Hepatitis

is a medical condition defined by the inflammation of the liver and characterized by the
presence of inflammatory cells in the tissue of the organ, poor appetite and malaise.
Hepatitis is acute when it lasts less than six months and chronic when it persists longer.
The acute condition usually is self-limiting (healing on its own)

Causes of acute hepatitis

1_Viral Hepatitis
-Hepatotropic viruses
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
5.Hepatitis E
_

Non Hepatotropic viruses

Cytomegalovirus (CMV)
1.

Mild hepatitis

Mononucleosis (EBV)
1. Mild hepatitis
Herpes Simplex Virus (HSV)
1. Severe hepatitis (especially in
immunocompromised patients)
Varicella
1. Severe hepatitis (especially in
immunocompromised pati

2_Bacterial hepatitis
1-Leptospirosis
1. Associated with animal or tick borne exposure
2-Q Fever
Relapsing Fever and myalgias
2. Alkaline Phosphatase significantly increased out
of proportion to transaminases
3-Rocky Mountain Spotted Fever
3.

Jaundice is prominent

4-Secondary Syphilis
5-Typhoid Fever
6-Overwhelming infection (Sepsis)

3_Parasite (e.g. Toxocariasis)

Toxocariasis
4. Associated with
pneumonitis, Leukocytosis withEosinophil predo
minance
Liver Trematodes (liver flukes)

4_Autoimmune Conditions
Systemic Lupus Erythematosus (SLE)
Autoimmune Hepatitis
Women predominate in a bimodal distribution (ages 15 to 25 and 45 to 60
years old)

5_ Medications and drugs

Alcohol Abuse
Carbon tetrachloride
paracetamole

Acute Viral Hepatitis

Acute viral hepatitis is inflammation of the liver caused by infection with one of the
five hepatitis viruses. In most people, the inflammation begins suddenly and lasts only
a few weeks.

Symptoms range from none to very severe.

Affected people may have a poor appetite, nausea, vomiting, fever, pain in the
upper right part of the abdomen, and jaundice.

Doctors do a physical examination and take blood samples to analyze.

Vaccines can prevent hepatitis A, B, and E.

Usually, specific treatment is not needed.

Big List of Acute Viral Hepatitis Symptoms

Initial Symptoms (Not in any particular order):

General malaise (a vague symptom where you feel uncomfortable and

a little tired)

Myalgia (muscle pain)

Arthralgia (joint pain)

Fatigue (extreme tiredness)

Headache

Anorexia (having no appetite)

Changes in your normal sense of smell and taste accompany anorexia

(For example, smokers sometimes develop a temporary distaste for
smoking)

Unusual sensitivity to bright light (photophobia)

Nausea and vomiting (these are very common symptoms)

Diarrhea (less common)

Constipation (less common)

Fever (usually low-grade and most common in hepatitis A and E)

Upper-right abdominal pain (pain in the upper belly on the right side,
usually mild and constant)
Later Symptoms:

Jaundice

Dark-colored urine
Light-colored stools

Clinical Picture
:Prodromal (pre-icteric) phase
Nonspecific symptoms occur; they include profound
anorexia, malaise, nausea and vomiting, a newly
developed distaste for cigarettes (in smokers), and often
fever or right upper quadrant abdominal pain. Urticaria
and arthralgias occasionally occur, especially in HBV
.infection

Icteric phase
After 3 to 10 days, the urine darkens, followed by
jaundice. Systemic symptoms often regress, and patients
feel better despite worsening jaundice. The liver is usually
enlarged and tender, but the edge of the liver remains soft
and smooth. Mild splenomegaly occurs in 15 to 20% of
.patients. Jaundice usually peaks within 1 to 2 wk

:Recovery phase
.During this 2- to 4-wk period, jaundice fades

Appetite usually returns after the first week of symptoms.

Acute viral hepatitis usually resolves spontaneously 4 to 8
.wk after symptom onset

Sometimes anicteric hepatitis, a minor flu-like illness

without jaundice, is the only manifestation. It occurs more
often than icteric hepatitis in patients with HCV infection
.and in children with HAV infection

Recrudescent hepatitis occurs in a few patients and is

characterized by recurrent manifestations during the
recovery phase. Manifestations of cholestasis may develop
during the icteric phase (called cholestatic hepatitis) but
usually resolve. When they persist, they cause prolonged
jaundice, elevated alkaline phosphatase, and pruritus,
.despite general regression of inflammation

Virus-specific:
What Are the Symptoms of Hepatitis A?
Hepatitis A is inflammation of the liver caused by the hepatitis A virus.
When symptoms occur, they may include:

Jaundice (condition causing yellow eyes and skin, dark urine)

Abdominal pain

Loss of appetite

Nausea

Fever

Diarrhea

Fatigue

Children often have hepatitis A with few symptoms.

A person can spread the hepatitis A virus about 2 weeks before his or her symptoms
appear and during the first week of having symptoms. People with no symptoms can
also spread the virus.

How Is Hepatitis A Transmitted?

The hepatitis A virus is found in the stool of people with hepatitis A. It is spread from
person to person by putting something in your mouth that has been contaminated with
the stool of an infected person.
Therefore, hepatitis A is most commonly transmitted in drinking water or food
contaminated with the stool containing the virus.
It is spread easily where there is poor sanitation or poor personal hygiene.
Other ways to get hepatitis A include:

Eating fruits, vegetables, or other foods that were contaminated during

handling

Eating raw shellfish harvested from water contaminated with the virus

Swallowing contaminated water or ice

Who Is at Highest Risk of Hepatitis A?

Those who are the highest risk of hepatitis A infection include:

People living with or having sex with an infected person

People traveling to countries where hepatitis A is common

Men who have sex with men

Injecting and noninjecting drug users

Children and employees in child care settings

How Is Hepatitis A Diagnosed?

Blood tests can diagnose hepatitis A.

Are There Any Long-Term Effects of Hepatitis A?

Hepatitis A causes acute (short-lived) infection. The liver heals itself over a few
weeks to months. Usually the virus doesn't cause any long-term problems or
complications. However, according to the CDC, 10% to 15% of people with hepatitis
A will have prolonged or relapsing symptoms over a six- to nine-month period.
Rarely, patients will develop acute liver failure, which can be fatal, or require a liver
transplant.

What's the Treatment for Hepatitis A?

There are no treatments that will cure hepatitis A. Your health care provider may
monitor your liver function tests to be sure your body is healing appropriately.

Prevention
Improved sanitation, food safety and immunization are the most effective ways to
combat hepatitis A.
The spread of hepatitis A can be reduced by:

adequate supplies of safe drinking water

proper disposal of sewage within communities

personal hygiene practices such as regular hand-washing with safe water.

Several hepatitis A vaccines are available internationally. All are similar in terms of
how well they protect people from the virus and their side-effects. No vaccine is
licensed for children younger than one year of age.
Nearly 100% of people develop protective levels of antibodies to the virus within one
month after a single dose of the vaccine. Even after exposure to the virus, a single
dose of the vaccine within two weeks of contact with the virus has protective effects.
Still, manufacturers recommend two vaccine doses to ensure a longer-term protection
of about five to eight years after vaccination.
Millions of people have been immunized worldwide with no serious adverse events.
The vaccine can be given as part of regular childhood immunizations programmes and
also with other vaccines for travellers.

Immunization efforts

Vaccination against hepatitis A should be part of a comprehensive plan for the

prevention and control of viral hepatitis. Planning for large-scale immunization
programmes should involve careful economic evaluations and consider alternative or
additional prevention methods, such as improved sanitation, and health education for
improved hygiene practices.
Whether or not to include the vaccine in routine childhood immunizations depends on
the local context, including the proportion of susceptible people in the population and
the level of exposure to the virus. Several countries, including Argentina, China,
Israel, Turkey, the United States of America have introduced the vaccine in routine
childhood immunizations.
While the two-dose regimen of inactivated hepatitis A vaccine is used in many
countries, other countries may consider inclusion of a single-dose inactivated hepatitis
A vaccine in their immunization schedules. Some countries also recommend the
vaccine for people at increased risk of hepatitis A, including:

travellers to countries where the virus is endemic;

men who have sex with men;

people with chronic liver disease (because of their increased risk of serious
complications if they acquire hepatitis A infection).

Regarding immunization for outbreak response, recommendations for hepatitis A

vaccination should also be site-specific, including the feasibility of rapidly
implementing a widespread immunization campaign.
Vaccination to control community-wide outbreaks is most successful in small
communities, when the campaign is started early and when high coverage of multiple
age groups is achieved. Vaccination efforts should be supplemented by health
education to improve sanitation, hygiene practices and food safety.

WHO response
WHO is working in the following areas to prevent and control viral hepatitis:

raising awareness, promoting partnerships and mobilizing resources;

formulating evidence-based policy and data for action;

preventing transmission; and

executing screening, care and treatment.

WHO also organizes World Hepatitis Day on July 28 every year to increase awareness
and understanding of viral hepatitis.

Acute Hepatitis B
An acute infection may last up to six months (with or without symptoms) and
infected persons are able to pass the virus to others during this stage. A patient
will test positive for the hepatitis B virus (HBsAg+), HBc-IgM, and possibly the HBeantigen. Safe sex practices and vaccination of close household members should be
recommended.

HBV is the 2nd most common cause of acute viral

hepatitis. Prior unrecognized infection is common but is
much less widespread than that with HAV
Symptoms of an acute infection may include loss of appetite, myalgia, nausea, lowgrade fever, and possible abdominal pain. Although most people do not experience
symptoms, they can appear 45 to 180 days after the virus enters the body. Some
people may experience more severe symptoms such as nausea, vomiting, or jaundice
(i.e. yellowing of the eyes and skin) that will require immediate medical attention.
A small number of people have symptoms that last for months. They may have signs
of abnormal liver function before they completely recover from the acute infection.
Most infected persons do not require hospitalization, although some may require
close medical attention.
Transmission
In highly endemic areas, HBV is most commonly spread from mother to child at birth,
or from person to person in early childhood.
Perinatal or early childhood transmission may also account for more than one third of
chronic infections in areas of low endemicity, although in those settings, sexual
transmission and the use of contaminated needles, especially among injecting drug
users, are the major routes of infection.
The hepatitis B virus can survive outside the body for at least 7 days. During this
time, the virus can still cause infection if it enters the body of a person who is not
protected by the vaccine.
The hepatitis B virus is not spread by contaminated food or water, and cannot be
spread casually in the workplace.
The incubation period of the hepatitis B virus is 75 days on average, but can vary
from 30 to 180 days. The virus may be detected 30 to 60 days after infection and
persists for variable periods of time.
Diagnosis

It is not possible, on clinical grounds, to differentiate hepatitis B from hepatitis caused

by other viral agents and, hence, laboratory confirmation of the diagnosis is essential.
A number of blood tests are available to diagnose and monitor people with hepatitis
B. They can be used to distinguish acute and chronic infections.
Laboratory diagnosis of hepatitis B infection focuses on the detection of the hepatitis
B surface antigen HBsAg. WHO recommends that all blood donations are tested for
this marker to avoid transmission to recipients.

Acute HBV infection is characterized by the presence of HBsAg and

immunoglobulin M (IgM) antibody to the core antigen, HBcAg. During the
initial phase of infection, patients are also seropositive for HBeAg.

Chronic infection is characterized by the persistence (>6 months) of HBsAg

(with or without concurrent HBeAg). Persistence of HBsAg is the principal
marker of risk for developing chronic liver disease and hepatocellullar
carcinoma (HCC) later in life.

The presence of HBeAg indicates that the blood and body fluids of the
infected individual are highly contagious

Prevention
The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO recommends
that all infants receive the hepatitis B vaccine as soon as possible after birth,
preferably within 24 hours.
The birth dose should be followed by 2 or 3 doses to complete the primary series. In
most cases, 1 of the following 2 options is considered appropriate:

a 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent)

being given at birth and the second and third (monovalent or combined
vaccine) given at the same time as the first and third doses of DTP vaccine; or

4 doses, where a monovalent birth dose is followed by 3 monovalent or

combined vaccine doses, usually given with other routine infant vaccines.

The complete vaccine series induces protective antibody levels in more than 95% of
infants, children and young adults. Protection lasts at least 20 years and is possibly
lifelong.
All children and adolescents younger than 18 years old and not previously vaccinated
should receive the vaccine if they live in countries where there is low or intermediate
endemicity. In those settings it is possible that more people in high risk groups may
acquire the infection and they should also be vaccinated. They include:

people who frequently require blood or blood products, dialysis patients,

recipients of solid organ transplantations;

people interned in prisons;

injecting drug users;

household and sexual contacts of people with chronic HBV infection;

people with multiple sexual partners, as well as health-care workers and others
who may be exposed to blood and blood products through their work; and

travellers who have not completed their hepatitis B vaccination series should
be offered the vaccine before leaving for endemic areas.

The vaccine has an excellent record of safety and effectiveness. Since 1982, over one
billion doses of hepatitis B vaccine have been used worldwide. In many countries,
where 815% of children used to become chronically infected with the hepatitis B
virus, vaccination has reduced the rate of chronic infection to less than 1% among
immunized children.
As of 2012, 183 Member States vaccinate infants against hepatitis B as part of their
vaccination schedules and 79% of children received the hepatitis B vaccine. This is a
major increase compared with 31 countries in 1992, the year that the World Health
Assembly passed a resolution to recommend global vaccination against hepatitis B.
Furthermore, as of 2012, 94 Member States have introduced the hepatitis B birth dose.
In addition, implementation of blood safety strategies, including quality-assured
screening of all donated blood and blood components used for transfusion can prevent
transmission of HBV. Safe injection - unnecessary as well as unsafe injections practices can protect against HBV transmission. Furthermore, safer sex practices,
including minimizing the number of partners and using barrier protective measures
(condoms), protect against transmission.
Treatment of acute hepatitis B is generally supportive, which may or may not require
hospitalization. Rest and managing symptoms are the primary goals of therapy.
Additional follow-up blood tests are needed to confirm recovery from an acute
infection or progression to a chronic infection.

http://www.who.int/mediacentre/factshe
ets/fs204/en/
Hepatitis C
Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV
infection is usually asymptomatic, and is only very rarely associated with life-

threatening disease. About 1545% of infected persons spontaneously clear the virus
within 6 months of infection without any treatment.
The remaining 5585% of persons will develop chronic HCV infection. Of those with
chronic HCV infection, the risk of cirrhosis of the liver is 1530% within 20 years.
What is Hepatitis C?
Hepatitis C is a contagious liver disease that ranges in severity from a mild illness
lasting a few weeks to a serious, lifelong illness that attacks the liver. It results from
infection with the Hepatitis C virus (HCV), which is spread primarily through contact
with the blood of an infected person. Hepatitis C can be either acute or chronic.
Acute Hepatitis C virus infection is a short-term illness that occurs within the
first 6 months after someone is exposed to the Hepatitis C virus,

Transmission / Exposure
How is Hepatitis C spread?
Hepatitis C is usually spread when blood from a person infected with the Hepatitis C
virus enters the body of someone who is not infected. Today, most people become
infected with the Hepatitis C virus by sharing needles or other equipment to inject
drugs. Before 1992, when widespread screening of the blood supply began in the
United States, Hepatitis C was also commonly spread through blood transfusions and
organ transplants.
People can become infected with the Hepatitis C virus during such activities as

Sharing needles, syringes, or other equipment to inject drugs

Needlestick injuries in health care settings

Being born to a mother who has Hepatitis C

Less commonly, a person can also get Hepatitis C virus infection through

Sharing personal care items that may have come in contact with another
persons blood, such as razors or toothbrushes

Having sexual contact with a person infected with the Hepatitis C virus

What are the symptoms of acute Hepatitis C?

Approximately 70%80% of people with acute Hepatitis C do not have any
symptoms. Some people, however, can have mild to severe symptoms soon after
being infected, including

Fever

Fatigue

Loss of appetite

Nausea

Vomiting

Abdominal pain

Dark urine

Clay-colored bowel movements

Joint pain

Jaundice (yellow color in the skin or eyes)

Who is at risk for Hepatitis C?

Some people are at increased risk for Hepatitis C, including

Current injection drug users (currently the most common way Hepatitis C
virus is spread in the United States)

Past injection drug users, including those who injected only one time or many
years ago

Recipients of donated blood, blood products, and organs (once a common

means of transmission but now rare in the United States since blood screening
became available in 1992)

People who received a blood product for clotting problems made before 1987

Hemodialysis patients or persons who spent many years on dialysis for kidney
failure

People who received body piercing or tattoos done with non-sterile

instruments

People with known exposures to the Hepatitis C virus, such as

o Health care workers injured by needlesticks
o Recipients of blood or organs from a donor who tested positive for the
Hepatitis C virus

HIV-infected persons

Children born to mothers infected with the Hepatitis C virus

Less common risks include:

Having sexual contact with a person who is infected with the Hepatitis C virus

Sharing personal care items, such as razors or toothbrushes, that may have
come in contact with the blood of an infected person

What is the risk of a pregnant woman passing Hepatitis C to her baby?

Hepatitis C is rarely passed from a pregnant woman to her baby. About 6 of every 100
infants born to mothers with Hepatitis C become infected with the virus. However, the
risk becomes greater if the mother has both HIV infection and Hepatitis C.
Can acute Hepatitis C be treated?

Yes, acute hepatitis C can be treated. Acute infection can clear on its own without
treatment in about 25% of people. If acute hepatitis C is diagnosed, treatment
does reduce the risk that acute hepatitis C will become a chronic infection. Acute
hepatitis C is treated with the same medications used to treat chronic Hepatitis
C. However, the optimal treatment and when it should be started remains
uncertain

Hepatitis E
Hepatitis E is a liver disease caused by the hepatitis E virus: a non-enveloped,
.positive-sense, single-stranded ribonucleic acid (RNA) virus
The hepatitis E virus is transmitted mainly through contaminated drinking water. It is
usually a self-limiting infection and resolves within 46 weeks. Occasionally, a
.fulminant form of hepatitis develops (acute liver failure), which can lead to death
Globally, there are approximately 20 million incidents of hepatitis E infections every
.year

Transmission
The hepatitis E virus is transmitted mainly through the faecal-oral route due to faecal
contamination of drinking water. Other transmission routes have been identified,
which include:

foodborne transmission from ingestion of products derived from infected

animals;

transfusion of infected blood products;

vertical transmission from a pregnant woman to her fetus.

Although humans are considered the natural host for the hepatitis E virus, antibodies
to the hepatitis E virus or closely related viruses have been detected in primates and
several other animal species.
Hepatitis E is a waterborne disease, and contaminated water or food supplies have
been implicated in major outbreaks. The ingestion of raw or uncooked shellfish has
also been identified as the source of sporadic cases in endemic areas.
The risk factors for hepatitis E are related to poor sanitation in large areas of the world
and shedding of the hepatitis E virus in faeces.

Symptoms
The incubation period following exposure to the hepatitis E virus ranges from three to
eight weeks, with a mean of 40 days. The period of communicability is unknown.
The hepatitis E virus causes acute sporadic and epidemic viral hepatitis. Symptomatic
infection is most common in young adults aged 1540 years. Although infection is
frequent in children, the disease is mostly asymptomatic or causes a very mild illness
without jaundice (anicteric) that goes undiagnosed.
Typical signs and symptoms of hepatitis include:

jaundice (yellow discolouration of the skin and sclera of the eyes, dark urine
and pale stools);

anorexia (loss of appetite);

an enlarged, tender liver (hepatomegaly);

abdominal pain and tenderness;

nausea and vomiting;

fever.

These symptoms are largely indistinguishable from those experienced during any
acute phase of hepatic illness and typically last for one to two weeks.
In rare cases, acute hepatitis E can result in fulminant hepatitis (acute liver failure)
and death. Fulminant hepatitis occurs more frequently during pregnancy. Pregnant
women are at greater risk of obstetrical complications and mortality from hepatitis E,
which can induce a mortality rate of 20% among pregnant women in their third
trimester.
Cases of chronic hepatitis E infection have been reported in immunosuppressed
people. Reactivation of hepatitis E infection has also been reported in
immunocompromised people.

Diagnosis
Cases of hepatitis E are not clinically distinguishable from other types of acute viral
hepatitis. Diagnosis of hepatitis E infection is, therefore, usually based on the
detection of specific IgM and IgG antibodies to the virus in the blood. Additional tests
include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the
hepatitis E virus RNA in blood and/or stool, but this assay may require specialised
laboratory facilities.

Hepatitis E should be suspected in outbreaks of waterborne hepatitis occurring in

developing countries, especially if the disease is more severe in pregnant women, or if
hepatitis A has been excluded.

Treatment
There is no available treatment capable of altering the course of acute hepatitis.
Prevention is the most effective approach against the disease.
As hepatitis E is usually self-limiting, hospitalization is generally not required.
However, hospitalization is required for people with fulminant hepatitis and should
also be considered for symptomatic pregnant women.

Prevention
The risk of infection and transmission can be reduced by:

maintaining quality standards for public water supplies;

establishing proper disposal systems to eliminate sanitary waste.

On an individual level, infection risk can be reduced by:

maintaining hygienic practices such as hand washing with safe water,

particularly before handling food;

avoiding drinking water and/or ice of unknown purity;

adhering to WHO safe food practices.

In 2011, the first vaccine to prevent hepatitis E infection was registered in China.
Although it is not available globally, it could potentially become available in a
number of other countries.

Guidelines for epidemic measures

In epidemics, WHO recommends:

determining the mode of transmission;

identifying the population specifically exposed to increased risk of infection;

eliminating a common source of infection;

improving sanitary and hygienic practices to eliminate faecal contamination of

food and water.

Diagnosis
Doctors suspect acute viral hepatitis on the basis of symptoms. During the physical
examination, a doctor presses on the abdomen above the liver, which is tender and
somewhat enlarged in about half of the people with acute viral hepatitis.
Blood tests to determine how well the liver is functioning and whether it is damaged
(liver function tests) are done. They can indicate whether the liver is inflamed and
often help doctors distinguish hepatitis due to alcohol abuse from that due to a virus.
Blood tests are done to help doctors identify which hepatitis virus is causing the
infection. These tests can detect parts of the viruses or specific antibodies produced by
the body to fight the viruses.
Occasionally, if the diagnosis is unclear, a biopsy is done: A sample of liver tissue is
removed with a needle and examined.
If acute hepatitis seems likely, the cause is identified if possible. To help identify the
cause, a doctor usually asks about activities that can increase the risk of getting viral
hepatitis (see Table 1: The Hepatitis Viruses ). To determine whether the cause may
be something other than a virus, the doctor may ask whether people take any drugs
that can cause hepatitis (such as isoniazid
, used to treat tuberculosis) and how much alcohol they drink.

Prevention of viral hepatitis

Vaccines, given by injection into muscle, are available to prevent hepatitis A, B, and E
infections.

Hepatitis A vaccine is recommended for all children (Fig. 1: Vaccinating

Infants and Children ) and for adults likely to be exposed to the virus, such
as travelers to areas where hepatitis A is common (see Hepatitis A).

Hepatitis B vaccine is recommended for all people under age 18 (starting at

birthsee Hepatitis B and Fig. 1: Vaccinating Infants and Children )

Hepatitis E vaccine, a new vaccine, is most likely to be used in areas where

hepatitis E is common.

As with most vaccines, protection requires allowing a number of weeks for the
vaccine to reach its full effect as the immune system gradually creates antibodies
against the particular virus.
If people who have not been vaccinated are exposed to hepatitis A virus, they can be
given an injection of an antibody preparation called standard immune globulin
. It prevents infection or decreases its severity. However, the amount of protection it
provides varies, and the protection is only temporary.

If people who have not been vaccinated are exposed to hepatitis B virus, they are
given hepatitis B immune globulin
and are vaccinated. Hepatitis B immune globulin
contains antibodies to hepatitis B, which help the body fight the infection. This
preparation prevents symptoms or decreases their severity, although it is unlikely to
prevent infection. Some people, such as those with a weakened immune system or
those being treated with hemodialysis, may need a booster dose of the vaccine.
No vaccines against hepatitis C or D virus are available. However, vaccination against
hepatitis B virus also reduces the risk of infection with hepatitis D virus.
Other preventive measures against infection with the hepatitis viruses can be taken:

Washing hands thoroughly before handling food

Not sharing needles to inject drugs

Not sharing toothbrushes, razors, or other items that could get blood on them

Practicing safe sexfor example, using barrier protection such as a condom

Limiting the number of sex partners

Donated blood is unlikely to be contaminated because it is screened. Nonetheless,

doctors help reduce the risk of hepatitis by ordering blood transfusions only when
essential. Before surgery, people can also sometimes prevent the need for transfusion
of blood from an unknown donor by donating their own blood weeks before the
operation.

Treatment
In most people, special treatment is not necessary, although people with unusually
severe acute hepatitis may require hospitalization. After the first several days, appetite
usually returns and people do not need to stay in bed. Severe restrictions of diet or
activity are unnecessary, and vitamin supplements are not required. Most people can
safely return to work after the jaundice clears, even if their liver function test results
are not quite normal.
People with hepatitis should not drink alcohol until they have fully recovered. A
doctor may need to stop a drug or reduce the dosage of a drug that could accumulate
to harmful levels in the body (such as warfarin
or theophylline
) because the infected liver cannot process (metabolize) them. Thus, people should tell
their doctor all the drugs they are taking (both prescription and nonprescription,
including any medicinal herbs), so that the dosage can be adjusted if necessary.

If hepatitis B causes extremely severe (fulminant) hepatitis, antiviral drugs may help.
However, liver transplantation is the most effective treatment and may be the only
hope of survival, particularly for adults.

Characteristics of Hepatitis Viruses

Hepatitis E
Virus

Hepatitis D
Virus

Hepatitis C
Virus

Hepatitis B
Virus

Hepatitis A
Virus

Characteristic

RNA

RNA

DNA

RNA

Nucleic acid

Anti-HEV

Anti-HDV

Anti-HCV

HBsAg

IgM anti-HA

Serologic diagnosis

Water

Needle

Blood

Blood

Fecal-oral

Major transmission

6014

18030

12020

18040

4515

Incubation period
(days)

Yes

No

No

No

Yes

Epidemics

No

Yes

Yes

Yes

No

Chronicity

Yes

Yes

Yes

No

Liver cancer

Alcohol-Related Liver Disease

How does alcohol affect the liver?
Alcohol can damage or destroy liver cells.
The liver breaks down alcohol so it can be removed from your body. Your liver can
become injured or seriously damaged if you drink more alcohol than it can process.

What are the different types of alcohol-related liver

disease?
There are three main types of alcohol-related liver disease: alcoholic fatty liver
disease, alcoholic hepatitis, and alcoholic cirrhosis.
Alcoholic fatty liver disease
Alcoholic fatty liver disease results from the deposition of fat in liver cells. It is the
earliest stage of alcohol-related liver disease. There are usually no symptoms. If
symptoms do occur, they may include fatigue, weakness, and discomfort localized to
the right upper abdomen. Liver enzymes may be elevated, however tests of liver
function are often normal. Many heavy drinkers have fatty liver disease. Alcoholic
fatty liver disease may be reversible with abstinence of alcohol.
Alcoholic hepatitis
Alcoholic hepatitis is characterized by fat deposition in liver cells, inflammation and
mild scarring of the liver. Symptoms may include loss of appetite, nausea, vomiting,
abdominal pain, fever and jaundice. Liver enzymes are elevated and tests of liver
function may be abnormal. Up to 35 percent of heavy drinkers develop alcoholic
hepatitis and of these 55% already have cirrhosis.
Alcoholic hepatitis can be mild or severe. Mild alcoholic hepatitis may be reversed
with abstinence. Severe alcoholic hepatitis may occur suddenly and lead to serious
complications including liver failure and death.
Alcoholic cirrhosis
Alcoholic cirrhosis, the most advanced type of alcohol induced liver injury is
characterized by severe scarring and disruption of the normal structure of the liver -hard scar tissue replaces soft healthy tissue. Between 10 and 20 percent of heavy
drinkers develop cirrhosis. Symptoms of cirrhosis may be similar to those of severe
alcoholic hepatitis. Cirrhosis is the most advanced type of alcohol-related liver disease
and is not reversed with abstinence. However, abstinence may improve the symptoms
and signs of liver disease and prevent further damage.

How does alcohol-related liver disease progress?

Many heavy drinkers will progress from fatty liver disease to alcoholic hepatitis to
alcoholic cirrhosis over time. However, some heavy drinkers may develop cirrhosis
without first having alcoholic hepatitis first. Others may have alcoholic hepatitis but
never have symptoms. Additionally, alcohol consumption may worsen liver injury
caused by non-alcoholic liver diseases such as chronic hepatitis C.
Since an individual's susceptibility to the toxic effects of alcohol may vary by many
factors including age, gender, genetics and coexistent medical conditions, it is
reaspnable for you to review alcohol use with your physician.

Symptoms
Yellowing of the skin and whites of the eyes (jaundice) and increasing girth (due to
fluid accumulation) are the most common signs of alcoholic hepatitis that lead people
to seek medical care.
People may also complain of:

Loss of appetite

Nausea and vomiting

Abdominal pain and tenderness

Weight loss

Just about everyone who has alcoholic hepatitis is malnourished. Drinking large
amounts of alcohol suppresses the appetite, and heavy drinkers get most of their
calories in the form of alcohol.
Signs and symptoms of severe alcoholic hepatitis include:

Retaining large amounts of fluid in your abdominal cavity (ascites)

Confusion and behavior changes due to brain damage from buildup of toxins
(encephalopathy)

Kidney and liver failure

Causes

Alcoholic hepatitis occurs when the liver is damaged by the alcohol you drink. Just
how alcohol damages the liver - and why it does so only in a minority of heavy
drinkers isn't clear. What is known is that the process of breaking down ethanol
the alcohol in beer, wine and liquor produces highly toxic chemicals, such as
acetaldehyde. These chemicals trigger inflammation that destroys liver cells. Over
time, web-like scars and small knots of tissue replace healthy liver tissue, interfering
with the liver's ability to function. This irreversible scarring, called cirrhosis, is the
final stage of alcoholic liver disease.

Risk increases with time, amount consumed

Heavy alcohol use can lead to liver disease, and the risk increases with the length of
time and amount of alcohol you drink. But because many people who drink heavily or
binge drink never develop alcoholic hepatitis or cirrhosis, it's likely that factors other
than alcohol play a role. These include:

Other types of hepatitis. Long-term alcohol abuse worsens the liver damage
caused by other types of hepatitis, especially hepatitis C. If you have hepatitis
C and also drink even moderately you're more likely to develop
cirrhosis than if you don't drink.

Malnutrition. Many people who drink heavily are malnourished, either

because they eat poorly or because alcohol and its toxic byproducts prevent
the body from properly absorbing and breaking down nutrients, especially
protein, certain vitamins and fats. In both cases, the lack of nutrients
contributes to liver cell damage.

Obesity.

Genetic factors. Having mutations in certain genes that affect alcohol

metabolism may increase your risk of alcoholic liver disease as well as of alcoholassociated cancers and other complications of heavy drinking.
The Risk

factors

Major risk factors for alcoholic hepatitis comprise:

Alcohol use. The amount of alcohol consumed is the most important risk
factor for alcoholic liver disease. One study found that the risk of cirrhosis of
the liver increased with daily ingestion of more than 2 to 2.8 ounces (60 to 80
grams) of alcohol over 10 years for men and 0.7 ounces (20 grams) for
women. Yet still, only about 35 percent of heavy long-term drinkers develop
alcoholic hepatitis.

Your sex. Women have a higher risk of developing alcoholic hepatitis than
men do. This disparity may result from differences in the way alcohol is
processed by women.

Genetic factors. A number of genetic mutations have been identified that

affect the way alcohol is broken down in the body. Having one or more of
these mutations may increase the risk of alcoholic hepatitis.

Other factors which may increase your risk include:

Type of beverage (beer or spirits are riskier than wine)

Binge drinking

Obesity alcohol and obesity may have a synergistic effect on the liver; that
is, their combined effect is worse than the effect of either of them alone

African-American or Hispanic

exact genetic associations have not yet been identified.

What are the complications of alcohol-related liver

disease?
Complications from alcohol-related liver disease usually occur after years of heavy
drinking. These complications can be serious.
They may include liver related conditions that are a consequence of portal
hypertension:
build up of fluid in the abdomen
bleeding from veins in the esophagus or stomach
enlarged spleen
brain disorders and coma
kidney failure
liver cancer
In addition alcoholic liver disease may be accompanied by multi-organ non-liver
conditions.

How is alcohol-related liver disease diagnosed?

Alcohol-related liver disease may be suspected based on a person's history of

alcohol abuse, laboratory or radiologic abnormalities or medical conditions
related to alcohol abuse. Blood tests may be used to rule out other liver diseases.
Your doctor also may need to do a liver biopsy. During a biopsy, a small piece of
liver tissue is removed and studied in the lab.

Tests and diagnosis

Identifying alcoholic liver disease depends on two main things:

Evidence of excessive alcohol consumption

Evidence of liver disease

Alcohol consumption
Your doctor will want to know about your history of alcohol consumption. It is
important to be honest in describing your drinking habits. Your doctor may ask to
interview family members about your drinking. Many people will have signs of
chronic alcoholism, such as skin lesions known as spider nevi.

Liver disease
Your doctor will likely order the following tests to look for liver disease:

Liver function tests (including international normalized ratio, total bilirubin,

and albumin)

Complete blood cell count

An ultrasound, CT or MRI scan of the liver

Blood tests to exclude other causes of liver disease

How is alcohol-related liver disease treated?

Treatment for alcohol-related liver disease requires a healthy diet including avoiding
alcohol. Your doctor may suggest changes in your diet to help your liver recover from
the alcohol-related damage. Treatment may require you to participate in an alcohol
recovery program. Medications may be needed to manage the complications caused
by your liver damage. Individuals with advanced alcoholic liver disease that does not

improve with abstinence and medical management may benefit from a liver
transplant.
Page updated: January 20th, 2015

Treatments and drugs

Stop drinking alcohol
If you've been diagnosed with alcoholic hepatitis, you must stop drinking alcohol. It's
the only way of possibly reversing liver damage or, in more advanced cases,
preventing the disease from becoming worse. Many people who stop drinking have
dramatic improvement in symptoms in just a few months.
If you continue to drink alcohol, you're likely to experience serious complications.
If you are dependent on alcohol and want to stop drinking, your doctor can
recommend a therapy that's tailored for your needs. This might include medications,
counseling, Alcoholics Anonymous, an outpatient treatment program or a residential
inpatient stay.

Treatment for malnutrition

Your doctor may recommend a special diet to reverse nutritional deficiencies that
often occur in people with alcoholic hepatitis. You may be referred to a dietitian who
can help you assess your current diet and suggest changes to increase the vitamins and
nutrients you are lacking.
If you have trouble eating enough to get the vitamins and nutrients your body needs,
your doctor may recommend tube feeding. This may involve passing a tube down
your throat and into your stomach. A special nutrient-rich liquid diet is then passed
through the tube.

Medications to reduce liver inflammation

Your doctor may recommend corticosteroids drugs if you have severe alcoholic
hepatitis. These drugs have shown some short-term benefit in increasing survival.
Steroids have significant side effects and are not recommended if you have failing
kidneys, gastrointestinal bleeding or an infection. About 40 percent of people do not
respond to corticosteroids. Your doctor may also recommend pentoxifylline,
especially if corticosteroids don't work for you. Some studies of pentoxifylline have
shown some benefit, others have not. You might also ask about clinical trials of other
therapies.

Liver transplant

For many people with severe alcoholic hepatitis, liver transplant is the only hope to
avoid death. Survival rates for liver transplant for alcoholic hepatitis are similar to
those for other forms of hepatitis, greater than 70 percent five-year survival.
However, most medical centers are reluctant to perform liver transplants on people
with alcoholic liver disease because of the fear they will resume drinking after
surgery. For most people with alcoholic hepatitis, the disease is considered a
contraindication for liver transplantation in most transplant centers in the U.S.
For transplant to be an option, you would need to find a program that will consider
you. You would have to meet the requirements of the program, including abstaining
from alcohol for six months prior to transplant and agreeing not to resume drinking
afterward.

Drug-induced hepatitis
Drug-induced hepatitis is inflammation of the liver that may occur when you take
certain medicines.

Causes
The liver helps the body break down certain medicines. These include some drugs that
you buy over-the-counter or your health care provider prescribes for you. However,
the process is slower in some people. This can make you more likely to get liver
damage.
Some drugs can cause hepatitis with small doses, even if the liver breakdown system
is normal. Large doses of many medications can damage a normal liver.
Many different drugs can cause drug-induced hepatitis.
Painkillers and fever reducers that contain acetaminophen are a common cause of
liver inflammation. These medications can damage the liver when taken in doses that
are not much greater than the recommended dose. People who already have liver
disease are most likely to have this problem.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen,

may also cause drug-induced hepatitis.
Other drugs that can lead to liver inflammation include:

Amiodarone

Anabolic steroids

Birth control pills

Chlorpromazine

Erythromycin

Halothane (a type of anesthesia)

Methyldopa

Isoniazid

Methotrexate

Statins

Sulfa drugs

Tetracyclines

Symptoms

Abdominal pain

Dark urine

Diarrhea

Fatigue

Fever

Headache

Jaundice

Loss of appetite

Nausea and vomiting

Rash

White or clay-colored stools

Exams and Tests

You will have blood tests to check liver function. Liver enzymes will be higher if you
have the condition.
Your doctor will do a physical exam to check for an enlarged liver and abdominal
tenderness in the right upper part of the belly area. A rash or fever may be part of
some drug reactions that affect the liver.

Treatment
The only specific treatment for most cases of liver damage caused by taking a drug is
to stop the drug that caused the problem.
However, if you took high doses of acetaminophen, treatment should be started as
soon as possible after you develop hepatitis.
You should rest during the acute phase of drug-induced hepatitis, when the symptoms
are most severe. If you have more severe nausea and vomiting, you may need to get
fluids through a vein.
People with acute hepatitis should avoid physical exertion, alcohol, acetaminophen,
and any other substances that harmthe liver.

Outlook (Prognosis)
Usually, drug-induced hepatitis goes away within days or weeks after you stop taking
the drug that caused it.

Possible Complications
Rarely, drug-induced hepatitis can lead to liver failure.

When to Contact a Medical Professional

Call your health care provider if:

You develop symptoms of hepatitis after you start taking a new medicine.

You have been diagnosed with drug-induced hepatitis and your symptoms do
not improve after you stop taking the medicine.

You develop any new symptoms.

Prevention
Never use more than the recommended dose of over-the-counter medicines containing
acetaminophen (Tylenol).
If you drink heavily or regularly, you should avoid these medicines or talk to your
health care provider about safe doses.
If you have liver disease, it is very important to tell your doctor about all the
medicines you take. You should avoid the following medications if you have liver
disease:

Acetaminophen

Phenytoin

This list does not include all medications.

Your health care provider can suggest medicines (including over-the-counter
medicines) that are safe for you.

Alternative Names
Toxic hepatitis

References
Teoh NC, Chittun S, Farrell GC. Drug-induced hepatitis. In: Feldman M, Friedman
LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th
ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 86.
Wedemeyer H, Pawlotsky J-M. Acute viral hepatitis. Goldman L, Schafer AI, eds.
Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 150.

Update Date: 10/8/2012

Updated by: George F. Longstreth, MD, Department of Gastroenterology, Kaiser
Permanente Medical Care Program, San Diego, California. Also reviewed by

A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA,
David R. Eltz, and Stephanie Slon.
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