Hepatitis
The many forms of hepatitis
Viral hepatitis is one of most common infectious diseases in the world. And no wonder -- there are at least five distinct hepatitis viruses: A, B, C, D, and E. All of them affect the liver in one way or another.
Several nonviral forms also exist. These include autoimmune hepatitis and toxic hepatitis. Toxic hepatitis is caused by drugs and toxins that directly injure the liver. Examples include long-term alcoholism, high doses of acetaminophen (the active ingredient in Tylenol and other pain relievers), or accidentally eating wild, poisonous mushrooms.
Hepatitis has gotten a lot of press in recent years, and public health officials have taken notice. More and more research dollars are being spent to find better treatments for the chronic versions of the disease.
Pronunciation
hep-ah-TY-tis
Synonyms & Abbreviations of Condition
- Hepatitis A, B, C, D, E (abbreviated as HAV, HBV, HCV, HDV, HEV)
- Acute viral hepatitis
- Chronic viral hepatitis
Detailed Description
Hepatitis A is the most common strain of the infection. But it's also the least serious. Most infected people recover completely within a month and have no lasting liver damage. Once you have it, you can never get sick from it again because your body develops immunity. Hepatitis A and E are spread through contaminated food or water. Hepatitis E is rare in the United States, but it's caused epidemics in developing countries such as India, Burma, Afghanistan, Algeria, and Mexico. Occasionally (less than 1% of the time), hepatitis A results in liver failure and death.
Hepatitis B is the next-most common. It can be either acute or chronic. It enters the body through infected bodily fluids, such as blood and semen, so it's considered a sexually transmitted disease. But you can also catch it from infected needles (for drugs, tattooing, acupuncture, etc.). Infected mothers can pass it on to their newborns during birth. Hepatitis D is dependent on hepatitis B, therefore only people infected with B can get D. D is also transmitted via bodily fluids.
Hepatitis C can also be either acute or chronic. It used to be transmitted primarily via blood transfusions, but since 1992 blood supplies are routinely screened for the virus and the incidence has been greatly reduced. These days it's mainly spread through unprotected sex and infected needles. Hepatitis C is the most likely of the viruses to cause chronic illness. It progresses slowly, usually over a course of 10 to 30 years.
Acute viral hepatitis tends to run its course and symptoms usually disappear within four to 16 weeks without any specific treatment. Chronic hepatitis will be either persistent (CPH) or active (CAH). CPH is more common, has few or no symptoms, and results in few long-term problems. CAH, on the other hand, has many symptoms and can lead to cirrhosis, liver failure, or liver cancer if left untreated.
Vaccines are only available to combat hepatitis A and B. Hepatitis A vaccines are usually given to people travelling to developing countries or countries where there have been outbreaks. Hepatitis B vaccines are recommended for sexually active people, healthcare workers, IV drug users, and newborn infants of infected mothers. The hepatitis B vaccine is increasingly being recommended as a routine childhood vaccination.
How Common Is Hepatitis?
New infections per year in the United States:
- Hepatitis A: Up to 200,000
- Hepatitis B: 150,000 to 300,000
- Hepatitis C: 28,000 to180,000
- Hepatitis D: about 5,000
- Hepatitis E: unknown, but thought to be few
Established Causes
Viral hepatitis is caused by any of the hepatitis viruses (A, B, C, D, or E).
Nonviral, or toxic hepatitis, can be caused by anything that inflames the liver, including:
- Excessive alcohol or drug use
- Eating wild, poisonous mushrooms
- Overdosing on acetaminophen (the active ingredient in Tylenol and other pain medications)
Risk Factors
Hepatitis A and E are spread by contact with something contaminated by the feces of an infected person, such as food. Some risk factors include:
- Poor sanitation
- Crowded conditions
- Contaminated water
- Contamined shellfish (hepatitis A)
Hepatitis B, C, and D are spread through direct contact with infected blood or bodily fluids. Risky behaviors include:
- Promiscuous, unprotected sex
- Sharing needles
- Working with infected blood without gloves (healthcare workers)
- Blood transfusions prior to 1992
- Tattoos or piercing with contaminated needles
- Using contaminated razors or toothbrushes
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population catch a certain illness. They are not necessarily "causes" of the condition.
Symptoms
Many people with hepatitis will feel only mildly ill, if at all. Symptoms include:
- Fever
- Malaise (ill feeling)
- Nausea and vomiting
- Anorexia
- Abdominal pain
- Diarrhea
- Fatigue
- Headache
- Dark urine
- Jaundice (yellow skin and eyes)
- Itchy red hives
- Foul breath with bitter taste
- Bleeding
- Altered mental status
Conditions That May Be Mistaken for Hepatitis
- Mononucleosis
- Hepatic malignancy
- Wilson's disease
- Gallbladder disease
- Appendicitis
- Peptic ulcer disease
How Hepatitis Is Diagnosed
Your doctor will ask about your history, including possible sources of viral exposure, and rule out other sources of liver infection such as drugs or alcohol.
A physical examination may reveal jaundice and tenderness around the liver upon touch.
Liver function tests, antibody assays, antigen assays, and PCR tests can determine the exact virus causing the hepatitis.
Laboratory Work
Laboratory tests are performed to determine abnormalities in the blood, resulting from the liver damage associated with hepatitis.
- Elevated AST, ALT, or alkaline phosphate levels
- Antibodies to the specific form of the virus (this can determine the viral source in 90% of cases)
- Alpha fetoprotein levels (can be elevated in liver cancer, a possible complication of chronic hepatitis C)
Imaging
A computed tomography (CT) scan may show irregularities of the liver consistent with inflammation, cirrhosis, or cancer.
Treatment Overview
No form of hepatitis is curable. Acute hepatitis needs no special treatment if symptoms are mild to moderate, but it's a good idea to avoid alcohol, eat a healthy diet, and get plenty of rest while you're recovering. It's unlikely that any medical treatments will alter the course of the disease. If you're experiencing severe itching, your doctor can prescribe Questran (cholestyramine). The medication binds with bile salts, which cause the itchy skin. Hospitalization is only required for people with complications such as encephalopathy (a neurologic illness) or hemorrhaging.
Chronic hepatitis can be managed with medications and complications can be treated as they arise. The goal is to reduce viral replication in order to decrease infection, reduce inflamed liver cells, and help get your bodily functions back into the normal range. It also will help prevent the disease from progressing to cirrhosis. Interferon has been most effective in treatment of chronic hepatitis B and C. These medications are a family of proteins that have antiviral and immune-enhancing features.
Healthcare Professionals Who May Be Involved in Treatment
- Internists
- Family physicians
- Gastroenterologists
- Transplant surgeons
Drug Therapy
Drugs most commonly prescribed for chronic conditions:
- Interferon (such as Intron A or Infergen) mimics the body's natural immune system to defend against viruses. These drugs are helpful against hepatitis B, C, and D.
- Rebetron is a combination of interferon and ribavirin that appears to suppress blood levels of HCV more effectively than a first course or repeat course of interferon alone.
- Corticosteroids may shorten the duration of hepatitis A.
- Hepatitis B immunoglobulin may help prevent recurrence of hepatitis B after liver transplantation.
- Lamivudine (such as Epivir-HBV) can be effective for hepatitis B sufferers. The hepatitis B virus carries its genetic information as DNA (as compared to types A, C, D and E, which carry their genetic information as RNA). Lamivudine interferes with DNA replication processes, thus limiting hepatitis B virus's ability to proliferate.
Surgery
Liver transplantation is only considered in end-stage liver disease, an occasional result of chronic hepatitis B or C, or when liver failure results from acute fulminant hepatitis.
Managing Hepatitis Treatment
Therapy for most cases of hepatitis is supportive (treats symptoms). The duration of hepatitis (acute) varies as follows:
- Hepatitis A lasts less than 2 months
- Hepatitis B averages 60 to 90 days
- Hepatitis C is usually a chronic illness that can be asymptomatic for years
- Hepatitis D duration is not known
- Hepatitis E averages 26 to 42 days
Monitoring the Condition
Regular checkups are extremely important if your condition turns chronic. Your doctor will need to monitor your liver enzymes and adjust your medication as needed. He or she will advise you of an appropriate schedule. Also, liver biopsies may be taken periodically.
Possible Complications
Chronic cases can lead to:
- Cirrhosis
- Liver failure
- Liver cancer
Activity & Diet Recommendations
In general, you should try to remain as active as possible given how you feel. There is no need for bed rest after the first few days unless there are complicating factors during the initial illness.During the acute phase, drink lots of liquids including vegetable broth and vegetable juices mixed with water. Do not drink alcoholic beverages. The liver is trying to repair itself and alcohol not only impedes its progress, it also increases the chances of liver damage.
In chronic cases of hepatitis, you should stick to a diet low in saturated fats, simple carbohydrates (sugar, white flour, fruit juice, etc.), fried foods, and animal products. This may help aid in the detoxification of your liver. It's also possible that a diet rich in fruits, vegetables, and whole grains can increase the elimination of bile acids, drugs, and other toxins from your system, thus helping the liver repair itself.
Considerations for Women
Autoimmune hepatitis, an overactive immune system that results in chronic liver inflammation, is more common among women than men. In young women with this disease, sporadic symptoms may arise such as acne, amenorrhea (loss of menstrual periods), joint pain, lung scarring, inflammation of the thyroid gland, kidney inflammation, and anemia.
In a typical case, a woman will come to her doctor's office seemingly healthy but with multiple spider veins, acne, and hirsutism (excessive growth of hair). Autoimmune hepatitis cases sometimes follow an attack of hepatitis A, Epstein-Barr, or measles.
Women with any form of hepatitis should stop taking birth control pills during the acute stages of the disease. Birth control pills are metabolized in the liver, causing it to work harder, thus slowing recovery from the hepatitis. In any case, consult your doctor.
Pregnancy
A pregnant woman with hepatitis can transmit the virus to her child during birth.
Considerations for Children and Adolescents
In younger children, acute viral hepatitis is a common mild infection. It often cures itself in two to three weeks, but it's prudent to wait two more weeks before sending your child back to school or daycare.
In older children, symptoms peak and then gradually disappear on their own within three to 16 weeks. Children who are in otherwise good health recover fully in four months or less. A very small percentage (1% to 2%) may progress to chronic hepatitis.
Children vary widely in their recuperation from hepatitis. Some need bed rest until fevers subside, and then can sit up, watch TV, and play video games. It's important to encourage your child to eat-- small, well-balanced meals promote a quick recovery. Have your child drink eight glasses of water each day. Hard candy is a fun treat that may be nourishing to the liver.
Call your healthcare provider if your child totally loses his or her appetite, has excessive drowsiness or mental confusion, vomiting, diarrhea or abdominal pain, a skin rash, or itching.
Considerations for Older People
Hepatitis B is occasionally fatal, primarily in older people. Immune responses to the vaccine in healthy individuals tend to decrease with advancing age. That's why it's a good idea to get vaccinated against HBV before you reach the golden years.
Supplements
- Antioxidants. Some research suggests that antioxidants -- notably, vitamin E and the mineral selenium -- help strengthen the liver and treat hepatitis. Most multivitamins contain these nutrients.
Herbs
- Milk thistle. Its seeds contain three compounds, collectively known as silymarin, that spur repair of damaged liver cells and protect the liver from toxins. Commission E, the German expert panel that judges the safety and effectiveness of herbal medicines for that nation's counterpart of the Food and Drug Administration, endorses milk thistle as a treatment for hepatitis. German researchers gave viral hepatitis sufferers either a placebo or silymarin. After three weeks, significantly more of the silymarin group showed normal liver function. [1] Milk thistle is marketed in a standardized extract. The standard dose is 140 mg three or four times a day.
Sources
1 Magliulo, E., et al. "Results of a Double-Blind Study on the Effect of Silymarin in Treatment of Acute Viral Hepatitis," Med. Klin [German] (1978) 73:1060.uvy{9(R)|}
Self-Care Measures
Although hepatitis cannot always be prevented, it can be slowed down. Here are a few ways to slow the progression of this disease:
- Avoid alcohol. It's a leading cause of liver damage.
- Take as few drugs as possible. They are metabolized through the liver. If you have hepatitis, drugs stress the liver and slow healing.
- Maintain good hygiene. Good sanitation and hygiene help reduce the incidence of hepatitis A. Wash your hands regularly, especially after using the toilet. If you are an IV drug user, use clean needles and don't share with anyone else. Use condoms every time you have sex.
Vaccinations
If you plan to travel abroad, consider getting a hepatitis A vaccination. Hepatitis B shots should be considered if you're planning to travel to high-risk areas: China, Southeast Asia, sub-Saharan Africa, South America, or the South Pacific. Hepatitis B vaccination is also a good idea if you're a health worker, sexually active, on kidney dialysis, or a sex partner of someone who is already infected.
If you've been exposed to hepatitis, there is a passive immunization called immune globulin (an antibody preparation). This vaccination could be useful for people in close contact with children (i.e., daycare staff), institutions with multiple cases, travelers to high-risk areas (with three-week lead time), and others.
There is also a longer-term hepatitis A vaccination called Havrix or Vaqta. Adults get one shot, then a booster shot six months later. This vaccine is recommended for travelers, daycare staff/children, custodial staff, sewage workers, military, food handlers, and Native Americans/Alaskan natives.
The vaccine for hepatitis B comes in three injections, the second one month after the first and the third six months later. High risk groups (healthcare workers, sexually active people with more than one partner, intravenous drug users, sexual partners and family members of people who have hepatitis B) are encouraged to get vaccinated as a preventative measure. People exposed to hepatitis B can use the vaccine within 24 hours of exposure. Doctors are beginning to recommend universal vaccination of infants at birth as a public health measure.
There are no specific measures to prevent hepatitis C or E. Preventing hepatitis B will naturally prevent hepatitis D because it depends upon hepatitis B for its occurrence.
Websites & Organizations
American Gastroenterological Association
7910 Woodmont Ave., Seventh Floor
Bethesda, MD 20814
Phone: 301-654-2055
Fax: 301-652-3890
Email: cdaniels@gastro.org
Centers for Disease Control and Prevention
1600 Clifton Rd., NE
Atlanta, GA 30333
Phone: 888-443-7232
The Hepatitis C Foundation
1502 Russett Drive
Warminster, PA 18974
Phone: 215-672-2606
Fax: 215-672-1518
Email: info@hepcfoundation.org
Hepatitis Education Project
P.O. Box 95162
Seattle, WA 98145-2162
Hepatitis Foundation International
30 Sunrise Terrace
Cedar Grove, NJ 07009-1423
Phone: 973-239-1035 or 800-891-0707
Fax: 973-857-5044
Email: mail@hepfi.org
HepNet
National Health Information Center
P.O. Box 1133
Washington, DC 20013-1133
Phone: 301-565-4167 or (800) 336-4797
Fax: 301-984-4256
Email: nhicinfo@health.org
Sources for This Article
Books
Balch, James F. and Balch, Phyllis A. Prescription for Nutritional Healing. Garden City Park, NY: Avery Publishing, 1997.
Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W.B. Saunders, 1996.
Fauci, Anthony J. et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.
Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.
Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.
Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.
Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.
Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.
Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.
Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.
Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.
Articles
Allander, T, Gruber, A, Naghavi, M, Beyene, A, Soderstrom, T, Bjorkholm, M, Grillner, L, Persson, MA. "Frequent Patient-to-Patient Transmission of Hepatitis C Virus in a Haematology Ward." Lancet. 345(8950):603-7. Mar 11, 1995.
Davis, GL. "Hepatitis B: Diagnosis and Treatment." South Med J. 90(9):866-70; quiz 871. Sep 1997.
Dickson, RC; Wright, RM, Bacchetta, MD, Bodily, SE, Caldwell, SH, Driscoll, CJ, Pruett, TL, Ishitani, MB. "Quality of Life of Hepatitis B and C Patients After Liver Transplantation." Clin Transplant. 11(4):282-5. Aug 1997.
Flamm, SL, Parker, RA, Chopra, S. "Risk Factors Associated With Chronic Hepatitis C Virus Infection: Limited Frequency of an Unidentified Source of Transmission." Am J Gastroenterol. 93(4):597-600. Apr 1998.
Hu, JF, Cheng, Z, Chisari, FV, Vu, TH, Hoffman, AR, Campbell, TC. "Repression of Hepatitis B Virus (HBV) Transgene and HBV-Induced Liver Injury by Low Protein Diet." Oncogene. 15(23):2795-801. Dec 4, 1997.
Huppertz, HI, Treichel, U, Gassel, AM, Jeschke, R, Meyer zum Buschenfelde, KH. "Autoimmune Hepatitis Following Hepatitis A Virus Infection." J Hepatol. 23(2):204-8. Aug 1995.
Magliulo, E. et al. "Results of a Double-Blind Study on the Effect of Silymarin in Treatment of Acute Viral Hepatitis," Med. Klin [German] (1978) 73:1060.uvy{9(R)|}
Marcus, EL, Tur-Kaspa, R. "Viral Hepatitis in Older Adults." J Am Geriatr Soc. 45(6):755-63. Jun 1997.
Najm, W. "Viral Hepatitis: How to Manage Type C and D Infections." Geriatrics. 52(5):28-30, 33-4, 37. May 1997.
Rosman, AS, Waraich, A, Galvin, K, Casiano, J, Paronetto, F, Lieber, CS. "Alcoholism is Associated with Hepatitis C But Not Hepatitis B in an Urban Population." Am J Gastroenterol. 91(3):498-505. Mar 1996.
Vail, BA. "Management of Chronic Viral Hepatitis." Am Fam Physician. 55(8):2749-56, 2759-61. Jun 1997.
