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Overview of Chronic Hepatitis
Chronic hepatitis is hepatitis that lasts > 6 mo. Common causes include hepatitis B and C viruses, autoimmune liver disease (autoimmune hepatitis), steatohepatitis (nonalcoholic steatohepatitis or alcoholic hepatitis), and some drugs. Many patients have no history of acute hepatitis, and the first indication is discovery of asymptomatic aminotransferase elevations. Some patients present with cirrhosis or its complications (eg, portal hypertension). Biopsy is necessary to confirm the diagnosis and to grade and stage the disease. Treatment is directed toward complications and the underlying condition (eg, corticosteroids for autoimmune hepatitis, antiviral therapy for viral hepatitis). Liver transplantation is often indicated for decompensated cirrhosis.
(See also Causes of Hepatitis, Overview of Acute Viral Hepatitis, and the American Association for the Study of Liver Disease’s Diagnosis, Management, and Treatment of Hepatitis C.)
Hepatitis lasting > 6 mo is generally defined as chronic, although this duration is arbitrary.
The most common causes are
Nonalcoholic steatohepatitis (NASH)
Idiopathic (probably autoimmune)
Hepatitis B virus (HBV) and hepatitis C virus (HCV) are frequent causes of chronic hepatitis; 5 to 10% of cases of HBV infection, with or without hepatitis D virus (HDV) coinfection, and about 75% of cases of HCV infection become chronic. Rates are higher for HBV infection in children (eg, up to 90% of infected neonates and 30 to 50% of young children). Although the mechanism of chronicity is uncertain, liver injury is mostly determined by the patient’s immune reaction to the infection.
Rarely, hepatitis E virus genotype 3 has been implicated in chronic hepatitis.
Hepatitis A virus does not cause chronic hepatitis.
Other causes of chronic hepatitis include nonalcoholic steatohepatitis (NASH) and alcoholic hepatitis. NASH develops most often in patients with at least one of the following risk factors:
Alcoholic hepatitis (a combination of fatty liver, diffuse liver inflammation, and liver necrosis) results from excess consumption.
Many cases are idiopathic. A high proportion of idiopathic cases have prominent features of immune-mediated hepatocellular injury (autoimmune hepatitis), including the following:
The presence of serologic immune markers
An association with histocompatibility haplotypes common in autoimmune disorders (eg, HLA-B1, HLA-B8, HLA-DR3, HLA-DR4)
A predominance of T lymphocytes and plasma cells in liver histologic lesions
Complex in vitro defects in cellular immunity and immunoregulatory functions
An association with other autoimmune disorders (eg, RA, autoimmune hemolytic anemia, proliferative glomerulonephritis)
A response to therapy with corticosteroids or immunosuppressants
Sometimes chronic hepatitis has features of both autoimmune hepatitis and another chronic liver disorder (eg, primary biliary cholangitis [formerly, primary biliary cirrhosis]). These conditions are called overlap syndromes.
Many drugs, including isoniazid, methyldopa, nitrofurantoin, and, rarely acetaminophen, can cause chronic hepatitis. The mechanism varies with the drug and may involve altered immune responses, cytotoxic intermediate metabolites, or genetically determined metabolic defects.
Cases of chronic hepatitis were once classified histologically as chronic persistent, chronic lobular, or chronic active hepatitis. A more useful recent classification system specifies the following:
Inflammation and necrosis are potentially reversible; fibrosis usually is not.
Clinical features of chronic hepatitis vary widely. About one third of cases develop after acute hepatitis, but most develop insidiously de novo.
Many patients are asymptomatic, especially in chronic HCV infection. However, malaise, anorexia, and fatigue are common, sometimes with low-grade fever and nonspecific upper abdominal discomfort. Jaundice is usually absent.
Often, particularly with HCV, the first findings are
Signs of chronic liver disease (eg, splenomegaly, spider nevi, palmar erythema)
Complications of cirrhosis (eg, portal hypertension, ascites, encephalopathy)
A few patients with chronic hepatitis develop manifestations of cholestasis (eg, jaundice, pruritus, pale stools, steatorrhea).
In autoimmune hepatitis, especially in young women, manifestations may involve virtually any body system and can include acne, amenorrhea, arthralgia, ulcerative colitis, pulmonary fibrosis, thyroiditis, nephritis, and hemolytic anemia.
Chronic HCV is occasionally associated with lichen planus, mucocutaneous vasculitis, glomerulonephritis, porphyria cutanea tarda, and, perhaps, non-Hodgkin B-cell lymphoma.
About 1% of patients develop symptomatic cryoglobulinemia with fatigue, myalgias, arthralgias, neuropathy, glomerulonephritis, and rashes (urticaria, purpura, leukocytoclastic vasculitis); asymptomatic cryoglobulinemia is more common.
(See also the American Association for the Study of Liver Disease’s practice guideline Diagnosis, Management, and Treatment of Hepatitis C and the U.S. Preventive Services Task Force’s clinical guideline Screening for Hepatitis C in Adults.)
The diagnosis is suspected in patients with any of the following:
In addition, to identify asymptomatic patients, the Centers for Disease Control and Prevention (CDC) recommends testing all people born between 1945 and 1965 once for hepatitis C.
Liver function tests are needed if not previously done and include serum ALT, AST, alkaline phosphatase, and bilirubin.
Aminotransferase elevations are the most characteristic laboratory abnormalities. Although levels can vary, they are typically 100 to 500 IU/L. ALT is usually higher than AST. Aminotransferase levels can be normal during chronic hepatitis if the disease is quiescent, particularly with HCV.
Alkaline phosphatase is usually normal or only slightly elevated but is occasionally markedly high.
Bilirubin is usually normal unless the disease is severe or advanced.
However, abnormalities in these laboratory tests are not specific and can result from other disorders, such as alcoholic liver disease, recrudescent acute viral hepatitis, and primary biliary cirrhosis.
If laboratory results are compatible with hepatitis, viral serologic tests are done to exclude HBV and HCV (see Table: Hepatitis B Serology*and Hepatitis C Serology). Unless these tests indicate viral etiology, further testing is required.
The next tests done include
Autoantibodies (antinuclear antibody, anti–smooth muscle antibody, antimitochondrial antibody, liver-kidney microsomal antibody)
Thyroid tests (thyroid-stimulating hormone)
Tests for celiac disease (tissue transglutaminase antibody)
Alpha-1 antitrypsin level
Iron and ferritin levels and total iron-binding capacity
Children and young adults are screened for Wilson disease by measuring the ceruloplasmin level.
Marked elevations in serum immunoglobulins suggest chronic autoimmune hepatitis but are not conclusive.
Autoimmune hepatitis is normally diagnosed based on the presence of antinuclear (ANA), anti–smooth muscle (ASMA), or anti-liver/kidney microsomal type 1 (anti-LKM1) antibodies at titers of 1:80 (in adults) or 1:20 (in children).Antimitochondrial antibodies are occasionally present in patients with autoimmune hepatitis. (See also the American Association for the Study of Liver Disease's practice guideline Diagnosis and management of autoimmune hepatitis.)
Serum albumin, platelet count, and PT should be measured to determine severity; low serum albumin, a low platelet count, or prolonged PT may suggest cirrhosis and even portal hypertension.
Unlike in acute hepatitis, biopsy is necessary.
Mild cases may have only minor hepatocellular necrosis and inflammatory cell infiltration, usually in portal regions, with normal acinar architecture and little or no fibrosis. Such cases rarely develop into clinically important liver disease or cirrhosis.
In more severe cases, biopsy typically shows periportal necrosis with mononuclear cell infiltrates (piecemeal necrosis) accompanied by variable periportal fibrosis and bile duct proliferation. The acinar architecture may be distorted by zones of collapse and fibrosis, and frank cirrhosis sometimes coexists with signs of ongoing hepatitis.
Biopsy is also used to grade and stage the disease.
In most cases, the specific cause of chronic hepatitis cannot be discerned via biopsy alone, although cases caused by HBV can be distinguished by the presence of ground-glass hepatocytes and special stains for HBV components. Autoimmune cases usually have a more pronounced infiltration by lymphocytes and plasma cells. In patients with histologic but not serologic criteria for chronic autoimmune hepatitis, variant autoimmune hepatitis is diagnosed; many have overlap syndromes.
If symptoms or signs of cryoglobulinemia develop during chronic hepatitis, particularly with HCV, cryoglobulin levels and rheumatoid factor should be measured; high levels of rheumatoid factor and low levels of complement suggest cryoglobulinemia.
Patients with chronic HBV infection should be screened every 6 mo for hepatocellular cancer with ultrasonography and serum alpha-fetoprotein measurement, although the cost-effectiveness of this practice is debated. (See also the Cochrane review abstract on Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B.) Patients with chronic HCV infection should be similarly screened only if advanced fibrosis or cirrhosis is present.
Prognosis is highly variable.
Chronic hepatitis caused by a drug often regresses completely when the causative drug is withdrawn.
Without treatment, cases caused by HBV can resolve (uncommon), progress rapidly, or progress slowly to cirrhosis over decades. Resolution often begins with a transient increase in disease severity and results in seroconversion from hepatitis B e antigen (HBeAg) to antibody to hepatitis B e antigen (anti-HBe). Coinfection with HDV causes the most severe form of chronic HBV infection; without treatment, cirrhosis develops in up to 70% of patients.
Untreated chronic hepatitis due to HCV causes cirrhosis in 20 to 30% of patients, although development may take decades and varies because it is often related to a patient's other risk factors for chronic liver disease, including alcohol use and obesity.
Chronic autoimmune hepatitis usually responds to therapy but sometimes causes progressive fibrosis and eventual cirrhosis.
Chronic HBV infection increases the risk of hepatocellular cancer. The risk is also increased in chronic HCV infection, but only if cirrhosis or advanced fibrosis has developed.
There are specific antiviral treatments for chronic hepatitis B (eg, entecavir and tenofovir as first-line therapies) and antiviral treatments for chronic hepatitis C (eg, interferon-free regimens of direct-acting antivirals).
Treatment goals for chronic hepatitis include treating the cause and managing complications (eg, ascites, encephalopathy) if cirrhosis and portal hypertension have developed.
Drugs that cause hepatitis should be stopped. Underlying disorders, such as Wilson disease, should be treated.
In chronic hepatitis due to HBV, prophylaxis (including immunoprophylaxis) for contacts of patients may be helpful. No vaccination is available for contacts of patients with HCV infection.
Corticosteroids and immunosuppressants should be avoided in chronic hepatitis B and C because these drugs enhance viral replication. If patients with chronic hepatitis B require treatment with corticosteroids, immunosuppressive therapies, or cytotoxic chemotherapy for other disorders, they should be treated with antiviral drugs at the same time to prevent a flare-up of acute hepatitis B or acute liver failure due to hepatitis B. A similar situation with hepatitis C being activated or causing acute liver failure has not been described.
(See also the American Association for the Study of Liver Disease's The diagnosis and management of non-alcoholic fatty liver disease.)
Treatment of NASH aims to
It may involve recommending weight loss, treating hyperlipidemias and hyperglycemia, stopping drugs associated with NASH (eg, amiodarone, tamoxifen, methotrexate, corticosteroids such as prednisone or hydrocortisone, synthetic estrogens), and avoiding exposure to toxins (eg, pesticides).
(See also the American Association for the Study of Liver Disease’s practice guideline Diagnosis and Management of Autoimmune Hepatitis.)
Corticosteroids, with or without azathioprine, prolong survival. Prednisone is usually started at 30 to 60 mg po once/day, then tapered to the lowest dose that maintains aminotransferases at normal or near-normal levels. To prevent long-term need for corticosteroid treatment, clinicians can transition to azathioprine 1 to 1.5 mg/kg po once/day or mycophenolate mofetil 1000 mg twice/day after corticosteroid induction is complete and then gradually taper the corticosteroid. Most patients require long-term, low-dose, corticosteroid-free maintenance treatment.
Liver transplantation may be required for decompensated cirrhosis.
Chronic hepatitis is usually not preceded by acute hepatitis and is often asymptomatic.
If liver function test results (eg, unexplained elevations in aminotransferase levels) are compatible with chronic hepatitis, do serologic tests for hepatitis B and C.
If serologic results are negative, do tests (eg, autoantibodies, immunoglobulins, alpha-1 antitrypsin level) for other forms of hepatitis.
Do a liver biopsy to confirm the diagnosis and assess the severity of chronic hepatitis.
Consider entecavir and tenofovir as first-line therapies for chronic hepatitis B.
Treat chronic hepatitis C of all genotypes with interferon-free regimens of direct-acting antivirals.
Treat autoimmune hepatitis with corticosteroids and transition to maintenance treatment with azathioprine or mycophenolate mofetil.