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 Dr Charles Panackel,Consultant in Hepatology & Liver Transplantation,Aster Medcity, Kochi “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.
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.
The Virus
Hepatitis B virus is present in blood, semen, cervico-vaginal secretions,
saliva, and other body fluids. Modes of transmission 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.
Clinical features
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 disappears by 12 weeks after the
onset of illness. Chronic 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 be vaccinated and response to vaccination documented.
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