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

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.

Laboratory features

  • · Serum AST 100 to 1000 units
  • · Serum bilirubin normal to 10 mgjdL
  • · Prothrombin time prolonged
  • · Hypergammaglobulinemia >2.5 gjdL
  • · ANA positive
  • · Smooth- muscle antibodies
  • · Anti-LKM 1 antibody.

Autoimmune Hepatitis Treatment

  • Glucocorticoid therapy Cyclosporine Tacrolimus.


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