Chronic Hepatitis

Chronic hepatitis is a continuing inflammation of the liver which may lead to cirrhosis and liver failure. If abnormal liver function persists for ten weeks or more without improvement, chronic liver disease is indicated. A liver biopsy showing ongoing inflammation of the liver confirms the diagnosis.

Two forms of chronic hepatitis can be identified by microscopic examination of liver tissue. Certain features visible under the microscope aid physicians in identifying chronic hepatitis.

In most instances, the cause of chronic hepatitis is unknown. It is probably related to inherited factors triggered by viruses, drugs or other environmental factors. In the United States, many patients with severe CAH have laboratory evidence of infection with hepatitis C virus. Infection with the hepatitis A virus does not cause CAH. Hepatitis B virus is also a well known cause of chronic hepatitis. Other viruses not yet identified may cause chronic hepatitis.

Fatigue, mild discomfort in the right upper abdomen, nausea, loss of appetite and achiness of the joints are the most common initial symptoms of chronic hepatitis. However, some patients may have no symptoms and some may have signs of liver failure, including jaundice, abdominal swelling or coma, depending on the severity of the disease. Most early complaints are vague and may be mistaken for other diseases. In about 20% of patients with severe CAH, other organs may be involved. Disorders of the thyroid, large intestine, eyes, joints, skin and kidneys may occur.

Typically, CPH is benign and does not require therapy while CAH is potentially aggressive and may call for treatment. The prognosis of CAH depends on the severity of the disease as indicated by physical and laboratory findings and microscopic examination of liver tissue. Patients with severe disease may be quite ill, and the majority may die within 10 years of diagnosis if untreated. Up to 20% of seriously ill patients get better without treatment.

Fortunately, most patients with CAH have less than severe disease and their immediate survival is not in danger. However, they still run the risk of eventual cirrhosis and liver failure. We do not know how often such progression occurs or whether medication can prevent this outcome without inducing serious side effects. The risk of drug-induced toxicity needs to be balanced against the possible benefits of treatment. Also to be considered is the unknown potential for mild disease to improve spontaneously.

Corticosteroid therapy has been found effective in managing the forms of severe CAH not associated with hepatitis B infections. Prednisone alone, or in combination with azathiprine, controls symptoms, improves most abnormalities and enhances immediate life expectancy. However, treatment can produce cosmetic changes (obesity, facial fullness and acne) as well as serious complications (diabetes, hypertension, cataracts, psychosis and bone thinning with fractures of the spine). The most compelling reasons for beginning therapy are life-threatening deterioration in liver functions and incapacitating symptoms.

Treatment Results
Over 60% of patients with severe CAH who are treated with corticosteroids enter remission from 6 to 36 months (average 20 months) after the start of therapy. Of these patients, 50% remain well after ending medication and 17% are free of all symptoms. The other 50% relapse after withdrawal of medication and require further treatment. The response to additional therapy is usually as successful as initially, although the likelihood of subsequent relapse increases. Auto-immune hepatitis, usually seen in young women, generally responds well to small doses of corticosteroids.

Unfortunately, 20% of patients deteriorate despite treatment and of these, 24% succumb to their disease. Unsatisfactory responses to therapy occur mainly in patients infected with the hepatitis B virus and in those with far advanced disease.

Serious complications from medication usually develop only after 18 months of treatment and occur less often with prednisone and azothiprine therapy (10%) than with prednisone alone in a fixed daily dose (44%). Five-year survival for all patients with corticosteroid-treated severe CAH is greater than 90%. Hepatitis B vaccine (Heptavax) is strongly recommended for family members, medical staff and contacts. Liver transplantation has been successfully employed in selected patients when medical treatment has failed.

Future Goals
Immediate investigative efforts must concentrate on the needs of patients with mild to moderately severe disease and on patients infected with the hepatitis B virus for whom a reliable treatment is as yet unavailable. Treatment procedures need to be developed that will maximize the benefits of therapy and minimize the risks.

Long-range efforts must be directed at uncovering the causes and mechanisms of disease in order to develop specific treatments that will permanently stop the processes injuring the liver.

We need to emphasize the quality as well as the quantity of life. Successes must be extended to include patients with all forms of the disease.