Hepatitis is an inflammation in the liver associated with disturbed liver functions leading to abnormal metabolic rate which may result in accumulation of toxins in the bloodstream. Hepatitis isn’t a tropical disease affecting a localized region as it is annually reported from almost all over the world. World health organization (WHO) has estimated that more than 350 million people are living with hepatitis resulting in the death of 1.5 million every year. Despite WHO efforts, the rate of new hepatitis cases is currently increasing.
Causes
So, what are the causes of hepatitis? And what is the most common type of it?
Unlike many other diseases, hepatitis has multiple origins. Viral hepatitis represents the majority of cases. Virus A, B, C, E, and D are commonly reported to be the causes of viral hepatitis. HBV and HCV usually cause chronic liver affection while HAV and HEV cause acute hepatitis with more rapid onset which makes it easier to be diagnosed and treated. Statistics declared that the hepatitis A virus (HAV) has the highest rate of infection globally. Bacterial infection is less common to cause hepatitis yet its risk is more in immune-compromised and old people.
Autoimmune diseases are the second most frequent cause of chronic hepatitis in which the human immune system attacks its own tissues and organs. Autoimmune hepatitis (AIH) is usually accompanied by other systemic symptoms. Physicians have divided AIH into two main types and fortunately, both are almost rare. The exact mechanism of autoimmune hepatitis is mostly unknown but it is found to usually affect middle-aged females.
Alcohol is also a well-known cause of hepatitis as it damages liver cells directly and destroys their architecture. Alcoholic hepatitis is found to present predominantly in east Europe and the US where alcohols are drunk more. Fortunately, mild to moderate alcohol toxicity and hepatitis are reversible. The amount of alcohol required to develop hepatitis is variable according to liver condition but 3.5 ounces (100 grams) is said to be enough to cause hepatitis for most people. 100 grams of alcohol is equivalent to six glasses of wine and seven beers.
Patients taking drugs for long periods or getting a higher dose than needed may develop hepatitis. Paracetamol is the most frequent cause of drug-induced hepatitis, especially during the COVID epidemic. Tuberculosis, as well as malaria drugs, cause liver inflammation especially in developing countries where TB and malaria are endemic. Hepatotoxic drugs are numerous and widely used, therefore it is essential to follow up and test frequently for your liver function to avoid hepatitis.
Modes of transmission
How do hepatitis viruses transmit?
Although HAV, HBV, HCV are considered sexually transmitted infections (STIs), they could be transmitted by other routes. HAV is a foodborne illness that people could catch by eating food/fluids contaminated with it. Carriers of HAV transmit the virus through their excreta (stool) which contaminates utensils and food. Street food and meals from restaurants with low sanitary procedures represent the source of more than 60% of every viral hepatitis infection. HAV and HEV are highly contagious so make sure to choose your food carefully.
HBV and HCV could be transmitted with human fluids like blood, semen, etc… . HCV-contaminated blood transfusion is less likely to occur especially in developed countries. However, drug addiction or multiple usages of syringes may lead to HBV or HCV infection. Hepatitis C surveillance in the United States has shown that new HCV infections occurred among people aged from 20 to 40 which is most likely to be sexually transmitted due to unprotected sex.
Risk factors
What are the risk factors of hepatitis? Who is more vulnerable to developing hepatitis?
People are at risk of catching viral hepatic infection with different degrees. False habits and current immunity condition affect mainly the probability of getting hepatitis. We have summarized the most vulnerable groups into:
1) Unprotected sex with an infected partner is considered the main reason for catching HBV and HCV. Neglecting protective sexual methods not only affects the couple but also puts the fetus in danger of HBV infection and anomalies. Bisexual and gays practicing sex with men are more susceptible to get hepatitis A, B, and C.
2) Drug addicts especially those injecting drugs intravenously. Reusing syringes puts them at great risk of getting infected with HBV and HCV. Despite the massive awareness campaigns about blood-borne infections and their high morbidity rates, some regions in the world have a rising rate of viral hepatic infection.
3) Patients with chronic debilitating diseases such as uncontrolled diabetes and malignancies are at higher risk to get hepatitis because of their reduced immunity and natural defense mechanisms. A weakened immune system increases the probability to catch infections such as viral hepatitis. Liver cirrhosis reduces the liver capability of detoxification and metabolism therefore mild hepatitis may have a greater impact on whatever is left functioning of it.
4) An unhealthy diet and fast food are believed to contribute to more than 80% of viral A hepatitis infections. HAV is considered mainly a foodborne infection that is mainly transmitted through contaminated meals, unwashed fruits, and vegetables. HAV infections occur in the form of outbreaks as they affect mostly a group of people who ate from the same source.
5) The underlying condition of the liver is usually the main concern of physicians to assess the prognosis as patients with liver cirrhosis or suffering from chronic liver disease are more susceptible to get complications. Liver functions affect almost all body systems so its deterioration will definitely expose the patient to infections and other systemic diseases.
6) A sedentary lifestyle and bad nutrition are indirect risk factors for any kind of infection particularly hepatitis. Physical activity contributes to preventing and managing cardiovascular malfunctions, diabetes mellitus, and other non-communicable diseases. WHO recommends exercising for 150 minutes per week (divided among days) ranging from mild to moderate intensity. Not to mention that a well-balanced diet rich in vitamins and minerals boosts immunity and enforces the defense mechanisms against pathogens.
7) Alcohol intake is one of the major causes of hepatitis and liver failure worldwide. Most alcoholics have a fatty liver which is usually the stage preceding hepatitis so physicians always ask alcohol addicts to cut off any kind of alcohol before liver damage becomes irreversible. WHO stated that people shouldn’t drink more than 16 units of alcohol a week.
Hepatitis symptoms
Hepatitis could be clinically presented with many symptoms that may be tricky and overlap with gastroenteritis or respiratory infection symptoms. Hepatitis has two main types of manifestation upon which we are going to discuss separately:
– Acute symptoms of hepatitis are associated with infection with HAV, HEV, and exposure to a high dose of hepatotoxic substances as alcohol. The parasitic liver infection causes acute hepatitis yet it is predominantly present in rural regions or developing countries. Fortunately, most of these symptoms are often reversible leaving no marked residual effect on the liver. Acute hepatitis is characterized by fast onset and regressive course of symptoms.
Constant right upper abdominal pain is usually the chief complaint of patients with hepatitis. This pain may radiate to the right shoulder, middle abdomen, or diffuse in the back, but fortunately, it responds to analgesics. Fever is also a common symptom, especially during infection. Frequent vomiting accompanied by nausea and headache. Patients with acute hepatic infection may be pale or even slightly yellowish due to malnutrition and disturbed metabolism of bilirubin that cause jaundice. Fatigue and malaise are frequently reported with the hepatic viral infection. Anorexia (loss of appetite) is usually present due to frequent vomiting.
– Although chronic hepatitis may be asymptomatic with no apparent affection, its symptoms are usually accompanied by other systemic manifestations. Keeping in mind that the liver is the main route of detoxification and synthesis of essential proteins so chronic liver inflammation will definitely interfere and obstacle its functions. Chronic hepatitis is usually caused by HBV, HCV infection, malignancy, and alcoholism. Symptoms of chronic hepatitis may take a longer period to resolve than acute hepatitis.
Frequent epistaxis (bleeding from the nose) or purpura (bleeding under the skin) may be the only complaint of patients with chronic hepatitis. Accumulation of fluids in the abdomen is commonly seen in chronic hepatitis which for some level helps in assessing the degree of liver affection. The liver may be enlarged or shrunken according to the cause and the course of inflammation while the spleen is usually enlarged because it shares with the liver the same blood drainage system. Patients with chronic viral hepatitis often get fatigued with minimal effort. Patients with chronic hepatitis may have hepatocellular jaundice making their skin and sclera yellowish-orange.
Complications
Is hepatitis a self-limited illness or may get complicated?
Acute hepatitis is usually recovered completely either by stopping exposure to the predisposing factors or eliminating the causative agent using anti-microbial drugs otherwise complications are developed. On the other hand, chronic hepatitis is often complicated unless it is managed early. HCV and HBV patients are more likely to get health complications because they are usually get diagnosed late.
Hepatitis complications are numerous and serious if they aren’t properly controlled. Liver failure is the last station of complicated liver disease. Hepatic necrosis which is the death of a group of cells is often present in unmanaged HBV and HCV which subsequently leads to liver cirrhosis (fibrosis). Chronic hepatitis of alcoholism is the major cause of hepatocellular carcinomas that have a high mortality rate. Generalized edema (accumulation of fluids underneath the skin) is seen in patients with unresolved chronic hepatitis especially HCV.
Systemic affection of complicated hepatitis is believed to be end-stage preceding liver failure, it includes hepatic encephalopathy due to accumulation of toxin in the bloodstream irritating the brain which may lead to hepatic coma. Marked coagulopathy that is presented by bleeding from the slightest injuries is commonly present in complicated hepatitis. Esophageal varices (enlarged tortuous veins around the esophagus) is too serious to be neglected as it may rupture then immediate surgical interference is needed.
Prophylaxis
Hepatitis could be avoided easily by following simple instructions and a few lifestyle modifications. Firstly cut off eating fast food as much as possible, instead eat fresh homemade meals. Hepatitis viruses are not killed by freezing so make sure to wash fruits and vegetables properly. Boil unpasteurized milk for at least a minute before using it. Physical activities and exercising boost your immunity against infections and lower the risks of catching viruses. Physicians always recommend stopping alcohol to avoid a lot of undesired complications as liver cirrhosis. Try not to get sexually in touch with a partner who is suspected to have viral hepatitis without using protection.
Is there a vaccine for viral hepatitis? Vaccinations against HAV and HBV are available for people at high risk of infection as healthcare providers, chefs, and waiters. However, they are available for anyone in some countries. HCV vaccine is under clinical trials and researches therefore it isn’t available for the public yet. HBV vaccine has more than 95% efficacy and it is taken as 3 shots with a seven-month interval between the first and the last shot. HAV vaccine is taken as two shots six months apart. Hepatitis A vaccine is highly effective as 94 out of 100 get immunized for many years against HAV after the first dose only.
Treatment of hepatitis
Hepatitis is a manageable disease and has two main options of treatment which are:
1) Medications that are mainly antiviral and anti-inflammatory are the first line of treatment for hepatitis. antiviral drugs proved their effectiveness in lowering the viral load to a neglectable level. Although HCV has no vaccine antiviral ribavirin and pegylated interferon could suppress the virus remarkably. Antivirals such as tenofovir (Viread), lamivudine (Epivir), and entecavir (Baraclude) are useful in preventing any further damage in the liver by HBV. Anti-inflammatory drugs and analgesics are also used in case of the presence of fever or pain.
2) The surgical option is the last resort for patients with severe liver damage or liver failure. Liver transplantation is pretty costly yet its survival rate is reasonable. Studies estimated that 75 of patients who had their liver transplanted lived more than 5 years.