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Overview

Definition

Hepatitis is a collective term for inflammation of the liver caused by a variety of causative factors such as viral infections, bacterial infections, parasitic infections, alcohol consumption, drugs, chemicals, autoimmunity, and obesity.

Classification

Classification according to causative factors

Viral hepatitis

Caused by a variety of hepatitis viruses, infectious.

According to the etiology, it is divided into viral hepatitis A, viral hepatitis B, viral hepatitis C, viral hepatitis D, and viral hepatitis E.

Non-alcoholic steatohepatitis

No history of excessive alcohol consumption, with the presence of hepatocellular steatosis and fat storage as the main clinical feature.

Alcoholic Hepatitis

Commonly seen in people who consume excessive amounts of alcohol.

Autoimmune Hepatitis

A chronic inflammatory disease of the liver caused by a variety of autoantibodies attacking liver cells in the presence of immunologic abnormalities.

Drug Hepatitis

This disease is caused by toxic damage to drugs or allergic reactions to drugs, such as anti-infective drugs, antitumor drugs, hormonal drugs, and herbal medicines, see drug-related liver injury drug-related liver injury.

Classification according to the duration of the disease

(1) Acute hepatitis

The course of the disease is mostly within half a year.

(2) Chronic hepatitis

The duration of the disease lasts more than half a year.

Morbidity

Viral hepatitis

Viral hepatitis occurs worldwide.

Hepatitis A has the highest incidence in preschool children, followed by young people, and the rate of hepatitis A virus antibody positivity is high in the group after 20 years of age.

The results of the 2006 epidemiologic survey showed that the hepatitis B surface antigen (HBsAg) positivity rate in China was 7.18%, and is currently estimated to be 5% to 6%, with more males than females.

The global infection rate of hepatitis C is about 2.8%, and the rate of hepatitis C virus positivity among the general population aged 1-59 years in China is 0.43%, with an estimated number of about 10 million cases.

Hepatitis D is dependent on hepatitis B. Among HBsAg-positive individuals, the hepatitis D virus infection rate is 0% to 32%.

Hepatitis E is most common in middle-aged and elderly people.

Autoimmune hepatitis

The disease is prevalent in people aged 30 to 50 years old and is more common in women.

Non-alcoholic Steatohepatitis

This disease mainly occurs in overweight or obese people.

Causes

Causes

Different types of hepatitis have different causes.

Causes of viral hepatitis

Viral hepatitis is caused by hepatitis virus infection.

Sources of infection

People with viral hepatitis and hepatitis virus carriers (including chronically infected and asymptomatically infected people, etc.) can be sources of infection.

Hepatitis E may also be transmitted from pigs infected with the hepatitis E virus, or from deer, cattle, chickens, sheep, and rodents such as rats.

Routes of transmission

Hepatitis A and Hepatitis E can be transmitted fecal-oral, while Hepatitis B, Hepatitis C, and Hepatitis D can be transmitted through blood, body fluids, and mother-to-child transmission.

Susceptible Population

All people are susceptible to hepatitis virus infection if they are not immunized with the appropriate vaccine.

Non-alcoholic Steatohepatitis

Primary NAFLD is associated with insulin resistance and genetic susceptibility.

Secondary NAFLD includes fatty liver due to obesity, diabetes, hyperlipidemia, and other causes.

Alcoholic hepatitis

Prolonged alcohol consumption, heavy drinking, nutritional status, genetic and metabolic characteristics can increase the risk of this disease.

Autoimmune Hepatitis

The cause of autoimmune hepatitis is unknown and may be the result of a combination of genetic and environmental factors.

Microbial infections, alcohol, drugs, etc. are predisposing factors for this disease.

Drug hepatitis

After using a certain kind of drug or several kinds of drugs, the drugs and their metabolites cause different degrees of liver damage, such as anti-infective drugs, anti-tumor drugs, hormone drugs and Chinese herbal medicine.

Predisposing factors

Alcoholic hepatitis

Short-term repeated large amount of alcohol consumption, combined with other viral infections, malnutrition, etc.

Autoimmune hepatitis

Microbial infection: virus, bacteria, etc. Especially hepatitis A, B, C virus and herpes simplex virus infection are more likely to induce this disease.

Drugs: methyldopa, furotoxin, diclofenac, interferon, minocycline, atorvastatin and certain herbs can induce the disease.

Alcohol: Chronic alcohol abuse can also induce autoimmune hepatitis.

Symptoms.

Acute hepatitis may be characterized by fever and yellowing of the skin and sclera.

Chronic hepatitis can have no obvious symptoms in the early stage, or show some non-specific digestive and systemic symptoms, such as nausea, loss of appetite, abdominal distension, fatigue, etc., and when the condition is serious, it can have the face of chronic liver disease as well as some other typical symptoms, and there will be some complications when it progresses to liver cirrhosis. The details are as follows.

Main symptoms

Fatigue and weakness: one feels weak and gets tired easily.

Abdominal distension: manifested as the whole abdomen or localized stuffiness and discomfort, which is a subjective feeling.

Loss of appetite: it shows that you don’t want to eat anything, you don’t like what you eat, you don’t feel hungry, and you can’t eat much even if you can barely eat something.

Itchy skin: mostly manifested as generalized itching of the skin.

Jaundice: the skin and sclera are light yellow to golden yellow.

Splenomegaly: generally no conscious symptoms, may appear epigastric pain and loss of appetite and other pressure symptoms.

Spider nevus: commonly found on the face, neck and chest, but also on the hands, shoulders and other parts of the body. Appearance is red and pinpoint, and there are tortuous blood vessels extending radially in all directions, similar to spiders; pressing the small artery in the center, the color can fade.

Liver palms: reddening of the skin of the lower part of the palms of the hands at the level of the greater and lesser fissures, with discoloration when pressed.

Other symptoms

Acute viral hepatitis may have fever and other symptoms.

Alcoholic hepatitis may have unsteady gait and hand tremor.

Autoimmune hepatitis can also be accompanied by Hashimoto’s thyroiditis and dry syndrome, which can have symptoms such as chills, bradycardia, dry eyes and dry mouth.

Complications

Hepatic encephalopathy

It can be caused by severe liver disease and often presents with mental and consciousness changes and behavioral abnormalities, such as personality changes, insomnia and convulsions.

Upper gastrointestinal bleeding

Vomiting blood, black stool or blood in the stool, as well as palpitations, dizziness and fainting may occur.

Ascites

Obvious abdominal distension may occur, and splenomegaly, hemorrhage, and varicose veins of the abdominal wall may be seen.

Cirrhosis

Bleeding of skin and mucous membrane, petechiae, abdominal distension, vomiting blood, black stool, etc. may appear.

Hepatocellular carcinoma

Discomfort and pain in the right side of the abdomen, weight loss, etc.

Consultation

Department of Medicine

Department of Infectious Diseases

Weakness, fatigue, loss of appetite, anorexia, yellowish skin color, discomfort in the right upper abdomen, etc. We suggest you to consult a doctor in time. If viral hepatitis is considered, you need to go to the Department of Infectious Diseases for further consultation and treatment.

Gastroenterology

Symptoms such as weakness, fatigue, loss of appetite, anorexia, yellowish skin color, discomfort in the right upper abdomen, etc. are recommended to consult a doctor promptly.

Emergency Medicine

For symptoms such as severe abdominal pain, vomiting blood, black stools, and confusion, immediate medical attention is recommended.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of documents, common problems

Tips for seeking medical treatment

Do not wear make-up before going to the doctor to avoid masking the symptoms.

Observe whether there is any black stool or vomiting, if so, take photos for the doctor’s reference.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Are there any symptoms such as fatigue, loss of appetite, anorexia of greasy food, yellowing of skin color, discomfort in the right upper abdomen, etc.?

Are there bleeding gums when brushing teeth? Or are there small bleeding spots on the skin?

Is there any vomiting of blood, black stools, etc.?

How long have these symptoms been present?

Medical History Checklist

Has there been any vaccination against hepatitis?

Any history of blood transfusions or donations?

Any history of unclean injections?

Any history of chronic alcohol consumption?

Any history of Hashimoto’s thyroiditis, dry syndrome, etc.?

Any history of hypertension, diabetes, hyperlipidemia, etc.?

Checklist

Test results in the past six months, which can be brought to the doctor’s office.

Laboratory tests: blood routine, liver function, coagulation function, alpha-fetoprotein (AFP), hepatitis virus serology, etc.

Imaging examination: abdominal ultrasound, abdominal CT.

Pathological examination: liver tissue puncture biopsy.

List of medications used

Medication used in the last 3 months, if there is a medicine box or package, you can bring it to the doctor

Hepatoprotective drugs: glycyrrhizic acid preparations, silymarin analogs, dicyclomine, etc.

Antiviral drugs: tenofovir, entecavir, interferon, etc.

Glucocorticoids: dexamethasone, prednisone acetate, etc.

Diagnosis

Diagnosis is based on

Medical history

History of close contact with patients with viral hepatitis, history of blood transfusion, blood products, organ transplantation, etc., history of prolonged and heavy drinking, history of taking liver-damaging drugs.

Clinical manifestations

Lack of appetite, greasiness, nausea, vomiting, yellowing of skin and sclera.

There may be tenderness and pressure in the liver area, splenomegaly and other signs.

Laboratory Tests

Blood test

Elevated eosinophils may indicate parasitic infection.

Red blood cell, white blood cell and platelet decrease can be seen when progressing to cirrhosis with hypersplenism.

Blood biochemistry

Blood biochemical indexes include alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum bilirubin, serum albumin and globulin, prothrombin time, γ-glutamyl transpeptidase (γ-GTP), serum alkaline phosphatase (ALP), total bile acids, cholinesterase, and so on.

ALT, AST: the most commonly used indicators to determine the degree of hepatocellular injury.

Serum bilirubin: Hepatocellular damage can lead to elevated serum bilirubin. In liver failure, serum bilirubin will increase while ALT and AST will decrease, i.e. the phenomenon of “bile enzyme separation”.

Serum albumin and globulin: The liver synthesizes albumin, and a decrease in albumin levels indicates impaired hepatic synthesis. With the aggravation of the disease, the ratio of albumin and globulin can gradually decline.

Gamma-GTP: Acute hepatitis, chronic active hepatitis, and decompensated cirrhosis will be mildly or moderately elevated, and if cholestasis occurs, it can be significantly elevated.

ALP: mainly excreted through the hepatobiliary system, excessive production or obstruction of excretion can be elevated, which can be used to observe the development of the disease and treatment.

Total bile acids: can be elevated in case of hepatocellular damage or obstruction of intrahepatic or extrahepatic biliary system.

Cholinesterase: reflects the reserve function of the liver.

Fasting is required for blood biochemistry tests, and a temporary dietary ban after dinner the night before the test is required until the blood is drawn.

Immunologic Tests

Autoimmune hepatitis patients may have autoantibodies in their serum, such as anti-nuclear antibodies (ANA), anti-smooth muscle antibodies (SMA), and anti-Liver Kidney Microsomal Antibody Type 1 (anti-LKM1).

Antibody and antigen detection

Detects antibodies to hepatitis viruses in the blood, mainly immunoglobulin M (IgM) and immunoglobulin G (IgG), and hepatitis B also includes surface antigens (HBsAg).

Viral RNA or DNA testing

Detects the presence of hepatitis viral nucleic acid in the blood, and if found can be used as a basis for confirming the diagnosis, HBV DNA for Hepatitis B, and HCV RNA for Hepatitis C.

Viral genotypes can also be detected to provide reference for treatment.

Imaging

Abdominal ultrasound

The most commonly used method for liver examination is easy to operate, intuitive and non-invasive.

It can understand the size and shape of the liver, texture, with or without occupancy, as well as the condition of blood vessels.

Liver transient elastography

It can assess the liver stiffness value, reflecting the degree of liver damage and the degree of liver fibrosis and cirrhosis.

It can also assess the degree of fatty liver.

CT Abdomen　

Abdominal CT is a radiologic test that can observe the morphology of the liver and find out whether there is cirrhosis and space-occupying lesions.

If space-occupying lesions are found, it can also roughly determine whether they are benign or malignant.

Magnetic Resonance Imaging (MRI) of the liver

MRI is non-radioactive and is able to show changes in liver tissue structure more clearly.

With the help of contrast material and dynamic enhancement scanning, it is possible to more effectively determine the benign or malignant nature of an occupying space.

Remove metal objects such as necklaces, earrings, cell phones, watches, etc. before the examination.

Pathologic examination

The main purpose of liver histopathology is to evaluate the degree of liver inflammation, necrosis and fibrosis, to determine the presence of cirrhosis and to exclude other liver diseases.

Autoimmune hepatitis may present with characteristic pathologic changes, including infiltration of lymphocytes and plasma cells in the ductal area and invasion of surrounding hepatocytes, so-called interfacial hepatitis. As the disease progresses, there is also damage to the hepatic lobules and the appearance of “rosette-like nodules” on the hepatocytes.

Differential diagnosis

Differential diagnosis is made between the various causes of hepatitis based on laboratory tests, imaging tests, and pathologic tests to determine which type of hepatitis is present. It is also necessary to differentiate it from the following diseases.

Functional gastrointestinal disease

Similarities: both have symptoms such as abdominal pain, nausea, vomiting, and loss of appetite.

Differences: Firstly, the etiology is different, functional gastrointestinal disease is usually related to psychological and social factors, such as work, life stress, overwork, affecting the function of the vegetative nervous system, which induces the disease, whereas hepatitis has more etiological factors, which can be caused by viral infections, parasitic infections, excessive alcohol consumption, medication, obesity, etc. Secondly, the liver function is different, the functional gastrointestinal disease has no abnormality of the liver function test, while hepatitis usually has abnormality, so it can be identified by this. Secondly, the liver function is different.

Treatment

Aim of treatment: alleviate symptoms, control disease development, prevent and reduce complications.

Treatment principle: general treatment, drug treatment, surgery if necessary.

General treatment

Rest

In the early stage of acute hepatitis, rest should be paid attention to; in chronic hepatitis, rest should also be paid attention to; when the condition improves and is in the recovery period, activities can be increased gradually, but excessive exercise should be avoided.

Alcohol abstinence

It is a very crucial measure for the prevention and treatment of alcoholic hepatitis.

Lifestyle change

Important for non-alcoholic steatohepatitis, including healthy diet and regular exercise.

Discontinuing liver-damaging medications

Important for drug-induced hepatitis to remove the cause, in addition to other types of hepatitis to avoid further damage to liver function.

Medication

Improve and restore liver function

Non-specific hepatoprotective drugs: vitamins, reduced glutathione.

Anti-inflammatory, antioxidant, enzyme-lowering drugs: glycyrrhizic acid preparations, silymarin analogs, bicyclic alcohol, etc.

Antiviral drugs

The main antiviral drugs commonly used for viral hepatitis B are nucleoside (acid) analogs (e.g., tenofovir disoproxil fumarate, tenofovir disoproxil fumarate, entecavir, and emtetanofovir) as well as alpha-interferon.

Alpha-interferon (INF-alpha)

This includes regular alpha-interferon (INF-alpha) and polyethylene glycol alpha-interferon (Peg IFN-alpha).

Treatment with interferon alpha is contraindicated if the following conditions are present [1].

Serum bilirubin ≥ 2 times the upper limit of normal.

Decompensated cirrhosis.

Autoimmune disease.

Critical organ disease (severe cardiac and renal disease, diabetes, etc.).

Pregnant women with a short-term pregnancy plan or pregnant women.

Influenza-like symptoms such as fever, chills, headache, muscle aches and malaise are common with interferon, and can be relieved by taking non-steroidal anti-inflammatory drugs (e.g., ibuprofen) at the same time as the interferon injection. However, if severe mental abnormalities or autoimmune diseases such as hypothyroidism or hyperthyroidism occur, prompt medical treatment should be sought.

Nucleoside (acid) analogs

Current guidelines recommend the use of tenofovir disoproxil fumarate, tenofovir disoproxil fumarate, entecavir, and emtinofovir.

Inappropriate discontinuation of the drug is likely to lead to viral rebound and exacerbation of the disease.

Tenofovir disoproxil fumarate: may lead to renal injury and hypophosphatemic bone disease in the elderly and with prolonged use; creatinine clearance and serum phosphorus levels should be monitored regularly.

Entecavir: Do not eat for 2 hours before or after administration.

Glucocorticoids, immunosuppressants

Mostly used in the treatment of autoimmune hepatitis, the more commonly used treatment program is glucocorticoids combined with immunosuppressive therapy, such as prednisone and azathioprine combination.

Adverse effects of long-term use of prednisone include acne (pimples), weight gain, full moon face, buffalo back, and osteoporosis, etc. Adverse effects of azathioprine include skin rashes, gastrointestinal discomforts such as nausea and vomiting.

Surgical treatment

Artificial liver therapy

Artificial liver support system simulates part of the function of the liver outside the body with the help of instruments and other devices, temporarily replacing the liver and performing detoxification and other functions.

Artificial liver support systems vary in complexity and can perform different liver functions, and some systems can replace more liver systems.

If liver failure occurs, artificial liver support systems can be an important treatment.

Liver transplantation

In the case of end-stage liver failure, surgical treatment such as liver transplantation may be required.

Healthy livers have a high regenerative capacity and can grow gradually after transplantation, allowing liver function to gradually return to normal.

Prognosis

Cure

The prognosis is good if treated early, but some patients may develop cirrhosis or even liver cancer, which has a poor prognosis.

Harmfulness

Viral hepatitis is an infectious disease, and the hepatitis virus can infect others and is contagious.

Part of hepatitis can progress to cirrhosis, and patients with cirrhosis can develop portal hypertension, which can be caused by the rupture of esophagogastric fundal varices and lead to bleeding, which is manifested as vomiting of blood and black stools, and large amount of bleeding can lead to shock and even death.

Some hepatitis may even progress to liver cancer, which may affect health and even lead to death.

Daily

Daily Management

Dietary management

Diet needs to avoid greasy, no high salt and high fat food, such as fatty meat, fried, barbecued and pickled food.

Eat less high-sugar foods, such as white sugar, candies, sweet drinks, pastries, concentrated fruit juices, jams and honey.

Eat more vegetables, especially green leafy vegetables.

Quit smoking and drinking.

Strictly prohibit intake of moldy food, substandard drinking water, etc.

Life management

Take medication according to the doctor’s requirements. As the liver function is impaired, most of the drug metabolism needs to pass through the liver, so do not take other medications on your own or change the dosage of medication.

Maintain a regular routine and avoid staying up late and being tired. You can choose to walk, tai chi and other low-intensity exercise, not too long, do not feel fatigue can be.

When itching occurs, do not scratch the skin to prevent bleeding and infection.

Do not share razors, nail clippers and other items with people with viral hepatitis and avoid contacting their blood.

Psychological support

Maintain optimism and a positive mental state and avoid bad moods.

Build up confidence, eliminate worries and actively cooperate with treatment.

Disease monitoring

Chronic hepatitis can be asymptomatic and requires blood and other tests to determine the progress of the disease.

If symptoms such as weakness, easy fatigue, abdominal distension, yellowing of the skin and discomfort in the right upper abdomen occur, timely consultation is required.

All kinds of chronic hepatitis should be checked regularly in the hospital, especially those infected with hepatitis B virus, and anti-viral treatment should be actively initiated.

Those with concurrent cirrhosis should pay attention to the presence of symptoms such as vomiting blood and black stools.

Family members should pay attention to whether the patient has personality changes, intellectual decline or even unconsciousness.

Follow-up and review

Chronic hepatitis should be followed up regularly regardless of whether there are symptoms of discomfort or not. If there are uncomfortable symptoms or new symptoms appear, it is necessary to go to the hospital in time.

Prevention

Get vaccinated with vaccines such as Hepatitis B, Hepatitis A, Hepatitis E, etc.

Do not share personal items such as nail clippers, mugs, razors, toothbrushes, etc. with others.

If you are going to undergo operations that may damage the skin and mucous membranes, such as piercing of ear nail holes, tattooing, injections, etc., you should go to a regular place, where standardized disinfection can reduce the risk of infection.

Abstain from alcohol.

Use drugs and health care products with caution.

Actively prevent infectious diseases, such as paying attention to personal hygiene.

For those with family history, regular physical examination is recommended.

Reasonable diet, appropriate exercise and weight control.