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Hepatitis is a condition where liver cells become inflamed (swollen). In hepatitis, the word ‘hepat’ refers to the liver and ‘itis’ refers to its inflammation.
Inflammation in hepatitis occurs in response to some damage which can be due to infections, alcohol, medicines, toxins, or antibodies. The infection of the liver caused by hepatitis viruses are the commonest cause of hepatitis in the world and in India. This can be caused by any of the 5 viruses namely hepatitis A, B, C, D, and E.
Hepatitis can be divided into two types on the basis of duration.
Acute hepatitis: the inflammation begins suddenly and lasts for less than 6 months period usually for a few weeks only. The affected person may have no symptoms to severe symptoms. Most of these cases resolve on their own, however, some persist for a longer period and cause chronic hepatitis.
Chronic hepatitis: the inflammation of the liver lasts for at least 6 months. It can be caused by hepatitis B and C viruses, NASH, alcohol, and others. Hepatitis C accounts for most of the cases of chronic hepatitis ie. 60 to 70% cases. Most of the people with chronic hepatitis have no symptoms, but some have non-specific symptoms, such as fatigue, poor appetite, and a general feeling of illness. Chronic hepatitis has a tendency to develop fibrosis which can complicate into cirrhosis and liver failure or liver cancer.
Around 400 million people all over the world suffer from chronic hepatitis and the Asia-Pacific region constitutes the epicenter of this epidemic.
Hepatitis can be caused by an infection or substance that can injure the liver cells and cause inflammation.
The causes can be broadly categorized into two:
These are the commonest causes of hepatitis. They can lead to both acute and chronic hepatitis. Below are causes of acute viral hepatitis:
• Hepatitis A virus (HAV): this infection occurs due to the consumption of food or drinks contaminated by feces from a person infected with the hepatitis A virus. It is closely related to poor sanitation and bad habits related to hygiene. In India, it is more commonly seen in children. A study showed that it is less common in children who used private toilets than who used open field.
• Hepatitis B virus (HBV): this infection is transmitted by coming in contact with blood and body fluids of a person infected with the hepatitis B virus. It can occur due to blood transfusion, injecting drugs, unprotected sex, or during pregnancy from mother to baby. In India, about 4 crore people are estimated to be carriers of HBV. About 2 in 3 people with HBV are not aware of their infection. It is estimated that about 15 to 25% of carriers are likely to develop cirrhosis or liver cancer and die with premature deaths. It is is a leading cause of liver cancer.
• Hepatitis C virus (HCV): infection is transmitted by coming in direct contact with the body fluids of an infected person, typically through injection drug abuse and sexual contact. About 50% of the people with hepatitis C are not aware of their infection.
• Hepatitis D virus (HDV): infection is transmitted through direct contact with infected blood. Hepatitis D is a rare type of hepatitis that only occurs with hepatitis B infection and can result in a serious condition.
• Hepatitis E virus (HEV): the infection is acquired by drinking water contaminated with faces of a person infected with HEV. It is seen in areas with poor sanitation and is a common cause of outbreaks in India.
Some bacterias can also rarely cause hepatitis such as Anaplasma, Nocardia, and others
These causes are less common
• Alcohol: chronic excessive alcohol drinking leads to alcoholic steatohepatitis (ASH) which can further lead to the development of cirrhosis.
• Autoimmune hepatitis
• Drugs: Paracetamol, Amoxycillin, antituberculosis medicines, minocycline, and many others
• Ischemic hepatitis
• Wilson’s disease
Some of the infections, toxins, or drugs may lead to persistent long-standing liver inflammation leading to the development of chronic hepatitis.
Causes of chronic hepatitis:
• Hepatitis C virus: constitute 60 to 70% of cases of chronic hepatitis. About 75 to 85% of cases of acute hepatitis C develop into chronic hepatitis. Hepatitis C is a leading cause of liver transplants and liver cancer.
• Hepatitis B virus: about 5 to 10% of infected people develop chronic hepatitis. Development into chronic hepatitis is highest in infants about 90% and lowest in adults about 5%.
• NASH (nonalcoholic steatohepatitis)
• Alcohol-related liver disease
• Autoimmune hepatitis
Hepatitis when it occurs in acute form may lead to no obvious symptoms to very severe symptoms. When the person develops symptoms, it develops suddenly causing anything from minor flu-like illness to liver failure.
Symptoms of acute hepatitis:
• Flu-like symptoms- fever, body ache, etc
• General feeling of being sick (malaise)
• Loss of appetite
• Nausea and vomiting
• Weakness and fatigue
• Pain in the abdomen on the upper right side, where the liver is located
• Jaundice- development of yellowish discoloration of the skin and whites of the eyes, which may be accompanied by itching.
• Dark-colored urine
• Pale colored stools
Jaundice occurs due to the inability of the damaged liver to remove bilirubin from the blood which gets accumulated in the skin and whites of the eye to impart its yellow color. The excess bilirubin is excreted through urine which gives a dark color to the urine. This also causes bilirubin not to be excreted into the intestine as it normally does making it pale-colored instead of brown colored.
Most of the initial symptoms such as fever, poor appetite, nausea, vomiting, usually reduce or resolves within a week’s time. The affected person starts feeling better even though jaundice may worsen. Jaundice usually peaks in 1 to 2 weeks and gradually disappears over a course of 2 to 4 weeks. However, sometimes it may last longer.
The severity of symptoms and speed of recovery differs amongst people, depending on the cause (type virus or toxin) and on the person’s body response. Hepatitis A and C usually causes milder symptoms or no symptoms at all. Hepatitis B and E more often produce severe symptoms. Infection with both hepatitis B and D together is usually severe may complicate into fulminant hepatitis.
People usually recover in 4 to 8 weeks. They generally need only symptomatic treatment or no treatment at all.
Some of the people infected with the hepatitis virus may recover fully or don’t show any significant symptoms but still carry the virus. These people are called the carrier and can eventually develop chronic hepatitis or act as a reservoir to spread the infection to others
In rare cases, hepatitis may rapidly progress to a severe form called fulminant hepatitis causing damage to a large part of the liver leading to liver failure and other complications such as hepatic encephalopathy, coagulopathy, and renal failure. It may lead to a coma in a matter of several days to weeks. It may cause death, especially in adults. Sometimes, liver transplantation is immediately done to save the person’s life.
Fulminant hepatitis is more commonly seen in people with hepatitis B infection especially when the infection is accompanied by hepatitis D infection (comprising 50% cases of hepatitis B turning into fulminant hepatitis). In India, the infection with the hepatitis E virus is the commonest cause of fulminant viral hepatitis. Another important cause is toxin and medicines overdose as seen with paracetamol overdose in western countries and anti-tubercular drugs in India.
Fulminant hepatitis needs to be suspected and evaluated for when a person develops the following:
• Sudden onset of coagulopathy with abnormal PT/INR tests.
• Development of encephalopathy with a sudden decline in mental function
• Development of severe disease with the rapid development of jaundice
Some of the causes of hepatitis continue to inflict damage to the liver over a long period of time resulting in chronic hepatitis.
Many people, ie 75 to 85% with acute hepatitis C eventually develop chronic hepatitis. Hepatitis B can eventually cause chronic hepatitis in infected children (developing in 90% infants and 25 to 50% young children). Only 5% of adults with hepatitis B infection develop chronic hepatitis.
• General feeling of being sick (malaise)
• Poor appetite
• Weakness and fatigue
• Low-grade fever and discomfort in the upper abdomen
The symptoms are usually non-specific and more specific symptoms typically appears when cirrhosis develops:
• Accumulation of fluid in the abdomen
• Swelling of lower limbs
• Small tortuous vessels visible in skin of the abdomen
Acute hepatitis can be diagnosed with the help of clinical presentation and blood tests including liver function tests and viral markers. Less often imaging tests or biopsy is required which is generally used for assessing chronic hepatitis and its complications. These can be categorized into blood tests, imaging studies, and liver biopsy.
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