Hepatitis

What hepatitis is

The liver filters blood, processes nutrients and medicines, makes clotting proteins and produces bile. When it is inflamed, liver cells are damaged and release enzymes (ALT and AST) into the blood, which is how hepatitis is often detected. Long-term inflammation leads to scarring (fibrosis) and eventually cirrhosis, which raises the risk of liver failure and liver cancer.

• Acute hepatitis: lasts less than 6 months. Most people recover fully.
• Chronic hepatitis: lasts 6 months or more and can progress silently for decades.

Types of viral hepatitis

See hepatitis B and hepatitis C for details on each.

Non-viral causes

• Alcoholic hepatitis: from heavy drinking over years. Can be severe and life-threatening.
• Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly fatty liver disease): linked to obesity, type 2 diabetes and high cholesterol. Its inflammatory form (MASH) can progress to cirrhosis. Now the most common cause of liver disease in the US.
• Medicines and toxins: acetaminophen overdose, some antibiotics, anti-seizure medicines, statins (rarely), herbal and bodybuilding supplements, poisonous mushrooms. See hepatitis due to a toxin.
• Autoimmune hepatitis: the immune system attacks the liver, often in women, treated with steroids and immune-suppressing medicines.
• Inherited conditions: hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency.

Symptoms

Many people, especially with chronic hepatitis B and C, have no symptoms for years. When symptoms occur:

• fatigue and weakness
• loss of appetite, nausea, vomiting
• discomfort or pain in the upper right belly
• low-grade fever
• dark, cola-colored urine and pale stools
• jaundice: yellow skin and yellow eyes
• itchy skin
• joint pain

Advanced liver disease causes swelling of the belly (ascites) and legs, easy bruising, confusion, and vomiting blood.

Diagnosis

1. Liver blood tests: ALT, AST, alkaline phosphatase, bilirubin, albumin and clotting (INR).
2. Virus tests: - hepatitis A IgM antibody for recent infection - hepatitis B surface antigen, core antibody and surface antibody to show infection, past infection or immunity - hepatitis C antibody, followed by HCV RNA to confirm active infection
3. Other tests: autoimmune antibodies, iron studies, ceruloplasmin, and screening for alcohol use and metabolic risk factors.
4. Liver ultrasound and elastography (FibroScan) to measure liver stiffness and scarring.
5. Liver biopsy occasionally.

Who should be tested

The CDC recommends that all adults be tested at least once for hepatitis B and hepatitis C, all pregnant women in every pregnancy, and people with ongoing risks (such as injecting drugs) regularly.

Treatment

• Hepatitis A and E: rest, fluids, nutrition and avoiding alcohol and liver-toxic medicines. Most recover in weeks to months.
• Hepatitis B: acute infection usually needs supportive care. Chronic infection is treated with antivirals such as tenofovir or entecavir when the virus is active or liver damage is present. These suppress the virus long term but rarely cure it. Regular monitoring and liver cancer screening are needed.
• Hepatitis C: direct-acting antiviral tablets taken for 8 to 12 weeks cure more than 95% of people, with few side effects.
• Alcoholic hepatitis: stopping alcohol completely, nutrition support, and steroids for severe cases.
• MASLD: weight loss of 7 to 10%, exercise, control of diabetes and cholesterol, and newer medicines for MASH in some people.
• Autoimmune hepatitis: steroids and azathioprine.
• Liver failure: liver transplant in selected patients.

Complications

• cirrhosis
• liver failure
• liver cancer (hepatocellular carcinoma)
• acute liver failure in rare cases of hepatitis A, B or E, and with acetaminophen overdose

Prevention

• Vaccines: hepatitis A and B vaccines are recommended for all children and for adults; the hepatitis B vaccine is recommended for all adults aged 19 to 59 and for older adults with risk factors.
• Safe practices: never share needles, razors or toothbrushes; use condoms; choose licensed tattoo and piercing studios.
• Food and water hygiene when traveling.
• Limit alcohol and keep a healthy weight.
• Medicines: follow the label dose for acetaminophen, especially if you drink alcohol, and tell your doctor about supplements.
• Newborns: babies of mothers with hepatitis B receive vaccine and immune globulin at birth.

Frequently asked questions

What are the different types of hepatitis?

The main viral types are A, B, C, D and E. Hepatitis A and E spread through contaminated food or water and usually clear. Hepatitis B, C and D spread through blood or body fluids and can become chronic. Non-viral types include alcoholic, fatty liver, drug-induced and autoimmune hepatitis.

What are the first symptoms of hepatitis?

Early symptoms are often vague: tiredness, loss of appetite, nausea, mild fever and discomfort under the right ribs. Dark urine, pale stools and yellow skin or eyes may follow. Many people with hepatitis B or C have no symptoms at all.

Is hepatitis curable?

It depends on the type. Hepatitis A and E usually resolve on their own. Hepatitis C is curable in more than 95% of people with antiviral tablets. Chronic hepatitis B can be controlled but rarely cured. Alcohol and fatty liver hepatitis improve when the cause is removed.

How is hepatitis spread?

Hepatitis A and E spread through food or water contaminated with feces. Hepatitis B spreads through blood, sex and from mother to baby. Hepatitis C spreads mainly through blood, such as shared needles. Hepatitis is not spread by hugging, coughing or sharing meals (except A and E through contaminated food).

Is there a vaccine for hepatitis?

Yes, for hepatitis A and B. Both are safe and highly effective and are part of routine childhood vaccination in the US. Adults who were not vaccinated should ask their doctor. There is no vaccine for hepatitis C, but treatment cures it.