Hepatitis: What Is
Alive; Summer 1999
Debra Johnson, RN, NP, PA-C, Samantha Cohen, PA-C
Hepatitis is the term used to describe a nonspecific inflammation of the
liver. The causes of hepatitis can be many, such as viral, parasitic,
infiltrative, drug or alcohol induced, or non-specific. The initial
clinical presentation of the acute phase of hepatitis may range from
asymptomatic (without any noticeable signs) to severe fatigue,
jaundice (yellow looking eyes or skin), nausea, vomiting, or
All patients whose laboratory values are monitored will have increases
in their liver enzymes. This article will provide information about the
pathophysiology, specific causes and treatments that are available both
commercially or in current clinical trials for viral hepatitis A, B, and
C, and drug/alcohol induced hepatitis.
So what is the liver and what does it do?
liver is located in the right upper section of your abdomen, underneath
your ribs. When the liver is enlarged (hepatomeglia) it can
protrude below the rib cage and be tender to touch. The liver plays an
important role as a detoxifier, by processing potentially harmful agents
into chemicals that are safe for the body. The liver is also responsible
for glucose metabolism, which is a source for energy, that our cells
need (including the brain) to sustain life. Another function of the
liver is to help control a portion of the pathway to allow our blood to
clot when it needs to. The liver is considered to be part of the
digestive system and controls the secretion of bile, an important enzyme
that breaks down fats and starches from the foods that we eat.
What is hepatitis?
Hepatitis is a non-specific term that is used to describe an
inflammation of the liver. It can be diagnosed after blood is obtained
and shows an elevation in liver enzymes (also referred to as ALT and
AST). Normal values for liver enzymes may vary from laboratory to
Hepatitis A (HAV) is transmitted through oral-fecal contact. Acute HAV
usually has an acute phase that lasts from 4-6 weeks with or without
jaundice, fatigue and hepatomeglia. During this acute phase, individuals
with a co-infection of human deficiency syndrome (HIV) may have a
considerable drop in T-cell counts that will rebound in 6-12 weeks after
acute infection. HAV is generally cleared from the body after 6 weeks.
It may take months to recover from acute HAV.
Treatment for HAV is usually supportive care with rest, discontinuation
of drug therapy until the acute phase is completed, at which time
therapies may be restarted. Drinking plenty of water, bed rest and good
nutrition are all essential for a complete recovery.
During the last year, a vaccination for HAV has become available and can
be considered as preventive therapy in those patients with chronic
terminal infections such as HIV infection. This may prevent potential
infections for those individuals who may be immuno-compromised. Some
insurance companies, health care facilities or studies may offer the
vaccination free of cost to patients. Check with your health care
Hepatitis B virus (HBV) infection remains a considerable health
problem worldwide and a significant cause of liver disease and liver
cancer in humans. HBV is readily transmitted via parenteral (sharing
needles or a blood transfusion) and sexual routes, and as such, it
commonly found in individuals who are coinfected with HIV. For the
patient with HIV infection, a frequent outcome of HBV is becoming a
chronic carrier. Chronic HBV occurs after an acute infection.
Approximately 20% of the patients are unable to clear the virus. The
infection may continue to develop an enlarged liver, liver failure
and/or primary liver cancer.
Certain population groups are considered to be at high risk of HBV
infection, including Native Alaskans, Pacific Islanders and infants born
to women who are first generation immigrants from regions where HBV is
very common. The risk for acquiring HBV through sexual contact is
highest among homosexual men, those with multiple sexual partners and
years of sexual activity. Unprotected heterosexual contact has also been
linked to HBV transmission.
blood and body fluids are considered to be potentially infectious. In
infected patients, HBV particles have been found in saliva, semen and
cervical secretions. Common modes of transmission include: accidental
puncture of the skin with an infected needle, blood splashed in the eye
or sharing of un-sterilized needles. Other modes include exposure to
instruments while receiving tattoos, ear piercing or acupuncture as well
as sharing razors or toothbrushes. It is believed that insects may also
serve as vectors by either biting or contaminating food.
Hepatitis B can be found in any age group. The normal incubation period
is 28 - 160 days. Patients may present with insidious symptoms such as,
joint pain, rash, nausea, vomiting and less commonly jaundice.
Suppressive therapy for HBV becomes extremely important to prevent
progression to cirrhosis, deterioration of the liver, liver cancer.
Little data is available about HIV-infected patients with chronic HBV.
from several studies suggests that 3TC (Epivir) shows promise as
an effective treatment for chronic HBV. Most of the data that is
available addressing chronic HBV response with 3TC has been done in HIV
negative patients. Little data is available in patients who are
co-infected with human immunodeficiency virus (HIV) and chronic
Several reports have found early resistance to 3TC in non-HIV infected
patients. Data from a study done on immunocompromised adults with
chronic HBV showed a high incident of 3TC resistance. This may have
implications for the concept of long-term virus-suppressive therapy of
chronic HBV using 3TC monotherapy. Adefovir has shown activity against
HBV in clinical trials.
Little data is available about hepatitis C. It has only been in the last
several years that we could test for the presence of HCV through the use
of PCR RNA testing. Many patients do not have the antibodies present to
test positive on a HCV antibody testing and must be diagnosed by PCR.
The route of transmission is still unclear. Several researchers believe
it may be transmitted through blood exposure during recreational drug
use. A co-infection in an HIV-infected patient with both HCV and HBV
increases illness and/or death.
Several studies have evaluated the use of alpha interferon
subcutaneously without a significant improvement in the patients disease
status. However, a new clinical trial using alpha interferon and
ribaviron is showing promise, but the results are still not known.
Hepatitis can be a direct result of taking drugs that may be required to
treat another illness. Prompt evaluation of an increase in liver enzymes
can lead to a diagnosis. Once diagnosed, further evaluation,
discontinuation of the offending drug and close follow-up can be
Prevention is still the best intervention. Condom use during sexual
encounters will help to decrease the risk of hepatitis B and has been
shown to be effective. Thorough handwashing is an important first line
prevention to protect transmission of most viruses. Little information
is available about other causes of hepatitis. Studies need to be done to
evaluate effective treatment for those individuals who are already
infected with chronic disease.
What should I do?
When you have sex use a condom (male or female should protect you).
Wash your hands frequently.
Have regular visits to you health care practitioner to discuss safe sex,
symptoms of hepatitis and have regular check ups.
Nevens F, Main J, Honkoop P, Tyrrell DL, et al. Lamivudine therapy for
chronic hepatitis B: A randomized dose-ranging study.
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Rostaing, L Henry S, Cisterne J-M, Duffaut M, et al. Efficacy and safety
of lamivudine on replication of recurrent hepatitis B after cadaveric
Transplantation. Vol. 64. No11, Dec.15, 1997.
Honkoop P, Niesters H. De Man R. , et al. Lamivudine resistance in
immunocompetent chronic hepatitis B.
Journal of Hepatology. '97; 26: 1393-1395.