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