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Overview of Chronic Hepatitis

By

Sonal Kumar

, MD, MPH, Weill Cornell Medical College

Last full review/revision Oct 2019| Content last modified Oct 2019
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Chronic hepatitis is inflammation of the liver that lasts at least 6 months.

  • Common causes include hepatitis B and C viruses and certain drugs.

  • Most people have no symptoms, but some have vague symptoms, such as a general feeling of illness, poor appetite, and fatigue.

  • Chronic hepatitis can progress to cirrhosis and ultimately liver cancer and/or liver failure.

  • A biopsy is sometimes done to confirm the diagnosis, but chronic hepatitis is usually diagnosed based on blood test results.

  • Drugs, such as antiviral drugs or corticosteroids, may be used, and for advanced disease, liver transplantation may be needed.

Chronic hepatitis, although much less common than acute viral 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.

Causes

The most common causes of chronic hepatitis are

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 in adults, sometimes with hepatitis D coinfection, become chronic. (Hepatitis D does not occur by itself. It occurs only as a coinfection with hepatitis B.) Acute hepatitis B becomes chronic in up to 90% of infected newborns and in 25 to 50% of young children.

Rarely, hepatitis E virus causes chronic hepatitis in people with a weakened immune system, such as those who are taking drugs to suppress the immune system after an organ transplant, who are taking drugs to treat cancer, or who have HIV infection.

Hepatitis A virus does not cause chronic hepatitis.

Nonalcoholic steatohepatitis usually occurs in people with excess body weight (obesity), diabetes, and/or abnormal levels of cholesterol and other fats (lipids) in the blood. All of these conditions cause the body to synthesize more fat or process (metabolize) and excrete fat more slowly. As a result, fat accumulates and is then stored inside liver cells (called fatty liver). Fatty liver can lead to chronic inflammation and cirrhosis.

Alcohol, after being absorbed in the digestive tract, is usually processed (metabolized) in the liver. As alcohol is processed, substances that can damage the liver are produced. Alcohol-related liver disease typically occurs in people who drink heavily for many months or years. Alcohol-related liver disease is characterized by fatty liver and widespread liver inflammation that can result in the death of liver cells. If people continue drinking, scar tissue can form in the liver and may eventually replace a large amount of normal liver tissue, resulting in cirrhosis.

In autoimmune hepatitis, the chronic inflammation resembles inflammation caused by the body attacking its own tissues (an autoimmune reaction). Autoimmune hepatitis is more common among women than men.

Certain drugs can cause chronic hepatitis, particularly when they are taken for a long time. They include isoniazid, methyldopa, and nitrofurantoin.

Less often, chronic hepatitis results from

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.

Did You Know...

  • Chronic hepatitis may not be suspected until after cirrhosis develops.

Symptoms

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 of chronic hepatitis often include a vague feeling of illness (malaise), poor appetite, and fatigue. Sometimes affected people also have a low-grade fever and some discomfort in the upper abdomen. Jaundice (a yellow discoloration of the skin and whites of the eyes caused by deposits of excess bilirubin) is rare unless liver failure develops.

Often, the first specific symptoms occur when liver disease has progressed and there is evidence of cirrhosis. Symptoms can include

  • An enlarged spleen

  • Small spiderlike blood vessels visible in the skin (called spider angiomas)

  • Redness of the palms

  • Accumulation of fluid within the abdomen (ascites)

  • A tendency to bleed (coagulopathy)

  • Deterioration of brain function (hepatic encephalopathy)

Brain function deteriorates because the badly damaged liver cannot remove toxic substances from the blood as it normally does. These substances then build up in the blood and reach the brain. Normally, the liver removes them from the blood, breaks them down, then excretes them as harmless by-products into the bile (the greenish yellow fluid that aids in digestion) or blood (see Functions of the Liver). Treatment of hepatic encephalopathy can prevent the deterioration of brain function from becoming permanent.

Blood cannot clot as it normally does because the damaged liver can no longer synthesize enough of the proteins that help blood clot.

A few people have jaundice, itchiness, and light-colored stools. Jaundice and itchiness develop because the damaged liver cannot remove bilirubin from the blood as it normally does. Bilirubin then builds up in the blood and is deposited in the skin. Bilirubin is a yellow pigment produced as a waste product during the normal breakdown of red blood cells. Stool is light-colored because the flow of bile out of the liver is blocked and less bilirubin is eliminated in stool. Bilirubin is what gives stool its typical brown color.

Autoimmune hepatitis may cause other symptoms that involve other body systems. Symptoms can include cessation of menstrual periods, joint pain and swelling, loss of appetite, and nausea. People with autoimmune hepatitis may also have other autoimmune disorders such as type I diabetes mellitus, ulcerative colitis, celiac sprue, or autoimmune disorders that cause anemia or inflammation of the thyroid gland or kidneys.

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:

  • Chronic hepatitis C, if untreated, causes cirrhosis in about 20 to 30% of people. However, cirrhosis may take decades to develop. The risk of liver cancer is increased usually only if cirrhosis is present.

  • Chronic hepatitis B tends to worsen, sometimes rapidly but sometimes over decades, leading to cirrhosis. Chronic hepatitis B also increases the risk of liver cancer whether cirrhosis develops or not. (In people with liver disease caused by other conditions, liver cancer is usually a risk only if cirrhosis develops.) Rarely, chronic hepatitis B resolves on its own, without treatment.

  • Chronic coinfection with hepatitis B and D, if untreated, causes cirrhosis in up to 70%.

  • Autoimmune hepatitis can be effectively treated in most people, but some develop cirrhosis.

  • Chronic hepatitis caused by a drug may completely resolve once the drug is stopped.

Diagnosis

  • Blood tests

  • A biopsy

Doctors may suspect chronic hepatitis when

  • People have typical symptoms.

  • Blood tests (done for other reasons) detect elevated liver enzymes.

  • 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.

Testing for chronic hepatitis usually begins with blood tests to measure the levels of liver enzymes and other substances produced by the liver (liver tests). These tests may help establish or exclude the diagnosis of hepatitis, identify the cause, and determine the severity of liver damage.

Blood tests are also done to help doctors identify whether a hepatitis virus is causing the infection. If no virus is identified, other blood tests are needed to check for other causes, such as autoimmune hepatitis.

A liver biopsy is sometimes done to confirm the diagnosis. The liver biopsy also enables a doctor to do the following:

  • Determine how severe the inflammation is

  • Determine whether any scarring (fibrosis) or cirrhosis has developed

  • Possibly help identify the cause of hepatitis

Other tests may be done to determine how badly the liver is damaged and to check for other liver problems. Tests may include

  • Specialized imaging tests, such as ultrasound elastography and magnetic resonance elastography

  • Blood tests to measure substances (called markers) that indicate whether and how much fibrosis is present

Screening for liver cancer

If people have chronic hepatitis B (or cirrhosis due to any liver disorder), screening for liver cancer is done every 6 months. Two tests are used:

  • Ultrasonography

  • Sometimes measurement of levels of alpha-fetoprotein in the blood

Levels of alpha-fetoprotein—a protein normally produced by immature liver cells in fetuses—may be elevated when liver cancer is present.

Treatment

  • Treatment of the cause (such as antiviral drugs for hepatitis B or C)

  • Treatment of complications

Treatment of chronic hepatitis focuses on treating the cause and managing the complications, such as ascites and hepatic encephalopathy in people with 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 is worsening or if liver enzyme levels are high, people are usually given antiviral drugs.

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.

With chronic hepatitis C, treatment with antiviral drugs is recommended for all unless their life expectancy is very short. Treatment can last from 8 to 24 weeks. Treating hepatitis C can eliminate the virus from the body and thus stop inflammation and prevent scarring and progression to cirrhosis.

Nonalcoholic steatohepatitis

Treatment of nonalcoholic steatohepatitis focuses on managing the conditions that contribute to it. For example, treatment may include

  • Losing weight

  • Eating a healthy diet (which can help control weight, diabetes, and possibly lipid levels)

  • Not taking drugs that can contribute to the disorder (such as tamoxifen, corticosteroids, and synthetic estrogens)

  • Avoiding toxins, such as pesticides

Autoimmune hepatitis

Usually, corticosteroids (such as prednisone or budesonide) are used to treat autoimmune hepatitis along 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. However, taking corticosteroids for a long time can have significant side effects. So doctors usually gradually reduce the dose of the corticosteroid so that people can stop taking it. People then take azathioprine or mycophenolate (other drugs that suppress the immune system) indefinitely.

Treatment of complications

Regardless of the cause or type of chronic hepatitis, cirrhosis, liver failure, and their complications require treatment.

Treating ascites involves restricting salt consumption and taking a drug that helps the kidneys excrete more sodium and water into the urine (a diuretic).

Treating hepatic encephalopathy involves taking drugs to help the body eliminate the toxic substances that can cause the brain function to deteriorate.

Liver transplantation

Liver transplantation may be considered for people with severe liver failure.

Drugs Mentioned In This Article

Generic Name Select Brand Names
FURADANTIN, MACROBID, MACRODANTIN
Mycophenolate
IMURAN
No brand name
PULMICORT, RHINOCORT
RAYOS
LANIAZID
NOLVADEX
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