Hepatitis means inflammation of the liver. This inflammation may be due to viruses, medicines, alcohol, problems with the immune system or not enough blood supply to the liver.
The liver is an essential organ in the body and carries out a wide range of functions, including removing poisons from the body, storing energy, and regulation of blood clotting.
Although other viruses can involve the liver, viral hepatitis refers to inflammation of the liver due to one of several viruses that specifically attack the liver. These viruses are labeled with the letters A, B, C, D and E. The most important viruses in the United States are viral hepatitis A, B and C.
Viral hepatitis A and E enter the body by way of the gastrointestinal tract. One gets these viruses by eating food or drinking fluids contaminated with the virus, usually from the stool of an infected person. Hepatitis A may also be transmitted in areas where there is overcrowding such as day care centers and correctional facilities, from eating raw shell fish that came from water contaminated with sewage or by sexual (usually anal-oral) contact. Hepatitis E, although similar to hepatitis A, is not frequently seen in the United States. This virus is seen primarily in the Indian subcontinent and in certain areas of Africa. It is transmitted primarily by fecal-oral contamination (as mentioned above).
The hepatitis B and C viruses are generally transmitted by contact with infected blood or blood products or by sexual contact. In the United States, intravenous drug use is the most frequent mode of transmission of hepatitis C. Sexual transmission is uncommon for hepatitis C. Hepatitis B is commonly transmitted sexually as well as through intravenous drug use and can also be passed from a mother to her fetus, usually at the time of delivery.
Hepatitis D (sometimes referred to as Delta hepatitis) only afflicts individuals who have the hepatitis B infection. The mode of transmission of hepatitis D is similar to that of hepatitis B.
Acute viral hepatitis refers to inflammation of the liver associated with symptoms and abnormalities of liver enzymes which last for a period less than six months. All of the viruses mentioned above can cause acute hepatitis. The symptoms of acute viral hepatitis can include low grade fever, headaches, muscle ache, tiredness, loss of appetite, nausea, vomiting, diarrhea, dark colored urine or light colored stools. The most notable symptom of acute viral hepatitis is jaundice, which is a yellow discoloration of the skin and the whites of the eyes. Patients also usually complain of vague upper abdominal pain. Very few patients with acute viral hepatitis go on to develop liver failure that would require liver transplantation or lead to death. However, hepatitis E may have serious consequences if the person is infected during pregnancy.
Except for patients infected with hepatitis C, most cases of acute viral hepatitis will disappear on their own. With hepatitis C, more than 80% of patients will develop a persistent infection called chronic hepatitis. Although most of those with acute hepatitis B will resolve their infection, a significant number of infants and young children with hepatitis B will develop chronic hepatitis B.
Chronic viral hepatitis refers to ongoing inflammation and/or abnormalities of liver enzymes which last more than six months. Most patients who develop chronic hepatitis will have life long disease, unless treated. Chronic viral hepatitis in the United States is limited primarily to hepatitis B and C. Consequences of chronic viral hepatitis may include progressive liver disease, including cirrhosis and its complications, liver failure, liver cancer, and bleeding disorders, although many patients will never develop any of these complications. Furthermore, chronic hepatitis may be accelerated in people who use drugs that are toxic to the liver (including alcohol). Most of these complications can be prevented by early diagnosis and early treatment, and in the case of hepatitis B, vaccination.
Viral hepatitis (both acute and chronic) can be easily diagnosed using simple blood tests. While a liver sample (called a biopsy) is not required in the vast majority of cases, it may sometimes be helpful, especially in difficult to diagnose cases or when deciding on treatment.
Acute viral hepatitis generally does not require treatment, as most patients will get better on their own. Acute hepatitis C is a notable exception, because only 15% of patients will clear the virus on their own and most people, if not treated, will develop chronic hepatitis C. In addition, there is a very high cure rate when patients are treated during the acute hepatitis infection stage.
Chronic hepatitis treatments are available for hepatitis B and C, the most predominant causes of chronic hepatitis. Chronic hepatitis B is usually treated by medications that interfere with the virus’ ability to reproduce. These medications include oral medications as well as injectable medications. The only approved injectable medications for chronic hepatitis B are alpha interferon and pegylated alpha interferon. The duration of treatment for chronic hepatitis B is dependent on many things, and can range from several months to life long.
Chronic hepatitis C is treated by a combination of injectable medication (alpha interferon) and oral medication (ribavirin). The duration of treatment for chronic hepatitis C ranges from six months to one year (depending upon the type of virus, referred to as genotype). After treatment, the cure rate is about 40-50 percent but it is highly dependent on viral and host factors. Also, monitoring of clinical symptoms and laboratory values during treatment of viral hepatitis is very important.
Chronic viral hepatitis B and C should be treated by individuals who are knowledgeable of these conditions, the medications utilized to treat these conditions and the side effects of these medications.
The main reason to treat chronic viral hepatitis is to prevent cirrhosis of the liver, in which the liver becomes scarred and gradually loses its ability to function. This can ultimately lead to liver failure or liver cancer. Another reason for treatment is to prevent the spread of infection. The longer a patient has chronic hepatitis, the more likely it is that cirrhosis will develop. Therefore, early diagnosis is crucial for initiating treatment as soon as possible. Unfortunately, since chronic viral hepatitis is usually not associated with symptoms, most patients remain undiagnosed.
The medications used to treat chronic viral hepatitis C, including the interferons and ribavirin, are associated with some side effects, most of which are manageable. The most frequently seen side effects include tiredness, fatigue and muscle aches, all resembling symptoms of the flu. Patients may also suffer from low red blood counts (anemia) and a decrease in their white blood cell count (these are the cells that are involved in fighting infections). Serious side effects due to interferon may also occur quite rarely, including severe depression and thoughts of suicide. Patients with stable depression generally may be safely treated.
The oral medications that are used to treat chronic hepatitis B are typically associated with minimal side affects. Hepatitis B may be treated with injectable medications (pegylated interferons) or oral medications. All of these medications, however, may require adjustments of doses and frequency in patients who have kidney disease. As mentioned previously, patients with chronic viral hepatitis should be treated in a center with a great deal of expertise in the management of these side effects.
Most cases of viral hepatitis can be prevented by using common sense precautions. Since hepatitis A and E viruses are transmitted through contaminated foods and liquids, patients should not eat or drink in areas with unsanitary conditions. Hence, international travelers should only consume bottled water, not use ice in beverages, and avoid food sold from street vendors. Also, individuals traveling to areas with high rates of hepatitis A should receive the hepatitis A vaccine in two (2) doses, 6 to 18 months apart.
Other persons who should receive the hepatitis A vaccine include men who have sex with men, intravenous and other drug users, persons with clotting factor disorders like hemophilia, people with chronic liver disease, and children who live in areas that have historically high rates of hepatitis A. For short term protection (for example, short term travel to endemic areas), immune globulin (IG) shots may be given. This is generally needed for people who are going to remain in those areas for a period of less than one month. This IG shot can temporarily prevent you from contracting the virus. An IG shot may also be given for protection within 2 weeks following exposure to a known hepatitis A carrier.
Most patients with acute hepatitis B will get better on their own, but this is a preventable disease. The best method of prevention is vaccination. The hepatitis B vaccine is highly effective in preventing the infection. Individuals who should receive this vaccine include those who use intravenous and other drugs, men who have sex with men, individuals with high risk sexual behavior and individuals with multiple sexual partners. As pregnant women who carry the virus are very likely to transmit it to their baby, newborns of hepatitis B infected mothers should receive the first dose of the hepatitis B vaccine within 12 hours of birth. It is also recommended that an IG (immune globulin) shot be given at the same time. This method is highly effective in preventing infection of the newborn. If the mother in addition has high amounts of the virus in her blood stream, it is recommended that she receive an oral antiviral agent after the second trimester of pregnancy to further reduce the risk of transmission to her baby.
Most states currently require hepatitis B vaccination of all newborns as well as “catch-up” vaccination for children and adolescents. A combined hepatitis A and B vaccine (Twinrix®) is also available for people who need both vaccines. These vaccines offer life long immunity (as does recovery from infection) unless the patient has underlying immune disease or kidney failure.
Although some herbal medicines may briefly improve liver enzymes, there is currently no evidence that any medicines (other than those previously mentioned) can cure viral hepatitis. One should never use any prescription or over-the-counter medications without consulting a physician first. Additionally, some herbal medications may seriously damage the liver.
George G. Abdelsayed, MD, FACP, FACG, and Daniel Stupak, MD, Bridgeport Hospital, Bridgeport, CT – Published November 2010.