4 Chronic Hepatitis

Chronic hepatitis
Abdulsemed M.
Gastroenterology & Hepatology Unit
Department of Internal Medicine
School of Medicine, Addis Ababa University
June 8 , 2018
Case
• A 40 year old known type 2DM patient was
found to have elevated serum tansaminases
during follow up. Lab tests and his sonography
reported moderate fatty liver.
• How do you analyze the case/DDx?

Outline
• Chronic hepatitis
• Chronic viral hepatitis
• Autoimmune hepatitis
• Drug induced chronic hepatitis
Chronic hepatitis
• Series of liver disorders causing hepatic
inflammation and necrosis for at least 6 months
• Milder forms are nonprogressive/ slowly

progressive
• Severe forms lead to scarring and cirrhosis

• Several categories of CH recognized
▫ Viral
▫ Drug induced
▫ Autoimmune
▫ Metabolic- Wilson’s, AATD
▫ NAFL/ALD
▫ Cryptogenic
• Classification of chronic hepatitis is based on
1. Its cause
2. Histologic activity/Grade
 Degree of necroinflammatory activity
3. Degree of progression/Stage
 Assessment of fibrosis
 HAI (0-6), METAVIR score (0-4)
 Non invasive markers of fibrosis (APRI, fibroscan)
Fibroscan (elastography)
Liver Bx: 1/50,000 of the liver

FibroScan: 1/500 of the liver
Classification by cause
Sofosbuvir
Velpatasvir
Cont’d
Chronic Viral Hepatitis
(B, C, D/B)
Chronic hepatitis B
• Likely hood of chronicity after acute hepatitis depends
on age
▫ Neonates: 90%
▫ Immunocompetent adults: 1-5%
• CHB can be eAg positive/negative
• Degree of liver injury is variable
▫ None in inactive carriers to mild/moderate/severe
• Inactive carrier
▫ HBsAg+, HBeAg-, normal liver enzymes, low or
undetectable viremia, normal liver biopsy
• Viral load correlates with degree of injury and
progression
Clinical feature
• Fatigue – most common symptom
• Jaundice (persistent/intermittent)- advanced
• Complications of cirrhosis
• HCC – can occur with out cirrhosis

Extrahepatic manifestations
• Due to Ag-Ab immune complex formation
▫ Arthralgia/arhtritis
▫ Vasculitis
▫ GN
▫ Polyarteritis nodosa
Laboratory feature
• Normal to modest enzyme elevation (100-1000), ALT>
AST
• Moderate elevation in bilirubin (3-10mg/dl)
• ALP- normal or slightly elevated
• In severe cases
▫ Low albumin, prolonged INR
• Markers of chronic hep B
• Viral load
1/21/2016
Treatment
• Goals
▫ Suppression of HBV DNA to undetectable level
▫ Reduce risk of progression, decompensation and death
• Drugs
▫ TDF/TAF
▫ Entecavir
▫ Telbivudine
▫ Lamivudine
▫ Adefovir
▫ PEG-IFN
AASLD 2018 guideline
• All of the following patients should be treated
▫ HBV associated cirrhosis

▫ HBV/HIV coinfection
▫ Extrahepatic manifestations of HBV
Chronic hepatitis D (with HBV)
• Similar clinical and lab feature
• Worse prognosis
• Treated with PEG-IFN

Chronic hepatitis C
• Most common indication for LT in the US
• Chronicity:
▫ 50-80%, regardless of mode or age of acquisition
• Most cases are identified incidentally
• Progresses slowly and insidiously
▫ 25% progress to ESLD
• 30% have normal liver enzymes despite ongoing liver
injury and fibrosis on biopsy
▫ Continuous clinical monitoring is imperative
• Factors associated with higher progression of
CHC
▫ Old age
▫ Long duration of infection
▫ Advanced histologic grade and stage
▫ High hepatic iron content
▫ Other liver diseases (ALD, CHB, HIV)
Clinical feature
• Fatigue- most common symptom
• Jaundice is rare
• Immune-complex medicated extrahepatic

manifetations are less common than CHB
▫ Essential mixed cryoglobulinemia
 Cutaneous vasculitis
 MPGN
▫ B-cell lymphoma, MGUS
• Other associated diseases - sicca synd, LP, PCT,

T2DM
Laboratory feature
• Similar to CHB
▫ Liver enzymes tend to fluctuate more

▫ Presence of autoantibodies
 Anti-LKM1
• Viral load and genotype

Treatment
• Evolved substantially
▫ PEG IFN + Ribavirin >> Direct acting antivirals
(DAAs)
• HCV is curable
• Treatment indication:
▫ All pts with CHC and detectable HCV RNA
DAAs
• Novel oral antivirals
• Some have pangenotypic action
• Given in combination for 12-24 weeks
Autoimmune Hepatitis
AIH
• Immune system attacks liver cells
• More common in women
• Associated with other autoimmune diseases
• Can lead to cirrhosis and liver failure
• Cause is unknown
▫ Genetics and environment
• May be asymptomatic or present with fatigue/
complications of cirrhosis
• High liver enzymes with lesser ALP & bilirubin

• High serum IgG
• Autoantibodies
▫ ANA, ASMA, anti-SLA
▫ Anti-LKM1
• Biopsy Interface hepatitis
Lymphoid follicles
• Diagnosis – clinical, biochemical & exclusion of

other diseases
• Treatment
▫ Prednisolone +/- Azathioprine
Drug induced chronic hepatitis
• Several drugs can cause chronic hepatitis

• Many have AIH picture
• F>M
• Jaundice, hepatomegaly
• Elevated liver enzymes
• Auto-Abs may be detected
Improvement with drug withdrawal and worsening
with reintroduction
• Eg- INH, amiodarone, MTX

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Chronic hepatitis

• How do you analyze the case/DDx?

• Milder forms are nonprogressive/ slowly

• Severe forms lead to scarring and cirrhosis

Liver Bx: 1/50,000 of the liver

• Jaundice (persistent/intermittent)- advanced

• HCC – can occur with out cirrhosis

• Moderate elevation in bilirubin (3-10mg/dl)

• ALP- normal or slightly elevated

▫ HBV associated cirrhosis

• Treated with PEG-IFN

• Immune-complex medicated extrahepatic

• Other associated diseases - sicca synd, LP, PCT,

▫ Liver enzymes tend to fluctuate more

• Viral load and genotype

• More common in women

• Associated with other autoimmune diseases

• Can lead to cirrhosis and liver failure

• High liver enzymes with lesser ALP & bilirubin

• Diagnosis – clinical, biochemical & exclusion of

• Several drugs can cause chronic hepatitis

• Eg- INH, amiodarone, MTX

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