Hepatitis (Viral)

What is it?
The liver is an organ that is housed in the right upper side of your abdomen, mostly behind the ribs. It is about the size of a football and has many functions. It stores energy and nutrients, makes proteins, breaks down and filters substances, processes old red blood cells, and kills germs that enter the body through the intestines. Hepatitis is inflammation of the liver. The most common cause of acute hepatitis is infection with a virus. There are several different viruses that can cause hepatitis and the symptoms can be variable ranging from no symptoms to a severe fatal infection. The viruses have been named A, B, C, D, and E. Each virus is a little different.

What are the symptoms?
Symptoms can include:

  • Fatigue
  • Lack of appetite
  • Nausea
  • Changes in your urine, appearing like dark soda or tea
  • Jaundice, a yellowing of your skin and eyes
  • Light stools
  • Fever
  • Vague abdominal discomfort

Some symptoms may be present in other places outside the liver, such as the blood vessels, joints, eyes, blood, and skin.

How is it diagnosed?
Blood work will be obtained to look at your liver function and for damage. Tests can also be ordered that look for antibodies, specific proteins your immune system makes to fight against the virus.

Who gets it and what happens?

Hepatitis A.
This occurs worldwide, but has significantly declined in the US since the development of a vaccine. All babies born in the US are now vaccinated and adults who are at risk of infection are encouraged to also be vaccinated. Its spread is mainly fecal-oral, meaning through food, water, or material that is contaminated with infected fecal material. This most often happens if a person is infected and does not wash their hands after using the bathroom and then touching objects, food, or a person. It also can occur on a larger scale if there is contaminated well water or if contaminated food is distributed. The disorder is more common in areas where there is poor sanitation and hygiene. International travel is the biggest risk factor for people in the United States. Other risks include sexual or household contact with someone who is infected, food or water outbreaks, daycare centers, injection drug use, or contact with infected blood. The virus gets into the liver and makes copies of itself. The immune system tries to attack the virus causing damage and destruction of the liver. This is usually a self limited illness, but if you already have liver disease it can cause significant damage to the liver. It usually takes around 30 days from the time you are infected to develop symptoms.

Testing
Antibodies against the virus are present at the time when symptoms develop and are present for 4-6 months after.

Treatment
There is no cure, but the infection usually resolves on its own over several weeks. The exact amount of time it will take to improve depends on the person. Some of the liver function tests may remain elevated for 3-6 months after the infection has passed. When recovering from the infection, you need to avoid things that can injure the liver such as alcohol or acetaminophen. Although uncommon, a more significant infection is possible which may require hospitalization.

Prevention

  • Getting the vaccine.
  • Practicing good hygiene. Washing hands! The virus can last up to four hours on your fingertips.
  • Making sure all food and water is sanitary. Things should be washed appropriately-chlorine will inactivate the virus and food needs to be heated to the correct temperature. This is especially important when traveling internationally.
  • If you know someone who has hepatitis A, they will be contagious during the 2-6 weeks prior to showing symptoms and then for about a week after jaundice (yellowing of skin) appears.

Hepatitis B
It is thought that over 300 million people in the world carry the hepatitis B virus. There are several ways to be infected with this virus. Most often, it is through contact with infected blood (this includes tattooing, acupuncture, IV drug use, and ear piercing), by having sex with an infected person, or passed from a mother to her child during childbirth. It can also be spread through close personal contact if blood or body fluids get into your mouth, eyes, or small breaks in your skin. The infection can be brief (acute) or in about 5% of people, the virus sets up shop in the liver and continues to make live copies of itself. These people are called “carriers” and if damage is continually done to the liver, it is called chronic hepatitis; sometimes these people have no symptoms. The development of a chronic infection mainly depends on how old you were when infected. It is more common, the younger you were when initially infected. Less than 5% of people who are infected in adulthood develop a chronic infection.

Testing
Specific proteins found on the virus (antigens) and levels of specific proteins made by your immune system (antibodies) to fight the virus will be monitored. Based on the proteins that are present, it can be determined if you are acutely infected, chronically, or if you have been vaccinated effectively. Levels of the DNA that is found in the hepatitis B virus can also be measured; the level is used to decide if you might respond to treatment and can be used to monitor treatment because it is usually not present when you have recovered.

Treatment
Treatment is usually not needed in adults because in 95% of people, the immune system takes care of the virus in about 6 months. If a chronic infection develops, there are antiviral medications available that might help with or prevent damage to the liver and prevent complications. If immediate treatment is not necessary, often people are monitored until the inflammation is more active before treatment will begin. Regular blood testing is required during treatment to make sure treatment is working and monitor for side effects. Treatment may include:

 Antiviral pills

  •  Lamivudine (Epivir-HBV).
  •  Adefovir (Hepsera).
  •  Tenofovir (Viread).
  •  Telbivuide (Tyzeka).

Interferon-alpha. This is given by injection and may cause many side effects, but the advantage is that it is given for a limited period of time opposed to the other treatments that require taking a pill by mouth for many years.

Liver transplantation.

Other health.

  •  If you have chronic hepatitis B, you should be vaccinated for hepatitis A, influenza yearly, and other standard immunizations
  •  Screening for liver cancer with an ultrasound (annually)
  •  Eating a normal healthy diet
  •  Avoiding substances that can further harm the liver including alcohol, some prescription, and over the counter medicine.

Prevention

  • Getting the vaccine against hepatitis B
  • All pregnant women are tested for this virus. If you are positive ,you will be given medication to lower the amount of virus in your blood before giving birth. The baby will also be given a shot of already formed antibodies soon after being born that will protect the baby. The protective effects last several months and the baby should be vaccinated normally. The baby should be tested for an infection with the virus at 9-18 months old.
  • Prevent further spread if you are infected. Tell sexual partners so they can be vaccinated. Do not share products that may have blood on them, do not share needles, and have family and household members be tested. Know the virus CANNOT be spread by hugging, kissing, sharing cups, forks or spoons, sneezing, coughing, or breastfeeding.

Hepatitis C
This virus is mainly spread through contact with infected blood, less commonly through childbirth and sexual contact. Before the early 1990’s, there was the risk of becoming infected with this virus after a blood transfusion, but there is now a test used to screen blood donors. The infection can be acute or chronic. 70-80% of people develop a chronic infection. Many times chronic infection will cause no symptoms, but it is the most common cause of chronic liver disease and is the reason for the majority of liver transplants in the United States each year. As the liver is damaged, scar tissue can form called fibrosis and this can lead to eventual cirrhosis with hardening of the liver and failure to function as it should. Cirrhosis occurs in about 20% of people chronically infected within 20 years of infection. After the development of cirrhosis in a few rare people, about 2%, liver cancer (hepatocellular carcinoma) may develop.

Testing
Blood tests looking for antibodies to the virus will be obtained if you have risk factors for infection or if you have symptoms of infection. If you have antibodies present in your blood, further testing is performed. The amount of virus that is circulating in your blood is measured by looking at the hepatitis C virus RNA level. Also the specific type of hepatitis C you are infected with will be determined by testing for the genotype.

Treatment
Often times, prior to starting treatment a liver biopsy is obtained to see how much damage has been done to the liver. The goal of treatment is to prevent worsening of the disease and to get rid of the virus. Not everyone with this virus will be treated and it is important to discuss treatment with a health care professional. Things such as depression, pregnancy, use of birth control, autoimmune disorders, and the severity of your infection with the virus all impact the decision. Treatment may include:

  • Pegylated interferon and ribavirin. The interferon is given as a shot once a week and the ribavirin is a pill. The length of treatment depends on what type of hepatitis C virus you are infected with. Blood tests will monitor how much virus is present in your blood during treatment. The treatment will be stopped if you do not respond or have severe side effects.
  •  Protease inhibitors. In addition to the above medicines, if you have a specific type of hepatitis C, genotype 1, you will also take one of these pills.

Six months after finishing treatment, you will be tested for levels of the virus. Sometimes another course of treatment is necessary. But, if the virus cannot be detected, it is considered a cured infection.

Other health management with hepatitis C:

  •  Screening for liver cancer.
  •  If cirrhosis is present, screening for varices.
  •  Eat a normal healthy diet
  •  Get vaccinated against hepatitis A and B, pneumonia, influenza, and other routine vaccinations
  •  Avoid substances that can further harm the liver including alcohol, prescription and over the counter medicine.

Prevention

  • There is an increased risk of cirrhosis if you have hepatitis C and drink alcohol, smoke marijuana, and are obese, so avoid these things.
  • There is a small risk of transmitting the virus to your baby during childbirth and this depends on how much virus is present in your blood. The risk is about 1 in 20, but is even higher if you also have HIV.
  • Follow the same recommendations for preventing the spread of hepatitis B.

Hepatitis D
To be infected with hepatitis D, you must already be infected with hepatitis B. The infection with the two viruses can happen at the same time and usually causes brief, self-limited inflammation of the liver, or the infection can occur in a person who has chronic hepatitis B. Hepatitis D can also become a chronic infection. The virus is seen more in IV drug users and people who live near the Mediterranean, tending to occur more in children and young adults in this population with the spread seemingly to be through mucus membranes or skin in regions with poor sanitation.

Testing
Because infection with hepatitis B is necessary for hepatitis D, you are first tested for hepatitis B. Infection with hepatitis D is rare in the United States, so not all people who have hepatitis B will be tested for D. If risk factors are present, blood tests can then be obtained to look for hepatitis D.

Treatment
The goal of treatment is to stop hepatitis D from continuing to make copies of itself. This can be followed by watching levels of virus RNA and antigen. A second goal is to clear infection with hepatitis B. Acute infection does not need to be treated.

  • Interferon alpha. This is the only drug that is approved to treat hepatitis D. Treatment should be given for one year.

Prevention.

  •  Vaccinate against hepatitis B.

Hepatitis E
This virus is spread similarly to hepatitis A with contaminated food or water. Spread from person to person is uncommon. It is more common in Asia, Africa, Middle East, and Central America. Most cases of this type of hepatitis resolve.

  • Testing
    The virus can be indentified in stool or by levels of specific antibodies in the blood.
  • Treatment
    There is no specific treatment. Supportive measures are taken.
  • Prevention
    A vaccine has been developed, but is not yet available. In the meantime, in regions where the infection is common, measures should be taken to avoid spread such as avoiding drinking questionable water, do not eat uncooked shellfish, fruits or vegetables.

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