta.com]

  Ankle swelling (fluid retention). Haematemesis and melaena (gastrointestinal haemorrhage). Pruritus (cholestasis). Breast swelling (gynaecomastia), testicular atrophy, loss of libido and amenorrhoea due to endocrine dysfunction. [patient.info]

  Such conditions may include: Abnormal heart rhythms Dehydration Heart failure Infection Severe bleeding Other causes may include: Blood clots in the main artery to the liver (hepatic artery) after a liver transplant Swelling of blood vessels leading to [web.archive.org]

  Several forms of hepatocyte injury can be seen under light microscopy, including ballooning degeneration (severe swelling), focal necrosis, and acidophil bodies (apoptosis). [emedicine.medscape.com]

• Malaise

  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 [symptoma.com]

  Headache, fever, skin rash, general malaise, gastrointestinal complaints, sleeplessness, cough and, in some cases, inflammation of the pancreas have been described. [infohep.org]

  Symptoms of hepatitis A range from mild to severe, and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the skin and whites of the eyes). [web.archive.org]

  Chronic hepatitis often causes general symptoms, such as a vague feeling of illness (malaise), poor appetite, and fatigue. Sometimes affected people also have a low-grade fever and some discomfort in the upper abdomen. [msdmanuals.com]

• Abdominal Pain

  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]

  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]

  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]

  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]

• Hypertension

  […] pressure only in patients with clinical signs or evidence of evolving intracranial hypertension. [doi.org]

  Distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join the systemic veins ( Caput Medusae ) indicative of severe portal hypertension. Multiple lienorenal and gastrosplenic varices. [radiopaedia.org]

  Splenomegaly (portal hypertension). Hirsutism. Investigation of chronic hepatitis Urinalysis : bilirubin and urobilinogen. [patient.info]

• Fracture

  The present report describes detailed our experience with the diagnosis of pathologic femoral fracture due to tenofovir-induced Fanconi syndrome and treatment. [ncbi.nlm.nih.gov]

  Prevalence of osteoporosis and bone fracture was 2-fold higher in chronic hepatitis B compared to non-chronic hepatitis B patients and continued to increase in the last decade: Results of a United States population-based cohort study. [vemlidyhcp.com]

  In the DART trial, no significant evidence of lower birth weight or other growth parameters up to age 4 years and no fractures during follow-up were reported among 120 children who were exposed to TDF prenatally [ 28 ]. [doi.org]

  4) or requiring treatment discontinuation because of renal complications (0 vs. 12; P < .001).19 While longer‐term data in HBV‐monoinfected patients are lacking, particularly with respect to the impact on clinical outcomes such as renal disease and fracture [aasldpubs.onlinelibrary.wiley.com]

• Ulcer

  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. [symptoma.com]

  Take PROMACTA at least 2 hours before or 4 hours after taking these products: antacids used to treat stomach ulcers or heartburn multivitamins, mineral supplements, or products that contain iron, calcium, aluminum, magnesium, selenium, and zinc Ask your [us.promacta.com]

  People with autoimmune hepatitis may also have other autoimmune disorders such as type 1 diabetes mellitus, ulcerative colitis, celiac disease, or autoimmune disorders that cause anemia or inflammation of the thyroid gland or kidneys. [msdmanuals.com]

• 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, the first findings are Signs of cirrhosis (eg, splenomegaly, spider nevi, palmar erythema) A few patients with chronic hepatitis develop manifestations of cholestasis (eg, jaundice, pruritus, pale stools, steatorrhea). [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]

  […] vomiting, poor appetite, and joint pain.[18] Jaundice can occur as well, but much later in the disease process and is typically a sign of advanced disease.[18] Chronic hepatitis interferes with hormonal functions of the liver which can result in acne, hirsutism [en.wikipedia.org]

• Amenorrhea

  In autoimmune hepatitis, especially in young women, manifestations may involve virtually any body system and can include acne, amenorrhea, arthralgia, ulcerative colitis, pulmonary fibrosis, thyroiditis, nephritis, and hemolytic anemia. [merckmanuals.com]

  [18] Jaundice can occur as well, but much later in the disease process and is typically a sign of advanced disease.[18] Chronic hepatitis interferes with hormonal functions of the liver which can result in acne, hirsutism (abnormal hair growth), and amenorrhea [en.wikipedia.org]

• Encephalopathy

  In patients with subacute presentations, even low-grade encephalopathy indicates an extremely poor prognosis, whereas in hyperacute disease, high grades of encephalopathy may clearly indicate a poor prognosis. [doi.org]

  An exacerbation of hepatitis with encephalopathy and pancytopaenia have been observed. Parvovirus B19 and HBV co-infection does not increase the frequency of liver function abnormalities in patients with chronic hepatitis B. [ncbi.nlm.nih.gov]

  Specific entities addressed in this chapter include hepatic-related coagulopathy, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy. [web.archive.org]

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.

• Dyslipidemia

  NAFLD and NASH are associated with metabolic syndrome including obesity, type 2 diabetes mellitus and/or dyslipidemia. [doi.org]

  NAFLD develops most often in patients with at least one of the following risk factors: Obesity Dyslipidemia Insulin resistance NASH is the progressive form of NAFLD that causes chronic hepatitis. [merckmanuals.com]

• Colitis

  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. [symptoma.com]

  One patient each was diagnosed with Crohn’s disease, autoimmune gastritis, collagen colitis, hypophysitis and sarcoidosis. [doi.org]

  […] glomerulonephritis, an inflammation of blood vessels in the kidneys thyroiditis, an inflammation of the thyroid gland Graves’ disease, the leading cause of overactive thyroid Sjögren’s syndrome, a syndrome that causes dry eyes and mouth autoimmune anemia ulcerative colitis [web.archive.org]

  People with autoimmune hepatitis may also have other autoimmune disorders such as type 1 diabetes mellitus, ulcerative colitis, celiac disease, or autoimmune disorders that cause anemia or inflammation of the thyroid gland or kidneys. [msdmanuals.com]

  People with autoimmune hepatitis may also have other autoimmune disorders such as type I diabetes mellitus, ulcerative colitis, celiac sprue, or autoimmune disorders that cause anemia or inflammation of the thyroid gland or kidneys. [merckmanuals.com]

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]

Six medications are now approved for the treatment of chronic hepatitis B, but there is still significant uncertainty with regards to treatment outcomes, cost impact, and benefits in view of the absence of long-term outcomes data. [doi.org]

care and treatment of infection due to the hepatitis C virus (HCV). [web.archive.org]

However if patients recieved valid management and effective treatment, they were able to maintain their health and benign prognosis. [ncbi.nlm.nih.gov]

Histopathology can also detect steatohepatitis and iron deposition and helps to plan further disease management and prognosis. [symptoma.com]

The histological differentiation between chronic persistent hepatitis (no cell necrosis) and chronic active hepatitis (cell necrosis) does not correlate with prognosis and is therefore now much less used. [patient.info]

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]

The most common etiologies are acute viral hepatitis A and B, medication overdose (e.g., acetaminophen), idiosyncratic drug reactions, ingestion of other toxins (e.g., amanita mushroom poisoning), and metabolic disorders (e.g., Reye's syndrome). [doi.org]

Unless these tests indicate viral etiology, further testing is required. [merckmanuals.com]

Improvements in socioeconomic and hygienic conditions have led to a change in its epidemiology worldwide. [doi.org]

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]

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]

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]

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]

$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]

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 [web.archive.org]

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.