Introduction:

Hepatitis is a serious disorder in which liver cells become inflamed. The inflammation usually occurs because of a virus. It can also be caused by an overactive immune system, and from drugs, alcoholism, chemicals, and environmental toxins. Viral hepatitis usually appears as type A, B, or C, although hepatitis D and E have been reported.

Type A, the most common form of viral hepatitis, often affects school-aged children. The disease is transmitted by contaminated food or water, or contact with a person ill with hepatitis A. The hepatitis A virus is shed in the stools of an infected person during the incubation period of 15 - 45 days before symptoms occur and during the first week that the person feels sick. Blood and other body fluids may also carry the infection. The virus does not stay in the body after the infection has resolved, and, unlike hepatitis types B and C, there is no "carrier" state (a person who spreads the disease to others but does not become ill).

Hepatitis types B and C affect people of all ages. Most people who become infected with hepatitis B get rid of the virus within 6 months. This type of short infection is known as an "acute" case of hepatitis B. About 10% of people infected with the hepatitis B virus develop a chronic, life-long infection. People with chronic infection may or may not have symptoms. Those who do not develop symptoms are referred to as carriers. Having chronic hepatitis B increases your chance of permanent liver damage, including cirrhosis (scarring of the liver) and liver cancer.

Anyone who has chronic hepatitis B is also susceptible to infection with another strain of viral hepatitis known as hepatitis D (formerly called delta virus). Hepatitis D virus can only infect cells if the hepatitis B virus (HBV) is present. Injection drug users with hepatitis B have the greatest risk of developing the infection. Individuals who are infected with both HBV and hepatitis D are more likely to develop cirrhosis or liver cancer than patients who only have HBV.

Hepatitis E is uncommon in the United States. This disease is primarily spread through food or water that is contaminated by feces from an infected person. There is no vaccine for hepatitis E. The only way to prevent the disease is to reduce the risk of exposure to the virus. Hepatitis E usually resolves without treatment, within several weeks to months.

Signs and Symptoms:

Acute Hepatitis

• Flu-like symptoms including fever, as well as aching or painful muscles and joints
• Jaundice (yellow discoloration of both your skin and the whites of your eyes)
• Abdominal discomfort
• Fatigue
• Loss of weight
• Loss of appetite
• Nausea, vomiting
• Dark urine, colorless stool
• Diarrhea
• Whole-body itching (called pruritus)
• Mild anemia
• Enlarged, tender liver

Chronic Hepatitis

Chronic hepatitis may not be preceded by an acute (immediate) phase, or the acute symptoms may be quite subtle and go unnoticed. Some people with hepatitis C feel only mild ongoing fatigue and, perhaps, whole-body itching. The virus is then found by a blood test.

Causes:

Hepatitis A is usually transmitted from feces on unwashed hands (putting dirty hands into the mouth) and by ingesting contaminated food and water (for example, seafood from sewage contaminated water). It can also be transmitted through close contact with someone who has the virus.

Hepatitis B and C are transmitted via blood. Therefore, these forms of the virus can be transmitted by people who have a blood transfusion, use intravenous (IV) drugs with contaminated needles, and through sexual activity. In as many as 40% of the cases of hepatitis C, the specific cause of transmission is unknown. Blood and blood products that are used for transmission can now be tested for both hepatitis B and C.

Risk Factors:

Hepatitis A

• Chronic institutionalization (nursing home or rehabilitation center)
• Day care employees or children
• Recent hepatitis A infection in a family member
• Recent travel or immigration from Asia, South, or Central America
• Food industry workers
• Sewage workers

Hepatitis B

• Contact with blood in work setting: this puts physicians, nurses, dentists, and other health care providers at particular risk
• Sex with multiple partners without the use of a barrier, such as a condom
• History of blood transfusion prior to the early 1990s
• Receiving a tattoo with contaminated instruments
• IV drug use with sharing of contaminated needles
• Birth to a hepatitis B infected mother
• Travel to underdeveloped nations and immigrants from areas where disease rates are high (namely, the Asia Pacific and Mediterranean regions and southern Africa)
• Having the human immunodeficiency virus (HIV) puts you at greater risk for chronic hepatitis and its potential complications

Hepatitis C

• Blood transfusion prior to July 1992
• Solid organ transplantation from a donor who has hepatitis C
• IV drug use and sharing of contaminated needles
• Long-term kidney dialysis
• Contact with blood in work setting: this puts doctors, nurses, dentists, and other health care providers at particular risk
• Sex with a person who has hepatitis C
• Birth to a hepatitis C infected mother, particularly if she has HIV
• Having HIV or hepatitis B puts you at greater risk for chronic hepatitis C and its potential complications

Diagnosis:

First, your doctor will ask you questions to assess your risk for the different types of viral hepatitis. Questions will include whether you:

• Work in health care setting, including either a medical laboratory or a dialysis unit
• Have a parent, sibling, or child infected with hepatitis
• Engage in unprotected sex or have a sexual partner with either hepatitis B or C
• Use drugs by injection
• Live in or are exposed to unsanitary conditions
• Consume possibly contaminated food or water
• Eat or handle raw shellfish

Next, your doctor will examine your abdomen carefully, including palpating your liver and spleen to see if either is enlarged or tender. Then, a blood test will be performed to assess your liver function and test for antibodies against the specific hepatitis viruses. Your doctor will likely request a urine test as well. For chronic hepatitis, a liver biopsy may be required, which must be done under general anesthesia. A liver biopsy is particularly important if you have chronic hepatitis C because this test assesses the degree of liver damage, which can occur even if you have no symptoms.

Prevention:

Hepatitis A

Transmission of the virus can be reduced by faithfully following these practices, particularly in child daycare facilities and other institutions involving close contact with people:

• Avoid unclean food and water.
• Wash hands thoroughly after using the toilet or changing a diaper, as well as before serving food.
• Clean yourself thoroughly if you come into contact with any type of body fluid from an infected person (such as blood and feces).
• Those with the virus should not prepare food for others.

Hepatitis B and C

Preventive measures are the same for both hepatitis B and C.

• Avoid contact with blood or blood products whenever possible.
• Do not inject drugs of abuse, and especially do not share needles with anyone.
• Avoid having multiple sexual partners.
• Practice safer sex behaviors, including use of appropriate barrier methods such as condoms.
• Go to a reputable shop for tattoos and body piercing.
• Health care workers should practice universal precautions when handling blood and bodily fluids. This includes wearing gloves when performing any procedure with blood exposure, disposing of needles properly, and other precautions.

Immunization

Hepatitis A

Candidates for the hepatitis A vaccine include:

• Anyone who lives or works in a community where outbreaks occur (such as a daycare center)
• Those who travel frequently or have long overseas stays in high-risk areas
• Sexually active homosexual men
• People who already have a chronic form of hepatitis should be vaccinated against hepatitis A before the chronic form reaches late stages of liver disease.
• Health care workers
• Those living in high-risk U.S. states, which include Alaska, Arizona, Arkansas, California, Colorado, Idaho, Missouri, Montana, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, Washington, and Wyoming
• Those with intimate exposure to someone with hepatitis A. In this case, your doctor will decide if the vaccine or immunoglobulin (an immunizing agent) is most appropriate. This depends, in part, on the timing of the exposure.

Hepatitis B

There are several inactivated vaccines available for hepatitis B. Immunization provides the only definitive protection against hepatitis B. The hepatitis B vaccine is one of the recommended childhood immunizations, and is now part of routine pediatric care in the United States. Adults who are at higher risk, should also be vaccinated:

• Those who live with someone with hepatitis B
• Health care workers
• Travelers to high-risk areas
• Sexually active people who have multiple partners
• People on hemodialysis
• People who have suppressed immune systems (such as HIV)
• High-risk pregnant women

Hepatitis C

There is no vaccine for hepatitis C, but immunoglobulin helps protect against it after blood transfusions. Periodic doses in sexual partners of an infected person may also help to give protection.

Treatment:

Acute Hepatitis

The goals for treating acute viral hepatitis include:

• Assuring adequate nutrition and hydration
• Preventing further damage to the liver
• Avoiding transmission of the virus to others

There are no medications to treat acute hepatitis, although your doctor may recommend drugs that alleviate some of the symptoms. Most cases of acute hepatitis are mild and do not even require hospitalization. Only people who are at high risk for complications, such as pregnant women, the elderly, people with serious underlying medical conditions, or those who become significantly dehydrated from excessive nausea and vomiting need to be hospitalized. The very rare cases of acute hepatitis that lead to liver failure (called fluminant acute hepatitis) not only require hospitalization but also need liver transplantation.

Chronic Hepatitis

The goals for treatment of chronic viral hepatitis include:

• Preserving liver function and preventing liver damage
• Boosting the immune system to help fend off damage from the virus

There are several medications from which your doctor will choose to help achieve these goals.

Because the conventional medications used to treat chronic hepatitis have a lot of unpleasant side effects, many people with this condition turn to alternative medical therapies instead. CAM practices that may help boost your immune function and help make you feel stronger and less tired while taking conventional medications include herbal and vitamin supplements, homeopathy, acupuncture, and massage therapy. Make sure that your health care providers know that you have hepatitis so that the necessary precautions can be taken to avoid spread of the virus.

Lifestyle

Your doctor will talk with you about steps you can take to keep from spreading the virus. For hepatitis A, these include:

• Washing clothes thoroughly with hot water.
• Washing your hands after using the toilet.
• Heating contaminated articles for one minute, which should kill the virus.
• Using household bleach for disinfecting hard surfaces.
• Separating the eating and cooking utensils used by the household member with the virus from those used by other people living there.
• Abstaining from sexual activity while acutely infected.

For hepatitis B and C, these measures include:

• Avoiding sharing personal items, such as toothbrushes and razors (microscopic blood particles may be on these items).
• Abstaining from sexual activity, or taking strict precautions, such as always using a condom. Women should abstain during menstruation in particular.
• Handling objects contaminated with blood with special care, like wearing gloves when drawing blood if you work in a hospital.
• Not sharing drug needles if you use street drugs intravenously and making sure that tattoo and piercing artists and acupuncturists use sterile needles. (Note: due to the standard use of sterile, disposable needles by licensed acupuncturists, there have been no reports of hepatitis infection from acupuncture therapy in the United States.)

If you are traveling to a high-risk country, take the following precautions:

• Get vaccinated against hepatitis A and possibly hepatitis B.
• Use bottled water for drinking and brushing teeth.
• Eat heated food promptly. Heated food should be hot to the touch.
• Avoid buying food from street vendors.
• Avoid sliced fruit. It may have been washed in contaminated water.
• Avoid raw or undercooked fish and shellfish.

Other general lifestyle measures to take include:

• Don't drink alcohol during the acute phase of hepatitis or if you become a carrier of types B or C.
• Quit smoking. Evidence suggests that cigarette smoking is associated with more severe infection.

Medications

Interferons -- This group of medications are natural proteins that activate immune functions in the body and have anti-viral properties. Examples of interferon medications include Roferon-A, Intron-A, Rebetron, Alferon-N, and Peg-Intron. These drugs do not work for everyone who takes them, but for those who do respond, the possible benefits include:

• Diminished viral levels of hepatitis B and C
• Reduced symptoms
• Improved survival rates

Drawbacks for this class of drugs include:

• Need to administer via injection
• Hepatitis B and C can become resistant to the medication; in other words, the drugs become ineffective over time.
• Side effects from the interferons are often very unpleasant, even intolerable, to some people as they may be worse than symptoms of chronic hepatitis itself (particularly since some people with hepatitis C have no symptoms). Common side effects are flu-like symptoms including fever, chills, and muscle aches. Additional side effects include depression, hair loss, weight loss, and a drop in white blood cells (the cells in the body that help fight infection).

Corticosteroids -- Corticosteroids may be used in the early stages of chronic hepatitis to enhance the effects of interferon. Corticosteroids include prednisone (Deltasone) and methylprednisolone (Medrol).

Nucleoside Analogues -- This class of drugs, including lamivudine (Epivir), ribavirin (Rebetol), are used to stop replication of the virus. Advantages of lamivudine, often used to treat chronic hepatitis B, over interferon include:

• Can be taken orally
• Fewer side effects
• Less expensive

Like interferon, nucleoside analogues can lose their effectiveness over time.

Ribavirin is often used in combination with interferon for chronic hepatitis C. Although ribavirin improves the response rate for those with hepatitis C, side effects from the interferon become more likely when this second drug is added. Potential side effects from the ribavirin itself include:

• Anemia
• Skin disorders
• Coughing and shortness of breath
• Sleep disturbance
• Depression or anxiety
• Heartburn
• Weight loss

Newer nucleoside analogues developed for hepatitis treatment include adefovir (Hepsera) and entecavir (Baraclude). Adefovir is used in people with hepatitis B who do not respond to lamivudine. Entecavir was approved by the U.S. Food and Drug Administration in 2005 for treatment of hepatitis B. Entecavir may cause symptoms of hepatitis to worsen once medication is discontinued. Talk to your doctor about the best medicine for your condition.

Surgery and Other Procedures

People with the following conditions may qualify for a liver transplant:

• Life-threatening cirrhosis and life expectancy is more than 12 years
• Liver cancer that remains confined to the liver
• Fulminant acute hepatitis (liver failure)

Five-year survival rate after liver transplantation is 60 - 80%. Unfortunately, in about 50% of those with chronic hepatitis who receive a liver transplant, the infection recurs.

Nutrition and Dietary Supplements

Although no special diets have been shown to help treat acute hepatitis, eating small snacks during the day, with larger ones in the morning, may be recommended. Eating this way helps optimize digestion, prevent weight loss, and reduce nausea. Following these nutritional tips may help improve general health and well-being:

• Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy oils in foods, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

You may address nutritional deficiencies with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 - 3 tablespoonfuls oil, 1 - 3 times daily, to help decrease inflammation and help with immunity. Cold-water fish, such as salmon or halibut, are good sources but not substitutes for supplementation.
• Vitamin C, 500 - 1,000 mg 1 - 3 times daily, as an antioxidant and for immune support. Your heath care provider may recommend several times this amount as an intervention, and often high dose intravenous vitamin C is used to treat hepatitis C.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
• Acetyl-L-carnitine, 500 mg daily, for antioxiant and antiviral activity.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements need refrigeration.
• L-glutamine, 500 - 1,000 mg 3 times daily, for support of gastrointestinal health and immunity.
• Resveratrol (from red wine), 50 - 200 mg daily, for antioxidant and antiviral effects.
• L-theanine, 200 mg 1 - 3 times daily, for nervous system support.
• Melatonin, 2 - 5 mg 1 hour before bedtime, for sleep and immune protection. Ask your health care provider about potential drug interactions with the use of melatonin.
• N-acetyl cysteine (NAC), 200 - 500 mg 3 times daily, for liver and antioxidant support.
• SAMe (s-adenosylmethionine), 400 - 1,600 mg daily in divided dosages, for liver and antioxidant support.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• Green tea (Camelia sinensis ) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Milk thistle (Silybum marianum ) seed standardized extract, 80 - 160 mg 2 - 3 times daily, for detoxification support and antiviral effects.
• Cat's claw (Uncaria tomentosa ) standardized extract, 20 mg 3 times a day, for inflammation and antiviral activity.
• Garlic (Allium sativum ), standardized extract, 400 mg 2 - 3 times daily, for antibacterial or antifungal and immune activity.
• Reishi mushroom (Ganoderma lucidum), 150 - 300 mg 2 - 3 times daily, for inflammation, antiviral and immune effects. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.
• Maitake mushroom (Grifola frondosa ) standardized extract (D-fraction), 600 mg 2 times daily, for immune and antiviral effects. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.
• Phyllanthus (Phyllanthus amarus ) standardized extract, 200 mg 2 - 4 times daily, for antiviral effects.

Acupuncture

While research in China has shown some promise in treating hepatitis B, few acupuncturists in the United States provide treatment for this or other forms of hepatitis. Acupuncture is generally used in China and other countries to boost the immune system of those with hepatitis.

There has been some concern that patients could contract hepatitis from dirty needles or infected practitioners. However, there have been no reported incidents of infection in the U.S. Because of the customary, and in many instances legally mandated, use of sterile, disposable needles by acupuncturists in the U.S., there is virtually no risk of contracting hepatitis from acupuncture therapy here or other countries with similar standards and safe practices.

Massage

Therapeutic massage may help enhance immune function.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for viral hepatitis based on his or her knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Aconitum -- used during initial phases of hepatitis when the individual has a fever, jaundice, and sharp pains in the liver; can be used in newborns.
• Belladonna -- used in early stages of hepatitis when the individual has occasional liver pains that are worsened by inhalation and movement.
• Chelidonium -- for individuals with pain that originates in the liver and extends to the back and right shoulder; this remedy is most appropriate for individuals who have gray or yellow loose stools, fever, and jaundice. A craving for milk may be present. Lying on the left side and ingesting hot food or drink may bring some relief.
• China -- for individuals with a tender liver and a sensation of fullness in the stomach. The individual may burp frequently although it provides no relief. The individual may also have cravings for sweets, cold drinks, or coffee.
• Lycopodium-- one of the primary remedies for hepatitis in children and adults. This remedy is most appropriate for individuals who feel tension in the liver area, have difficulty standing up, and feel full after eating only small amounts of food.
• Mercurius-- for individuals with a swollen, tender liver and jaundice; the tongue may also be yellow and swollen. This remedy is most appropriate for individuals with clammy perspiration, excessive salivation, sensitivity to temperature variations, and bleeding gums. Lying on the right side is painful and stools may be light gray or green.
• Phosphorus -- for individuals with burning pains under the right rib cage and in the back between the shoulder blades that are relieved by cold drinks. This remedy may be used in newborns with jaundice.

Traditional Chinese Medicine (TCM)

Traditional Chinese Medicine (TCM) is a range of traditional medical practices originating in China that developed over several thousand years. When assessing a person with hepatitis, a TCM practitioner might make one of the following diagnoses:

• Hepatic qi (energy) stagnation
• Hepatic yang excess with yin deficiency (balance)
• Hepatic yin insufficiency

Once the diagnosis is established, the practitioner is likely to use acupuncture, moxibustion (a burning of an herb called mugwort over acupuncture sites), and herbal drugs to address the imbalances of hepatic qi (energy) and yin-yang (balance).

Other Considerations:

If an individual is at increased risk of contracting hepatitis or if they have already been infected with any form of the hepatitis virus, a doctor will recommend the hepatitis B vaccine. A vaccine is also available for hepatitis A.

Food handlers should be extremely careful of contracting hepatitis A, and health care workers should always exercise universal precautions to avoid contraction or transmission of hepatitis B or C.

Support groups are available for people with chronic hepatitis B or C. It is often difficult to cope with having this particular disease. Talking with people who also have this condition in a formal setting is often very helpful. Check with your doctor or hospital to locate a support group near you.

Pregnancy

Hepatitis B and C can be transmitted during pregnancy or childbirth. Women who are pregnant or planning to become pregnant soon cannot take interferon or nucleoside analogues.

Warnings and Precautions

Because the liver processes many types of medications, you will most likely be advised to stop taking all drugs other than those recommended for treatment of hepatitis.

Similarly, certain herbs and supplements are known to cause harm to the liver:

• Kava kava (Piper methysticum), an herb used for anxiety and tension, may be toxic to the liver and cause severe hepatitis and even liver failure if taken excessively or long-term, especially if the individual is predisposed to liver conditions. Liver-related risks have prompted regulatory agencies in other countries, including Germany, Switzerland, France, Canada, and the United Kingdom, to warn consumers about the potential risks associated with kava use and to remove kava-containing products from the marketplace. Similarly, the U.S. Food and Drug Administration issued an advisory in March of 2002 regarding the potential risk of liver failure associated with kava-containing products, but this herb has not been taken off the market in this country.
• Vitamin A in large quantities can be toxic to the liver. Vitamin A is often found in cod liver oil supplements. Some manufacturers remove the vitamin A so that consumers can get benefits of high-dose cod liver oil without the risks of taking high doses of vitamin A. Read the labels carefully or ask a health care provider.
• Do not take over-the-counter drugs that contain acetaminophen (Tylenol) if you have hepatitis without first talking to your doctor. Acetaminophen can be toxic to the liver, even in individuals with healthy livers. It is recommended that healthy individuals not take more than 4 g of acetaminophen daily.

Prognosis and Complications

In the acute phase of hepatitis, jaundice generally disappears in 2 - 8 weeks. Occasionally, hospitalization is necessary (for example, if you become significantly dehydrated), but most people completely recover. Full recovery of normal liver function tests, however, may take several months.

Rare yet serious complications of acute hepatitis include aplastic anemia (when the bone marrow makes no new cells) which can be fatal, pancreatitis, very low blood sugar, and polyarteritis (inflammation of blood vessels). Also quite rare is liver failure (called fulminant hepatitis) with bleeding from the gastrointestinal tract and brain damage, known as hepatic encephalopathy. Occasionally, the acute phase of hepatitis B or C is more mild yet prolonged, with recovery taking up to 1 year; 5 - 10% of people with this prolonged acute phase go on to develop chronic hepatitis.

After the acute phase, long-term prognosis depends on many factors, including the cause of the hepatitis, whether you go on to become a carrier of type B or develop a chronic form of the disease, and whether you have any other underlying medical problems. about 5 - 10% of people with hepatitis B become carriers, and about 25% of carriers progress to chronic hepatitis. The vast majority of people infected with hepatitis C go on to become life-long carriers, and anywhere from 50 - 90% of these carriers eventually develop chronic hepatitis.

The chronic form of hepatitis can ultimate lead to scarring of the liver (known as cirrhosis) and liver failure. There are two types of chronic hepatitis – chronic active and chronic persistent. The latter is mild and either doesn't get worse or only does so very slowly. Chronic active hepatitis, on the other hand, is much more likely to lead to cirrhosis, permanent damage to the liver. Cirrhosis occurs in 5 - 10% of people with chronic hepatitis from hepatitis B and as many as 20 - 30% of those with chronic hepatitis from hepatitis C. About 14% of people with cirrhosis develop liver cancer.

Alternative Names:

Hepatitis - viral