HEPATITIS

What is hepatitis?

Hepatitis is an inflammation of the liver that is most commonly caused by viruses but may also be due to chemicals, drugs, alcohol, inherited diseases, or autoimmune disease. The inflammation can be acute, flaring up and then resolving within a few weeks to months, or chronic, enduring over many years. Chronic hepatitis may persist for 20 years or more before causing significant symptoms related to progressive liver damage such as cirrhosis, liver cancer, or death.

The liver is a vital organ located in the upper right-hand side of the abdomen. It performs many functions in the body, including processing the body's nutrients, manufacturing bile to help digest fats, synthesizing many important proteins, regulating blood clotting, and breaking down potentially toxic substances into harmless ones that the body can use or excrete. Inflammation may (in severe cases) interfere with these processes and allow potentially toxic substances to accumulate.


How many types of hepatitis are there?


There are five main types of hepatitis that are caused by a virus, A, B, C, D, and E - plus types X and G
.
What are the signs and symptoms of hepatitis?

Many people with Hepatitis experience either mild symptoms or none at all. Remember that an infected person's feces are always infectious to other people. When symptoms appear, they usually do so about 15 to 180 days after the person has become infected.

The acute phase of hepatitis - symptoms

The initial phase of hepatitis is called the acute phase. The symptoms are like a mild flu, and may include:

• Diarrhea
• Fatigue
• Loss of appetite
• Mild fever
• Muscle or joint aches
• Nausea
• Slight abdominal pain
• Vomiting
• Weight loss

The acute phase is not usually dangerous, unless it develops into the fulminant or rapidly progressing form, which can lead to death. 
As the patient gets worse, these symptoms may follow:

• Circulation problems (only toxic/drug-induced hepatitis)
• Dark urine
• Dizziness (only toxic/drug-induced hepatitis)
• Drowsiness (only toxic/drug-induced hepatitis)
• Enlarged spleen (only alcoholic hepatitis)
• Headache (only toxic/drug-induced hepatitis)
• Hives
• Itchy skin
• Light colored feces, the feces may contain pus
• Yellow skin, whites of eyes, tongue (jaundice)

Patient outcomes after the acute phase depend on various factors, especially the type of hepatitis.

How is Hepatitis transmited?


Hepatitis A -

This type of hepatitis is usually spread by fecal-oral contact, or fecal-infected food and water, and may also be spread by blood-borne infection (which is rare). The following is a list of modes of transmission for hepatitis A:

• consuming food made by someone who touched infected feces
• drinking water that is contaminated by infected feces - a problem in developing countries with poor sewage removal
• touching infected person's feces, which may occur with poor handwashing
• outbreaks may occur in child care centers especially when there are children in diapers
• international travel to areas where hepatitis A is common

• sexual contact with an infected person
• use of intravenous (IV) drugs
• blood transfusions (very rare)
• vertical transmission (very rare)

Hepatitis B - 

Hepatitis B virus has a wide range of clinical presentations. The virus can be mild, without symptoms, or may cause chronic liver disease and liver failure. Transmission of hepatitis B virus occurs when blood from an infected person enters another person's body. Infants may also develop the disease if they are born to a mother who has the virus. The following describes persons who are at risk for developing hepatitis B:

• children born to mothers who have hepatitis B
• children who are born to mothers who have immigrated from a country where hepatitis B is widespread such as southeast Asia and China
• children who live in long-term care facilities or who are disabled
• children who live in households where another member is infected with the virus
• children who have a blood clotting disorder such as hemophilia and require blood products
• children who require dialysis for kidney failure
• adolescents who may participate in high-risk activities such as IV drug use and/or unprotected heterosexual or homosexual contact

Hepatitis C - 

The symptoms of hepatitis C are usually mild and gradual. Children often show no symptoms at all. Transmission of hepatitis C occurs primarily from contact with infected blood, but can also occur from sexual contact or from an infected mother to her baby. Although hepatitis C has milder symptoms initially, it leads to chronic liver disease in a majority of people who are infected. According to the Centers for Disease Control and Prevention (CDC), hepatitis C is the leading indication for liver transplantation in adults. With some cases of hepatitis C, no mode of transmission can be identified. The following describes persons who may be at risk for contracting hepatitis C:

• children born to mothers who are infected with the virus
• persons who have a blood clotting disorder such as hemophilia and received clotting factors before 1987
• children who require dialysis for kidney failure
• individuals who received a blood transfusion before 1992
• adolescents who participate in high-risk activities such as IV drug use and/or unprotected heterosexual or homosexual contact.

Hepatitis D - 

This form of hepatitis can only occur in the presence of hepatitis B. If an individual has hepatitis B and does not show symptoms or shows very mild symptoms, infection with D can put that person at risk for liver failure that progresses rapidly. Hepatitis D can occur at the same time as the initial infection with B, or it may show up much later. Transmission of hepatitis D occurs the same way as hepatitis B, except the transmission from mother to baby is less common.

Hepatitis E - 

This form of hepatitis is similar to hepatitis A. Transmission occurs through fecal-oral contamination. It is less common in children than hepatitis A. Hepatitis E is most common in poorly developed countries. There is no vaccine for hepatitis E at this time.


 Hepatitis G - 

This is the newest strain of hepatitis and very little is known about it. Transmission is believed to occur through blood and is most commonly seen in IV drug users, individuals with clotting disorders such as hemophilia, and individuals who require hemodialysis for renal failure. Often hepatitis G shows no clinical symptoms and has not been found to be a cause of acute or chronic hepatitis.

Diagnostic Tests

The doctor will take a thorough medical history with emphasis on the patients medications, alcohol consumption, previous surgeries and sexual activity. He or she may palpate the area over the liver to check for tenderness or enlargement.

There are several laboratory tests that may be used in cases of known or suspected hepatitis. These tests may be used for various reasons and may fall into one or more of these categories:

• General chemistry tests used to detect liver inflammation and damage
• Screening tests used to detect Viral Hepatitis; for example, screening for exposure to hepatitis B or hepatitis C may be done because of increased risk of the disease (use of illegal drugs, multiple sex partners) or at the time of blood donation.
• Tests used to help diagnose the underlying cause
• Follow-up tests used to monitor progression of hepatitis and/or help guide treatment

Acute hepatitis is often suspected and testing done because of the appearance of symptoms such as fever, loss of appetite, and nausea, often accompanied by dark urine, pale stools, and yellow discoloration of the skin and the whites of the eyes (jaundice or icterus).

Chronic hepatitis is more commonly detected as a result of abnormal routine test results. In a patient who is having no, few, or vague symptoms, hepatitis may be first discovered during routine testing such as a Comprehensive Metabolic Panel (CMP).

The CMP is a group of tests frequently ordered as part of a yearly physical. It includes several tests from the liver panel. These tests may be the first indication of liver inflammation or injury. While these tests may help to detect hepatitis, they do not determine the underlying cause. Additional testing may be necessary to pinpoint the cause and to help direct treatment.

In addition to the CMP, other general tests may be used both to detect liver injury and to give an indication of how severe it may be. Some of these are listed below:

• Alanine aminotransferase (ALT) - an enzyme found mainly in the liver; the best test for detecting hepatitis
• Aspartate aminotransferase (AST) – an enzyme found in the liver and a few other places, particularly the heart and other muscles
• Alkaline phosphatase (ALP) – an enzyme related to the bile ducts; often increased when they are blocked, but may also be increased with bone disorders
• Gamma-glutamyl transpeptidase (GGT) - an enzyme found in the liver that is very sensitive to changes in liver function; helps to differentiate between the causes of an elevated ALP; if GGT is increased, then the elevated ALP is due to liver, not bone disease.
• Bilirubin - a waste product made from the breakdown of old blood cells; it is a yellow compound that causes jaundice and dark urine when present in increased amounts.
• Albumin - measures the main protein made by the liver and tells how well the liver is making this protein
• Total Protein - measures albumin and all other proteins in blood, including antibodies made to help fight off infections
• Prothrombin time (PT). This test may be ordered in a person with hepatitis or suspected hepatitis. Proteins used in the formation of a blood clot (coagulation factors) are mostly produced by the liver, and prolonged PT may indicate the severity of liver damage.
• A liver biopsy, in which a needle is inserted into the liver to withdraw a small amount of cells that are examined under a microscope by a pathologist, is the most definitive way to diagnose the disease. Since this is an invasive procedure, it is used primarily when other tests are inconclusive or to determine how much damage to the liver has occurred.

Additional lab tests include the antibody tests (ELISA II, RIBA II) and the hepatitis C RNA test via PCR technology for diagnosis of hepatitis C only.
Imaging tests such as ultrasound and specialized X-rays may be used to evaluate the liver, detect hepatitis, help make a diagnosis, and help determine a cause of livery injury.

Treatment of Hepatitis

There is no specific treatment for hepatitis A. The doctor will recommend the abstinence of alcohol and drugs during recovery. Most cases of hepatitis A resolve themselves spontaneously.

The only treatment for hepatitis B is rest, combined with a high protein/high carbohydrate diet to repair damaged liver cells and protect the liver. If hepatitis B persists, the doctor may recommend an antiviral agent called interferon.

The only approved treatment for hepatitis C virus, and the only one with demonstrated efficacy, is interferon alfa-2b (Intron A).

Currently, there is not effective treatment for hepatitis D and E.

For treatment of nonviral hepatitis, the doctor will first remove the harmful substance by flushing out the stomach via inducing vomiting or hyperventilation. If necessary, the patient with drug-induced hepatitis will be treated with corticosteroids.

Hepatitis Vaccines

Hepatitis A vaccine is made of killed hepatitis A viruses and causes the body's immune system to produce antibodies against the hepatitis A virus. In 94% to 100% of vaccine recipients, antibodies start to develop immediately after the first dose but do not reach protective levels for 2 to 4 weeks. A second dose of the vaccine is recommended at least six months after the first dose to provide prolonged protection.

Two hepatitis A vaccines are currently available; these vaccines are Hepatitis A vaccine injection (Havrix and Vaqta). The vaccine is given as an injection into the deltoid muscle of the arm. Both Havrix and Vaqta provide high level protection against hepatitis A. There is also a combination vaccine called hepatitis-b-hepatitis-a-vaccine injection (Twinrix) that protects against both hepatitis A and hepatitis B. The dosing schedule for Twinrix is different from the other hepatitis A vaccines and requires three doses over six months.

Now a days, hepatitis A vaccination is recommended for all children at one year of age. Vaccination also is recommended for individuals in high-risk settings. Examples include:

• travelers to developing countries,
  
• men who have sex with men,
  
• users of illicit drugs,
  
• persons needing frequent blood products, and
  
• people who have chronic liver disease.

Side effects of the hepatitis A vaccine usually are mild. Soreness at the site of injection is common. Less commonly, recipients may complain of headache or fatigue. Serious allergic reactions are possible, but are rare.

A second option for protecting people against hepatitis A is to administer antibodies that are already programmed to attack the virus. When people donate blood, the part of the blood carrying antibodies (the 'immune globulin' fraction) can be separated. Because some blood donors are likely to have antibodies against the hepatitis A virus, pooled immune globulin from many donors is likely to contain antibodies against hepatitis A. This immune globulin can be injected into a person at risk for hepatitis A and will provide immediate but temporary protection against infection. Protection with immune globulin lasts two to four months depending on the dose. Immune globulin is used when immediate protection against hepatitis A is required. An example would be someone who is leaving immediately to travel to rural areas of a developing country. Such a traveler would also receive hepatitis A vaccine but would not have time to develop antibodies before departure. Immune globulin sometimes is in short supply and should be used only when necessary.

• If an unvaccinated person is exposed to hepatitis A, he or she should be given the vaccine or immune globulin as soon as possible.
  
• Vaccine is used for exposed persons aged one to 40 years.
  
• Immune globulin currently is recommended for exposed persons over the age of 40 years.

These measures will reduce the risk that the exposed person will contract hepatitis A by 85% to 90% if given within two weeks of exposure.

Vaccination has reduced the number of new cases of hepatitis B by more than 75%. The hepatitis B vaccine contains a protein(antigen) that stimulates the body to make protective antibodies. Examples of hepatitis B vaccines available include hepatitis b vaccine-injection (Engerix-B, Recombivax-HB). Three doses (given at 0, 1, and 6 months) are necessary to assure protection.

There are also combination vaccines on the market that provide protection against hepatitis B and other diseases. For example:

• hepatitis-b-hepatitis-a-vaccine injection (Twinrix), which provides protection against both hepatitis A and hepatitis B;
  
• Haemophilus B/hepatitis B vaccine - injection (Comvax) provides protection against hepatitis B and Haemophilus influenzae type b (a cause of meningitis); and
  
• Pediarix provides protection against hepatitis B, tetanus, pertussis and polio.

Hepatitis B vaccines are effective and safe. Up to 95% of vaccinated individuals develop protective antibodies when they get the vaccine and are protected from infection with hepatitis B. Among individuals at high risk for infection with hepatitis B include:

• healthcare workers,
  
• high-risk public safety workers,
  
• dialysis patients, and
  
• sexual partners of infected persons

A blood test for hepatitis B antibodies is recommended after vaccination to ensure that antibodies have been produced. For the few who do not form antibodies, revaccination may improve the response, especially in infants. However, a small proportion of individuals will never respond to hepatitis B vaccination. Side effects from the vaccine usually are mild, primarily soreness at the site of injection. The risk of serious allergic reactions (anaphylaxis) is less than one per million doses.

Hepatitis B vaccination is recommended for all infants at birth. Older children and adolescents should receive the vaccine if they did not receive it at birth. Adults in high risk situations also are advised to receive hepatitis B vaccine.

This includes:

• health care workers,
  
• dentists,
  
• intimate and household contacts of patients with chronic hepatitis B infection,
  
• public safety workers who may be exposed to blood products,
  
• men who have sex with men,
  
• individuals with multiple sexual partners,
  
• dialysis patients,
  
• injection drug users,
  
• persons with chronic liver disease,
  
• residents and staff in institutions that care for persons with developmental disabilities,
  
• persons infected with human immunodeficiency virus (HIV), and
  
• persons who require repeated transfusions or blood products.

Centers that serve high-risk individuals are encouraged to provide the vaccine to their clients. Such centers include:

• dialysis units,
  
• drug treatment facilities,
  
• sexually transmitted diseases clinics and correctional facilities.

Some countries have a high prevalence of hepatitis B in their population. Travelers who visit these countries for a prolonged period of time (usually 6 months or longer) and those who may be exposed to blood or semen should consider vaccination.

Unvaccinated individuals who are exposed to a known case of hepatitis B or to a person at high risk for hepatitis B should be evaluated by a physician. Examples of such exposures include needle stick injuries in health care workers or sexual intercourse with an infected person. If the exposure is significant, the physician will recommend vaccination and may also recommend an injection of hepatitis B immune globulin (HBIG). HBIG is prepared from the plasma of blood donors and contains antibodies to hepatitis B. Vaccination and HBIG can substantially reduce the risk of disease in persons exposed to hepatitis B if given within one week of a needle stick or two weeks of sexual intercourse.

Vaccination provides long-term immunity in people who respond to the vaccine. There is no need for HBIG if an exposure occurs to a vaccinated person who is known to have responded to the vaccine; however, a blood test might be drawn to verify that the person did respond to the vaccine and form antibodies.

Infected mothers can pass hepatitis B to their newborn infants. All pregnant women should have blood drawn to determine if they are infected. Infants born to infected mothers should receive HBIG and hepatitis B vaccine at birth. This is 85% to 95% effective in eliminating the risk of hepatitis B infection in the infant.

Prevention

How to prevent Hepatitis A

• Wash your hands with soap after going to the toilet
• Only consume food that has just been cooked
• Only drink commercially bottled water, or boiled water if you unsure of local sanitation
• Only eat fruits that you can peel if you are somewhere where sanitation is unreliable
• Only eat raw vegetables if you are sure they have been cleaned/disinfected thoroughly
• Get a vaccine for Hepatitis A if you travel to places where hepatitis may be endemic

How to prevent Hepatitis B

• Tell the partner if you are a carrier or try to find out whether he/she is a carrier
• Practice safe sex
• Only use clean syringes that have not been used by anyone else
• Do not share toothbrushes, razors, or manicure instruments
• Have a Hepatitis B series of shots if you are at risk
• Only allow well sterilized skin perforating equipment (tattoo, acupuncture, etc.)

How to prevent Hepatitis C

• If you are infected do not let others share your toothbrush, razor, manicure equipment
• If you are infected cover open wounds
• Do not share needles, toothbrushes, or manicure equipment
• If your skin is to be pierced, make sure equipment is well sterilized (tattoo, etc.)
• Go easy on the alcohol
• Do not share drug equipment

How to prevent Hepatitis D

• Use the same guidelines as for Hepatitis B. Only a person who is infected with Hepatitis B can become infected with Hepatitis D.

How to prevent Hepatitis E

• Do the same as you would to protect yourself from Hepatitis A infection.

How to prevent Alcoholic Hepatitis

• Go easy on the alcohol, or abstain from consuming alcohol

How to prevent Toxic/Drug Induced Hepatitis

• Make sure you know about the lethal contents of all chemicals
• Make sure the spray is not pointing at you
• Make sure you wear protective gear if you have to