Chronic hepatitis

Pamphlet by: American Liver Foundation, Sept 23, 1991

Definition - Chronic Hepatitis (CAH) is ongoing injury to the cells of the liver with inflammation which lasts for longer than six months. The causes of chronic hepatitis are several: viruses, metabolic or immunologic abnormalities and medications.

Symptoms - Symptoms result from the liver cell injury, the inflammation or from the resulting scarring which is called cirrhosis. Chronic hepatitis may follow acute hepatitis B or C (formerly called bloodborne or transfusion non-A, non-B) or may develop quietly without an acute illness.

Liver biopsy is helpful in that it confirms the diagnosis, aids in establishing the cause (etiology) and can demonstrate the presence of cirrhosis. It is less helpful in judging the response to treatment.

Causes - The most common causes of chronic hepatitis are the viruses of hepatitis B and hepatitis C. Together they account for more than 75% of the cases in the world. Hepatitis B is far more common in China and sub-Saharan Africa and among male homosexuals and IV drug users.

Chronic hepatitis C behaves differently from hepatitis B. The disease is generally mild, with fatigability being the main symptom. However, ten or more years later, the complications of cirrhosis appear in some patients, sometimes unexpectedly. By contrast with Hepatitis B, the percentage of patients infected who develop cirrhosis is much greater. While primary liver cancer can also develop from hepatitis C, it appears to be much less common than after hepatitis B.

Autoimmune chronic hepatitis varies from mild to serious disease from one patient to the next and from time to time in the same patient. The percentage of patients who develop cirrhosis is high and it may appear early. Most of the patients are young women but postmenopausal women and males may get the disease. Only a few cases of primary liver cancer have been reported with this disease.

Among 25% of the cases of chronic hepatitis results from damage to the liver by the immune system. The trigger for this autoimmune chronic hepatitis is unknown, but the damage to the liver is caused by the individual's lymphocytes and by antibodies produced to the individual's own tissue. Autoimmune chronic hepatitis is usually a progressive disease ending in cirrhosis.

Hepatitis A and E (formerly epidemic or enteric non-A, non-B) are rarely, if ever, responsible for cases of chronic hepatitis.

Hepatitis D infection needs the hepatitis B virus to multiply. Hepatitis D can cause acute hepatitis in someone who is a carrier of the hepatitis B virus and can cause acute hepatitis at the same time that the hepatitis B virus does. In any event, the combination of hepatitis B and D is worse than hepatitis B alone and is more likely to cause serious chronic hepatitis and cirrhosis. IV drug users have a high incidence of hepatitis D.

Other Causes - Viruses of the Herpes family which cause cold sores, genital herpes, chicken pox, shingles and infectious mononucleosis can cause acute hepatitis, especially when the immune system is not properly functioning but is unlikely that they produce chronic hepatitis. The AIDS virus does seem to directly attack the liver. Other viruses, as yet undiscovered, may be responsible for some cases of chronic hepatitis.

Drug-Induced Hepatitis - Few medications still in use and several that have been withdrawn from the market can also cause chronic hepatitic (CAH). These include isoniazid, used for tuberculosis; methyldopa, used for hypertension; nitrofurantoin, used for urinary tract infections; phenytoin, used for seizure disorders and selected other prescription medications. These medications must be taken for long periods of time and the number of cases of CAH produced by these medications is small.

Chronic hepatitis caused by medicines is usually recognized early so that stopping the medicine before cirrhosis has developed reverses the disease.

Inherited Disorders - Some inherited disorders of metabolism also can appear as chronic hepatitis. The most frequent of these uncommon conditions is Wilson's disease, a familial disorder of copper metabolism Alpha-1-antitrypsin deficiency and tyrosinemia may appear as chronic hepatitis although other features help in distinguishing these rare conditions from those caused by viruses.

Signs and Symptoms - Fatigue, mild discomfort in the upper abdomen, loss of appetite and aching joints are the common symptoms of chronic hepatitis. Fatigue is by far the most common symptom and it might be quite disa bling. Often it gets worse as the day wears on. Some patients, however, may have no symptoms. Others may have signs of liver failure, including jaundice, abdominal swelling (due to fluid retention called ascites), or coma, depending on the severity of the liver disease and whether or not cirrhosis has developed. Most complications are vague and may be mistaken for other diseases or simply a consequence of aging. Disorders of other organs like the thyroid, intestine, eyes, joints, blood, spleen, kidneys and skin may occur in about 20% of patients depending on the cause of the chronic hepatitis.