Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Autoimmune Hepatitis article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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.
- Viral hepatitis: 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.
Presentation of chronic hepatitis
See also the separate Abdominal Examination article.
- Nonspecific symptoms - eg, 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).
- Spider naevi (chest and upper body), slate-grey appearance in haemochromatosis.
- Palmar erythema.
- 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).
Investigation of chronic hepatitis
- Urinalysis: bilirubin and urobilinogen.
- Blood tests:
- FBC (associated anaemia, thrombocytopenia, raised MCV with alcohol abuse), clotting studies (clotting impairment with hepatic dysfunction).
- Renal function and electrolytes (associated renal dysfunction).
- LFTs, 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 the separate Plasma Autoantibodies (Disease Associations) article.
- Hepatitis B and C serology.
- Nucleic acid tests for viral load if appropriate.
- Alpha-1-antitrypsin (deficiency of which can affect the liver as well as the lungs).
- 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.
- Point shear wave elastography and transient elastography have been shown to be simple and effective methods of assessing liver fibrosis.
- Genetic testing - eg, haemochromatosis, viral hepatitis genotyping.
- Upper gastrointestinal endoscopy (diagnosis and management of oesophageal varices).
- Liver biopsy: improved non-invasive diagnostic techniques mean that in chronic viral hepatitis liver biopsy can be reserved for assessment of the severity of necro-inflammation (grade) and fibrosis (stage). The increasing availability of biomarkers and sophisticated imaging techniques means that the need for liver biopsy in children with chronic viral hepatitis should be reduced in the future. Likewise, the development of serological techniques can be used to identify the subset of patients with potential liver injury who would most likely benefit from liver biopsy.
See the separate articles on specific causes - eg:
- Viral hepatitis: Hepatitis B, Hepatitis C, Cytomegalovirus, Epstein-Barr virus.
- Metabolic: NAFLD - Steatohepatitis and Steatosis (Fatty Liver), Haemochromatosis, Wilson's disease, Alpha-1-Antitrypsin Deficiency.
- Autoimmune: Autoimmune Hepatitis, Primary Biliary Cholangitis, Primary Sclerosing Cholangitis.
- Where indicated, address alcohol consumption: Alcoholism and Alcohol Misuse - Management. Stop/replace any implicated medication.
- Liver failure.
- Portal hypertension: ascites, hypersplenism, lower oesophageal and rectal varices.
- Hepatopulmonary syndrome (defect in arterial oxygenation induced by pulmonary vascular dilatation in patients with liver disease).
- Hepatorenal syndrome.
- Hepatocellular carcinoma: most cases of hepatocellular carcinoma are associated with cirrhosis related to chronic hepatitis B virus or hepatitis C virus infection.
Further reading and references
Liu A, Le A, Zhang J, et al; Increasing co-morbidities in chronic hepatitis B patients: experience in primary care and referral practices during 2000-2015. Clin Transl Gastroenterol. 2018 Mar 149(3):141. doi: 10.1038/s41424-018-0007-6.
Karnsakul W, Schwarz KB; Hepatitis B and C. Pediatr Clin North Am. 2017 Jun64(3):641-658. doi: 10.1016/j.pcl.2017.01.007.
Jiang W, Huang S, Teng H, et al; Diagnostic accuracy of point shear wave elastography and transient elastography for staging hepatic fibrosis in patients with non-alcoholic fatty liver disease: a meta-analysis. BMJ Open. 2018 Aug 238(8):e021787. doi: 10.1136/bmjopen-2018-021787.
Lee S, Kim DY; Non-invasive diagnosis of hepatitis B virus-related cirrhosis. World J Gastroenterol. 2014 Jan 1420(2):445-59. doi: 10.3748/wjg.v20.i2.445.
Pokorska-Spiewak M, Kowalik-Mikolajewska B, Aniszewska M, et al; Is liver biopsy still needed in children with chronic viral hepatitis? World J Gastroenterol. 2015 Nov 1421(42):12141-9. doi: 10.3748/wjg.v21.i42.12141.
Zeng DW, Zhang JM, Liu YR, et al; A Retrospective Study on the Significance of Liver Biopsy and Hepatitis B Surface Antigen in Chronic Hepatitis B Infection. Medicine (Baltimore). 2016 Feb95(8):e2503. doi: 10.1097/MD.0000000000002503.
El-Serag HB; Epidemiology of viral hepatitis and hepatocellular carcinoma. Gastroenterology. 2012 May142(6):1264-1273.e1. doi: 10.1053/j.gastro.2011.12.061.