Chronic hepatitis is defined as inflammatory disease of the liver lasting for more than six months. The histological differentiation between chronic persistent hepatitis (no cell necrosis) and chronic active hepatitis (cell necrosis) does not correlate with prognosis and is therefore now much less used.

Aetiology

• Viral: hepatitis B, hepatitis C, cytomegalovirus, Epstein-Barr virus
• Metabolic: non-alcoholic fatty liver disease (NAFLD), haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency
• Toxic and drugs: alcoholic liver disease, amiodarone, isoniazid, methyldopa, methotrexate, nitrofurantoin
• Autoimmune: autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis
• Sarcoidosis

Presentation of chronic hepatitis

Symptoms

• Nonspecific symptoms, e.g. fatigue, anorexia, muscle pains, arthralgia, weight loss
• Right hypochondrial pain (liver distension)
• Abdominal distension (ascites)
• Ankle swelling (fluid retention)
• Haematemesis and melaena (gastrointestinal haemorrhage)
• Pruritus (cholestasis)
• Breast swelling (gynaecomastia), testicular atrophy, loss of libido and amenorrhoea due to endocrine dysfunction
• Confusion and drowsiness (encephalopathy)

Signs

• Spider naevi (chest and upper body), slate-grey appearance in haemochromatosis
• Palmar erythema
• Jaundice
• Clubbing
• Dupuytren's contracture (alcoholic cirrhosis)
• Xanthomas: palmar creases or above the eyes in primary biliary cirrhosis
• Initial hepatomegaly may be followed by a small liver in well-established cirrhosis
• Splenomegaly (portal hypertension)
• Hirsutism

Investigation of chronic hepatitis

• Urinalysis: bilirubin and urobilinogen
• Full blood count (associated anaemia, thrombocytopenia, raised MCV with alcohol abuse), clotting studies (clotting impairment with hepatic dysfunction)
• Renal function and electrolytes (associated renal dysfunction)
• Liver function tests, serum albumin, prothrombin time
• Immunoglobulins (IgG raised in autoimmune hepatitis; IgM raised in primary biliary cirrhosis)
• Autoantibodies: antinuclear antibodies, smooth muscle antibodies, anti-mitochondrial antibodies; see separate article Plasma Autoantibodies (Disease Associations)
• Hepatitis B and C serology
• Alpha-1 antitrypsin
• Caeruloplasmin, copper (haemochromatosis)
• Iron studies
• Alpha-fetoprotein (hepatocellular carcinoma)
• Ultrasound, CT or MRI scan: local liver or biliary tract abnormality, especially hepatocellular carcinoma which may occur as a complication of cirrhosis
• Genetic testing, e.g. haemochromatosis
• Upper gastrointestinal endoscopy (diagnosis and management of oesophageal varices)
• Liver biopsy

Differential diagnosis

Other causes of chronic liver failure (e.g. primary sclerosing cholangitis (PSC), right heart failure) or the development of cirrhosis.

Management

See articles on specific causes.

Complications

• Liver failure
• Portal hypertension: ascites, hypersplenism, lower oesophageal and rectal varices
• Hypoalbuminaemia
• Coagulopathy
• Osteoporosis
• Hepatopulmonary syndrome (defect in arterial oxygenation induced by pulmonary vascular dilatation in patients with liver disease)
• Hepatorenal syndrome
• Encephalopathy
• Cirrhosis
• Hepatocellular carcinoma

Prevention

• Hepatitis B prevention, Hepatitis C prevention.

Internet and further reading

• Primary Care Society for Gastroenterology
• British Society of Gastroenterology
• British Liver Trust. Support and Information.

Acknowledgements