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 article on Abdominal Examination.
- 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 article on 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.
- Transient elastography has been shown to be a simple and effective method for assessing liver fibrosis.
- Genetic testing - eg, haemochromatosis.
- Upper gastrointestinal endoscopy (diagnosis and management of oesophageal varices).
- Liver biopsy: the main indication for liver biopsy in chronic viral hepatitis is to assess the severity of the disease, in terms of both necro-inflammation (grade) and fibrosis (stage), which is important for management and prognosis.
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 Cirrhosis, Primary Sclerosing Cholangitis.
- Where indicated, address alcohol consumption: Alcoholism and Alcohol Abuse - 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
Diagnosis of fibrosis and cirrhosis. Liver biopsy is not always necessary.; Diagnosis of fibrosis and cirrhosis. Liver biopsy is not always necessary. Prescrire Int. 2010 Feb19(105):38-42.
Guido M, Mangia A, Faa G; Chronic viral hepatitis: the histology report. Dig Liver Dis. 2011 Mar43 Suppl 4:S331-43. doi: 10.1016/S1590-8658(11)60589-6.
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.
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