Hepatitis is a diffuse inflammation of the liver tissue due to a toxic, infectious or autoimmune process. General symptoms – heaviness and pain in the right hypochondrium with irradiation under the right shoulder blade, nausea, dryness and a feeling of bitterness in the mouth, lack of appetite, belching. In severe cases – jaundice, weight loss, skin rash. The outcome of hepatitis can be a chronic form, hepatic coma, cirrhosis and liver cancer. Diagnosis includes examination of biochemical blood samples, liver ultrasound, hepatocholecystoscintiography, puncture biopsy. Treatment is based on following a diet, taking hepatoprotectors, detoxification, specific etiotropic and pathogenetic therapy.
Meaning
Hepatitis is an inflammatory liver disease. According to the nature of the course, acute and chronic form are distinguished. Acute hepatitis occurs with pronounced symptoms and has two possible outcomes: complete cure, or transition to a chronic form. The vast majority of hepatitis (90%) have an alcoholic, viral or drug etiology. The incidence of hepatitis in different groups of individuals varies depending on the form and cause of the disease.
Hepatitis is recognized as chronic, which lasts more than six months. According to the morphological picture, the chronic process represents dystrophic changes in the liver tissue of inflammatory origin that do not affect the lobular structure of the organ. Primary chronic hepatitis initially proceeds either without pronounced symptoms, or with minimal manifestations. The disease is often detected during medical examinations and examinations for other pathologies. They develop more often in men, but women have a greater tendency to some specific hepatitis. Particular attention is paid to the condition of the liver in patients who have suffered acute form and are carriers of the Australian antigen, as well as in people who abuse alcohol or are being treated with hepatotoxic drugs.
Pathogenesis
Acute hepatitis develops either as a result of direct liver damage by hepatotoxic factors or viral infection, or as a result of the development of an autoimmune reaction – the production of antibodies to the body’s own tissues. In both cases, acute inflammation develops in the liver tissue, damage and destruction of hepatocytes, inflammatory edema and a decrease in the functional activity of the organ. Insufficiency of the biliary function of the liver is the root cause of bilirubinemia and, as a consequence, jaundice. Since there are no pain receptor zones in the liver tissues, pain syndrome is rarely expressed and is associated with enlargement of the liver, stretching of its well-innervated capsule and inflammatory processes in the gallbladder.
Chronic inflammation, as a rule, develops as a result of untreated or insufficiently healed acute form. Often, jaundice-free and asymptomatic forms of hepatitis are not detected in time, and the inflammatory process becomes chronic, foci of dystrophy and degeneration of liver tissue occur. The decrease in the functional activity of the liver is aggravated. Often, chronic hepatitis gradually turns into cirrhosis of the liver.
Classification
Hepatitis is classified:
- due to development – viral, alcoholic, medicinal, autoimmune hepatitis, specific hepatitis (tuberculosis, opisthorchiasis, echinococcal, etc.), secondary hepatitis (as complications of other pathologies), cryptogenic hepatitis (of unclear etiology);
- downstream (acute, chronic);
- according to clinical signs (jaundice, non-jaundice, subclinical forms).
Viral hepatitis can be acute (hepatitis A and B viruses) and chronic (hepatitis B, D, C). Hepatitis can also be caused by viral and virus–like infections that are not specific to the liver – mononucleosis, cytomegalovirus, herpes, yellow fever. Autoimmune hepatitis varies in types depending on the targets of antibodies (type 1, type 2, type 3).
Symptoms of hepatitis
The course and symptoms of hepatitis depend on the degree of damage to the liver tissue. The severity of the disease also depends on this. Mild forms of acute form can be asymptomatic and, often, flow into a chronic form if the disease is not detected randomly during a preventive examination.
With a more severe course, the symptoms can be expressed, rapidly increase, combined with general intoxication of the body, fever, toxic damage to organs and systems.
Both for acute hepatitis and for exacerbation of the chronic form of the disease, jaundice of the skin and sclera of a characteristic saffron hue is common, but the disease can occur without pronounced jaundice. However, it is possible to detect a slight degree of yellowing of the sclera, as well as to identify the jaundice of the upper palate mucosa, and with a mild form of hepatitis. Urine darkens, with pronounced violations of the synthesis of bile acids, the stool loses color, becomes whitish-clay.
Patients may notice symptoms such as itching, the appearance of red dots on the skin – petechiae, bradycardia, neurotic symptoms. On palpation, the liver is moderately enlarged, slightly painful. There may also be an increase in the spleen. Chronic form is characterized by the gradual development of the following clinical syndromes:
- asthenovegetative (weakness, fatigue, sleep disorders, mental lability, headaches) – due to intoxication of the body due to increasing liver failure;
- dyspeptic (nausea, sometimes vomiting, decreased appetite, flatulence, diarrhea alternating with constipation, belching bitterness, unpleasant taste in the mouth) is associated with digestive disorders due to insufficient liver production of enzymes and bile acids necessary for digestion);
- pain syndrome (pain of a constant, aching nature is localized in the right hypochondrium, increases with physical exertion and after severe diet disorders) – may be absent or expressed in a moderate feeling of heaviness in the epigastrium;
- subfebrility (moderate temperature rise to 37.3 – 37.5 degrees can last for several weeks);
- persistent redness of the palms (erythema palmar), telangiectasia (vascular asterisks on the skin) on the neck, face, shoulders;
- hemorrhagic (petechiae, tendency to bruising and bruising, nasal, hemorrhoidal, uterine bleeding) is associated with a decrease in blood clotting due to insufficient synthesis of clotting factors in liver cells;
- jaundice (yellowing of the skin and mucous membranes – as a consequence of an increase in the level of bilirubin in the blood, which in turn is associated with a violation of its utilization in the liver);
- hepatomegaly is an enlargement of the liver, can be combined with splenomegaly.
Diagnostics
Diagnosis of hepatitis is carried out on the basis of the presence of symptoms, data from a physical examination by a gastroenterologist or therapist, functional and laboratory studies.
Laboratory tests include: biochemical liver tests, determination of bilirubinemia, decreased activity of serum enzymes, an increase in the level of gamma-albumins, with a decrease in albumin content; also note a decrease in the content of prothrombin, coagulation factors VII and V, fibrinogen. There is a change in the indicators of thymol and sulem samples.
During ultrasound of the abdominal organs, an increase in the liver and a change in its sound permeability are noted, and, in addition, an increase in the spleen and, possibly, an expansion of the vena cava are noted. Rheohepatography (examination of hepatic blood flow), hepatocholecystoscintiography (radioisotope examination of the biliary tract), puncture liver biopsy will also be informative for the diagnosis of hepatitis.
Treatment of hepatitis
Treatment of acute hepatitis
Treatment is necessarily carried out in a hospital. In addition:
- alcohol and hepatotoxic drugs are contraindicated in all forms of hepatitis;
- intensive detoxification infusion therapy is performed to compensate for this liver function;
- prescribe hepatoprotective drugs (essential phospholipids, silymarin, milk thistle extract);
- prescribe a daily high enema;
- they make a correction of metabolism – preparations of potassium, calcium and manganese, vitamin complexes.
Viral hepatitis is treated in specialized departments of infectious diseases hospitals, toxic – in departments specializing in poisoning. In infectious form, the focus of infection is sanitized. Antiviral and immunomodulatory agents are not yet widely used in the treatment of acute forms of hepatitis.
Oxygen therapy and oxygenobarotherapy give good results in improving the general condition with severe hypoxia. If there are signs of hemorrhagic diathesis, vitamin K (vikasol) is prescribed intravenously.
Treatment of chronic hepatitis
Patients with chronic hepatitis are also prescribed therapeutic diet therapy (diet No. 5A in the acute stage and diet No. 5 outside the exacerbation), a complete refusal to drink alcohol, a reduction in physical exertion is necessary. During the period of exacerbation, inpatient treatment in the gastroenterology department is necessary.
Pharmacological therapy includes basic therapy with hepatoprotective drugs, the appointment of drugs that normalize digestive and metabolic processes, biological drugs for the correction of the bacterial flora of the intestine.
Hepatoprotective therapy is carried out with drugs that promote regeneration and protection of hepatic tissue (silymarin, essential phospholipids, tetraoxyflavonol, potassium orotate), prescribed in courses of 2-3 months with semi-annual breaks. Therapeutic courses include multivitamin complexes, enzyme preparations (pancreatin), probiotics.
As detoxification measures, infusion of a 5% glucose solution with the addition of vitamin C. enterosorbents (activated carbon, hydrolysis lignin, microcellulose) are prescribed for detoxification of the intestinal environment.
Antiviral therapy is prescribed for the diagnosis of viral hepatitis B, C, D. Corticosteroids and immunosuppressants are used in the treatment of autoimmune hepatitis. Treatment is carried out with constant monitoring of biochemical blood samples (transferase activity, blood bilirubin, functional tests).
Prevention and prognosis
Primary prevention of viral hepatitis is compliance with hygiene regulations, implementation of sanitary and epidemic measures, sanitary supervision of enterprises that may become a hotbed of infection, vaccination. Prevention of other forms of hepatitis is to avoid the effects of hepatotraumatic factors – alcohol, drugs, toxic substances.
Secondary prevention of chronic form consists in following a diet, regimen, medical recommendations, regular examination, monitoring of clinical blood parameters. Patients are recommended regular spa treatment, hydrotherapy.
The prognosis with timely diagnosis and treatment of acute form is usually favorable and leads to recovery. Acute alcoholic and toxic hepatitis end fatally in 3-10% of cases, often severe course is associated with the weakening of the body by other diseases. With the development of chronic hepatitis, the prognosis depends on the usefulness and timeliness of therapeutic measures, adherence to a diet and a gentle regime.
The unfavorable course of hepatitis can be complicated by cirrhosis of the liver and liver failure, in which a fatal outcome is very likely. Other common complications of chronic hepatitis are metabolic disorders, anemia and clotting disorders, diabetes mellitus, malignant neoplasms (liver cancer).
Literature
- Abstracts of Presentations at the Association of Clinical Scientists 143rd Meeting Louisville, KY May 11-14,2022. [No authors listed] Ann Clin Lab Sci. 2022 May;52(3):511-525. link
- Acute Hepatitis. Schaefer TJ, John S. 2022 Jul 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan link
- Natural history of chronic hepatitis B virus infection in adults with emphasis on the occurrence of cirrhosis and hepatocellular carcinoma. Chu CM. J Gastroenterol Hepatol. 2000 May;15 Suppl:E25-30. link
- Impact of etiological treatment on prognosis. Su CW, Yang YY, Lin HC. Hepatol Int. 2018 Feb;12(Suppl 1):56-67. link
- [What General/Family Medicine Practitioner should Know about Viral Hepatitis]. Vučak J, Vučak E. Acta Med Croatica. 2016 Apr;70(2):87-95. link