Liver Disease: Hepatitis Awareness and Types, and Understanding Cirrhosis

HEPATITIS

Hepatitis is inflammation of the liver (hepa-liver; itis-inflammation). Inflammation is the response and damage caused in the body due to any injurious agent.

For the liver, the injuring agent can be infectious organisms like bacteria, viruses, parasites, and fungi, or noxious substances like alcohol, tobacco, certain medicines/drugs and toxic substances.  Sometimes too much deposition of some dietary components like fats, or even iron and copper can cause long term injury to the liver. Injury can also be caused when there is lack of blood (oxygen) supply, or the body’s own immune system mistakenly attacks the liver (autoimmune response).

Inflammation can occur over a short period of time (acute) or over a long period of time (chronic) causing long term liver damage and loss of function.

CAUSES

• Infections: Caused most commonly due to Hepatitis virus (HV) types A,B,C,D,E
  • Hepatitis A and E spread by contaminated water/food. Hepatitis A is more common in children, but can rarely affect adults also in whom it causes more severe disease. Hepatitis E affects young adults and can lead to complications including death in pregnant women.
  • Hepatitis B and C spread by blood contact like infected needles, blood transfusion, sexual contact, and mother to child at birth). Hepatitis D virus causes co-infection with B virus.

• • Other infections: parasitic, bacterial, fungal, viral (like yellow fever)

• Alcoholic liver disease (ALD): It is caused by the consumption of high quantities of alcohol over many years.
• Non-alcoholic fatty liver disease (NAFLD): This is seen in people with risk factors like diabetes, obesity, gastric bypass surgery, and high fats (cholesterol and triglycerides). Most patients have NAFL which is the stage of fat deposition without inflammation. Around 5-10% progress to the stage of inflammatory damage (NASH -Non-alcoholic steatohepatitis), with some of them progressing to cirrhosis.
• Drugs, Metals, and Toxins – It is caused by certain medicines (DILI: drug-induced liver injury) and other toxic substances. Genetically inherited conditions called Hemochromatosis (iron accumulation) and Wilson’s disease (copper accumulation), if not treated and controlled meticulously, can cause damage to various organs including the liver, leading to cirrhosis over a period of time.
• Autoimmune hepatitis: It is caused due to attack by own immune system.
• Ischemic (hypoxic) hepatitis: Due to interruption or lack of adequate blood supply leading to oxygen deprivation. This can occur due to an injury, shock, sepsis, heart failure, or obstruction by a blood clot (thrombosis).

TYPES

Acute Hepatitis

Duration: Usually lasts a few weeks (<6 months).

Symptoms: Fever, body ache, nausea, jaundice (yellowing of the white of the eye, and skin), dark urine, pain in the upper right part of the abdomen, loss of appetite

Common causes – Viral (HVA and HVE), Drugs/Toxins, Ischemic

Recovery in acute viral cases is usually spontaneous though rarely it can cause complications like liver failure (seen more in adults; Hepatitis E can especially be serious and even fatal in pregnant women)

Chronic Hepatitis

Duration: Prolongs for > 6 months

Symptoms: Initially weight loss, weakness, body ache, and decreased appetite.  Often there are no specific symptoms, and diagnosis is made on routine lab tests.

Common causes – Viral (HVB, HVC, HVD), Alcohol, NASH, autoimmune, and certain medicines/toxins.

CIRRHOSIS

It is the scarring (fibrosis) of the liver resulting from progressive damage due to chronic hepatitis. In cirrhosis, the normal structure of the liver is gradually lost and replaced by scar tissue thereby compromising liver function.

Chronic hepatitis and cirrhosis also increases the risk of developing liver cancer (hepatocellular carcinoma)

Blood from the entire digestive (gastrointestinal) tract flows through the portal vein into the liver, and thereafter from the liver to the heart through the hepatic veins. Cirrhosis causes restriction of this flow, leading to back pressure in the portal and gastrointestinal veins (portal hypertension). This leads to many of these veins and their smaller connections (collaterals) becoming dilated and tortuous (varices) as seen in the lower esophagus, stomach, and rectum. These varices can rupture and cause massive bleeding, manifesting as vomiting blood (hematemesis), or rarely a rectal bleed.

The liver is the organ detoxifying a lot of harmful substances in our body like ammonia that starts to accumulate with advanced cirrhosis affecting the functioning of many other organs, especially the brain (hepatic encephalopathy). This manifests as confusion, drowsiness, flapping tremors, personality changes, slurred speech, and impaired muscle coordination

When signs of portal hypertension and encephalopathy appear, cirrhosis is said to be decompensated. Cirrhosis eventually causes chronic liver failure. Cirrhosis can also result in compromised kidney function and failure (called hepatorenal syndrome).

MANAGEMENT

Vaccines 

Preventive vaccines are now available for viral hepatitis A and B and are regularly given to children as part of the immunization schedule. Adults prone to needle injuries like doctors and lab workers should be given the hepatitis B vaccine.

A vaccine for hepatitis E is available in China and is likely to soon be available in other countries. Vaccine for hepatitis C is still in the research stages.

Diagnosis

There are specific antigen and IgM/IgG antibody tests available for hepatitis viruses that help establish the causative virus, and also the stage of the disease.

Liver function tests (LFT) are blood tests that help to assess the amount and type of liver damage, the degree of functioning of the liver, and to monitor disease progression/improvement. These include liver enzymes (SGOT, SGPT, ALP, GGT), bilirubin, proteins (albumin and globulin), and prothrombin time (PT-INR).

Cirrhosis is usually diagnosed by screening with an ultrasound test called fibroscan, and it is confirmed and staged by performing a liver biopsy.

Treatment

Acute hepatitis (mainly due to HVA and HVE common with water and food contamination), is managed with rest, adequate fluids, dietary fat and alcohol restriction, and no drugs/medicines. It usually shows a full recovery in 3-4 weeks. Rarely it may present as a severe form spiraling quickly into liver failure. Adults especially the migrating population, and pregnant women are most at risk for complications and fatality due to hepatitis A and E.

Chronic hepatitis if due to HVB or HVC is managed with medicines now available (tenofovir and entecavir for hepatitis B, and sofosbuvir, ledipasvir, daclatasvir and velpatasvir for hepatitis C). Usually, treatment continues for several months with regular monitoring and lab tests in order to effectively control the infection and prevent the development of cirrhosis. Even after long-term treatment and recovery, monitoring continues for life as the increased risk of developing liver cancer remains.

ALD and NAFLD currently have no specific medicines, though supportive therapy with tonics, nutritional supplements, and antioxidants is often prescribed. Research on specific drugs is in progress. Treatment and management of underlying risk factors is the cornerstone.

Cirrhosis if diagnosed, requires regular monitoring for liver function, progression of cirrhosis, and signs of liver failure. The patient is registered for liver transplant and advised precautionary procedures like endoscopy and banding of varices (dilated tortuous blood vessels of the food pipe). Sometimes an interim shunt surgery called transjugular intrahepatic portosystemic shunt (TIPS) may be performed to ease out the back pressure and protect against gastrointestinal bleeding.

Medicines for cirrhosis are given mainly to reduce and detoxify ammonia that builds up as the liver cannot convert it to urea. Such medicines include antibiotics like rifaximin to control ammonia-producing gut bacteria, laxatives like lactulose that maintain bowel function and produce an acidic gut milieu inhibiting ammonia-producing bacteria, probiotics that increase friendly gut bacteria and reduce ammonia producing bacteria, and amino acids like LOLA (L-ornithine L-aspartate) that divert ammonia to form glutamine. Other medicines include diuretics to reduce fluid accumulation and swelling, and drugs to reduce back-pressure in the gastrointestinal veins (portal hypertension causing varices).

Signs of chronic liver failure

• Jaundice (yellowing of skin/eye)
• Skin itching
• Fluid in abdomen (ascites)
• Swelling of feet and ankles
• Superficial bruising/bleeding spots, or dilated tortuous veins under the skin (spider nevi/angioma)
• Reddening of palms and bulging club-like fingers
• Prominent tortuous blood vessels around the umbilicus (caput-medusae)
• Bleeding from vessels of food pipe and stomach (esophageal /gastric varices) manifesting as blood in the vomit (hematemesis).
• Bleeding from rectum (melena) or formation of hemorrhoids (piles)
• Dark urine and pale stools
• Severe fatigue and weakness
• Brain symptoms (hepatic encephalopathy) – confusion, disorientation, delirium, tremors (flapping type), sweet fecal odor in the breath (due to ammonia), finally progressing to coma

For any query, additional information or to discuss any case, write to info@drvarsha.com, and be assured of a response soon.

References

WHO Hepatitis July 2019,

CDC Hepatitis Goal 2020

Also read –

Water-Borne Diseases, Contaminated Food and Gastrointestinal Infections