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.  Chronic hepatitis
may follow acute hepatitis B or C (formerly called non-A, non-B), or may develop
quietly without an acute illness.

Symptoms  Symptoms result from the liver cell injury, the inflammation, or from the resulting
scarring (which is called cirrhosis).  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 disabling.  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 a large percentage of patients depending on the cause of the chronic hepatitis.

Diagnosis   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:

             Viral  Hepatitis B (HBV, formerly called "infectious hepatitis") and C (HCV) are themost common causes of chronic hepatitis.  Together they account for more than 75% of the cases in the world.  HBV is transmitted mainly through infected blood (such as transfusion or IV drug use) or sexual contact. About 10-15% of persons infected with HBV will develop chronic disease.  HCV is also transmitted through infected blood, but sexual transmission is much more rare.  About 80-90% of persons infected with HCV will develop chronic hepatitis.   Chronic HCV behaves differently from HBV.  The disease is generally mild, with fatigue being the main symptom.
Ten or more years later, however, the complications of cirrhosis appear in some patients, sometimes unexpectedly.  By contrast, with HBV the percentage of patients infected who develop cirrhosis is much greater.  While primary liver cancer can also develop from HCV, it appears to be much more common with HBV.

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

Hepatitis D (HDV) infection needs the hepatitis B virus to multiply.  HDV can cause acute hepatitis in some one who is a carrier of the HBV 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 highincidence of hepatitis D.

Treatment - Interferon and Ribaviron in combination or Interferon independent are the current treatment option.  The treatment has been shown to reduce the inflammation and liver damage caused by the virus by reducing the virus therefore reducing the development of scar tissue.  This avoids the development of cirrhosis.  There are still a large number of relapsers and non-responders.

Other Viruses - 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 functioning properly.  It is unlikely that they will produce chronic hepatitis.  Other viruses, as yet undiscovered, may be responsible for some of the cases of chronic hepatitis.

Autoimmune Hepatitis - This varies from mild to serious disease.  The percentage of patients who develop cirrhosis is high and it may appear early in the course of the disease. Only a few cases of primary liver cancer have been reported with this disease.  25% of cases of chronic hepatitis result from damage to the liver by the immune system.  The trigger for autoimmune chronic hepatitis is unknown, but the damage to the liver is caused by the individual's lymphocytes (white blood cells) and by antibodies produced in the individual's own tissue.  Autoimmunehepatitis is usually a progressive disease ending in cirrhosis.  Treatment usually consists of corticosteriods.

Drug-induced Hepatitis - A few medication still in use, and several that have been withdrawn from the market can also cause chronic hepatitis.  These include:  isoniazid (used for tuberculosis), methyldopa (used for hypertension), nitrofrantoin (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 chronic hepatitis  produced by these medications is small.  Chronic hepatitis caused by drugs is usually recognized early.  Stopping the medication before cirrhosis has developed usually reverses the disease. 

A number of herbs and "naturopathic" medications can also cause chronic hepatitis.

Inherited Disorders - Some inherited disorders of metabolism also can appear as chronic hepatitis.  The most frequent of these 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 rate conditions from those caused by viruses.  A familial disorder of iron metabolism, Hemochromatosis, can also lead to chronic hepatitis and cirrhosis.