What Is Hepatitis?

The liver is the largest organ in the body, occupying the entire upper right quadrant of the abdomen. It performs over 500 vital functions. It processes all of the nutrients the body requires, including proteins, glucose, vitamins, and fats. The liver manufactures bile, the greenish fluid stored in the gall bladder that helps digest fats. One of the liver's major contributions to life is to render harmless potentially toxic substances, including alcohol, ammonia, nicotine, drugs, and harmful by-products of digestion. Old red blood cells are removed from the blood by the liver and spleen, and the iron is cycled to the bone marrow to make new ones. Damage to the liver can impair these and many other processes. Hepatitis is a disorder in which viruses or other mechanisms produce inflammation in liver cells, resulting in their injury or destruction. In most cases, this inflammatory process is triggered when the immune system fights off infections caused by viruses. It can also be caused, however, by an overactive immune system that attacks its own liver cells. Inflammation of the liver can also occur from medical problems, drugs, alcoholism, chemicals, and environmental toxins. Hepatitis varies in severity from a self-limited condition with total recovery to a life-threatening or life-long disease.

Experts define hepatitis as short-term (acute hepatitis) or prolonged (chronic hepatitis). In some cases, acute hepatitis develops into a chronic condition, but chronic hepatitis can also occur on its own. Although chronic hepatitis is generally the more serious condition, patients having either condition can experience varying degrees of severity.

Acute Hepatitis

Acute hepatitis can begin suddenly or gradually, but it has a limited course and rarely lasts beyond one or two months. Usually there is only spotty liver cell damage and evidence of immune system activity, but on rare occasions, acute hepatitis can cause severe, even life-threatening, liver damage.

Chronic Hepatitis

The chronic forms of hepatitis persist for prolonged periods. Experts usually categorize chronic hepatitis as either (1) chronic persistent or (2) chronic active hepatitis.

Chronic Persistent Hepatitis. Chronic persistent hepatitis is usually mild and nonprogressive or slowly progressive, causing limited damage to the liver. Cell injury in such cases is usually limited to the region of portal tracts , which contains vessels that carry blood to the liver from the digestive tract. In some cases, however, more extensive liver damage can occur over long periods of time and progress to chronic active hepatitis.

Chronic Active Hepatitis. If damage to the liver is extensive and cell injury occurs beyond the portal tract, chronic active hepatitis can develop. Significant liver damage has usually occurred by this time. Liver cells are destroyed between the portal tract and the central veins in the liver, and progressive cell damage can build a layer of scar tissue over the liver, resulting in the condition known as cirrhosis. In such cases, the entire liver is threatened with malfunction and failure.

What Causes Hepatitis?

Viral Causes of Hepatitis

Most cases of hepatitis are caused by viruses that attack the liver, defined by the letters A through G. It should be noted that the cause of hepatitis is sometimes unexplained, indicating that additional viruses have not yet been discovered.

Hepatitis A. Hepatitis A, formerly called infectious hepatitis, is always acute and never becomes chronic. The virus is excreted in feces and transmitted by contaminated food and water. Eating shellfish taken from sewage-contaminated water is a common means of contracting hepatitis A. It can also be acquired by close contact with individuals infected with the virus. The hepatitis A virus does not directly kill liver cells, and experts do not yet know how the virus actually injures the liver.

Hepatitis B and D. The virus for hepatitis B, formerly called serum hepatitis, is found in semen, blood, and saliva. It is usually spread by blood transfusions, contaminated needles, and sexual contact. Blood screening has reduced the risk from transfusions. The virus does not kill cells directly, but seems to activate cells in the immune system, which cause inflammation and damage in the liver. Hepatitis D virus can replicate only by attaching to hepatitis B and therefore cannot exist without the B virus being present. Between 1% and 10% of hepatitis B patients go on to develop chronic hepatitis and hepatitis B can become chronic without an acute stage.

Hepatitis C. Hepatitis C was the major cause of all cases of hepatitis resulting from transfusions and most cases resulting from intravenous drug use. About 10% to 60% of acute hepatitis C patients develop the chronic form, which can also occur without a preceding acute stage.

Hepatitis E. Hepatitis E is similar to hepatitis A and is transmitted by contact with contaminated food or water. Up to 20% of people in the US may be infected, even those who haven't traveled.

Hepatitis G. Hepatitis G accounts for about 9% of cases that cannot be diagnosed as hepatitis A through E. It also occurs in about 25% of patients with hepatitis A, 32% of those with hepatitis B, and 20% of patients with hepatitis C. Hepatitis G may be transmitted sexually or through transfusions and exchange of body fluids. It is always chronic, but to date much research indicates it does not cause disease or even increase the severity of any accompanying virus, including HIV or other hepatitis viruses. Still, a few studies indicate some risk for liver damage and more are needed.

Other Viruses Causing Hepatitis or Liver Damage. Hepatitis GB has been discovered as a new distinct hepatitis virus. Another recently detected virus called transfusion-transmitted virus (TTV) may be more common than previously thought and may be transmitted via means in addition to transfusions. It is not yet known whether either of these viruses injure the liver. A number of other common viruses, including herpes simplex, can sometimes injure the liver, although they rarely cause severe hepatitis.

Autoimmune Chronic Hepatitis

Autoimmune chronic hepatitis accounts for about 20% of all chronic hepatitis cases. Like other autoimmune disorders, this condition develops because a genetically defective immune system attacks the body's own cells and organs, in this case, the liver, after being triggered by an environmental agent, probably a virus. Suspects include the measles virus, a hepatitis virus, or the Epstein-Barr virus, which causes mononucleosis. It is also possible that a reaction to a drug or other toxin that affects the liver also triggers an autoimmune response in susceptible individuals. In about 30% of cases, autoimmune hepatitis is associated with other disorders that involve autoimmune attacks on other parts of the body.

Hepatitis Caused by Alcohol and Drugs

Alcohol. About 10% to 35% of heavy drinkers develop alcoholic hepatitis. In the body, alcohol breaks down into various chemicals, some of which are very toxic in the liver. After years of drinking, liver damage can be very severe, leading to cirrhosis in about 10% to 20% of cases.

Drugs. Because the liver plays such a major role in metabolizing drugs, hundreds of medications can cause reactions that are similar to those of acute viral hepatitis. Symptoms can appear anywhere from two weeks to six months after starting drug treatment. In most cases, they disappear when the drug is withdrawn; but, in rare circumstances, they may progress to serious liver disease. Among the drugs most prominently cited for liver interactions are halothane, isoniazid, methyldopa, phenytoin, valproic acid, and the sulfonamide drugs. Notably, very high doses of acetaminophen (Tylenol) have been known to cause severe liver damage and even death, particularly when used with alcohol.

Nonalcoholic Steatohepatitis

Nonalcoholic steatohepatitis (NASH) has features similar to alcohol-induced hepatitis, particularly a fatty liver, but it occurs in individuals who do not consume significant amounts of alcohol. This disorder may occur in conjunction with obesity, diabetes, high cholesterol levels, small intestine surgery, or other factors. NASH should be considered as a possible cause of chronic hepatitis when other acquired causes have been eliminated.

Who Gets Hepatitis?

Risk Factors for Hepatitis A

About one third of the Kerala population has antibodies to hepatitis A, indicating previous infection by the virus. Almost 70% are children under age 15. Feces-contaminated water and food are the major sources of infection, and infected people can transmit it to others if they do not take strict sanitary precautions. Of the various strains of hepatitis, hepatitis A is the one people are most likely to encounter in the course of international travel. In fact, in spite of the availability of a vaccine, the increase in travel to underdeveloped countries has kept the incidence of hepatitis A steady in Western nations. In fact, the trend is toward an increase in cases. Outbreaks have occurred in day care centers, but the risk is low if hygienic precautions are used, particularly when changing babies and handling diapers. The disease has also been transmitted sexually among homosexual men and it often occurs in intravenous drug users. An Israeli study reported that workers at higher risk are those in the food industry, kindergarten and day care teachers, physicians, dentists, and medical technicians.

Risk Factors for Hepatitis B and D

About 350 million people carry hepatitis B worldwide; it is very common in southern Africa, Asia, and the Mediterranean.  Chronic infection occurs in 6% to 10% of infected people, so that there are between 1 and 1.25 million chronic carriers of the virus. It can infect children and adults, although up to 90% of hepatitis B patients are men. Despite blood screening and routine testing in children the current annual incidence is holding steady. This may indicate that sexual activity is an important route for viral transmission and that the protective effect of the vaccine has not yet reached older, high-risk groups. Also, as with hepatitis A, the increase in travelers to underdeveloped nations may also be responsible for the steady rate. Drug users who share needles are at considerable risk. Pregnant women with hepatitis B can transmit the virus to their babies. Even if they are not infected at birth, unvaccinated children of infected mothers run a 60% risk of developing it before age five. Children are more likely than adults to become chronic carriers. The virus can be passed from cuts, scrapes, and other breaks in the skin. Also at risk are hospital workers exposed to blood products, staff members of institutions for mentally impaired people, prisoners, and emigrants from areas where the disease rate is high. Contaminated medical instruments, including finger stick devices used for more than one individual, have been known to transmit the virus.

Hepatitis D occurs only in people with hepatitis B. It is not common in the US except in intravenous drug abusers and people who require multiple transfusions. Those who recover from hepatitis B are immune to further infection from both hepatitis B and D viruses.

Risk Factors for Hepatitis C

Hepatitis C is a worldwide major health problem, infecting an estimated 150 million people. There are about 36,000 new infections every year in the US and up to 30% are symptomatic; an estimated 2.7 million Americans are chronically infected. Although some risk factors have been identified, it is still not known how 40% of patients acquire this form of hepatitis. Until blood screening began in 1990, the primary mode of transmission was through transfusions. Hepatitis C can exist for decades, however, without symptoms, and nearly 300,000 people who had transfusions before 1992, including many who were children at the time, may have been infected. People who are still at high risk for hepatitis C include intravenous drug users, intranasal cocaine users, people who have had body piercing, and organ transplant recipients. (Unfortunately, programs to reduce needle sharing do not seem to be very protective against hepatitis C.) Either sexual promiscuity or a long-term sexual and intimate relationship with an infected partner increases the risk, although it is not fully known how transmission occurs in these cases. One study, for instance, found no genetic traces of the virus in the semen of men infected with hepatitis C. Another study of 109 patients found only one infected family member. Although most health care providers are at low risk, the chance of infection in hospital workers who are accidentally stuck with a needle is high, ranging from 4% to 10%. There appears to be some risk for a mother to pass the infection on to her infant; some studies estimate the risk as between 5% to 10%. Of some reassurance was a 1999 study of 458 people who had transfusions when they were children. After an average of 20 years only 8% tested positive for hepatitis C and only three people showed signs of any liver abnormalities. These results suggest that the virus may be less aggressive in children than adults, but further observations are needed to learn if the infection remains mild beyond age 30.

Risk Factors for Hepatitis G

Hepatitis G is detected in between 1.5% and 3.2% of blood donors and is believed to be more common than hepatitis C. From what is known of hepatitis G, its risk factors are probably similar to those of hepatitis C, although incidence among patients with multiple blood transfusions is much lower than with hepatitis C.

Risk Factors for Autoimmune Chronic Hepatitis

Autoimmune chronic hepatitis may occur in women between the ages of 20 and 40 who have other diseases of the immune system, including systemic lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, inflammatory bowel disease, glomerulonephritis, and hemolytic anemia. About 30% of patients are men, however, and in both genders there is often no relationship to another autoimmune disease. In general, no major risk factors have been discovered for this condition.

Risk Factors for Alcoholic Hepatitis

Women who abuse alcohol are at higher risk for alcoholic hepatitis and cirrhosis than are men who drink heavily. High fat diets may also increase the risk in heavy drinkers.

What Are The Symptoms Of Hepatitis?

Symptoms of Acute Viral Hepatitis

General Symptoms. Symptoms of acute viral hepatitis may begin suddenly or develop gradually. They may be so mild that patients mistake the disease for the flu. Nearly all patients experience some fatigue and often have mild fever. Gastrointestinal problems are very common, including nausea and vomiting and a general feeling of discomfort in the abdomen or a sharper pain that may occur in the upper right area if the abdomen. This pain tends to increase during jerking movements, such as climbing stairs or riding on a bumpy road. GI problems can lead to loss of appetite, weight loss, and dehydration. After about two weeks, dark urine and jaundice, a yellowish color in the skin and whites of the eyes, develops in some, but not all, patients. Children tend not to develop jaundice. About half of all hepatitis patients have light colored stools, muscle pain, drowsiness, irritability, and itching, usually mild. Diarrhea and joint aches occur in about a quarter of patients. The liver may be tender and enlarged and most people have mild anemia. In about 10% of patients, the spleen is enlarged.

Symptoms of Fulminant Hepatitis. In very rare cases, within two months of onset, a very serious condition known as fulminant hepatitis develops. Symptoms may include a large swollen abdomen (known as ascites) and a peculiar hand-flapping tremor (called asterixis). These symptoms may be followed by stomach and intestinal bleeding and mental confusion, stupor, or coma caused by brain injury (encephalopathy).

Symptoms Typical of Acute Hepatitis A. Symptoms of hepatitis A are usually mild, especially in children. They generally appear between two and six weeks after exposure to the virus. Adult patients are more likely to have fever, jaundice, and itching that can last one to several months.

Symptoms Typical of Acute Hepatitis B. Hepatitis B symptoms appear long after the initial infection, usually four to 24 weeks. Many patients may not even experience symptoms, or they may be mild and flu-like. About 10% to 20% of patients have a fever and rash. Nausea is not common. Hepatitis B patients may experience general aching in the joints, but sometimes the pain can resemble arthritis, affecting specific joints and accompanied by redness and swelling.

Symptoms Typical of Acute Hepatitis C. If they appear at all, symptoms develop about a month or two after a person is infected with hepatitis C. These are usually milder than those of hepatitis B. About 75% of patients show no signs of jaundice, and many do not experience any symptoms.

Symptoms of Chronic Hepatitis

Symptoms of Chronic Hepatitis B and C. Both hepatitis B and C can progress to chronic hepatitis usually with no early acute symptoms. Symptoms of progressive chronic viral hepatitis may be very subtle and no more than a mild persistence of acute symptoms for six or more months. In fact, chronic hepatitis C can be present for 10 to 30 years without presenting any obvious problems. In some patients, itchy skin may be the first symptom. Symptoms of chronic hepatitis can impair daily function, vitality, and mood in ways that are similar to other chronic diseases. Some patients develop pain in small joints in the body (such as the hand) that may be nearly indistinguishable from symptoms of rheumatoid arthritis, fibromyalgia, or carpal tunnel syndrome. In some cases, however, cirrhosis or liver failure can develop before patients experience any symptoms at all.

Symptoms of Chronic Autoimmune Hepatitis. The symptoms of chronic autoimmune hepatitis range from minimal to severe, including fatigue, jaundice, fever, and weight loss. The liver and spleen are often enlarged. In addition, patients with this condition may experience skin disorders, including palmar erythema (red palms) and spider angioma (a blood-red spot, the size of a pinhead, from which tiny blood vessels radiate like spider legs). Itching is not common, however. The abdomen or legs may be swollen due to the accumulation of fluid.

How Is Hepatitis Diagnosed?

Tests to Diagnose the Presence of Hepatitis

In people suspected of having or carrying viral hepatitis, physicians would measure certain substances in the blood. One of the most important factors indicative of hepatitis is bilirubin, a red-yellow pigment that is normally metabolized in the liver and then excreted in the urine. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise, sometimes causing jaundice. Physicians will also look at blood levels of enzymes known as aspartate (AST) and alanine (ALT) aminotransferases, which are released when the liver is damaged.

Tests to Determine Causes of Hepatitis

To identify the particular virus causing hepatitis, blood tests called radioimmunoassays are performed. Some of these tests can pinpoint hepatitis antigens, which are proteins that are unique to the specific viruses. More commonly, radioimmunoassays identify particular antibodies, which are molecules in the immune system that attack specific antigens. Antibodies may not appear for up to weeks or months after hepatitis develops, so if the tests are performed too early, they may not detect antibodies even if the patient is infected. Antibodies also persist after patients recover, so a positive antibody test can indicate a previous infection but cannot necessarily determine if the infection is active.

Tests for Hepatitis A. The first antibodies produced to fight the hepatitis A virus are IgM antibodies. They appear early in the course of the disease and usually can be identified using radio immunoassays as soon as symptoms appear. IgM antibodies disappear during recovery, but IgG antibodies persist, indicating previous infection.

Tests for Hepatitis B and D. A radioimmunoassay for hepatitis B must be done promptly to identify the antigen HB_sAg, which is found in the blood in early stages but disappears within four months unless the patient becomes a long-term carrier. Antibodies to the antigen appear during convalescence and may be identified then, even if the antigen itself was missed early on. To diagnose hepatitis D using an antibody test, hepatitis B must also have been identified.

Tests for Hepatitis C and G. A number of tests, including an accurate home test (Hepatitis C Check), are available for identifying the antibody to the hepatitis C virus. The standard test is known as enzyme-linked immunosorbent assay (ELISA). The antibody for hepatitis C is used to identify the virus but it may not show up for three to six months after the onset of the disease, so its absence is not necessarily an indication of a healthy liver. If the physician still firmly believes the virus is present, another test, polymerase chain reaction (PCR), may be performed. A PCR is able to make multiple copies of the genetic material (the RNA) of the virus to the point where it is detectable. It is also the only test available to identify hepatitis G but it is very expensive and not recommended for what seems to be, so far, a mild disorder.

Tests for Autoimmune Chronic Hepatitis

If a patient experiences symptoms of chronic active hepatitis for six months or more and a virus cannot be identified, then autoimmune hepatitis is usually suspected. To help confirm this condition, test results may show high levels of immune factors called serum globulins or certain antibodies to liver proteins. In some cases, a successful trial of steroid drugs may be the only way to diagnose autoimmune hepatitis.

Tests Performed after a Diagnosis of Hepatitis

Blood tests for hepatitis include measurements of aminotransferase levels, bilirubin levels, and detection of blood clotting problems. Immunoassays to detect antibodies to hepatitis viruses are also performed. A liver biopsy may be performed for acute viral hepatitis caught in a late stage or for severe cases of chronic hepatitis. Some experts are now recommending biopsies for all chronic hepatitis C patients, regardless of severity, because of the risk for liver damage even in patients without symptoms. A biopsy helps determine treatment possibilities, the extent of damage, and the long-term outlook.

How Serious Is Hepatitis?

Prognosis for Acute Viral Hepatitis

In most cases of acute viral hepatitis, recovery is complete and the liver returns to normal within two to eight weeks. In a small number of cases of hepatitis B or C, the condition can be prolonged and recovery may not occur for a year. About 5% to 10% of these patients will experience a flare-up of symptoms in a milder form before full recovery. A few of these patients may go on to develop chronic hepatitis. In the rare event that fulminant hepatitis develops, the liver fails and gastrointestinal hemorrhage and brain damage (encephalopathy) occur, resulting in mental confusion, or even coma. Without liver transplantation, death occurs in up to 80% of these cases. Pregnant women with acute hepatitis B, C, or E are at higher risk for these complications. Other serious, and also rare, consequences of acute viral hepatitis are aplastic anemia (which can be fatal), pancreatitis, hypoglycemia, and polyarteritis, a serious inflammation of blood vessels. People who have been infected with a hepatitis virus continue to produce antibodies to that specific virus. This means that they cannot be re-infected with the same hepatitis virus again. Unfortunately, they are not protected from other types.

Specific Prognosis for Hepatitis A and E. Hepatitis A is the least serious hepatitis virus; it never becomes chronic. Fulminant hepatitis is the major concern, but even if this condition develops, it is almost always less dangerous than with other viral types; only one in a thousand patients are at risk for death from this complication. If, however, a person with chronic hepatitis C, even without cirrhosis, becomes infected with hepatitis A, super-infection can occur leading to a life-threatening form of fulminant hepatitis. (In patients with hepatitis B who do not have cirrhosis, infection with hepatitis A does not appear to be as dangerous.) Hepatitis E is acute and also not serious except in pregnant women, when it can be life threatening.

Specific Prognosis for Hepatitis B and D. Acute hepatitis B is lethal in only 1% of patients, but even patients with mild symptoms can remain chronically infected with the virus. Between 5% and 15% of hepatitis B patients carry the virus throughout their lives, and about 25% of these carriers progress to chronic hepatitis. People most at risk for carrying the virus are children infected before they are five and newborns, most of whom become carriers. People most at risk for progression to chronic hepatitis are those infected in early childhood and people with damaged immune systems, such as AIDS patients.

If a patient with hepatitis B becomes co-infected with hepatitis D, the consequences can be very serious. There is an increased risk for fulminant hepatitis. The risk for developing a chronic form of hepatitis D is the same as for hepatitis B alone.

Specific Prognosis for Acute Hepatitis C. The mortality rate for acute hepatitis C is well below 1%, but people infected with hepatitis C tend to become life-long carriers of the virus. Between 40% and 60% of these patients develop chronic hepatitis within four years. It is currently not possible to predict which patients will develop the chronic form of hepatitis C.

Prognosis for Chronic Hepatitis B and C

Patients with chronic persistent hepatitis who have mild or no symptoms have a favorable outlook. In chronic active hepatitis, however, liver biopsies often reveal scarring, which is indicative of cirrhosis, and damage to the liver cells that bridge the portal and central veins of the liver. Nearly every bodily process is affected by a damaged liver, including digestive, hormonal, and circulatory systems. Symptoms can significantly impair daily life. The risk for cirrhosis is much higher in patients with hepatitis C than in those with hepatitis B. Recent studies indicate, however, that a latent hepatitis B infection may occur with hepatitis C more commonly than believed and that its presence may significantly increase the risk for cirrhosis. If cirrhosis develops, the average survival time is about ten years. Severe complications occur in half of cirrhosis patients within 10 years, however, and in such cases, the average survival time drops to only nine months. Life-threatening complications include encephalopathy, stomach and intestinal bleeding, and kidney failure. The risk for liver cancer in patients with cirrhosis is about 14%. (Liver cancer is rare in patients who do not develop cirrhosis.) [For more information, see the report, Cirrhosis.]

Prognosis of Patients with Chronic Hepatitis B. The great majority of people with chronic persistent hepatitis B have a good long-term outlook, but between 5% and 10% become carriers of the virus and 5% to 10% eventually develop cirrhosis. The addition of hepatitis D is a particular danger and increases the risk for cirrhosis. Hepatitis B is a primary cause of liver cancer. In Asia about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. (One Italian study that followed a group of hepatitis B patients for 11 years found no development of liver cancer over that period of time.) Vaccinations for hepatitis B are proving to significantly reduce this risk.

Prognosis of Patients with Chronic Hepatitis C. About 15% of hepatitis C patients recover spontaneously, and about 25% have a mild and benign course with normal liver enzymes. Even among those with abnormal liver enzymes, most will have minimal liver damage. Between 20% and 30% of people with hepatitis C develop cirrhosis after twenty years. Factors that put a patient at higher risk for developing cirrhosis include the following: developing hepatitis C at an older age, alcoholism, and co-infection with HIV or hepatitis B. The genetic type of the virus strongly affects severity, with genotype 1 being the most serious and type 2 and 3 posing less danger. (Unfortunately, a 1999 study suggested that nearly three quarters of infected people carry genotype 1.) Men are at higher risk for a poor outlook than women. Large iron stores in the liver occur in about 25% of patients and may also increase the severity of the disease. One study suggested that hepatitis C patients who are overweight, particularly if their fat is distributed in the abdomen (an apple-shape), may be at higher risk for a fatty liver, which in turn is more apt to become scarred and cirrhotic.

Patients with chronic hepatitis C may be at higher risk for a variety of autoimmune disorders, particularly hypothyroidism and rheumatoid arthritis.

Prognosis of Patients with Autoimmune Hepatitis

The persistent form is usually benign and causes little trouble, although there is a very small risk that chronic persistent hepatitis can evolve to the active form. One study found that the overall outlook for treated patients with autoimmune hepatitis and no indication of hepatitis viruses was very favorable. In this study, the 10-year survival rate was 95%, similar to the same age group in the general population. The five-year survival rate for the chronic active form of this hepatitis is only 50% if the disease is not treated. (This rate may be higher in people with milder symptoms and less liver damage.) During the early years, patients are most at risk for liver failure and bleeding in the stomach and esophagus. This risk diminishes over time but is replaced by an increase in liver cancer rates and bleeding in the stomach and intestines. The risk for liver cancer is not as high, however, as with chronic viral hepatitis.

What Precautions Should People With Hepatitis Take?

Periods of Highest Contagion

Hepatitis A is infectious for two to four weeks before symptoms develop and for a few days afterward. People with hepatitis B or C may become carriers of the virus after recovery, even if chronic disease does not develop and symptoms are not present.

Life-Style Preventive Measures

Daily Precautions. Patients with viral hepatitis should abstain from sexual activity or take strict precautions if they cannot. Sterilizing utensils or clothing is not necessary with any type of hepatitis, but hot water and thorough cleanings are necessary for items used by patients with hepatitis E and A. Utensils used by the patient for eating and cooking should be kept separate from those used by others. Because hepatitis A and E are usually passed through contaminated food, people with these viruses should not prepare food for others; unfortunately, these viruses are most contagious before symptoms appear. Restrictions on food preparation are not necessary for other types of hepatitis. All objects contaminated by blood from patients with hepatitis B or C must be handled with special care. Of special note, ibuprofen  apparently increases liver enzymes in hepatitis C patients. Ibuprofen is known as a nonsteroidal anti-inflammatory drug (NSAID). Others include aspirin and naproxen. The usual alternative to an NSAID is acetaminophen (Paracetamol). It should be noted that acetaminophen also could be toxic in the liver, particularly when drinking alcohol. Patients should discuss options with their physician.

Travel to Countries at High Risk for Hepatitis. Travelers should be vaccinated against hepatitis A if they are traveling for long periods of time to countries where epidemics occur. They should peel and wash all fresh fruits and vegetables themselves and avoid raw or undercooked meat and fish. Even ice cubes can cause infection, and only carbonated bottled water should be used for brushing teeth and drinking. If carbonated water is not available, tap water should be boiled for ten minutes.

Vaccinations and Preventive Measures for Specific Viruses

Prevention of Hepatitis A. The standard preventive measure against hepatitis A has been immune globulin (formerly gamma globulin) injections. Two vaccines (Havrix, VAQTA) are now available and both are very safe and effective. It can be given along with immune globulin and other vaccines. Although not yet routinely given to children under two, the vaccine is proving to be safe for infants. Vaccinations are recommended for the following individuals: people in communities where outbreaks occur, sexually active homosexual men, people with chronic hepatitis C and other liver disease, health care workers exposed to the virus, and travelers to developing countries.

Prevention of Hepatitis B and D. Several vaccines for hepatitis B are available and are effective and safe, including for infants and children. Vaccination programs are also proving to reduce the risk for liver cancer. Hepatitis B vaccine protection lasts at least eight to ten years in most children. Booster shots after that may be recommended depending on continuing risk. A higher percentage of adults may not develop immunity after being given the vaccine, and booster shots may be needed. Experts recommend immunizations against hepatitis B in all infants and in all children not previously vaccinated by the time they reach seventh grade. Infants of mothers infected with HBV should be treated with immune globulin and a series of vaccinations at birth, one month, and six months. Healthcare and public safety workers who may be exposed to blood products, people in the same household as HBV infected individuals, uninfected people requiring transfusions, and travelers to developing countries should receive the vaccination. (Vaccination against both Hepatitis A and B may prove to be particularly beneficial for travelers.) Other people who would benefit from the vaccine are sexually active people with multiple partners, patients and workers in mental institutions, morticians, patients on hemodialysis, and people who use injected drugs. Pregnant women who are at risk for the virus should be vaccinated; there is no evidence that the vaccine is dangerous to the fetus. People receiving treatments or who have conditions that suppress the immune system may need the vaccination, although its benefits for this group are unclear except for those at high risk, such as people with HIV or spleen abnormalities. Chronic hepatitis C patients should also be vaccinated against hepatitis B. Hepatitis B vaccine protection lasts at least seven years. Booster shots after that may be recommended depending on continuing risk. Three doses given over six months are usually required for adults; a recent study reported that older adults would benefit from a fourth dose without incurring serious side effects. People with alcoholism may need high doses. Of some concern are reports of inflammation in the central nervous system similar to multiple sclerosis that occurred in a few people after receiving the vaccination. Although these occurrences are very rare, as a precaution, the vaccine should be avoided in people with a personal or family history of central nervous system diseases, particularly multiple sclerosis. Unvaccinated people who have had intimate exposure to people with HBV may be protected with immune globulin, sometimes administered with the vaccine.

Prevention of Hepatitis C. Although transfused blood has been tested for both hepatitis B and C since 1990, those with previous transfusions, even those performed decades ago, may be at risk. Such individuals are urged to be tested. Immune globulin helps protect against developing hepatitis C after transfusions. Periodic doses of immune globulin in sexual partners of infected people also appear to confer protection. Avoiding exposure or preventing transmission is, however, still very important for hepatitis carriers and for those in contact with them. Infected patients should use condoms and contraceptives that prevent passage of the virus, possibly even in relationships that last for years. Sexual partners, no matter what the duration of the relationship, should avoid sharing personal items, such as razors or toothbrushes, and abstain from sexual activity during menstruation or infections that cause bleeding in the genital or urinary areas.

What Are The Treatments For Acute Hepatitis?

Treatment for Acute Viral Hepatitis

For mild cases of acute viral hepatitis, no drug therapy or other treatment is either available or necessary. Hospitalization is needed only for people at high risk for complications, such as pregnant women, elderly people, patients with other serious conditions, or those who have severe nausea and vomiting and need to have fluids administered intravenously. The primary goals for managing acute viral hepatitis are to provide adequate nutrition, to prevent additional damage to the liver, and to prevent transmission to others.

No vitamins or special diets have been proven to be particularly beneficial. Eating many small snacks during the day, with larger ones in the morning, may help prevent weight loss while reducing the severity of nausea. Patients might be able to tolerate high-caloric drinks to supplement the regular diet.

The liver processes many types of medications, so as soon as hepatitis is diagnosed, the patient should stop taking all drugs, including over-the-counter medications, except those a physician specifically prescribes or recommends. In some cases, the physician may prescribe drugs that have minimal impact on the liver to alleviate the symptoms of hepatitis, such as nausea or severe itching. All patients should abstain from alcohol and sexual contact during the acute phase. Moderate drinking (one or two drinks per evening) after recovery is not harmful for most people. Although most patients with hepatitis experience fatigue and require more rest than usual, they can be as physically active as they want without affecting recovery. In fact, patients should be encouraged to be as active as they can. Depression is common, particularly in people used to an active life. Patients should be reassured that in the great a majority of hepatitis cases, recovery is complete.

At the onset of acute hepatitis, periodic visits to the physician for repeat blood tests are necessary, the frequency of which depends on how well the patient feels. If symptoms still occur after three months and laboratory tests still indicate active presence of the virus, the patient should be evaluated every month. If symptoms persist beyond 6 months, a liver biopsy may be required to determine any liver damage.

Treatment for Fulminant Acute Hepatitis

For those who develop fulminant hepatitis and liver failure, treatment is aimed at the affected organs and systems. No medications, including corticosteroids, have any effect against the condition itself. Liver transplantation is currently the only life-saving treatment for fulminant acute hepatitis and has survival rates of up to 60%. Without liver transplantation, the chance of survival is only 20%.

What Are The Treatments For Chronic Hepatitis B And C?

Drug treatments for chronic hepatitis B and C are aimed at reducing or preventing liver damage and boosting or modifying the immune system to promote its attack on the viruses. Treatment outcomes are assessed by testing levels of aminotransferase to determine liver damage and using polymerase chain reaction (PCR) tests to detect the amount of virus left. After treatment, however, some patients may have low levels of virus and high indicators of liver damage while others display opposite results. It is not yet clear how to weigh these criteria in evaluating the overall health of the patient.

The important agents for treating chronic hepatitis are interferons (particularly interferon alpha) and nucleoside analogues (ribavirin, lamivudine, famciclovir, and adefovir), which act directly against the virus. They are being used as sole therapy and in combinations. These drugs are used differently depending on the specific hepatitis. Other drugs with different mechanisms are also being tested.

Treatments for Hepatitis B

Interferon Alpha for Hepatitis B. Interferon alpha (Roferon-A, Intron A) is the standard drug currently used for both chronic viral hepatitis B and C. It has eliminated the virus and sustained significant remission in 25% to 40% of patients with chronic hepatitis B. The drug is usually taken by injection every day for 16 weeks. (It does not appear to be effective for hepatitis D.) Unfortunately, even in hepatitis B, the virus recurs in almost all cases, although this recurring mutation may be weaker than the original strain. Administering the drug for longer periods may produce sustained remission in more patients while still being safe. Interferon beta is benefiting many children with hepatitis B who do not respond to interferon alpha.

Nucleoside Analogues. Nucleoside analogues are drugs that can block viral replication. Lamivudine is a recently approved oral nucleoside that has reduced viral count in over half of hepatitis B patients who have taken it as sole therapy for about a year. It also appears to significantly reduce the risk for liver damage and cirrhosis. The drug even suppresses. hepatitis B viral replication in HIV-positive patients and liver transplant recipients. Lamivudine causes muscle aches and chills but does not appear to have some of the distressing side effects of interferon, such as depression, hair loss, weight loss, or a drop in white blood cells (leukopenia). Of some concern, however, is eventual resistance to the drug in many patients. Some researchers fear that, although the drug may prevent cirrhosis, it might not protect against liver cancer, particularly in those who have harbored the virus since childhood. Preliminary data suggest that other nucleoside analogues, including ganciclovir, adefovir, and famciclovir, are also active against the hepatitis B virus.

Researchers speculate that future therapy for hepatitis B may need to involve combination treatment to achieve the greatest possible viral reduction and to minimize the chances of drug resistance.

Treatments for Hepatitis C

Interferon Alpha for Hepatitis C. Patients with hepatitis C and abnormal liver tests are candidates for interferon alpha with the goal of reducing viral levels to zero. Interferon improves symptoms significantly in all patients who respond, and in patients who have a sustained response to interferon (being viral free longer than six months) between 90% and 95% remain free of the infection indefinitely. Unfortunately, only about half of patients treated respond to the drug, and only about 15% to 20% have a sustained response. A better chance for a sustained response depends on several factors, such as being younger, having a less aggressive viral genotype (2 or 3), or lower initial levels of hepatitis C virus (less than 2 million/mL). (Experts now recommend that patients with genotype 1 remain on interferon for at least a year.) Ethnic differences also come into play. For instance, studies indicate that a sustained response is achieved in fewer African-American patients (2% to 3%) than in Caucasian (12%) or Asian (28%) patients. The response of children to interferon appears to be similar to an adult's, although large studies are needed to confirm this. Extending treatments to up to 24 months have improved early relapse rates, but the regimen is costly and side effects are more severe. Patients who relapse or do no respond may be treated with a higher dose of interferon or with a combination of interferon and the nucleoside analogue ribavirin.

Combination of Interferon Alpha and Ribavirin (Rebetron). The combination of interferon alpha and ribavirin (Rebetron) is showing double the success rates of interferon alone, with initial response rates up to 66% for type 2 and 3 and up to 30% for the more severe genetic type 1. Sustained responses are as high as 40%. Two studies using the combination reported a sustained response in 30% of patients who had relapsed and in 4% to 14% of patients who had not responded at all to initial interferon therapy. Side effects from the combination are similar to interferon alone , although they occur more often, and ribavirin adds the risk for anemia. Experts now recommend the following durations for taking the combination: six months for patients with genotype 2 or 3 (regardless of the viral count), six months for patients with genotype 1 and low viral count (less than 2 million/ml), and 12 months if their viral count is higher). Early studies indicated that the later the virus was eradicated, the poorer the chance for a sustained remission. Many experts, then, have advised stopping treatment after 12 weeks if patients continue to show evidence of the virus. However, later studies indicated that even if the virus is not eradicated until up to 24 weeks of treatments, remission is sustained in a large proportion of patients taking either interferon alone or the combination.

Other Interferons. Other drug combinations and interferon forms are under investigation. A genetically designed drug called interferon alfacon-1 (Infergen) is showing particular promise. This agent is referred to as a consensus interferon because it was developed using the most commonly occurring amino acid sequences from each of the natural alpha interferons. One study suggested that three quarters of patients may respond to initial treatment using a high-dose regimen (five times a week for 48 weeks). Another reported that Infergen produced a response in 27% of patients who had experienced relapse after initial treatments and 8% of those did not respond at all. Another agent showing promise is called pegylated interferon (PEG-INF). In one study, sustained response after six months was similar to that with Rebetron.

General Description of Interferon Alpha

Interferons are natural proteins that activate certain immune functions in the body and have anti-viral properties. There are two types of natural interferons: type I (which includes alpha, beta, and omega interferon) and type II (gamma interferon). Type I interferons are the most potent. Interferon alpha is the standard drug currently used for both chronic viral hepatitis B and C. Candidates for this treatment include those who have detectable levels of the virus and have above-normal levels of alanine aminotransferase for at least six months. Ineligible patients include women who are pregnant or planning to become pregnant soon, those with advanced cirrhosis, fluid in the abdomen, or any serious medical or psychiatric problems. It is unclear if the drug improves survival in patients with advanced cirrhosis and, in any case, it may be dangerous for them. One study suggested that interferon in hepatitis C (but not B) patients with cirrhosis may help prevent progression to liver cancer, although more studies are needed to confirm this. In those who respond, studies are showing improved symptoms, a normal long-term survival rate, and, in some, no return of the disease. In some cases, a very short course of corticosteroids may be used initially to boost the effect of interferon. Initial effects of the drug may also be enhanced in certain patients by reducing iron levels through a series of blood-drawings before starting interferon. Unfortunately, the percentage of patients who benefit over the long-term using interferon as sole therapy is small. Even when the drug is effective, the disease nearly always recurs and requires additional treatment. Common side effects are flu-like symptoms that usually occur within six hours and last for twelve. More chronic or serious effects include depression (which can be very severe), anxiety, amnesia, confusion, irritability, changes in sensation, weight loss, skin rashes, hair loss, vomiting, general weakness, exacerbation of asthma, and possible negative effects on cholesterol and lipid levels. Interferon often causes a drop in platelet and white blood cell counts, increasing susceptibility to bacterial infections. The drug can cause heart rhythm disturbances, which, in rare cases can be serious. It may also trigger an autoimmune response, possibly causing anemia, diabetes, lupus-like symptoms, thyroid abnormalities, or even autoimmune hepatitis. The drug can also cause complications in the eye, in some cases leading to loss of vision if not detected promptly.

Experimental Agents

Drugs that Boost the Immune System. A number of drugs have been developed that boost the body's own immune system to fight the virus. For example, Thymosin is a synthetic version of a peptide derived from the thymus gland (which produces immune factors call T-cells). It is showing promise alone or in combination for patients with hepatitis B and C. Vaccines, including Hepagene, is being investigated for treating as well as preventing hepatitis B. Researchers are also looking at interleukin 12, an immune factor that may enhance the immune response to hepatitis C.

Antioxidants. Antioxidants may help reduce liver injury from damaging particles known as oxygen free radicals. Among the antioxidants being investigated are an agent known as a histamine type-2 receptor agonist (Maxamime), N-acetylcysteine (an amino acid byproduct), and vitamin E.

Other Investigative Drugs. Amantadine is a drug commonly used for Parkinson's disease but which may have some antiviral effects. In hepatitis C patients who had failed interferon, the drug produced normal aminotransferase levels in 27% and it reduced the viral load to undetectable levels while producing a sustained response in 18% of these patients. Ursodiol, or ursodeoxycholic acid, a drug ordinarily used for gallstones, improves aminotransferase levels. It has no effect against the virus, but may be useful in combination with interferon. Protease inhibitors (used for HIV) are under investigation for hepatitis C patients who fail other treatments.

Alternative Treatments. Any patient with a serious disease should question any alternative so-called cure, and should certainly discuss any with the physician. Many interact with standard treatments and any remedy that is effective against severe illness is bound to have side effects, just like any drug. Alternative medications are not regulated, so their quality, side effects, or benefits are not fully known or guaranteed. In one study, for example, the over-the-counter supplement, thymic extract, used for hepatitis C, was ineffective in a group of patients who had not responded to interferon. One patient developed thrombocytopenia, an abnormal blood condition that can cause severe bleeding. Among the natural substances being investigated for hepatitis are glycyrrhizin (a compound in licorice), catechin (found in green tea), silymarin (found in milk thistle). A Chinese herbal medicine called Bing gan ling is also being studied.

Liver Transplantation

Liver transplantation is indicated in patients who have developed life-threatening cirrhosis and who have a life expectancy of more than 12 years. Patients with liver cancer that has not spread beyond the liver may also be candidates. Current five-year survival rates are about 70% after liver transplantation. Unfortunately, in about half of hepatitis patients, the viruses recur in the transplanted organ. (One study of patients with hepatitis C reported five-year risks for viral recurrence of 80% and for cirrhosis of 10%. The success rate is higher in those who have hepatitis D.) Experiments using monthly infusions of hepatitis B immune globulin (HBIg) after transplantation show great promise in preventing recurrence in these patients. These may need to be administered life long. Lamivudine may also be helpful in preventing recurrence of hepatitis B after liver transplantation. Autoimmune hepatitis may also recur after liver transplantation, but only after several years. Unfortunately, the waiting time for a liver doubled between 1991 and 1996 to 241 days. And, given the large number of people with hepatitis C, this situation will almost certainly worsen over the following years.

What Are The Treatment For Other Forms Of Chronic Hepatitis

Treatment for Chronic Autoimmune Hepatitis

Patients with autoimmune hepatitis who have mild symptoms and slight inflammation of the liver do not require any treatment except to alleviate symptoms. They should be monitored, however, for any signs of disease progression. Severe autoimmune hepatitis is a life-threatening condition and requires intensive therapy.

Corticosteroids. Corticosteroids, prednisone and prednisolone, suppress the immune system and reduce inflammation, producing remission of symptoms in about 80% of patients with autoimmune hepatitis. Azathioprine is often prescribed along with steroids to help reduce severe side effects caused by using steroids alone. Azathioprine also suppresses the immune system and helps prevent relapse, but the drug will not induce remission by itself. About half of patients relapse within six months, and only about 20% of patients achieve remission (are disease-free) for more than five years. Readministering prednisone therapy after relapse achieves another remission in 80% of patients. In one promising study, patients who continued to use azathioprine after prednisolone was withdrawn had no relapses for at least a year. Unfortunately, long-term use of azathioprine may increase the risk for cancer, although studies indicate that this risk is very low.

For most patients, steroids reduce symptoms within three months, improve liver function within six months, and restore liver health within two years. Between 10% and 20% of patients continue to deteriorate despite steroid treatment, although higher doses may help some of these people. Treatment usually needs to continue about two years before the disease is in complete remission, but it rarely lasts more than three years. Side effects can be very distressing and sometimes serious; they include weight gain, skin problems, moon-shaped face, high blood pressure, diabetes, cataracts, mental disturbances, infections, and osteoporosis. Usually, steroids are stopped when disease symptoms have disappeared, when blood tests show that aminotransferase levels are less than two times normal, and liver biopsies reveal no active cell damage. Steroid medications must be withdrawn very slowly. Patients who are very elderly or who have advanced (decompensated) cirrhosis are not good candidates for this treatment. It should also be noted that about 85% of people with chronic active autoimmune hepatitis do not have severe symptoms; in these cases, physicians often must weigh the risk for progression to a more serious condition against the long-term adverse effects of steroid treatment. If all therapies fail and the disease becomes life threatening, liver transplantation may be performed. Because of all of these effective treatment options and in spite the high rate of relapse, long-term survival rates in patients with autoimmune hepatitis are excellent. (Steroids are generally not useful for chronic hepatitis B or C and, in fact, suppressing the immune system in these patients can encourage the viruses to replicate more quickly.)

Treatment for Nonalcoholic Steatohepatitis

Weight reduction and management of any accompanying medical condition are the primary approaches to nonalcoholic steatohepatitis. To date, however, there is no effective treatment for NASH, although experimental therapies, such as bile acids (UDCA), antibiotics, nutritional supplements, and antioxidants, have had some success in selected patients.