Understanding Hepatitis | Types, Diagnosis, Prevention and Treatment

Dr. Charles Panackel
Consultant in Hepatology and Liver Transplantation
Aster Integrated Liver Care
Aster Medcity, Kochi

Introduction

“Hepatitis” means inflammation of the liver. Toxins, certain drugs, some diseases, heavy alcohol use, and bacterial and viral infections can all cause hepatitis.

Viral Hepatitis is a group of viral infections that affect the liver; the most common types are Hepatitis A, Hepatitis B, Hepatitis C and Hepatitis E. Rarely other viruses like dengue, herpes and H1N1 can affect the liver. Although each can cause similar symptoms, they have different modes of transmission and can affect the liver differently.

Hepatitis A and Hepatitis E appears only as an acute or newly occurring infection and does not become chronic. People with Hepatitis A and Hepatitis E usually improve without treatment. Hepatitis B and Hepatitis C can also begin as acute infections, but in some people, the virus remains in the body, resulting in chronic disease and long term liver problems.

There are vaccines to prevent Hepatitis A and B; however, there is not one for Hepatitis C or Hepatitis E. If a person has had one type of viral hepatitis in the past, it is still possible to get the other types.

Hepatitis A and Hepatitis E is usually spread when the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (or stool) of an infected person. A person can get Hepatitis A through: Person to person contact, contaminated food or water.

Prevalence of the disease

Hepatitis B and Hepatitis C are the leading cause of liver cirrhosis and liver cancer in the world. Viral hepatitis accounts for 1.45 million deaths every year. India has the intermediate endemicity of hepatitis B, with hepatitis B surface antigen prevalence between 2% and 10% among the population studied.

The number of carriers in India has been estimated to be over 40 million. Globally, an estimated 71 million people have chronic hepatitis C infection. Approximately 399000 people die each year from hepatitis C, mostly from cirrhosis and hepatocellular carcinoma.

Transmission of the Virus

Hepatitis B virus is present in blood, semen, cervico-vaginal secretions, saliva, and other body fluids. Modes of transmission are

(1) Blood borne- Transfusion of blood/blood products, injecting drug users, hemodialysis recipients, health care and other workers exposed to blood,

(2) Sexual transmission,

(3) Percutaneous or permucosal transfer– needle stick accidents, reuse of contaminated medical equipment, shared razor blades, tattoos, acupuncture, body piercing, shared toothbrushes,

(4) Mother to infant transmission- No risk factor can be identified in 25% cases.

HCV virus predominantly spreads via the blood borne route (recipients of blood or blood products, hemodialysis, IV drug abusers, tattooing and body piercing and health care workers). Mother to child transmission and sexual transmission can also occur but at a low frequency. No risk factor is identified in 10% of cases of HCV infection.

The acute hepatitis B infections are heralded by a serum sickness–like prodrome of fever, arthralgia or arthritis, and rash, followed by manifestations of liver disease (jaundice, vomiting, anorexia).

Clinical symptoms and jaundice generally disappear after one to three months.

HBsAg (Hepatitis B surface antigen) disappears by 12 weeks after the onset of illness. Chronic or persistant HBV infection is defined by the continued presence of HBsAg in the blood for longer than six months. Chronic hepatitis B develops in 2% to 5% of persons who acquire HBV infection in adulthood. Long standing hepatitis B leads to cirrhosis and liver cancer.

Acute hepatitis C is rarely seen in clinical practice because nearly all cases are asymptomatic. Jaundice probably occurs in about 10% of patients. Severe impairment of liver function and liver failure are rare. Chronic hepatitis C is defined by presence of HCV RNA in blood for more than six months. Chronic hepatitis C occurs in 45% to 90% of cases. Chronic HCV infection if not treated progresses to cirrhosis and liver cancer.

 Diagnosis of Hepatitis B and Hepatitis C

To diagnose hepatitis B the blood needs to be checked for the hepatitis B surface antigen (HBsAg). The HBs antigen is a part of the virus and will usually appear in your blood six to twelve weeks after infection. If the test is positive, you have hepatitis B.

Further testing includes IgM antibody to hepatitis B core antigen (IgMHBcAg), Hepatitis B e antigen (HBeAg) and hepatitis B DNA. A positive IgMHBcAg indicates an acute infection. If HBsAg is positive and IgMHBcAg is negative it indicates a chronic HBV infection. HBeAg is a marker for viral replication. A positive HBeAg indicates high viral replication and high chance for infectivity. HBV DNA is checked in all patients with chronic hepatitis B to decide on antiviral treatment.

In case of HCV infection, presence of anti-HCV in high titer in serum indicates exposure to the virus but does not differentiate among acute, chronic, and resolved infection. Molecular assays for HCV RNA are required for confirming infection, monitoring response to treatment, and evaluating immunocompromised patients. A positive anti HCV test and a negative HCV RNA indicates a resolved infection.

All patients with liver disease should have a complete blood count, liver function tests and Prothrombin time. Low platelet may be the sole indicator of chronic liver disease. Liver function tests help to characterize and stage the liver disease, prothrombin time helps to assess the severity. An ultrasound of liver is done to look for features of cirrhosis and hepatocellular carcinoma.

Prevention of Hepatitis B and Hepatitis C

Hepatitis B is a vaccine preventable infection. All persons at risk should be vaccinated against hepatitis B.

In the absence of active or passive immunization the prevention of hepatitis C is by precautions to limit the exposure to HCV contaminated blood or body fluids.

Use of protective attire and barrier techniques when attending to persons infected with HBV or HCV and Safe sex are important precautions.

Treatment of Patients with HBV or HCV

Currently there are potent antiviral drugs available to treat hepatitis B and hepatitis C. Acute hepatitis B and hepatitis C needs only supportive treatment to manage symptoms.

Patients with chronic hepatitis B and C are evaluated for treatment. Patients with chronic hepatitis B and chronic hepatitis C should receive treatment with oral antiviral drugs. Patients should be educated to prevent transmission of virus to their contacts. All contacts of patients with hepatitis B should be vaccinated and response to vaccination must be documented.