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Autoimmune Hepatitis

Functions of the liver
The liver is in the upper right part of the tummy (abdomen). It performs various functions:

  1. It makes proteins that are essential for blood to clot(clotting factors).
  2. It helps to process fats and proteins from digested food.
  3. It stores glycogen, a chemical made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream.
  4. It makes bile which passes from the liver to the gut and helps to digest fats.
  5. It helps to remove or process alcohol, poisons and toxins from the body.
  6. It processes many medicines which one may take.

Reducing autoimmune hepatitis?
Inflammation of the liver is called hepatitis. There are many causes of hepatitis. Excessive alcohol consumption and infections with various viruses are the common causes of hepatitis.

An uncommon cause of chronic hepatitis is autoimmune hepatitis. Chronic means that the inflammation is persistent or long-term. The chronic inflammation gradually damages the liver cells, which can result in serious problems.

How does autoimmune hepatitis occur?
The cause for autoimmune hepatitis is not clear and It is taken as an autoimmune disease. Our immune system normally defends us against infection from bacteria, viruses and other germs. In people with autoimmune diseases the immune system itself attacks part or parts of the body as if they were foreign. This causes inflammation and may damage the affected part or parts of the body.

The immune system consists of special proteins (antibodies) and white blood cells which attack and destroy foreign germs and materials. There are various kinds of autoimmune diseases. For example, rheumatoid arthritis, myasthenia gravis, some forms of thyroid disease, and autoimmune hepatitis. The symptoms of each disease depend on which part or parts of the body are attacked by the immune system. In some autoimmune diseases it is antibodies which do the damage. In autoimmune hepatitis, it is white blood cells called lymphocytes which are mainly involved. The lymphocytes attack the liver cells (hepatocytes) which causes inflammation and damage.

The cause for the occurrence of autoimmune hepatitis or other autoimmune diseases is yet not known. Some factor may trigger the immune system to attack the body’s own tissues. There are various theories as to possible triggers. For example, a virus, a chemical or some other factor may trigger the disease. There is also an inherited factor which makes some people more prone to autoimmune diseases. One may be genetically susceptible to the disease for it to trigger off.

Acquisition of autoimmune hepatitis
Autoimmune hepatitis is uncommon. It affects around 1 in 10,000 people. About 7 in 10 cases are in women. It most commonly develops in women aged around 45 years but it can affect people at all ages (including children and the elderly).

Indications of autoimmune hepatitis
The symptoms develop gradually over weeks or months in many cases. At the beginning of the disease, most people have no symptoms at all. The most common early symptoms include:

  1. Joint and muscle pains which are usually worse in the mornings.
  2. Feeling of generally unwell
  3. Feeling sick (nauseated).
  4. Feeling more tired than usual

Worsening of the liver inflammation can lead to jaundice. In jaundice, skin goes yellow. One tends to notice it first when the whites of the eyes become yellow. This is due to a build-up of the chemical bilirubin which is made in the liver and spills into the blood in some liver conditions. (With jaundice due to hepatitis one’s urine goes dark, stools (faeces) may go pale and one tends to itch.

The persistent inflammation causes liver damage without in time treatment and can lead to cirrhosis. Cirrhosis is like a scarring of the liver which can cause serious problems and liver failure when it is severe.

A quick development of symptoms can be seen over a few days in some cases with an acute hepatitis. (Acute means sudden in onset or of short duration.) This can cause a fairly sudden onset of:

  1. Feeling sick
  2. Feeling unwell.
  3. High temperature (fever).
  4. Jaundice
  5. Being sick (vomiting).
  6. Tummy (abdominal) pain.

In some of these cases, the acute hepatitis settles down to the more common type of chronic hepatitis. In some cases, the acute hepatitis becomes severe and rapidly leads to liver failure.

If left untreated, the time it takes from the onset of the condition until severe cirrhosis develops varies from person to person. However, with treatment, the inflammation can usually be controlled and the outlook is good.

Identification of autoimmune hepatitis
Many people with autoimmune hepatitis have no symptoms, or only vague symptoms, for quite some time in the early stages of the disease. Therefore, the diagnosis is often made when one has investigations for an unrelated condition. When symptoms suggest that one has hepatitis, one’s doctor will normally arrange tests to confirm hepatitis and to find the cause of the hepatitis. Following investigations are generally done

  1. An Ultrasound scan may be done.
  2. Blood tests called liver function tests. These measure the activity of chemicals (enzymes) and other substances made in the liver. This gives a general guide as to whether the liver is inflamed, and how well it is working.. These tests can confirm that one has hepatitis but not usually the cause of the hepatitis.
  3. A small sample (biopsy) of the liver is likely to be taken to look at under the microscope. This can show inflammation and extent of any scarring of the liver. The type of cells involved in the inflammation usually help to confirm the diagnosis of autoimmune hepatitis, and to rule out other causes of hepatitis.
  4. Other blood tests can measure various auto-antibodies which occur in various autoimmune
    Diseases. For example, antinuclear antibodies (ANAs) or smooth muscle antibodies (SMAs). Some of these auto-antibodies are raised in autoimmune hepatitis and indicate that this may be the cause of the hepatitis.
  5. Besides various tests may be done to rule out other liver disorders such as viral hepatitis.

Remedies for autoimmune hepatitis

One almost always seeks remedies. Early treatment can improve symptoms, reduce the risk of complications, and also greatly improve one’s progress. Treatment aims to reduce inflammation and suppress the immune system with immunosuppressant medicines.

Steroid medication (Prednisolone) is the usual first treatment. Steroids are good at reducing inflammation. A high dose is usually needed at first. The dose is then gradually reduced over a few weeks. The aim is to find the lowest dose needed to control the inflammation. The dose needed varies from person to person.

Azathioprine though immunospressant it works in a different way to steroids. It is generally used in addition to the steroid. A steroid plus azathioprine tends to work better than either alone. Also, the dose of steroid needed is usually less if you also take azathioprine. This means that any side-effects from steroids may be less severe.

In most cases the treatment works well. The settling of inflammation and improvement in symptoms is noticed.
However, it may take a year or more to get the disease totally under control. Azathioprine is usually prescribed for at least three years.

Side-effects from the treatment may be troublesome in some cases. The dose of treatment is kept as low as possible to keep the condition under control with the minimum of side-effects. If one is not tolerant to the azathioprine and/or steroids then alternative treatment may be given. This may include other medicines called ciclosporin or tacrolimus.

Side-effects from the steroids can occur. These can include ‘thinning’ of the bones (osteoporosis), weight gain and increased pressure in the eye (glaucoma). One’s doctor is likely to advise that one takes vitamin D and calcium supplements while one is taking steroid medication. These work by strengthening the bones and lowering your chances of developing osteoporosis. DEXA (Dual energy X – ray absorptionmetry) may be done before starting steroids.

Once the condition has completely settled, one’s doctor may advise a trial without treatment. A liver biopsy is usually done at the end of the course of treatment, to ensure that the liver inflammation has fully resolved. However, only around one in five people can remain off treatment for long periods of time. This is because the hepatitis usually returns (relapses), which means you will have to then take medication again. In many cases, long-term maintenance treatment is needed. This means that the majority of people with autoimmune hepatitis will need to take low doses of immunosuppressant treatment for long periods of time, or even indefinitely.

A liver transplant may be an option for some people – for example:

  • In the few people who do not respond to treatment with the medicines mentioned above; or
  • In people diagnosed in the late stage of the disease with severe scarring of liver (Cirrohosis) or liver failure.

The long-term prognosis after liver transplantation is good.
Hepatitis A & B vaccination is a must along with annual influenza vaccine.

Diet and alcohol
Most people with autoimmune hepatitis will be advised to eat a normal healthy diet. Ideally, anybody with inflammation of the liver should avoid alcohol fully as even small amount can cause maximum damage. If you already have liver inflammation, alcohol may increase the risk and speed of developing cirrhosis.

What is the outlook (prognosis)?
Most people with autoimmune hepatitis have a normal life expectancy and feel well most of the time with treatment. There has been a considerable improvement in the outlook. It is very important that one does not stop one’s treatment too early without one’s doctor’s knowledge, as your hepatitis may relapse.

A minor increased risk of developing cancer is there. increased especially if one also has scarring of the liver (cirrhosis) due to one’s autoimmune hepatitis. Some doctors recommend a blood test and an ultrasound scan of the liver every now and then to screen for this.

One of the developing areas of medicine is the treatment of autoimmune hepatitis. New treatments continue to be developed and researched and the information above is very general. The specialist who knows the uniqueness of one’s case can give more accurate information about the outlook for that specific situation.

CONCLUSION
A persistent liver inflammation or chronic hepatitis, without an apparent cause is called autoimmune hepatitis. If left untreated, the inflammation causes scarring of the liver or cirrhosis. However, with treatment, the prognosis for people with this condition is very good. It’s treatment usually involves steroids and other medicines which suppress inflammation.