Chronic Hepatitis Overview

Chronic hepatitis is a hepatitis which is more than six months. Common causes include infection with the hepatitis B and C virus, autoimmune liver disease (autoimmune hepatitis), steatohepatitis (nonalcoholic steatohepatitis or alcoholic hepatitis) and some drugs. Many patients have no history of acute hepatitis, and the first indication is the diagnosis of asymptomatic transaminase. Some patients will be the first time noticeable when cirrhosis or complications already exist (eg. As portal hypertension). A biopsy is needed to confirm the diagnosis and to assess degree and stage of disease. Treatment depends on the complications and the circumstances underlying (z. B. corticosteroids in autoimmune hepatitis, antiviral therapy for viral hepatitis). In decompensated cirrhosis liver transplantation is often indicated.

(See also causes of hepatitis, Acute Viral Hepatitis at a glance and the American Association for Study of Liver Disease Diagnosis, Management, and Treatment of Hepatitis C)

Chronic hepatitis is a hepatitis which is more than six months. Common causes include infection with the hepatitis B and C virus, autoimmune liver disease (autoimmune hepatitis), steatohepatitis (nonalcoholic steatohepatitis or alcoholic hepatitis) and some drugs. Many patients have no history of acute hepatitis, and the first indication is the diagnosis of asymptomatic transaminase. Some patients will be the first time noticeable when cirrhosis or complications already exist (eg. As portal hypertension). A biopsy is needed to confirm the diagnosis and to assess degree and stage of disease. Treatment depends on the complications and the circumstances underlying (z. B. corticosteroids in autoimmune hepatitis, antiviral therapy for viral hepatitis). In decompensated cirrhosis liver transplantation is often indicated. (See also causes of hepatitis, Acute Viral Hepatitis at a glance and the American Association for Study of Liver Disease Diagnosis, Management, and Treatment of Hepatitis C) Hepatitis A, which is more than 6 months, is defined as chronic usually although this time is arbitrarily selected. Etiology Common causes The most common causes are hepatitis B virus Hepatitis C virus Non-alcoholic steatohepatitis (NASH) Alcoholic Hepatitis Idiopathic (probably autoimmune hepatitis B virus (HBV) and hepatitis C virus (HCV) are common causes of a chronic hepatitis, 5-10% of cases of HBV (with or without HDV co-infection) and about 75% of cases of HCV are chronic. the numbers are higher for HBV infection in children (eg., up to 90% in infected newborns and 30-50% in young children). Although the exact mechanism of the chronic course is not known, the liver injury in most cases is determined by the antiviral immune response of the patient. There have been rare hepatitis e virus genotype 3 chronic hepatitis associated. The hepatitis A virus v Caused no chronic hepatitis. Other causes of chronic hepatitis are the non-alcoholic steatohepatitis (NASH) and alcoholic hepatitis. NASH most commonly develops in patients with at least one of the following risk factors: obesity dyslipidemia glucose intolerance The alcoholic hepatitis (a combination of fatty liver, diffuse liver inflammation, and liver necrosis a) results from an excessive consumption. Many cases are idiopathic. A high proportion of idiopathic cases has distinct features of an immunologically-mediated hepatocellular injury (autoimmune hepatitis), including the following: Detection of serological immune markers associated with Histokompatibilitätshaplotypen, which are frequently in autoimmune diseases, such. B. HLA-B1, HLA-B8, HLA-DR3, HLA-DR4 dominance of T-lymphocytes and plasma cells in the damaged liver tissue complexes in vitro disorders of cellular immunity and immune-regulatory functions associated with other autoimmune diseases (eg. B. RA, autoimmune anemia, glomerulonephritis) response to therapy with corticosteroids or immunosuppressants Less common causes Sometimes chronic hepatitis presenting with signs of both Autoimmunhepatitiden as other chronic liver diseases (eg. as primary biliary cholangitis former primary biliary cirrhosis]). These diseases are so-called overlap syndrome. Numerous drugs, incl. Isoniazid, methyldopa, nitrofurantoin and rare acetaminophen can cause chronic hepatitis. The mechanism of damage depends on the drug and may consist of altered immune responses, cytotoxic intermediate metabolites or genetically determined metabolic defects. Less often arises chronic hepatitis due to Alpha-1 antitrypsin deficiency, celiac disease, a thyroid disorder, hereditary hemochromatosis or Wilson’s disease. Classification Sooner were histologically divided the cases of chronic hepatitis in chronic persistent, chronic lobular or chronic active hepatitis. A useful recent classification system defines the following states: etiology The intensity of histological inflammation and necrosis (degree) degree of histological fibrosis (stage) inflammation and necrosis are potentially reversible, fibrosis is usually not. Symptoms and signs The clinical picture of chronic hepatitis is very different. About a third of the cases resulting from acute hepatitis, but most develop insidiously de novo. Many patients are asymptomatic, especially in chronic HCV infection. On the other hand, often appear malaise, loss of appetite and fatigue, sometimes also low-grade fever and discomfort in the right upper abdomen. Jaundice is not usually. Often, particularly with HCV, the first results are signs of chronic liver disease (eg. As splenomegaly, spider nevi, palmar erythema) complications of cirrhosis (z. B. portal hypertension, ascites, encephalopathy) Some patients with chronic hepatitis develop Cholestasezeichen (z. B. jaundice, itching, pale stools, steatorrhea). In autoimmune hepatitis, especially in young women, the manifestations can affect any organ system, and z. occur as as acne, amenorrhea, arthralgia, ulcerative colitis, pulmonary fibrosis, thyroiditis, nephritis or hemolytic anemia in appearance. Chronic hepatitis C is occasionally connected to a Lichen planus, a mucocutaneous vasculitis, glomerulonephritis, porphyria cutanea tarda, and probably a non-Hodgkin’s B-cell lymphoma. About 1% of patients develop symptomatic cryoglobulinemia with fatigue, muscle pain, joint pain, neuropathy, glomerulonephritis and rashes (urticaria, purpura, leukocytoclastic vasculitis); asymptomatic cryoglobulinemia is more common. Diagnostic liver function tests, which are compatible with Hepatitis Viral serological tests may autoantibodies, immunoglobulins, alpha-1 antitrypsin levels and other tests Usually biopsy serum albumin, platelet count and prothrombin time or INR (See also the American Association for Study of Liver . Disease practice guideline diagnosis, management, and Treatment of hepatitis C and the US Preventive Services task Force clinical guideline screening for hepatitis C in Adults) the diagnosis found in patients suffering from one of the following causes: Suggestive symptoms and signs randomly noted surveys of transaminase Previously diagnosed acute hepatitis In addition, the Center for Disease Control and Prevention (CDC) recommends the US G esundheitsministeriums, the one-time check for hepatitis C in all people who were born from 1945 to 1965 to identify asymptomatic patients. Determining the liver (Function) The liver parameter values ??are determined, if this is not done before. These include serum transaminases (ALT and AST), alkaline phosphatase and bilirubin. Transaminases are the most characteristic laboratory findings. Although their levels may vary, they are typically 100-500 I.E./l. The ALT is higher than AST normally. The levels of transaminases may be normal in the course of chronic hepatitis in times of less active phases of the disease, especially in the HCV infection. Alkaline phosphatase is generally within the normal range or slightly elevated and only occasionally greatly increased. Bilirubin is usually normal, unless the disease is severe or advanced. However, it must be noted that the abnormal values ??of these laboratory tests are nonspecific and may be caused by other diseases, such. As alcoholic liver disease, recurrent acute viral hepatitis, primary biliary Zirrhose.Weitere laboratory tests, when the lab results are consistent with the presence of hepatitis virus serology is applicable to preclude HBV and HCV infection (see Table: Hepatitis-B -Serologie * and hepatitis C serology). If the inquiries reveal no Virusätiologie, other test methods are needed. For the next tests performed include autoantibodies (anti-nuclear antibodies, antigens smooth muscle, antimitochondrial antibody, liver kidney microsomal antibody) immunoglobulins TSchilddrüsentests (thyroid-stimulating hormone), tests for celiac disease (tissue transglutaminase antibodies) Alpha-1-antitrypsin mirrors iron and ferritin and total iron binding capacity. Children and young adults are examined by determining the ceruloplasmin to a Wilson’s disease. Strong increases in serum immunoglobulins suggest suspected chronic autoimmune hepatitis, but are not conclusive. Autoimmune hepatitis is usually due to the presence of antibodies against cell nuclei (ANA), smooth muscle (ASMA) or antibodies to liver / kidney microsomes type 1 (anti-LKM1) with antibody titers of 1:80 (in adults) or 1:20 (in children). Anti-mitochondrial antibody are uncommon in patients with autoimmune hepatitis. (. See also: American Association for Study of Liver Disease practice guideline Diagnosis and management of autoimmune hepatitis) Clinical Calculator: diagnostic criteria for autoimmune hepatitis serum albumin, platelet count and prothrombin time and INR should be measured to determine the severity of the disease; low serum albumin, a decreased platelet count or an increase in INR let the presence of cirrhosis, possibly with portal hypertension vermuten.Biopsie In contrast to acute hepatitis, a biopsy is necessary. Mild running cases have only slightly pronounced liver cell necrosis and inflammatory infiltration, usually in the portal fields, with normal Läppchenarchitektur and little or no fibrosis. These cases do not develop severe clinical liver disease and cirrhosis not usually. In more severe cases, the biopsy typically shows periportal necrosis with mononuclear cell infiltration (so-called piecemeal necrosis), which are accompanied by varying degrees of periportal fibrosis and bile duct proliferation. The Läppchenarchitektur may be destroyed by collapse and fibrosis, a complete cirrhosis sometimes coexists with signs of active hepatitis. The biopsy is also used for so-called grading and staging of the disease. In most cases the specific cause of chronic hepatitis can not only be revealed by biopsy, although cases that are caused by HBV can be detected by the detection of Milchglashepatozyten and special staining for HBV components. Autoimmune hepatitis usually show a greater infiltration of lymphocytes and plasma cells. In patients with histological but not serologic criteria for chronic autoimmune hepatitis variants of autoimmune hepatitis are diagnosed; many have called overlap syndrome screening for complications, a high rheumatoid factor and low complement levels are suggestive of cryoglobulinemia. If symptoms or signs of cryoglobulinemia in the course of chronic hepatitis, especially in HCV infection occur provisions of Kryoglobulins and rheumatoid factor should be carried out. Patients with chronic HBV infection should be checked every 6 months for the presence of hepatocellular carcinoma by sonography and determination of alpha-fetoprotein in serum, although the cost-benefit effect of this approach is discussed. (See also the Cochrane summary under Alpha-fetoprotein and / or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B.) patients with chronic HCV infection should be screened in a similar manner in the presence of advanced fibrosis or cirrhosis. Prognosis The prognosis is very different. A drug-induced chronic hepatitis often recedes completely when the causative drug is discontinued. Without treatment, HBV-induced chronic hepatitis can spontaneously regress (very rare), progress rapidly or slowly pass over decades in cirrhosis. The healing often begins with a temporary active episode of illness and is accompanied by seroconversion from HBeAg to anti-HBe. Coinfection with HDV causes the most severe form of chronic HBV infection. Without treatment, cirrhosis develops in up to 70% of patients. Untreated chronic hepatitis due to HCV infection result in 20-30% of patients to cirrhosis, this development may extend over decades and varies because it is often depend on other risk factors PAaienten for chronic liver disease, including alcohol consumption and obesity. Chronic autoimmune hepatitis usually respond well to therapy, only in certain cases, a progressive fibrosis and possibly cirrhosis develops. Chronic HBV infection increases the risk of liver cancer. The risk is also elevated in chronic HCV infection, but only if cirrhosis or advanced fibrosis has developed. Treatment Supportive treatment treating the cause (eg. As corticosteroids for autoimmune hepatitis, antiviral drugs for HBV and HCV infection) There are specific antiviral treatment for chronic hepatitis B (z. B. entecavir and tenofovir as a first-line therapy) and antiviral treatments for chronic hepatitis C (z. B. interferon-free regimens of direct-acting antiviral drugs). General treatment goals of therapy of chronic hepatitis are treating the cause and dealing with potential complications (eg. As ascites, encephalopathy) when cirrhosis and portal hypertension have developed. Drugs that cause hepatitis, must be discontinued. Causal diseases such as Wilson’s disease must be treated. In chronic hepatitis by HBV prophylaxis (including immune prophylaxis) may be useful for the contacts of patients. There is no vaccination for contacts of patients with HCV infection. Corticosteroids and immunosuppressive agents should be avoided in chronic hepatitis B and C, because these drugs increase the viral replication. If patients require chronic hepatitis B treatment with corticosteroids, immunosuppressive therapies or cytotoxic chemotherapy for other diseases, they should be treated simultaneously with antiviral drugs to prevent a flare-up of acute hepatitis B or acute liver failure caused by hepatitis B. There was no similar situation with hepatitis C, which has been activated or cause of acute liver failure beschrieben.Nichtalkoholische steatohepatitis (NASH) (See also the American Association for Study of Liver Disease’s The diagnosis and management of non-alcoholic fatty liver disease.) treatment of NASH is aimed at eliminating the causes control risk factors for NASH, you can include the recommendation of weight loss, the treatment of hyperlipidemia and hyperglycemia, discontinuation of drugs that are associated with NASH (z. B. amiodarone, tamoxifen, methotrexate, corticosteroids such as prednisone or hydrocortisone, synthetic estrogens) and avoiding exposure to toxins (eg. as pesticides) .Autoimmune hepatitis (See also the American Association for Study of Liver Disease practice guideline Diagnosis and management of Autoimmune hepatitis.) corticosteroids alone or in Combination azathioprine increase the survival time. The initial dose of prednisone is 30-60 mg po usually once a day. It is then reduced to the lowest dose that is currently holding the transaminases in the normal range. To prevent long-term need for corticosteroid treatment, doctors on azathioprine 1 to 1.5 mg / kg to p. 1000 mg twice / day after the corticosteroid-induction is complete, proceed and then gradually tapering off the corticosteroid o. Once / day or mycophenolate mofetil. In most patients, a low-dose, kortikosteroidfreie term therapy is required. In decompensated cirrhosis, a liver transplant may be indicated. Summary One chronic hepatitis is usually no acute hepatitis ahead and its course is often asymptomatic. If liver enzyme elevations (z. B. unexplained increase in aminotransferases) are compatible with chronic hepatitis, serological tests for hepatitis B and C should be performed. If the serological results are negative, followed by tests for other hepatitis types, (z. B. autoantibodies, immunoglobulins, alpha-1 antitrypsin levels) A liver biopsy is performed to confirm the diagnosis and determine the severity of chronic hepatitis , Entecavir and tenofovir should be considered as first choice for the treatment of chronic hepatitis B. Treat Chronic Hepatitis C all genotypes with interferon-free therapies of direct-acting antiviral drugs. Autoimmune hepatitis is treated with corticosteroids to maintain treatment with azathioprine. More information American Association for the Study of Liver Disease Practice Guidelines U.S. Preventive Services Task Force’s hepatitis C screening diagnosis and treatment of autoimmune hepatitis Alpha-fetoprotein and / or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B. The diagnosis and treatment of non-alcoholic fatty liver disease

Health Life Media Team

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