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Chronic hepatitis.

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.

When the hepatitis is mild and limited in extent, it is called chronic persistent hepatitis (CPH). When it is more extensive and seems to be destroying the cells of the liver, it is called chronic active hepatitis (CAH).

Treatment - Treatment of chronic hepatitis depends first on recognizing its cause. Some patients with chronic hepatitis B and C are being treated with interferon, a natural substance in the body which improves the immune system and may also have some antiviral ability. Everyone, however, does not respond to interferon treatment. It works best in sicker patients with a more recent onset of disease and without cirrhosis.

Steroid therapy with or without azanthioprine, is still widely used but as more specific causes of chronic hepatitis are discovered the number of patients so treated is diminishing. Steroid therapy remains the only useful treatment for autoimmune disease, but it may have to be given for a lifetime and may also not prevent the ultimate development of cirrhosis.

Liver transplantation has become an accepted form of therapy when chronic hepatitis becomes life-threatening, usually as a result of complications of cirrhosis. Recurrence of hepatitis C or autoimmune hepatitis does not seem to occur, but hepatitis B, if virus is still present and the patient is contagious, will recur in the new liver and often be acute. Attempts are being made to prevent this recurrence with interferon and with monocional antibody directed to hepatitis B surface antigen.

The most important treatment is prevention. Hepatitis B vaccine should be given to all who are exposed to this disease on a regular basis. The vaccine is being given in some areas to all newborn babies. All pregnant women should be tested for hepatitis B. Carriers of hepatitis B, many of them unaware that they are infected, can pass it on to their babies. The newborn can be vaccinated at birth, providing protection from this disease.

Testing of blood for hepatitis B and C is going to provide as safe a blood supply as possible. Health care personnel must be extremely careful in handling sharp instruments, they should always wear gloves and be immunized against hepatitis B. Attempts are being made to offer needles to addicts to try to stem this means of spreading the disease.

An important aspect of treatment is supportive care. Diet should be well balanced. The use of high carbohydrate or high protein or low fat diets has no scientific basis, and in some instances, such diets may be harmful. Vitamin and mineral supplementation also has no place in the management of chronic hepatitis unless some deficiency is present. No substance is known that will help the main symptom, fatigue. However, a good physical fitness program may lessen this distressing symptom. Patients should be advised to limit the amount of salt that they use in an attempt to forestall the accumulation of fluids as ascites or ankle swelling. Since almost all drugs must be detoxified by the liver, and since the injured liver does not perform this task well, limiting the amount of drugs that a patient uses to only essential ones is important. This includes discouraging the use of sedatives and tranquilizers.

Looking to the Future - Learning more about the viruses responsible for chronic hepatitis and how to control them will occur in the next decades. Similarly, learning about the body's immune system and how to control it has already begun. Preventive efforts will be enhanced so that fewer cases of chronic hepatitis will develop. The goal of eliminating this group of diseases seems to be just over the horizon, and while our skills at transplantation are rapidly increasing, the form of therapy for chronic hepatitis, like the disease itself, will disappear.

Interferon is given by injection (like insulin, by the patient himself) three times a week for three or four months. Side effects are numerous and include flu-like symptoms with fever and achiness. These diminish but do not disappear with time. Abnormalities in blood counts may develop, making frequent monitoring mandatory. Often a flare-up of hepatitis occurs as the virus disappears. In some studies, when a patient is not very sick before treatment, prednisone has been given for a few weeks to permit the virus to multiple more vigorously so that the interferon may be more effective. Trials of antiviral therapy are still being assessed in large multicenter studies.

Interferon does not seem to work well in patients

* who are not very sick,

* whose tests results are not very abnormal,

* whose immune system is not functioning well because of AIDS,

* with hepatitis B who were infected from their mothers at birth,

* or carriers who are no longer contagious or infectious.

Knowing the cause of the disease is more helpful in estimating prognosis than what the liver biopsy shows in the absence of cirrhosis.

Only a small percentage of patients with chronic hepatitis B develop cirrhosis. In those patients, cirrhoris develops early in the course of the disease with complications appearing in the first few years of the disease. Chronic hepatitis most often causes acute hepatitis or flare-ups and p eriods with no signs. Scarring becomes more extensive with each flare-up. Patients in the Orient have about a 15% chance of developing primary liver cancer, usually after the age of 50 with men more likely candidates than women. This complication is much less common in the Western World.

The disease becomes life-threatening only after cirrhosis has developed in most instances and the complications of cirrhosis are common causes of death. More than half of all patients live at least 15 years from the time of t he first diagnosis and this number is continuously improving. Previously, prognosis was felt to depend on what was found on liver biopsy. This is now only partly true. Prognosis is worse and complications more numerous and severe if cirrhosis has already developed. Much attention has been paid to the location and extent of the inflammation in the liver.

Chronic hepatitis C responds differently to interferon than hepatitis B. The initial response is more rapid as far as the return of the blood test results to normal, sometimes in a couple of weeks. Side effects are the same but unless interferon is given for longer periods of time, usually a year, the disease will recur. Prednisone prior to interferon does not seem to be helpful, nor is it helpful when it is given without interferon. No other antiviral treatment has been found as yet.
COPYRIGHT 1991 American Liver Foundation
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Copyright 1991 Gale, Cengage Learning. All rights reserved.

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Publication:Pamphlet by: American Liver Foundation
Article Type:pamphlet
Date:Sep 23, 1991
Previous Article:Cancer of the liver.
Next Article:Cystic disease of the liver.

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