What Is Hepatitis?

Hepatitis is inflammation of the liver. Though it is most often caused by one of five different viruses (hepatitis A, B, C, D, and E), there are also nonviral causes such as heavy alcohol use, certain medications or toxins, and autoimmune diseases.

Hepatitis can be acute (sudden and severe) or chronic (persistent or recurrent). Some chronic infections can cause liver scarring, cirrhosis, liver cancer, and liver failure.

Symptoms of hepatitis may include fatigue, upper right abdominal pain, dark urine, clay-colored stools, and jaundice (yellowing of the eyes and skin). The diagnosis often involves blood tests and ultrasounds. The treatment varies by the underlying cause.

This article describes hepatitis in its various forms, including how you get it and ways to prevent it. It also explores the treatment options and how to stay well if diagnosed with the disease.

Types of Hepatitis

The two broad categories of hepatitis are infectious hepatitis and noninfectious hepatitis. Both can cause acute liver injury that's often reversible. Some cases can progress and become chronic, and may cause irreversible liver damage.

Infectious Hepatitis

Infectious hepatitis, also known as viral hepatitis, is the most common form of the disease worldwide. It is associated with five viruses, called hepatoviruses, that specifically target liver cells (hepatocytes).

The viruses are classified as:

• Hepatitis A: Caused by the hepatitis A virus (HAV)
• Hepatitis B: Caused by the hepatitis B virus (HBV)
• Hepatitis C: Caused by the hepatitis C virus (HCV)
• Hepatitis D: Caused by the hepatitis D virus (HDV)
• Hepatitis E: Caused by the hepatitis E virus (HEV)

In the United States, the most common types are hepatitis A, B, and C. Though the five viruses are related, they have different modes of transmission (ways of being spread) and may be treated and prevented differently.

Noninfectious Hepatitis

Noninfectious hepatitis, also referred to as nonviral hepatitis, involves conditions that are not communicable (you cannot "catch" them).

The four causes can be broadly categorized as follows:

• Alcoholic hepatitis: Caused by heavy alcohol use and alcoholic fatty liver disease (AFLD)
• Nonalcoholic hepatitis: Associated with nonalcoholic fatty liver disease (NAFLD), a disease primarily linked to obesity, diabetes, and metabolic syndrome
• Toxic hepatitis: Caused by chemicals or toxins like carbon tetrachloride or medicines and supplements like Tylenol (acetaminophen), or kava kava
• Autoimmune hepatitis: A specific autoimmune disorder that causes the immune system to attack liver cells
  

How Does Hepatitis Spread?

Viral hepatitis is the communicable form of the disease that can be transmitted from one person to the next by different means, as follows:

• Hepatitis A: Spread by direct or indirect contact with HAV-infected stools, eating contaminated food, or person-to-person contact through inadequate handwashing
• Hepatitis B: Spread by contact with HBV-infected blood, semen, and other body fluids, most commonly through sex, childbirth, or the shared use of needles
• Hepatitis C: Spread by contact with HCV-infected blood, most commonly through shared needles, vaginal childbirth, and possibly sex
• Hepatitis D: Caused by exposure to HDV-infected blood, most commonly in developing countries through shared needles or non-sterile medical or dental procedures
• Hepatitis E: Caused by exposure to HEV-infected stools, most commonly in developing countries lacking clean water supplies or adequate sanitation

Hepatitis Symptoms

Symptoms of hepatitis can vary based on whether it is acute or chronic. Acute hepatitis may cause liver injury that is often reversible. Chronic hepatitis is characterized by fibrosis (tissue scarring), which is typically irreversible.

Acute Symptoms

Acute symptoms of hepatitis are those caused by the sudden and severe inflammation of the liver. The infection can be short-lived and clear on its own without treatment.

Acute symptoms of hepatitis include:

• Fatigue
• Weakness
• Headaches
• Joint pain
• Fever
• Loss of appetite
• Upper right abdominal pain
• Upper right abdominal swelling
• Nausea and vomiting
• Dark urine
• Clay-colored stools
• Jaundice
• Skin rash

Chronic Symptoms

Chronic hepatitis is defined as liver inflammation that recurs or persists for longer than six months. It is often asymptomatic (without symptoms) in its early course and may only be detected by lab tests.

However, as the inflammation persists, fibrosis can develop and start to affect the function of the liver. This can lead to nonspecific symptoms that could be attributed to a number of other illnesses, such as fatigue, joint pain, nausea, and poor appetite.

Over time, the mounting fibrosis can lead to a significant loss of liver function, known as cirrhosis. If the liver is still functional (referred to as compensated cirrhosis), there may be few notable symptoms. But when the liver is no longer functional (decompensated cirrhosis), a person may experience a cascade of symptoms, including:

• Fatigue
• Jaundice
• Persistent itchiness
• Nausea and vomiting
• Loss of appetite
• Weight loss
• Easy bruising and bleeding
• Spider veins
• Ascites (fluid accumulation in the belly)
• Peripheral edema (fluid overload in the lower legs)
• Variceal bleeding (gastrointestinal bleeding)
• Hepatic encephalopathy (neurological symptoms such as confusion, memory loss, and slurred speech)

What Causes Hepatitis?

The cause of hepatitis varies based on whether it is infectious or noninfectious.

Infectious Hepatitis

With viral hepatitis, the infection of hepatocytes triggers inflammation, the body's natural response to infection. While inflammation can help clear the infection—as it often does with hepatitis A, B, C, D, and E—it can start to damage the liver if the inflammation persists unchecked.

With viral hepatitis, the inflammatory response progresses in three stages:

• Prodromal stage: This is the early stage before overt symptoms appear. As part of the frontne defense, the immune system will flood the body with inflammatory chemicals, called cytokines, which cause symptoms like fever, headache, fatigue, nausea, skin rashes, and joint pain.
• Icteric stage: This is the stage when inflammation causes the swelling of the liver and bile ducts. When this happens, waste products like bilirubin (a yellow pigment) spill into the bloodstream, causing jaundice and dark urine. The loss of bile, a digestive fluid, causes stool to turn pale.
• Convalescent stage: This is when the immune system can rein in the acute infection and heal symptoms. If this does not occur, the infection can become chronic.

Chronic infections occur with hepatitis B and C because the viruses secrete proteins that block signaling between immune cells. By doing so, the viruses can evade immune detection and avoid neutralization.

Noninfectious Hepatitis

The cause of hepatitis differs, whether it is triggered by fatty liver disease, toxins, or autoimmunity,as follows:

• Fatty liver disease: Hepatic steatosis, the buildup of fat in the liver, is the cause of hepatitis in people with AFLD and NAFLD. Fat accumulation in the liver triggers an inflammatory response in the same way it would in other areas of the body.
• Toxic hepatitis: Hepatotoxicity is a liver injury caused by drugs and other substances. Unlike an immune reaction, hepatotoxicity triggers the release of compounds (called reactive metabolites) that kill liver cells and incite inflammation in the aftermath.
• Autoimmune hepatitis: The cause of the disease is unknown, although it is thought to be the result of genetic and environmental factors that cause the abnormal immune response.

Tests to Diagnose Hepatitis

The diagnosis of hepatitis starts with a review of your medical history and a physical exam. The physical exam would involve palpation (touch) to check for ascites, peripheral edema, or hepatomegaly (enlarged liver). The healthcare provider would also visually inspect for jaundice, spider veins, and abnormal bruising.

Different lab and imaging tests would be used to diagnose the cause of the symptoms and/or characterize the severity of the liver injury. These include:

• Liver function tests (LFTs): This battery of blood tests checks for liver enzymes that increase whenever the liver is inflamed or injured.
• Hepatitis screening: These blood tests can diagnose hepatitis A, B, C, D, and E by detecting the virus or immune proteins, called antibodies, that are produced in response to the infection.
• Abdominal ultrasound: This noninvasive imaging test creates detailed images of the liver using reflected sound waves. It can detect scarring and other abnormal changes in the liver.
• Computed tomography (CT): This imaging test compiles multiple X-ray images to create three-dimensional "slices" of the liver and adjacent structures.
• Magnetic resonance imaging (MRI): This imaging test uses magnetic and radio waves to create highly detailed images of soft tissues. It may help detect smaller growths, like cancer.
• Percutaneous biopsy: This involves the insertion of a hollow needle through the abdomen to obtain a liver tissue sample to be sent to a lab for analysis.

Hepatitis Complications

The main complication of hepatitis is fibrosis. Fibrosis is an indication that liver inflammation is chronic and typically progressive. In some people, this can lead to cirrhosis and liver failure.

Cirrhosis, in turn, is associated with other potentially life-threatening complications, including:

• Portal hypertension: This is high blood pressure in the portal vein that brings blood from the intestine to the liver. This can cause bloating, blood in stool, bloody vomit, and confusion.
• Hepatopulmonary syndrome: This is when portal hypertension causes blood vessels in the lungs to widen, leading to shortness of breath, bluish skin, and other signs of hypoxia.
• Hepatocellular carcinoma (HCC): This is the most common type of liver cancer, the risk of which is up to 45 times greater in people with cirrhosis than the general population.
• Cholangiocarcinoma: This common form of bile duct cancer is increased twelvefold in people with cirrhosis.

Hepatitis Treatment

The treatment of hepatitis is as varied as its causes. An overview of the treatment approach can be broadly described as follows:

• Hepatitis A: No treatment is needed as the infection will clear on its own.
• Hepatitis B: Pegasys (peginterferon alfa-2a), a type of interferon, is often used to manage chronic HBV infection, along with certain antiviral drugs.
• Hepatitis C: The treatment involves an eight- to 12-week course of a newer class of drugs called direct-acting antivirals (DAAs).
• Hepatitis D: The treatment may also involve interferons like Pegasys.
• Hepatitis E: No treatment usually is necessary, as the infection usually clears on its own.
• AFLD: Central to the treatment is the discontinuation of alcohol.
• NAFLD: The first-line treatment is usually weight loss through exercise and a healthy diet.
• Toxic hepatitis: Discontinuing the offending drug may be all that is needed.
• Autoimmune hepatitis: Treatment typically involves immunosuppressant drugs like prednisone and Imuran (azathioprine).

Complications of hepatitis, including cirrhosis and HCC, may require specific treatments to manage symptoms and slow the progression of the disease, including:

• Lifestyle change: This includes quitting cigarettes, losing weight, and avoiding alcohol.
• Diuretics: These are "water pills" that can ease portal hypertension and peripheral edema.
• Antihypertensives: These include angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers used to treat high blood pressure that can also ease portal hypertension.
• Questran (cholestyramine): This cholesterol drug may help reduce itching from cirrhosis.
• Inderal (propranolol): This heart medication can help reduce variceal bleeding.
• Lactulose syrup: This laxative may clear toxins that cause hepatic encephalopathy.
• Liver cancer treatment: This may include liver surgery, chemotherapy, ablation therapy, embolization, radiation, and targeted therapy.
• Liver transplant: Liver transplantation may be the only option for people with advanced HCC or decompensated cirrhosis.

Hepatitis Vaccines

Several vaccines protect against hepatitis A and hepatitis B. They are either inactivated vaccines made with dead viruses or recombinant vaccines made in the lab, neither of which cause disease. All are given by injection into a large muscle.

Seven hepatitis vaccines are currently approved for use in the United States;

• Engerix B (hepatitis B ): Given in three doses for people 16 years and over
• Havrix (hepatitis A): Given in two doses for persons 12 months and older
• Heplisav-B (hepatitis B): Given in two to three doses for adults 18 and over
  
• PreHevbrio (hepatitis B): Given in three doses for adults 18 and over
• Recombivax HB (hepatitis B): Given in three doses for people of all ages
• Vaqta (hepatitis A): Given in two doses for persons 12 months and older
  
• Twinrix (combination hepatitis A/B): Given in three to four doses for adults 18 and over

There are no vaccines to prevent hepatitis C, D, or E. Talk with a healthcare provider to determine which vaccines are recommended for you or your child.

How to Limit the Spread of Hepatitis

The different types of viral hepatitis vary in their modes of transmission and, therefore, require different strategies to avoid acquiring or transmitting the infection.

Among the public health recommendations are:

• Hepatitis A: Get the hepatitis A vaccine. Wash your hands thoroughly after using the restroom or before serving food. Avoid raw shellfish or food from unlicensed street vendors.
• Hepatitis B: Get the hepatitis B vaccine. Practice safer sex, including consistently using condoms and having fewer sex partners. Do not share needles or other drug paraphernalia.
• Hepatitis C: Avoid sharing needles or other drug paraphernalia. Seek treatment if you have hepatitis C and are pregnant or planning to get pregnant. Limit your number of sex partners.
• Hepatitis D: Take special precautions in countries where HDV is common. This includes avoiding tattoo or piercing parlors, unnecessary dental or medical procedures, shared needles, and shared personal care items (like razors).
• Hepatitis E: Take special precautions in countries where HEV is common, avoiding tap water, raw vegetable or fruits, and undercooked foods. If bottled water is unavailable, bring tap water to a rolling boil for at least three minutes to kill any germs.

Living a Healthy Life With Hepatitis

Being diagnosed with viral hepatitis can be distressing, particularly if you have visible symptoms like jaundice. The stress can even be greater if you have an incurable type like hepatitis B or hepatitis E, or are awaiting the approval of hepatitis C treatment from your insurer.

Others fear the stigma of having an infectious disease like hepatitis or worry about the impact hepatitis may have on their relationships or finances. These are all reasonable concerns.

To better cope with your hepatitis diagnosis, here are six things that can help:

• Educate yourself: Learning about the disease removes the fear of the unknown and helps you educate others. This includes knowing how the virus is transmitted and prevented.
• Seek support: This not only includes families and friends you can trust but also hepatitis support groups that can offer advice, referrals, or just a shoulder to cry on.
• Work with a social worker: Your healthcare provider can refer you to a clinical social worker (CSW) who can help you navigate counseling services, financial aid, and other support services.
• Practice good nutrition: Eating more whole grains, fiber, and vegetables while reducing saturated fats, alcohol, and sugar can help keep your liver healthy.
• Exercise routinely: Exercise not only helps you lose body fat and fat in your liver, but it can also help lower your blood pressure and improve your mood.
• Reduce stress: You will be better able to cope if you can manage stress. Try mind-body therapies like yoga, meditation, tai chi, deep breathing, or biofeedback. Practice good sleep hygiene.

If you cannot cope, do not hesitate to ask for a referral to a psychologist or psychiatrist who can offer therapy and medications, if needed, to treat anxiety or depression.