Chronic hepatitis is inflammation of the liver that lasts at least 6 months.
Chronic hepatitis, although much less common than acute hepatitis, can persist for years, even decades. In many people, it is quite mild and does not cause significant liver damage. However, in some people, continued inflammation slowly damages the liver, eventually resulting in cirrhosis (severe scarring of the liver), liver failure, and sometimes liver cancer.
Hepatitis C virus was not identified until 1989. People may have been infected before this time without knowing it. Because unrecognized infection is possible, researchers tested various age groups for hepatitis C. They found that among adults in the United States, about three fourths of all chronic hepatitis C cases occur in people born between 1945 and 1965.
Chronic hepatitis is usually caused by one of the hepatitis viruses (see see Table 1: The Hepatitis Viruses). Hepatitis C virus causes about 60 to 70% of cases, and at least 75% of acute hepatitis C cases become chronic. About 5 to 10% of hepatitis B cases, sometimes with hepatitis D coinfection, become chronic. Hepatitis A and E viruses do not cause chronic hepatitis.
Certain drugs can cause chronic hepatitis, particularly when they are taken for a long time. They include isoniazid, methyldopa, and nitrofurantoin. Other causes include alcoholic hepatitis and fatty liver not due to alcohol use (nonalcoholic steatohepatitis). Less often, chronic hepatitis results from alpha1-antitrypsin deficiency (a hereditary disorder), celiac disease, a thyroid disorder, or, in children and young adults, Wilson disease—a rare hereditary disorder involving abnormal retention of copper in the liver (see Wilson Disease).
No one knows exactly why a particular virus or drug causes chronic hepatitis in some people but not in others or why the degree of severity varies. In many people with chronic hepatitis, no obvious cause can be identified. In some of these people, the chronic inflammation resembles inflammation caused by the body attacking its own tissues (an autoimmune reaction—see Autoimmune Disorders). This type of inflammation, called autoimmune hepatitis, is more common among women than men.
In about two thirds of people, chronic hepatitis develops gradually, often without causing any symptoms of a liver disorder until cirrhosis occurs. In the remaining one third, it develops after a bout of acute viral hepatitis that persists or returns (often several weeks later).
Symptoms often include a vague feeling of illness (malaise), poor appetite, and fatigue. Sometimes affected people also have a low-grade fever and some upper abdominal discomfort. Jaundice is rare.
Complications of chronic liver disease and cirrhosis may eventually develop. They can include an enlarged spleen, small spiderlike blood vessels visible in the skin (called spider angiomas), redness of the palms, and accumulation of fluid within the abdomen (ascites—see Ascites). Liver malfunction may lead to deterioration of brain function (hepatic encephalopathy—see Hepatic Encephalopathy), particularly in people with cirrhosis due to hepatitis C.
Autoimmune hepatitis may cause other symptoms that can involve virtually any body system, especially in young women. Such symptoms include acne, cessation of menstrual periods, joint pain, scarring of the lungs, inflammation of the thyroid gland and kidneys, and anemia.
In many people, chronic hepatitis does not progress for years. In others, it gradually worsens. The outlook depends partly on which virus is the cause:
Doctors may suspect hepatitis C when people have typical symptoms, when blood tests (done for other reasons) detect abnormally high liver enzymes, or when people have had acute hepatitis before. Also, everyone born between 1945 and 1965, regardless of whether symptoms are present, should be tested once for hepatitis C. Such testing is recommended because hepatitis C is common among this age group and is often unrecognized.
Blood tests are done. They may help establish or exclude the diagnosis, identify the cause, and determine the severity of liver damage. However, a liver biopsy (see Biopsy of the Liver) is essential to confirm the diagnosis. The liver biopsy also enables a doctor to determine how severe the inflammation is and whether any scarring or cirrhosis has developed. The biopsy may help identify the cause of hepatitis.
If people have chronic hepatitis B, ultrasonography and blood tests to measure alpha-fetoprotein levels are done every 6 to 12 months to screen for liver cancer. Levels of alpha-fetoprotein—a protein normally produced by immature liver cells in fetuses—usually increase when liver cancer is present. People with chronic hepatitis C are screened similarly, but only if they have cirrhosis.
If a drug is the cause, the drug is stopped. If another disorder is the cause, it is treated.
Hepatitis B and C:
If chronic hepatitis B or C is worsening or if liver enzyme levels are high, people are usually given antiviral drugs.
For hepatitis B, entecavir or tenofovir is usually used. These drugs are taken by mouth. These drugs are very effective, and the chance that viruses will develop resistance to them is slight. Other drugs that can be used include telbivudine and lamivudine (taken by mouth) and interferon alfa and pegylated interferon alfa (given by injection under the skin).
In some people, hepatitis B tends to recur once drug treatment is stopped and may be even more severe. Thus, these people may need to take an antiviral drug indefinitely.
There are several types of hepatitis C virus (called genotypes). Each type has a slightly different its genetic material. Treatment varies by type. For some types, pegylated interferon alfa plus ribavirin (taken by mouth) is most effective. This combination may stop the inflammation. After taking these drugs for 6 months, 45 to 75% of people improve and have no further problems. For other types of hepatitis C, people are given pegylated interferon alfa and ribavirin plus a type of drug usually used to treat HIV infection, called a protease inhibitor (such as telaprevir or boceprevir).
Antiviral drugs taken by mouth (such as entecavir, tenofovir, telbivudine, and lamivudine) have few side effects. Lamivudine may have fewer side effects than the others. Ribavirin can cause birth defects. Both men and women who have to take this drug should use birth control during treatment and for 6 months after treatment ends.
Pegylated interferon alfa can cause a flu-like illness at first. Later, it can cause fatigue, a general feeling of illness (malaise), and depression. The drug may also suppress activity in the bone marrow, including the production of blood cells.
Pegylated interferon alfa should not be taken by people who have certain conditions:
If family members and close contacts of people with chronic hepatitis B have not been vaccinated, they should be. They are also given hepatitis B immune globulin by injection. Such measures are not necessary for chronic hepatitis C.
Usually, corticosteroids (such as prednisone) are used, sometimes with azathioprine, a drug used to suppress the immune system. These drugs suppress the inflammation, relieve symptoms, and improve long-term survival. Nevertheless, scarring in the liver may gradually worsen. Stopping these drugs usually leads to recurrence of the inflammation, so most people have to take the drugs indefinitely.
Treatment of complications:
Regardless of the cause or type of chronic hepatitis, complications require treatment. For example, treating ascites involves restricting salt consumption and taking a drug that helps the kidneys excrete more sodium and water into the urine (a diuretic—see Treatment). If brain function deteriorates, eliminating meat and other animal protein from the diet can help (see Treatment).
Transplantation (see see Liver Transplantation) may be considered for people with severe liver failure. However, in people with hepatitis C, the virus virtually always recurs in the transplanted liver, and transplantation is less likely to be successful than transplantation done for other reasons.
Last full review/revision May 2013 by Anna E. Rutherford, MD, MPH