Chronic Hepatitis

Aetiology

Viral hepatitis: hepatitis B, hepatitis C, cytomegalovirus, Epstein-Barr virus.

Metabolic: non-alcoholic fatty liver disease (NAFLD), haemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency.

Toxic and drugs: alcoholic liver disease, amiodarone, isoniazid, methyldopa, methotrexate, nitrofurantoin.

Autoimmune: autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis. Sarcoidosis.
Appearance of inveterate hepatitis.

Manifestations

Confusion and drowsiness (encephalopathy).

Haematemesis and melaena (gastrointestinal haemorrhage). Pruritus (cholestasis).

Breast swelling (gynaecomastia), testicular atrophy, loss of libido and amenorrhoea due to endocrine dysfunction.

Nonspecific symptoms – eg, fatigue, anorexia, muscle pains, arthralgia, weight loss. Right hypochondrial pain (liver distension).

Abdominal distension (ascites). Ankle swelling (fluid retention).

Patient signs

Spider naevi (chest and upper body), slate-grey appearance in haemochromatosis.

Dupuytren’s contracture (alcoholic cirrhosis).

Palmar erythema.

Hirsutism.

Jaundice.

Clubbing.

Splenomegaly (portal hypertension).

Xanthomas: palmar creases or above the eyes in primary biliary cirrhosis.
Initial hepatomegaly may be followed by a small liver in well-established cirrhosis.

Investigations

Urinalysis: Bilirubin & Urobilinogen
Blood tests:

Iron studies.

FBC (associated anaemia, thrombocytopenia, raised MCV with alcohol abuse), clotting studies (clotting impairment with hepatic dysfunction).

Renal function and electrolytes (associated renal dysfunction).

LFTs, serum albumin, prothrombin time.

Alpha-fetoprotein (hepatocellular carcinoma).

Immunoglobulins (IgG raised in autoimmune hepatitis; IgM raised in primary biliary cirrhosis).

Autoantibodies: antinuclear antibodies, smooth muscle antibodies, anti-mitochondrial antibodies;

Alpha-1 antitrypsin.

Caeruloplasmin, copper (haemochromatosis).

Hepatitis B and C serology.

Radiology:

Ultrasound, CT or MRI scan: local liver or biliary tract abnormality, especially hepatocellular carcinoma which may occur as a complication of cirrhosis.

Transient elastography has been shown to be a simple and effective method for assessing liver fibrosis.

Genetic testing – eg, haemochromatosis.

Upper gastrointestinal endoscopy (diagnosis and management of oesophageal varices).

Liver biopsy: the main indication for liver biopsy in chronic viral hepatitis is to assess the severity of the disease, in terms of both necro-inflammation (grade) and fibrosis (stage), which is important for management and prognosis.

Treatment: To treat indiviual causes like

Viral hepatitis: Hepatitis B, Hepatitis C, Cytomegalo Virus, Epstein-Barr Virus

Metabolic: NAFLD – Steatohepatitis & Steatosis (Fatty Liver), Wilson’s disease, Alpha – 1 – Antitrypsin defeciency, Haemochromatosis.

Autoimmune: Autoimmune hepatitis, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis, Sarcoidosis

If Alcohol abuse then to address it..

Stop/replace any implicated medication.

Complications

Hepatic enecephalopathy
cirrhosis
Coagulopathy.
Hepatopulmonary syndrome (defect in arterial oxygenation induced by pulmonary vascular dilatation in patients with liver disease).
Liver failure
Portal Hypertension: Ascites, hypersplenism, oesophageal & retcal varicies
Osteporosis
Hypoalbuminaemia
Hepatocelluar Carcinoma: most associated with cirrhosis secondary to hepatitis B & Hepatitis C virus infection.

​CONCLUSION
Inflammatory disease of the liver lasting for more than six months is termed as Chronic hepatitis. Whenever possible cause of the hepatitis should be identified and treated to prevent chronic hepatitis from developing thus preventing all pausible future complications.