Hepatitis is nothing but the inflammation of the liver.
The liver is susceptible to injury because of its dual blood supply ( hepatic artery and portal vein). Injury can be caused by infections ( virus, bacteria, protozoa, fungus etc), drugs, alcohol, vascular injury etc. It is important to note that hepatitis caused by viruses is preventable. Viruses which are hepatotropic can cause acute hepatitis which if uncontrolled may progress to chronic hepatitis ( 6 months ) and subsequently to cirrhosis and hepatocellular carcinoma. Similar changes can be seen with alcohol and drugs.
Common hepatitis viruses are Hepatitis A, B, C and E. Hepatitis A and E (HAV and HEV) are transmitted by contaminated food and water. Hepatitis B(HBV), Hepatitis C ( HCV) and Hepatitis D ( HDV) are transmitted by blood and blood products.
Symptoms of Hepatitis
Acute viral hepatitis is characterized by symptoms like malaise, anorexia, nausea, and vomiting. Flu-like symptoms of pharyngitis, cough, coryza, photophobia, headache, and myalgias may be seen. Fever usually subsides once jaundice appears. The onset of symptoms tends to be abrupt for HAV and HEV; in the other onset is usually insidious. The patient may have itching at a later date.
It is very important to rule out common infections like Malaria, Dengue and Leptospirosis in our coastal area. Some drugs (antitubercular, cardiac, anticonvulsants ) can also cause hepatitis.
Chronic hepatitis is characterized by malaise, generalized fatigue with/without jaundice, and right upper abdominal pain.
Cirrhosis is characterized by generalized weakness, easy fatiguability, jaundice, abdominal and leg swelling, vomiting of blood and altered sensorium.
Hepatocellular carcinoma may be characterized by the above features with right upper abdominal pain and weight loss.
Most acute hepatitis A infections are self-limiting. Some may proceed to fulminant hepatic failure characterized by altered sensorium and bleeding tendencies. Some may have intractable itching( cholestatic hepatitis) or relapse of illness may be seen after 1-2 months of complete recovery (Relapsing hepatitis). The florid disease may be seen in elderly or with underlying chronic liver disease.
Most of the HEV infection may be self-limiting. But it may cause mortality in pregnant females (third trimester).
Hepatitis B and Hepatitis C can cause acute hepatitis, chronic hepatitis, cirrhosis or hepatocellular carcinoma. 90% of the infected neonates become HBV carries but only 1-5% of the infected adults develop chronic HBV infection. More than 50-80% of acutely infected HCV patients will have chronic infection which subsequently progresses to cirrhosis and cancer.
Diagnosis of Hepatitis
Typical clinical symptoms along with supportive laboratory parameters.
Low blood counts may be seen. Liver function tests will be deranged with an increase in total bilirubin and the liver enzymes ( AST / ALT ) will be raised in thousands. USG abdomen may show an enlarged liver and spleen. Serological tests for specific viruses ( IgM HAV, IgM HEV, HCV, HBsAg and IgMantiHBc ) may be positive.
Prevention of viral hepatitis
Hepatitis A
It can be prevented by good hygienic habits (washing hands before food and after using toilets). Use of clean and safe water supplies. Avoiding uncontrolled water sources, raw shellfish, and uncooked food. Using boiled water or adding iodine to water which inactivates the virus. All fruits should be washed and peeled. Immunization, particularly of high-risk individuals.
Immunisation
Usually by the vaccine (Inactivated HAV vaccine)
Pre-exposure prophylaxis (before contact with the virus) for at-risk individuals.
Protective efficacy rate is 95-100%. Protection can be seen for 20-50years.
Who should receive vaccines?
Travellers to high – risk areas, susceptible patients with chronic liver disease, laboratory workers handling HAV, children in regions with high HAV attack rates like India, persons with clotting disorders. persons with HIV infection and workers in institutions for developmentally disadvantaged.
Post-exposure prophylaxis: For households and intimate contacts of individuals with acute HAV infection. Immunoglobulin can be given.
HEV: No vaccine is available against HEV infection to date.
HBV: Precautions to be taken against blood-borne virus infection: Follow safe sexual practice ( using barrier methods of contraception), avoid sharing needles, razors and toothbrushes. Use safe blood products. (NOTE: NO BLOOD IS SAFE. VIRUS MAY BE UNDETECTABLE DURING LATENT PERIOD).
Pre-exposure prophylaxis
Hepatitis B Vaccine is safe. Protective efficacy 95-98%
Note: Please rule out HBV infection by HBsAg ELISA test before taking the vaccination. No use of vaccination if the test if positive.
Who should be vaccinated?
Newborn shortly after birth, All children and adolescents not vaccinated at birth, household and spouse contacts of HBV carriers or patients with acute hepatitis B, health care and other workers exposed to blood, Injecting drug users, homosexual and bisexual men, Individuals with multiple sexual partners, workers in institutions for developmentally disadvantaged, recipients of multiple types of blood and blood products, hemodialysis patients, patients with pre-existing liver disease ( alcohol, HCV etc) and potential organ transplant recipients.
IT IS ALWAYS CHEAPER AND WISER TO PREVENT HBV INFECTION BY VACCINATION THEN TO TREAT CHRONIC INFECTION. Consult with the gastroenterology doctors in Mangalore to know more.
Post-exposure prophylaxis (after contact): with HBV vaccine and Hepatitis B Immunoglobulin. Good results if taken within 24hours of exposure.
Who should receive: susceptible sexual contacts of acutely HBV-infected individuals. Newborn of HBsAg-positive mothers identified during pregnancy.
Hepatitis D – Vaccination against HBV protects against HDV.
No vaccine is available against HCV infection.
Treatment of Hepatitis
Most of the acute viral hepatitis are self-limiting. Jaundice subsides within 4-8 weeks.
Acute hepatitis needs symptomatic treatment. No specific diet. Adequate calories rich in carbohydrates preferred. Avoid fatty food. Alcohol is prohibited. Avoid alternative medicines.
Patients can also visit the top gastroenterology hospital in Mangalore only if the patient has intractable vomiting, altered sensorium or bleeding tendencies.
It is important to note that chronic hepatitis caused by HBV, HCV and HDV are treatable by oral medications and injections which is against the myth that there is “no treatment available for HBV, HDV and HCV”. Treatment is costlier and response rate varies. Hence “PREVENTION IS BETTER THAN CURE”.
Once cirrhosis is present, further treatment may prevent progression of underlying liver disease or development of its complications like ascites, hepatocellular carcinoma, variceal bleed etc. Liver transplantation can be considered in advanced disease.
Hepatocellular carcinoma can be treated by resection, chemotherapy, radiologically ( TACE/ RFA) or liver transplantation.
Conclusion
Hepatitis caused by viruses is preventable by good hygiene, safe water, safe blood and blood products and safe sexual practice. Hepatitis A and B can be prevented by vaccines. It is wiser to prevent than to treat a disease or its complication.
Consultant Gastroenterology
