Chronic hepatitis

Chronic hepatitis is an inflammation of the liver that lasts longer than six months. Frequent causes of chronic hepatitis are:

• Toxins; some medicines taken chronically may cause chronic liver inflammation. The toxin that most often causes chronic hepatitis is alcohol.
• Accumulated fat in the liver (hepatic steatosis) is an increasingly frequent cause of chronic hepatitis. Obesity is a chronic illness that results from a systemic metabolic disorder which leads to an excessive accumulation of body fat. Obesity is associated with a higher risk of suffering from hepatic steatosis and liver inflammation.
• Hepatitis viruses. The most common member of this family of viruses is the hepatitis C virus (HCV). Between 60% and 80% of patients infected with HCV end up with chronic hepatitis.
• The hepatitis B virus (HBV) also causes chronic inflammation of the liver. Roughly 5%-10% of patients infected with HBV in adult life and > 90% of patients infected with it during the neonatal stage (transmission from mother to child during birth) will end up developing chronic hepatitis.
• There are other less frequent causes of chronic hepatitis such as alpha-1-antitrypsin deficiency, Wilson's disease and autoimmune hepatitis.

Two thirds of patients show no symptoms of the illness by the time they have developed hepatic cirrhosis. It is at this stage they may present cirrhosis-derived symptoms such as:

• Portal hypertension; cirrhosis scars make the liver harder than normal. So blood attempting to enter the liver does so with greater difficulty, leading to a situation known as portal hypertension. The most common signs of this situation are an enlarged spleen (splenomegaly), a build-up of fluid in the abdomen (ascites), the appearance of spider angiomas on the skin and a reddening of the palms of the hands. At the same time, blood that cannot correctly enter the liver looks for alternative pathways to pass through. One of the most frequent of these are the oesophagus’ veins, which become dilated and form what is known as gastrooesophageal varices (venous dilatations in the stomach and oesophagus). Sometimes these varices can break and lead to gastrointestinal bleeding, causing patients to vomit blood (haematemesis) and leave digested blood in their stools (melaenas).
• Liver dysfunction: The liver has mainly synthetic (protein and lipid forming) and purification functions. When the liver's normal tissue is replaced with scar-tissue, these functions deteriorate. On the one hand, there is a drop in the production of the proteins it synthesises (especially coagulation factors and albumin). On the other hand, mental function deteriorates because toxic substances build up in the blood and reach the brain. Under normal conditions, these are eliminated from the blood by the liver, broken down and excreted into bile or blood as harmless by-products.
• Some people with very severe liver dysfunction or obstruction of the bile duct may present a yellowing of their skin (jaundice), itching (pruritus) and pale-coloured, oily and foul-smelling stools (steatorrhoea).
• For many people chronic hepatitis remains stable for years while for others it gradually worsens. Prognoses depend partly on the cause of the illness.

Who is affected by the condition?

Hepatitis B and C viruses are most often transmitted sexually or through intravenous injections among drug addicts. They may also be transmitted from mother to child during birth. Infection through blood transfusion is very controlled these days and practically never occurs

Toxic hepatitis is caused by exposure to toxins, some well known, others by an unexpected reaction to medicines that have no adverse effect on most of the population (idiosyncrasy). Alcohol abuse is the most common toxin.

Hepatic steatosis is directly linked to obesity among the general population.

Diagnosis

Diagnosis is based on three sets of features.

1. Family, personal and case histories

Patients suffering from chronic hepatitis usually present histories that help with the diagnosis, such as alcohol abuse or intravenous drug injections, use of certain medicines, being a child of a mother with HCV or HBV, or obesity. As for people with autoimmune hepatitis, they or their direct family members may present other autoimmune illnesses (such as diabetes, ulcerative colitis, lupus, vitiligo.)

2. Physical examination

Patients may show characteristic signs of portal hypertension (ascites, spider angiomas, reddening of the palms of the hands, collateral circulation in the abdomen). In the case of non-alcoholic steatohepatitis, patients are overweight/obese.

3. Complementary examinations:

- General analysis: Analytical tests can be taken to reveal inflammation of the liver (transaminases) and loss of its synthetic (coagulation and albumin tests) and purification (increased ammonium) functions. At the same time, a systemic detection can be made of the cause of the inflammation (viral serologies in cases of suspected virus illness, autoantibodies and immunoglobulins for autoimmune hepatitis, copper in urine and caeruloplasmin for Wilson’s disease, etc.)

- Imaging tests (abdominal ultrasound and CT scan) show the presence of a heterogeneous liver with probable fibrosis. Nodular margins and indirect signs of portal hypertension (collateral circulation, splenomegaly, etc.,) can be seen with patients presenting hepatic cirrhosis.

- Elastography may reveal the presence of hepatic fibrosis and determine its severity.

- Hepatic biopsy: may be used for helping with a differential diagnosis (accumulation of copper in Wilson's disease, interface hepatitis in autoimmune hepatitis, macrovesicular steatosis in non-alcoholic steatohepatitis, etc.) It will also reveal the extent of the hepatic fibrosis/cirrhosis.

Typical treatment

Treatment will depend on the cause of the chronic hepatitis.

- Viral hepatitis; hepatitis B and C viruses require specific antiviral treatment. In the case of hepatitis C, new direct-acting antivirals have radically changed the prognosis for patients, so that it is now a disease which is curable with few side effects.

- Hepatic steatosis requires a change of patient lifestyle (balanced diet and exercise). Several pharmacological treatments are currently being studied which could help to lessen the build-up of fat in the liver.

- Autoimmune hepatitis; this has a specific treatment where the defence system is modulated with corticoids and Azathioprine.

- Wilson's disease; this is an illness that causes copper to build up in the liver and other organs. Treatments are aimed at increasing the elimination of copper through urine (D-penicillamine) or at reducing its absorption (zinc salts)

Typical tests

Mainly analytical tests for diagnosing the cause of the inflammation of the liver and evaluating its dysfunction, and elastography to assess the extent of fibrosis.

Prevention 

• Vaccination against the A and B viruses is the best treatment possible (included in the vaccination calendar). There is currently no vaccine for the C virus.
• Contraceptive barrier methods (condoms) protect against STD infections (including hepatitis B and C).
• Use of early vaccination +/- gammaglobulins against the hepatitis B virus can prevent the transmission of the HBV from infected mothers to newborns.
• Toxic hepatitis is prevented by avoiding exposure to the various toxins involved.
• Finally, in the case of hepatic steatosis, prevention is promoted under healthcare-education programmes encouraging better habits.