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Overview |
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Definition |
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Hepatitis—inflammation of the
liver—refers to a broad range of conditions with viral,
toxic (including alcohol), pharmacologic, and immune-mediated etiologies. A
systemic infection, hepatitis can be localized in the liver or be part of a
generalized process. Viral hepatitis, the most common, can be subdivided into a
number of types.
- Type A (HAV)
- Type B (HBV)
- Type C (HCV)
- Type D (HDV) or delta hepatitis
- Type E (HEV)
- Non-A, non-B, non-C hepatitis (NANBNC
hepatitis)
Hepatitis also is categorized by duration.
- Acute hepatitis: Less than six months
- Chronic hepatitis: Longer than six
months—chronic persistent hepatitis is more common
while chronic active hepatitis is more serious
HAV, HBV, and HCV, the most prevalent, affect a half million Americans
annually and millions worldwide.
- HAV, the most common, occurs both sporadically and in epidemics
(autumn and winter), often affecting school children. Incubation is 15 to 50
days; infectivity two to three weeks near end of incubation. Does not become
chronic.
- HBV affects all ages. Six-month incubation; infectivity during HBsAg
positivity. Can become chronic.
- HCV affects all ages. Incubation is 30 to 90 days; infectivity during
anti-HCV positivity. Can become
chronic.
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Etiology |
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- HAV: 27-nm RNA virus transmitted via fecal-oral and ingestion of
contaminated food and water
- HBV: 42-nm DNA virus transmitted via injection of contaminated
blood/derivatives, IV drug use, and sexual intercourse
- HCV: Flavivirus-like RNA agent transmitted via blood transfusion, IV
drug use, and possibly sexual intercourse
Viral hepatitis may also result from herpes, yellow fever, rubella,
coxsackie, and adenovirus. |
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Risk Factors |
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HAV:
- Poor hygiene, unsanitary conditions
- Contaminated food and water
- Raw shellfish
HBV and HCV:
- Transfusions
- Employment as health care worker, medical laboratory technician,
dialysis technician (needlestick)
- IV drug use
- Unprotected sex
- Vertical transmission during pregnancy
- Impaired immunity (leukemia, Down's syndrome, dialysis
patients)
- Tattoos
- Organ transplants
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Signs and Symptoms |
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Symptoms range from mild to severe. Although HAV, HBV, and HCV symptoms are
similar, HBV and HCV symptoms usually will be more severe. Importantly, even
patients with chronic active hepatitis may be asymptomatic. (Increased
transaminase level may be the first sign.)
Symptoms include:
- Jaundice (although most are anicteric)
- Malaise, fatigue, anorexia
- Nausea, vomiting, abdominal discomfort
- Dark urine, colorless stool
- Myalgia, arthralgia
- Headache, fever,
flu
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Differential
Diagnosis |
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- Cytomegalic inclusion infection
- Mononucleosis
- Hepatic malignancy
- Ischemic hepatitis
- Leptospirosis
- Drug-induced hepatitis
- Alcoholic hepatitis
- Extrahepatic biliary obstruction
- Autoimmune hepatitis
- Wilson's disease
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Diagnosis |
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Physical Examination |
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Physical signs include:
- Enlarged and tender liver
- Enlarged spleen
- Posterior cervical
lymphadenopathy
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Laboratory Tests |
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Serodiagnosis reveals the presence of components of HBV (e.g., HBsAg) and HCV
viruses and of antibodies to HAV (IgM antibodies), HBV (anti-HBs, anti-HBc), and
HCV (not for a number of weeks), markers that help determine the type, severity,
and status of the condition. Urinalysis reveals bilirubin and an increase in
serum aminotransferases.
Other findings include:
- Hepatocellular damage (elevated transaminase levels)
- Elevated serum alkaline phosphatase
- Depressed white cell count
- Signs of cirrhosis (fibrous scarring and hepatic lobular architecture
damage)
- Necrosis of periportal liver cells
- Lymphocytic and plasma cell infiltration
- Mild transient anemia, mild hemolytic anemia
- Granulocytopenia
- Lymphocytosis
- Increase in reticulocyte
count
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Imaging |
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Ultrasound can indicate ascites or exclude obstruction. |
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Other Diagnostic
Procedures |
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Diagnosis involves both physical assessment and laboratory work and may
require biopsy. A detailed history can reveal risk factors as well as previous
incidences of hepatitis. Liver biopsy may be needed to confirm chronic hepatitis
(active or persistent) and to assess disease
progression. |
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Treatment Options |
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Treatment Strategy |
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Treatment is usually outpatient, but hospitalization may be necessary for
severe cases. Treatment regimen depends on condition severity and
prognosis.
- Acute viral hepatitis: Treat with rest, aggressive hydration, and
balanced nutrition. Base patient activity on fatigue limits. Mandate that
patients avoid alcohol at least until liver enzymes are normal, perhaps longer.
Use drug therapy to alleviate symptoms.
- Chronic active hepatitis: Generally treated by hepatologist with
immunomodulators following a liver
biopsy.
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Drug Therapies |
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HAV: Immune globulin administered pre- and postexposure, <2 weeks, at a
dose of 0.02 cc/kg intramuscular, may prevent infection.
HBV: Prophylaxis with hepatitis B immune globulin following exposure and/or
vaccine prior to exposure may be used; the vaccine is given in 3 doses over a
7-month time course. Promising new approaches include the second-generation
nucleoside analogs lamivudine, which seems to be well tolerated, safe, and
efficacious, and famcyclovir. a-interferon has been
shown to eliminate viral replication in 25 to 40% of patients. Other approaches
currently under evaluation include b-interferon,
thymosin, and the combination of a-interferon with
ursodeoxycholic acid.
HCV: Treatment for low doses of a-interferon are
used to treat chronic hepatitis C and are effective in less than half of
patients. Discontinuation of treatment leads to a high rate of relapse.
Ribavarin used in conjunction with interferon has shown promise in yielding a 40
to 50% response rate, higher than with interferon alone, making this combination
the first-line therapy for suitable patients. Ribavirin, though, does increase
the patient's toxicity profile, and is not effective when used alone.
Sedatives can precipitate hepatic encephalopathy and should be
avoided. |
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Surgical Procedures |
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Transplantation may be necessary with fulminant active hepatitis and
end-stage liver disease. |
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Complementary and Alternative
Therapies |
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Fulminant active hepatitis and end-stage liver disease require immediate
medical attention. Alternative therapies may be hepatoprotective, support liver
function, minimize severity of the disease, and enhance
healing. |
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Nutrition |
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- Reduction or elimination of alcohol, caffeine, refined foods, sugar,
food additives, and saturated fats (meat and dairy products) may be
recommended.
- Small, frequent meals are suggested to optimize digestion and
absorption, as well as to stabilize blood sugar. Hypo- and hyperglycemic
conditions place undue strain on the liver.
- Increased intake of whole grains, fresh vegetables, fruits, vegetable
proteins (legumes such as soy), and essential fatty acids (cold-water fish,
nuts, and seeds) may support overall health. Foods that are specifically
supportive to liver function include beets, artichokes, yams, onions, garlic,
green leafy vegetables, apples, and lemons.
- Green tea is a powerful antioxidant and contains flavonoids that
decrease inflammation. 2 to 3 cups/day may be recommended. Decaffeinated should
be used, or caution exercised with caffeinated form. Green tea is also a good
source of vitamin K – see below for additional
information.
- Acidophilus supplements (one capsule with meals) help normalize bowel
flora. Vitamin K is synthesized by these beneficial bacteria and is essential
for normal clotting activities of the liver. Vitamin K levels are often low in
hepatitis and may be supplemented, 100 to 500 mg/day. Dark leafy green
vegetables are high in vitamin K.
- Vitamin C (1000 to 1500 mg/day), beta-carotene (100,000 IU/day),
vitamin E (400 to 800 IU/day), and zinc (30 to 50 mg/day) enhance immunity.
B-complex (50 to 100 mg/day), especially folic acid (800 to 1000 mcg/day) and
B12 (1000 mcg/day), are thought to be hepatoprotective and optimize
liver function.
- Selenium (200 mcg/day) is useful for liver detoxification and fatty
acid metabolism.
- Dessicated liver and thymus extracts may be considered to improve
liver regeneration and immune function.
- Glutathione (500 mg bid) or N-acetylcysteine (200 mg bid to tid, a
precursor to glutathione) provide detoxification and antioxidant
support.
- Consider lecithin, choline, and methionine to support fat
metabolism.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Many herbs have powerful liver-protective properties, aiding in
detoxification and promoting bile production and flow, as well as nourishing and
repairing liver tissue. For best results, three to four liver-supportive herbs
should be combined with two to three antiviral and immune-stimulating herbs. The
herbal treatment of hepatitis can be complicated and should be administered
under physician supervision. Choice of herbs is dependent on disease state and
presentation of pathology. The high doses of single herbs suggested may be best
administered via dried extracts (encapsulated), although tinctures (60 drops
qid) and teas (4 to 6 cups/day) may also be used.
Herbs for liver support:
- Milk thistle (Silybum marianum, 200 to 250 mg tid) protects
the liver parenchyma and may prevent necrotic changes. May also be used as
phosphatidylcholine-bound silymarin (100 to 150 mg tid), which is more specific
for hepatitis infections.
- Chinese thoroughwax (Bupleurum falcatum) contains steroid-like
molecules that are potent anti-inflammatories. May induce nausea in sensitive
individuals; decrease dose to ameliorate side effect. (Please note that while
glucocorticoids are used occasionally for viral hepatitis, there is a great deal
of controversy about their use particularly for HBV and HCV; so, Bupleurum
falcatum should be used with particular caution.)
- Globe artichoke (Cynara scolymus) promotes liver
regeneration.
- Schizandra berry (Schizandra chinensis) is hepatoprotective
and promotes liver regeneration and detoxification.
- Eclipta alba inhibits hepatitis B replication and is usually
used with phyllanthus.
- Phyllanthus amarus (200 mg tid) is an ayurvedic herb shown to
inhibit hepatitis B replication. Long-term use of a year or more may be
necessary for optimum effectiveness.
- Turmeric (Curcuma longa, 250 to 500 mg tid) is a potent
anti-inflammatory herb that is also hepatoprotective. Combine with bromelain
(250 to 500 mg tid between meals), a proteolytic enzyme, to potentiate
effects.
Immune support and antivirals:
- Licorice root (Glycyrrhiza glabra, 250 to 500 mg tid),
particularly its extract, glycyrrhizin, is hepatoprotective. Concurrent
administration of glycine and cysteine appear to modulate glycyrrhizin's actions
and prevent its aldosterone-like action.
- Astragalus root (Astragalus membranaceus) augments natural
killer cell activity and interferon response and promotes liver
detoxification.
- Coneflower (Echinacea purpurea) is an antiviral and
immune-stimulating herb best used during acute infection.
- Goldenseal (Hydrastis canadensis) has antimicrobial and
immune-stimulating properties, and also enhances liver
function.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and
potency. |
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Acupuncture |
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May be beneficial in modulating immune function and supporting liver
function. |
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Massage |
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Therapeutic massage may be helpful in reducing the effects of stress, which
inhibits immune function. |
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Patient Monitoring |
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- Although patient isolation usually is not required during treatment,
strict attention to hygiene is. Food handlers should be extremely cautious in
the case of HAV. Healthcare workers should always exercise universal precautions
to avoid contraction or transmission of HBV or HCV.
- Monitor patients at one- to three-week intervals; normal activities
can resume when symptoms disappear and laboratory tests are normal. HBV patients
with detectable surface antigen at six months should be managed with a
hepatologist.
- Patients with chronic persistent hepatitis may require a follow-up
liver biopsy after two to three years to confirm the
diagnosis.
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Other
Considerations |
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Prevention |
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- HAV: Attention to hygiene and immune serum globulin; hepatitis A
vaccine
- HBV: Attention to hygiene, blood-product screening, proper needle
use/disposal, safe-sex practices, hepatitis B immune globulin,
vaccine
- HCV: Attention to hygiene, blood-product screening, proper needle
use/disposal, safe-sex practices, and possibly immune serum
globulin
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Complications/Sequelae |
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- Posthepatitis syndrome
- Cholestatic hepatitis
- Fulminant hepatitis (necrosis)
- Chronic hepatitis
- Cirrhosis
- Hepatocellular carcinoma
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Prognosis |
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Acute:
- Self-limiting, generally resolves in one to three months
- Suspect chronic active liver disease after 12 weeks
- In rare cases, progresses to necrosis and possibly death in less than
six months
Chronic:
- Persists for longer than six months
- Chronic persistent hepatitis is benign, generally asymptomatic,
seldom results in cirrhosis, and generally resolves without
progressing.
- Chronic active hepatitis can result in cirrhosis and liver
failure.
Jaundice, if present, usually disappears in two to eight weeks. Fulminant
hepatitis (more common in HBV) is the primary cause of death.
Morbidity and mortality are higher with HBV and HCV:
- HAV: Seldom fatal, but requires up to 30 days bed rest. Could recur
after 90 days.
- HBV: Patients sometimes become asymptomatic carriers. Frequently slow
to resolve, thus a common cause of chronic liver disease and
cirrhosis.
- HCV: Virus remains in the blood for many years, thus a common cause
of liver failure, liver cancer, and
cirrhosis.
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Pregnancy |
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Active viral hepatitis can be a serious complication in pregnancy. The safety
of herbs in pregnancy has not been adequately investigated. Milk thistle (1 cup
of tea tid) is safe to use as maintenance. Other herbs and high doses of
vitamins should be used only under the supervision of a qualified
practitioner. |
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References |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |