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Updated: Dec 11 2021

Chronic Hepatitis

  • Snapshot
    • A 35-year-old man presents to his primary care physician for routine check-up. During this visit, review of systems reveals that he has been feeling excessively fatigued with weight loss, lack of energy, and vague abdominal discomfort. He has a history of alcohol abuse as well as acute hepatitis. On physical exam, he has mild tenderness to palpation and no hepatomegaly. Laboratory evaluation shows elevated liver enzymes and positive anti-HCV antibodies.
  • Introduction
    • Overview
      • chronic hepatitis is defined by hepatic inflammation of > 6-month duration
    • Associated conditions
      • hepatocellular carcinoma
  • Epidemiology
    • Risk factors
      • alcohol use
      • IV drug use
      • international travel
      • unprotected sexual practices
  • etiology
    • Hepatitis C virus (most common)
    • Hepatitis B virus with or without hepatitis D coinfection
    • Nonalcoholic steatohepatitis
    • Alcoholic hepatitis
    • Autoimmune hepatitis
    • Alpha-1-antitrypsin deficiency
    • Wilson disease
    • Hemochromatosis
    • Medications, when taken long term
      • isoniazid
      • methyldopa
      • nitrofurantoin
    • Pathogenesis
      • mechanism
        • chronic hepatitis can last for years but remain mild without significant hepatic injury
        • chronic hepatitis can also result in cirrhosis, liver failure, and increase the risk for hepatocellular carcinoma
  • Presentation
    • History
      • patients may have a history of acute hepatitis
    • Symptoms
      • common symptoms
        • malaise
        • poor appetite
        • fatigue
        • abdominal discomfort
    • Physical exam
      • inspection
        • jaundice is rare
      • palpation
        • hepatomegaly
  • Imaging
    • Ultrasound of liver
      • indications
        • screen for hepatocellular carcinoma
      • findings
        • liver mass
  • Studies
    • Serum labs
      • liver function tests
        • elevated AST and ALT (at least 3x higher than normal)
          • degree of elevation does not correlate with disease severity
          • AST:ALT > 2 suggests alcoholic hepatitis
        • elevated prothrombin time (PT)
      • hepatitis viral panel
        • HBV
          • quantitation of
            • HBsAg
            • presence of anti-HBc IgM/IgG, anti-HBs Ab
        • HCV
          • presence of anti-HCV Ab, genotyping, and HCV RNA quantitation
    • Invasive studies
      • liver biopsy
        • confirm diagnosis and assess for degree of inflammation/cirrhosis
  • Differential
    • Acute hepatitis
      • key distinguishing factor
        • acute onset with flu-like symptoms, jaundice, abdominal pain, and transaminitis
  • Treatment
    • Management approach
      • depends on underlying etiology
      • see individual topics for treatment regimens
    • Lifestyle
      • weight loss
      • alcohol cessation
    • Medical
      • antiviral treatment
        • indications
          • chronic hepatitis B
            • monitor therapy with HBV DNA and alanine aminotransferase (ALT) levels
        • chronic hepatitis C
          • based on genotype, previous treatment history and, if cirrhosis is present, degree of severity based on MELD-Na score
          • examples of regimens include interferon + ribavirin
      • immunosuppression
        • indication
          • autoimmune hepatitis
    • Surgical
      • liver transplant
        • indication
          • end-stage liver disease and/or for those refractory to medical therapy.
  • Complications
    • Cirrhosis
    • Hepatocellular carcinoma
    • Portal hypertension
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