In Conversation with Doctors

 

Hepatitis – The silent disease

by Dr. Ruveena Bhavani Rajaram – Consultant Gastroenterologist

What is hepatitis?
Hepatitis simply means inflammation of the liver. Inflammation happens as a result of injury to the
liver. This may occur as an insult directly/primarily targeting the liver or indirectly, thus injuring the
liver as part of a systemic/multi-organ illness. In the setting of direct injury to the liver, hepatitis may
be due to “one-off” exposure (single hit) or constant exposure (multiple hits) to the particular insult.
Hepatitis can affect an individual with healthy liver as well as a person with known liver problem.
Depending on the nature of hepatitis and also importantly the baseline health of the liver, liver may
recover within few weeks or months, or may become chronically affected leading to liver scarring
(fibrosis) and may not gain full recovery. Typically, hepatitis may be classified as acute (recovery
within 6 months) or chronic (no full recovery beyond 6 months).

What are the main causes of hepatitis?
There are various causes of hepatitis, namely infection by certain virus or bacteria, fatty liver,
drugs/medication, excessive alcohol intake, immune-mediated or rarely, certain genetic disorders. In
Malaysia, hepatitis due to Hepatitis B virus, Hepatitis C virus, and fatty liver are the most common
cause, followed by drugs/medication and alcohol induced hepatitis. Depending on the cause of
insult, hepatitis may result in an acute infection with recovery within weeks or may last for many
months or years. Rarely, it becomes very severe, resulting in failure of liver to function normally,
leading to death or need for liver transplantation
Hepatitis due to bacterial infection is uncommon and gives rise to acute hepatitis with recovery
within few weeks. Examples of bacterial infection that often leads hepatitis are liver abscess (pus
formation in liver), cholecystitis (infection leading to inflammation of gall bladder), cholangitis
(infection leading to inflammation of bile duct) and Leptospirosis (infection caused by Leptospira
spp.)

Liver inflammation due to fatty liver is due to excess fat accumulation around liver cells
(hepatocytes). These excess fat is harmful to the liver and leads to chronic inflammation (hepatitis).
Fatty Liver is commonly associated with Diabetes Mellitus, Obesity, rapid weight loss, certain
medication such as prednisolone and tamoxifen. The good news is hepatitis due to fatty liver
improves with good blood glucose control, gradual weight loss or cessation of causative medication.
Drug or medication induced hepatitis is rather common. It is caused when harmful amount of some
medication, herbal remedies or food supplement affects the liver as a result of chronic consumption.
Rarely, overdose of certain medication may lead to acute hepatitis. Cessation of the culprit
drug/medication almost always leads to improvement and recovery of hepatitis. Very rarely, it may
lead to severe liver damage.

With regards to alcohol induced hepatitis, the amount of alcohol (>30g/day) and type of alcohol,
drinking pattern (daily drinking or binge drinking) as well as rate of alcohol metabolism in the body
play a role. Sustained abstinence of alcohol consumption will aid in recovery of hepatitis for a small
number of individuals but majority will go on to develop liver scarring (fibrosis).

What are the different types of hepatitis?
Hepatitis due to viral infection is most commonly caused by Hepatitis B virus, Hepatitis C virus,
Dengue virus and less commonly due to Hepatitis A virus, Cytomegalovirus (CMV), Epstein-Barr virus
(EBV), Hepatitis E virus or Hepatitis D virus. Typically, viruses such as Hepatitis B, C and D lead to
chronic hepatitis and can result in scarring of liver (liver fibrosis) and liver failure. Hepatitis A & E
viruses, CMV and EBV usually have a short duration of infection and recover within few weeks to
months.

What are the common symptoms of the disease?
Hepatitis is a silent disease as most people with hepatitis do not have any symptoms. Hepatitis is
detected via blood test where liver enzymes are elevated. Some may experience nausea, poor
appetite or discomfort at the right upper abdomen. Rarely, those with severe hepatitis present with
anorexia, fever, jaundice (yellowish discoloration of sclera), dark coloured urine, easy bruising,
abdominal or leg swelling.

Do people sometimes mistake these symptoms for other conditions/delay in seeking treatment?
If a person does not manifest any symptom of hepatitis, which is the most common scenario, he or
she will not seek medical attention, hence hepatitis will not be detected early. Only when this
person happens to go for a routine health screen which includes blood test of the liver function, he
or she will be alerted to an abnormal liver blood results and be investigated for hepatitis. So, the
diagnosis of hepatitis is missed and will only be detected much later on. For those with mild
symptoms, this may mimic any mild viral infection, but unlike mild viral infection, the symptoms may
persist longer, prompting a blood test. With abnormality in liver blood test, the doctor is then
triggered to investigate for hepatitis. In severe hepatitis, especially with the presence of jaundice,
the right diagnosis is made fairly quick, as jaundice is a specific indicator of liver problem.

Are some individuals more prone to developing the disease?
Hepatitis B and C viruses spread through an infected person’s blood or body fluids. Parent with
Hepatitis B infection are more prone to pass on Hepatitis B infection to their off-spring during
childbirth or at a very young age (vertical transmission). Those with high-risk behavior such as
unprotected sex, high-risk sexual behavior, usage of non-sterile needle during tattooing or
intravenous drug usage are more prone to acquire Hepatitis C or Hepatitis B infection. Also, in
Malaysia, those who had transfusion of blood products before year 1992 and 1996 may be at higher
risk to develop Hepatitis B and Hepatitis C infection, respectively. Hepatitis A virus is transmitted via
consumption of contaminated water or food. Although this infection is not very common in
Malaysia, there has been limited outbreaks of Hepatitis A infection over the years. As mentioned
earlier, those with Diabetes Mellitus, overweight individuals or those on medications such as
prednisolone and tamoxifen are more prone to develop fatty liver. Those who consume excessive
amount of alcohol are at risk of developing alcoholic hepatitis.

Which type of hepatitis can be prevented with vaccination?
In Malaysia, there are specific vaccines which are available commercially to prevent
Hepatitis A & Hepatitis B infection.

How is hepatitis best prevented?
Hepatitis A & E are transmitted via faecal-oral route. Hence, avoiding contaminated food and water
source is vital in prevention. Hepatitis B, C and D virus are spread via blood and body fluid. Hence it
is important to avoid or reduce risk of transmission by practice of safe sex, avoidance of high risk
sexual behavior, avoid needle sharing among intra venous drug users and use sterile needles for
tattooing. Avoid or minimize alcohol consumption as well as practicing healthy lifestyle reduces risk
of alcohol induced hepatitis and fatty liver, respectively. Also, avoid taking unregulated TCM as this
may lead to drug induced hepatitis.

How prevalent is this condition in Malaysia?
Overall prevalence of fatty liver is about 25% in Malaysia and it increases to about 70% among
patients with Diabetes Mellitus. Prevalence of hepatitis B infection is 5% with higher prevalence
among Chinese ethnic group. Hepatitis C infection affects 2 % of population.