hepatitis

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Solomon L. Lerer, M.D.

Gastroenterology

Office (305) 931-6220 Fax (305) 466-4755

Hepatitis means "inflammation of the liver." This ailment can be caused by many agents, including drugs, alcohol, and viruses. Just 20 years ago, there were thought to be just two types of viral hepatitis; now, there are so many identified it almost seems like "alphabet soup." Fortunately, only three viruses are prevalent in our country.

Hepatitis A, once called infectious hepatitis, spreads quickly wherever there is poor sanitation, poor hygiene, untreated drinking water, and crowded conditions. It is excreted or shed in feces. It is prevalent in Third World countries, especially among children. Adults from developed countries who travel to such areas are particularly susceptible, and may develop flu-like symptoms: gastrointestinal problems and jaundice. Symptoms usually begin two to six weeks after exposure.

There is no treatment for Hepatitis A, but this infection is rarely severe and never becomes chronic. Recovery can often take a few weeks to several months. An oral vaccine is now available.

Hepatitis B, previously known as serum hepatitis, is the most serious form of hepatitis. It is more prevalent and infectious than AIDS, with 300,000 new cases each year, and one million cancers in the United States.

When the Hepatitis B virus enters the body, it infects the liver. The infected individual frequently has no symptoms, but if symptoms do occur, they can appear as long as six to eight weeks after the initial infection and may include abdominal pain, appetite loss, fatigue, and jaundice. Immunity usually occurs after the body eliminates the virus. However, approximately 10% of those infected will not be able to rid themselves of the virus, and even those who do eliminate the virus can infect others during the weeks or months that they carry it, even if they suffer from no symptoms.

The 10% of those who develop a chronic Hepatitis B infection may ultimately develop liver scarring (cirrhosis) and possibly liver cancer. The younger the patient, the more likely it is that this will occur. Special antibody tests can distinguish between the small percent who continue to have infection from the majority who eradicate it. We can even measure the virus directly when indicated.

Hepatitis B is spread through sex, contaminated needles, or from an infected mother to infant at birth. In addition, approximately a third of cases have no known source. Hepatitis B, as well as C, can also be spread through blood transfusion. Blood is now tested for these viruses before transfusion. This has decreased the risk of developing post-transfusion hepatitis from 8 - 10% to 0.5%. An intramuscular vaccine is available for Hepatitis B, and the United States is beginning to vaccinate all newborn babies. Vaccination is also recommended for certain high-risk groups:

Although these are considered the high risk groups, nearly half of those who contract Hepatitis B do not fall into any of these categories. Specific gamma globulin is also available for people with known exposure to Hepatitis B. It must be given soon after exposure, however.

As mentioned, cirrhosis is a serious sequelae of Hepatitis B, if infection remains chronic. It occurs in up to 30 - 40% of patients over time. Presently, only one therapy is approved by the US Food and Drug Administration for the treatment of Hepatitis B (and C). Scientists have been able to commercially prepare proteins called interferons that are also produced by our body's cells. Interferons function to stimulate our body's immune systems to fight against viral infections. Commercial interferon can work the same way on chronic Hepatitis B. Use of this drug over time can lead to loss of hepatitis in approximately 35% of patients.

Administration of interferon for chronic Hepatitis B is via injection daily for four months. Most patients will have flu-like symptoms: muscle aches, fatigue, and low grade fevers. These can be monitored with analgesics and tend to lessen over time. Blood counts need to be monitored. The most serious side-effect is depression. Other side-effects can occur; overall, few are severe or persist after treatment.

Other agents are being investigated. A recent pilot study in the New England Journal of Medicine examined a nucleoside analog called lamivudine It inhibited Hepatitis B levels and cleared infection in some chronic patients. This oral medication appeared well-tolerated and safe. Further studies in a larger number of patients is needed, however. Whether it is effective in Hepatitis C is also unknown.

Hepatitis C. Since 1970, scientists had known of a new hepatitis often spread via blood transfusions. They named it "non A, non B" hepatitis as they knew better what it wasn't than what it was. The virus was first identified in 1989 by molecular cloning techniques and called Hepatitis "C". Shortly thereafter, diagnostic tests became available, and we can now accurately measure antibody to the Hepatitis C virus. Hepatitis C virus infects an estimated 3.5 million Americans with 150,000 - 170,000 new cases diagnosed each year. Hepatitis C is spread via blood products or contaminated needles as with B; however, approximately one-third is spread via unknown mechanisms. Sexual or mother-child transmission can occur, but this appears to be rare. Most acute infections with Hepatitis C go unaware with mild or absent symptoms. Others may experience symptoms similar to Hepatitis B such as fatigue, mild fever, muscle or joint aches, etc. A minority experience jaundice.

Thirty-five to fifty percent of patients will resolve this acute infection. Their liver tests will normalize; their Hepatitis C antibody test may remain positive for many years, however. The remaining 50 - 65% of patients will still have elevated liver tests six months later, and hence are "chronically infected" with Hepatitis C. Many patients first become aware of their chronic infection from routine labs.

Most patients with chronic Hepatitis C infection do well over their lifetime, free of symptoms and unaware of its presence. Indeed, several studies have shown they live as long as their non-Hepatitis C counterparts in society. However, 20 - 30% can develop cirrhosis. There is no good marker available to tell us who will develop cirrhosis and who will not. We do know it usually takes time to develop, an average of 20 years. Interferon is also approved for the treatment of chronic Hepatitis C. A smaller dose is needed than for Hepatitis B and only three times per week. However, therapy needs to be at least for six months. During therapy, about 40 - 50% of patients respond and develop normal liver tests. However, once therapy is discontinued, only half this group remains normal. Therefore, in terms of potential "cure," only 20 - 25% remain with normal liver tests over time after interferon therapy is complete.

One goal of the future is to increase this "cure" rate. One option may be a longer duration of treatment. A study in 1995 addressed this issue, treating for 12 to 18 months. As a result, long-term response rates with normal liver tests were seen in up to 45% of patients. Interferon may also be more beneficial when combined with other agents. One agent of interest is called ribavirin. One study combining this nucleoside analog with interferon showed a 33% long-term response in Hepatitis C versus the usual 20 - 25%. Chronic Hepatitis B and C patients should observe a nutritious, well-balanced diet. Excessive acetaminophen or Vitamin A use can be harmful. Alcohol intake should be severely limited. Be kind to your liver.