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Overview of Chronic Hepatitis

By

Sonal Kumar

, MD, MPH, Weill Cornell Medical College

Last full review/revision Jan 2021| Content last modified Jan 2021
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Chronic hepatitis is inflammation of the liver that lasts at least 6 months.

  • Common causes include hepatitis B and C viruses and certain drugs.

  • Most people have no symptoms, but some have vague symptoms, such as a general feeling of illness, poor appetite, and fatigue.

  • Chronic hepatitis can progress to cirrhosis and ultimately liver cancer and/or liver failure.

  • A biopsy is sometimes done to confirm the diagnosis, but chronic hepatitis is usually diagnosed based on blood test results.

  • Drugs, such as antiviral drugs or corticosteroids, may be used, and for advanced disease, liver transplantation may be needed.

Causes of Chronic Hepatitis

The most common causes of chronic hepatitis are

Hepatitis C virus causes about 60 to 70% of cases of chronic hepatitis, and at least 75% of acute hepatitis C cases become chronic.

About 5 to 10% of hepatitis B cases in adults, sometimes with hepatitis D Hepatitis D Hepatitis D virus is infection of the liver that occurs only in people who have hepatitis B. Hepatitis D can be spread by contact with blood and other body fluids. Coinfection with hepatitis... read more coinfection, become chronic. (Hepatitis D does not occur by itself. It occurs only as a coinfection with hepatitis B.) Acute hepatitis B becomes chronic in up to 90% of infected newborns and in 25 to 50% of young children.

Rarely, hepatitis E virus causes chronic hepatitis in people with a weakened immune system, such as those who are taking drugs to suppress the immune system after an organ transplant, who are taking drugs to treat cancer, or who have HIV infection.

Hepatitis A virus does not cause chronic hepatitis.

Nonalcoholic steatohepatitis Fatty Liver Fatty liver is an abnormal accumulation of certain fats (triglycerides) inside liver cells. People with fatty liver may feel tired or have mild abdominal discomfort but otherwise have no symptoms... read more (a type of chronic inflammation of the liver) usually occurs in people with excess body weight (obesity), diabetes, and/or abnormal levels of cholesterol and other fats (lipids) in the blood. All of these conditions cause the body to synthesize more fat or process (metabolize) and excrete fat more slowly. As a result, fat accumulates and is then stored inside liver cells (called fatty liver Fatty Liver Fatty liver is an abnormal accumulation of certain fats (triglycerides) inside liver cells. People with fatty liver may feel tired or have mild abdominal discomfort but otherwise have no symptoms... read more ). Fatty liver can lead to chronic inflammation and eventually progress to cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more Cirrhosis of the Liver . (Fatty liver due to any condition other than excessive consumption of alcohol is called nonalcoholic fatty liver disease.)

Alcohol, after being absorbed in the digestive tract, is usually processed (metabolized) in the liver. As alcohol is processed, substances that can damage the liver are produced. Alcohol-related liver disease typically occurs in people who drink heavily for many months or years. Alcohol-related liver disease is characterized by fatty liver and widespread liver inflammation that can result in the death of liver cells. If people continue drinking, scar tissue can form in the liver and may eventually replace a large amount of normal liver tissue, resulting in cirrhosis.

Less often, chronic hepatitis results from

In autoimmune hepatitis, the chronic inflammation resembles inflammation caused by the body attacking its own tissues (an autoimmune reaction Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers autoimmune disorders is not known. Symptoms vary depending on... read more ). Autoimmune hepatitis is more common among women than men.

Certain drugs can cause chronic hepatitis, particularly when they are taken for a long time. They include amiodarone, isoniazid, methotrexate, methyldopa, nitrofurantoin, and tamoxifen and rarely acetaminophen.

No one knows exactly why a particular virus or drug causes chronic hepatitis in some people but not in others or why the degree of severity varies.

Did You Know...

  • Chronic hepatitis may not be suspected until after cirrhosis develops.

Symptoms of Chronic Hepatitis

In about two thirds of people, chronic hepatitis develops gradually, often without causing any symptoms of a liver disorder until cirrhosis occurs. In the remaining one third, it develops after a bout of acute viral hepatitis that persists or returns (often several weeks later).

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. Jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more Jaundice in Adults (a yellow discoloration of the skin and whites of the eyes caused by deposits of excess bilirubin) is rare unless liver failure develops. Many people with chronic hepatitis have no symptoms.

Often, the first specific symptoms occur when liver disease has progressed and there is evidence of cirrhosis. Symptoms can include

Brain function deteriorates because the badly damaged liver cannot remove toxic substances from the blood as it normally does. These substances then build up in the blood and reach the brain. Normally, the liver removes them from the blood, breaks them down, then excretes them as harmless by-products into the bile (the greenish yellow fluid that aids in digestion) or blood (see Functions of the Liver Functions of the Liver The wedge-shaped liver is the largest—and, in some ways, the most complex—organ in the body. It serves as the body's chemical factory, performing many vital functions, from regulating the levels... read more ). Treatment of hepatic encephalopathy can prevent the deterioration of brain function from becoming permanent.

Blood cannot clot as it normally does because the damaged liver can no longer synthesize enough of the proteins that help blood clot.

A few people have jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more Jaundice in Adults , itchiness, and light-colored stools. Jaundice and itchiness develop because the damaged liver cannot remove bilirubin from the blood as it normally does. Bilirubin then builds up in the blood and is deposited in the skin. Bilirubin is a yellow pigment produced as a waste product during the normal breakdown of red blood cells. Stool is light-colored because the flow of bile out of the liver is blocked and less bilirubin is eliminated in stool. Bilirubin is what gives stool its typical brown color.

Autoimmune hepatitis may cause other symptoms that involve other body systems. Symptoms can include cessation of menstrual periods, joint pain and swelling, loss of appetite, and nausea. 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.

In many people, chronic hepatitis does not progress for years. In others, it gradually worsens. The outlook depends partly on which virus is the cause and whether treatment is available:

Diagnosis of Chronic Hepatitis

  • Blood tests

  • Occasionally a biopsy

Doctors may suspect chronic hepatitis when

  • People have typical symptoms.

  • Blood tests (done for other reasons) detect elevated liver enzymes.

  • People have had acute hepatitis before.

Also, everyone aged 18 or over, regardless of whether symptoms are present, should be tested at least once for hepatitis C. Such testing is recommended because hepatitis C is often unrecognized.

Testing for chronic hepatitis usually begins with blood tests to measure the levels of liver enzymes and other substances produced by the liver (liver tests Liver Blood Tests Liver tests are blood tests that represent a noninvasive way to screen for the presence of liver disease (for example, hepatitis in donated blood) and to measure the severity and progress of... read more ). These tests may help establish or exclude the diagnosis of hepatitis, identify the cause, and determine the severity of liver damage.

Blood tests are also done to help doctors identify whether a hepatitis virus is causing the infection. If no virus is identified, other blood tests are needed to check for other causes, such as autoimmune hepatitis.

Other tests may be done to determine how badly the liver is damaged and to check for other liver problems. Tests may include

Ultrasound elastography and magnetic resonance elastography use sound waves, applied to the abdomen, to determine how stiff the liver tissue is.

Screening for liver cancer

If people have chronic hepatitis B (or cirrhosis due to any liver disorder), screening for liver cancer is done every 6 months. Two tests are used:

  • Ultrasonography

  • Sometimes measurement of the level of alpha-fetoprotein in the blood

The level of alpha-fetoprotein—a protein normally produced by immature liver cells in fetuses—may be elevated when liver cancer is present.

Treatment of Chronic Hepatitis

  • Treatment of the cause (such as antiviral drugs for hepatitis B or C)

  • Treatment of complications

If a drug is the cause, the drug is stopped. If another disorder is the cause, it is treated. If the cause is alcohol-related liver disease Treatment Alcohol-related liver disease is liver damage caused by drinking too much alcohol for a long time. In general, the amount of alcohol consumed (how much, how often, and for how long) determines... read more Treatment , doctors recommend changes in lifestyle, mainly abstinence from alcohol.

Hepatitis B and C

In some people, hepatitis B tends to recur once drug treatment is stopped and may be even more severe. Thus, these people may need to take an antiviral drug indefinitely.

With chronic hepatitis C Hepatitis C, Chronic Chronic hepatitis C is inflammation of the liver that is caused by the hepatitis C virus and that has lasted more than 6 months. Hepatitis C often causes no symptoms until after it has badly... read more , treatment with antiviral drugs is recommended for all unless their life expectancy is very short. Treatment can last from 8 to 24 weeks. Treating hepatitis C can eliminate the virus from the body and thus stop inflammation and prevent scarring and progression to cirrhosis.

Nonalcoholic steatohepatitis

Treatment of nonalcoholic steatohepatitis focuses on managing the conditions that contribute to it. For example, treatment may include

Autoimmune hepatitis

Usually, corticosteroids (such as prednisone or budesonide) are used to treat autoimmune hepatitis along with azathioprine, a drug used to suppress the immune system. These drugs suppress the inflammation, relieve symptoms, and improve long-term survival. Nevertheless, scarring in the liver may gradually worsen.

Stopping these drugs usually leads to recurrence of the inflammation, so most people have to take the drugs indefinitely. However, taking corticosteroids for a long time can have significant side effects. So doctors usually gradually reduce the dose of the corticosteroid so that people can stop taking it. People then take azathioprine or mycophenolate (other drugs that suppress the immune system) indefinitely.

Treatment of complications

Liver transplantation

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