Chronic Hepatitis Classification viral hepatitis Clinical features and Treatment
Chronic Hepatitis
Chronic hepatitis is a liver disorder with inflammation and necrosis persisting for more than 6 months.
Chronic hepatitis may be mild, non-progressive, or severe, or may lead to cirrhosis.
Chronic hepatitis may be of three types:
· Chronic viral hepatitis
· Chronic drug-induced hepatitis
· Autoimmune chronic hepatitis.
Other presentations of chronic hepatitis may be
· Wilson’s disease
· Alcoho’lic hepatitis.
Chronic Hepatitis Classification viral hepatitis Clinical features and Treatment
Classification of Chronic Hepatitis Classification by extent of liver injury
1. Chronic persistent hepatitis
2. Chronic lobular hepatitis
3. Chronic active hepatitis.
Classification of Chronic hepatitis by Cause
· Hepatitis B
· Hepatitis B plus D
· Hepatitis C
· Autoimmune hepatitis type I, II and III based on serology
· Drug-associated chronic hepatitis
· Cryptogenic chronic hepatitis.
Classification of Chronic hepatitis by Grade
1. Periportal necrosis
a. Piecemeal necrosis or interface hepatitis
b. Bridging necrosis
2. Intralobular necrosis
3. Portal inflammation
4. Fibrosis.
Chronic viral hepatitis generally follows:
Viral hepatitis B
Viral hepatitis C
Viral hepatitis Band C with superimposed hepatitis D.
Hepatitis A and E are self-limited and do not progress to chronic hepatitis.
Chronic Hepatitis B
Hepatitis B infection at birth may be silent but there
is a 90% chance of chronic infection. •
In young adults there is overt symptomatic acute hepatitis but progression to chronic hepatitis is rare.
Chronic hepatitis may be asymptomatic, mild or severe.
Chronic hepatitis B may progress to severe form, cirrhosis, and liver failure in about a quarter of the cases.
Hepatitis B virus replication (HBV)
Replicative phase is identified by the presence of serum markers – HBeAg (Hepatitis B e antigen) and HBV DNA, presence of intrahepatocyte antigens HBcAg (Hepatitis B core antigen) and liver injury.
Non-replicative phase is characterized by absence of HBeAg and HBV DNA, and minimal liver injury.
Chronic HBV infection at birth and in early childhood leads to hepatocellular carcinoma in a majority of, cases.
Clinical features of Chronic hepatitis B
· Asymptomatic infection
· Deblitating disease
· Progresses to end-stage hepatic failure
· Onset may be insidious (slow), or chronic disease may follow acute hepatitis B.
· Fatigue
· Persistent or intermittent jaundice
· Malaise, anorexia, leading to slow hepatic decompensation
· Cirrhosis of liver – ascites, edema, bleeding gastroesophageal varices, hepatic encephalopathy, coagulopathy and hypersplenism.
Extrahepatic manifestations – arthralgias, arthritis, purpuric lesions due to vasculitis, polyarteritis nodosa.
Laboratory features
· Amino transferase elevation may be from 100 to 1000 units.
· ALT (Alanine amino transferase) is elevated more
than AST (aspartate amino transferase).
· In cirrhosis AST may be more than A LT.
· Alkaline phosphatase may be normal.
· Serum bilirubin may be moderately raised – 3 to 10 mg/dL.
· Hypoalbuminemia may be present.
· Prothrombin time increased.
Chronic hepatitis B Treatment
Progression of disease occurs in patients with active HBV replication.
Patients with high level HBV replication are at risk of hepatocellular carcinoma.
Antiviral therapy should be given to all patients of chronic hepatitis B. The drugs for chronic hepatitis B are injectable interferon alpha IFNa, oral lamivudine, oral adefovir dipivoxil.
Antiviral therapy should be given to patients with detectable· markers of HBV replication, in patients with incr~ased ALT twice the upper limit of normal, all immunocompromised individuals, patients of compensated or uncompensated disease. “,
Dose of interferon – IFN 5 million units subcutaneous daily for 16 weeks or 10 million units 3 times a week.
Dose of Lamivudine – Daily oral dose of 100 mg for 12 months.
Dose of Adefovir – Oral daily dose of 10 mg for 48 weeks (1 year).
Chronic Hepatitis D
Chronic hepatitis D may follow acute infection with hepatitis B virus.
HDV infection can increase the severity of acute hepatitis B but progression to chronic hepatitis mayor may not occur.
If HDV infection occurs in chronic hepatitis B then there is deterioration of liver function resulting in severe liver disease.
The clinical features of hepatitis D over hepatitis B are same as for chronic hepatitis B alone.
In chronic hepatitis D, anti-LKM i.e. antibodies to liverkidney microsomes is an important serological feature. This anti-LKM is called anti LKM3 (anti LKM1 is seen in patients with chronic hepatitis C and autoimmune hepatitis).
Chronic Hepatitis D Treatment
IFN-ex in high doses – 9 million units 3 times a week for 12 months.
Liver transplantation.
. Chronic hepatitis C
Acute hepatitis C virus infection may lead to chronic hepatitis C in more than half the cases.
In chronic transfusion-associated hepatitis there is progression to cirrhosis in l/Sth of cases.
Even in asymptomatic patients who go for blood donation, hepatitis C may be detected.
The source of HCV infection may be percutaneous exposure in the past.
ALT may be normal.
In patients with normal ALT the disease may not be serious and may not progress to failure and cirrhosis.
In chronic hepatitis C, progression to liver failure is common with old age, longer duration of infection, histological changes, alcoholic liver disease, chronic hepatitis B, HIV infection, a antitrypsin deficiency.
Chronic hepatitis C may also convert to hepatocellular carcinoma.
Clinical features
· Fatigue
· Jaundice – rarely
· Sjogren’s syndrome
· Lichen planus
· Porphyria cutanea tarda.
Laboratory features
· ALT may be raised
· Autoantibodies in serum
· Anti-LKM.
Chronic hepatitis C Treatment
IFN ex subcutaneous – 3 times a week for 6 months.
IFN ex plus Ribavirin daily.
Pegylated IFNs – Long acting IFN bound to polyethylene glycol (PEG) – have a longer half life with once weekly dose.
Chronic Autoimmune Hepatitis
It is a chronic hepatitis with continued hepatocellular necrosis with fibrosis progressing to cirrhosis and liver failure.
Mortality is high.
Clinical features are similar to chronic viral hepatitis. Onset may be insidious or abrupt.
Common in young or middle-aged women.
There is high titer of circulating ANA
There is fatigue, malaise, anorexia, amenorrhoea, acne, arthralgias, jaundice, arthritis, colitis, pericarditis, anaemia, sicca syndrome, cirrhosis.
Course is variable. There may be hepatocellular carcinoma as a late complication.
