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.

• 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.

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

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

• Cytomegalic inclusion infection
• Mononucleosis
• Hepatic malignancy
• Ischemic hepatitis
• Leptospirosis
• Drug-induced hepatitis
• Alcoholic hepatitis
• Extrahepatic biliary obstruction
• Autoimmune hepatitis
• Wilson's disease

Physical signs include:

• Enlarged and tender liver
• Enlarged spleen
• Posterior cervical lymphadenopathy

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

Ultrasound can indicate ascites or exclude obstruction.

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.

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.

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.

Transplantation may be necessary with fulminant active hepatitis and end-stage liver disease.

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.

• 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.

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.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

May be beneficial in modulating immune function and supporting liver function.

Therapeutic massage may be helpful in reducing the effects of stress, which inhibits immune function.

• 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.

• 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

• Posthepatitis syndrome
• Cholestatic hepatitis
• Fulminant hepatitis (necrosis)
• Chronic hepatitis
• Cirrhosis
• Hepatocellular carcinoma

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.

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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