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VIRAL HEPATITIS 

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Dr. Minocha  is a practicing gastroenterologist and author of "Natural Stomach Care: Treating and Preventing Digestive Disorders with Best of Eastern and Western Therapies"


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Viral hepatitis may be caused by a variety of viruses. Many of them are recognized by the English language alphabet in the order they were discovered.
 

Hepatitis A Virus (HAV)

 
HAV causes acute and not chronic hepatitis. It is spread via contaminated food and water or person-to-person contact. Other persons at risk include homosexual men and intravenous drug users. Transmission via intravenous drug use is uncommon these days. Incubation period is fifteen to 45 days before the symptoms develop.

Patients may have nausea and vomiting with or without jaundice. Severity increases with age. Children rarely develop jaundice. Course is usually self-limited. Illness resolves in three to 6 weeks, but may persist for several months. Treatment is supportive.

Active immunization (Havrix and Vaqta) is recommended for adults and children living in endemic areas, travelers traveling to an endemic area, and high risk persons like homosexuals and intravenous drug users. It is also recommended for patients infected with hepatitis B or C. A booster dose is recommended at six to 12 months after the initial dose.

Passive vaccination (ISIG) is also available for patients who have already been exposed to HAV and is effective in 90% cases. It may be given for a one-time travel to endemic area, and to family members of the patients.

 
 

Hepatitis B virus (HBV)

 
Risk factors for HBV include intravenous drug abuse, multiple or homosexual sex partners, tattooing, multiple transfusions especially prior to 1986, medical personnel, patients on hemodialysis and immigrants from endemic areas of Asia and Africa. Incubation period is 30-150 days. Acute hepatitis may not manifest any symptoms at all.

 

Progression to chronic form occurs in less than 5% of infected subjects. Acute infection progresses to chronic form in most infants but uncommonly in healthy adults. Active chronic viral infection may lead to cirrhosis in 15-30% of cases. A carrier state may also occur.

Risk of cancer is increased among patients who harbor the HBV. Such patients require a blood test as well a liver ultrasound every six to 12 months to look for early liver cancer.

 

Treatment of choice is Interferon injections daily for 4-6 months. An alternate is lamivudine (Epivir) which is given by mouth for a year.

Hepatitis B is a preventable disease. Passive immunization (HBIG) is recommended when a person is stuck by a used needle that has been exposed to a HBV patient. In addition, active vaccination is also administered. HBIG is also given to new born babies of mothers infected with HBV.

Active HBV vaccine (Engerix-B and Recombivax HB) is recommended for high risk groups like medical personnel, intravenous drug users, and infants of infected mothers. An initial dose is followed by a booster dose at one and six months.

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Hepatitis C Virus (HCV)

 
The most common form of chronic hepatitis in the U.S. is caused by HCV. Risk factors for acquiring infection include intravenous drug use, multiple blood transfusions and health care personnel in contact with patients. Transmission through sexual intercourse is uncommon (less than 5 percent). An infected pregnant mother may pass the virus on to the infant in three to 6 percent cases.

As many as 85% of infected individuals may develop chronic hepatitis, and one third go on to the stage of cirrhosis. Unlike HBV, only patients who develop cirrhosis are at an increased risk for liver cancer. The effect HCV infection on longevity is controversial.

The effects of hepatitis C are not limited to the liver alone. It can cause kidney and skin disorders. Treatment is indicated for patients with disease manifestations beyond the liver.

 
 

Hepatitis C can be diagnosed by testing blood for antibodies against the virus, or even the virus itself. Assessment of the damage to the liver however, requires a liver biopsy.

Treatment is generally not recommended for patients whose liver is minimally affected by the HCV and do not have any active inflammation or fibrosis in the liver. Patients with advanced cirrhosis, active alcoholism or intravenous drug abuse are not good candidates for treatment. Treatment of patients with HIV needs to be individualized.

We used to treat patients with alpha-interferon for 6 months. The present trend is to treat for at least 12 months. Side-effects include reduction in blood cell as well as platelet counts, and depression. Despite this very costly and sometimes toxic therapy, the virus can be eradicated only in a small fraction of patients.

Pegylated (long acting) interferons promise to improve compliance and increase eradication rates.

These days, the treatment of choice involves using a combination of alfa-interferon and ribavirin for twenty four to 48 weeks. The combination is marketed as Rebeteron. In contrast to interferon alone, this combination treatment can eradicate the virus in about 38 percent patients.

Ribavirin can be very toxic in as many as a quarter to one-third of

patients. The most common serious side-effect involves breaking down of blood cells causing anemia, which can necessitate cessation of treatment in some cases.

Rebeteron also has very serious toxic-effects on the fetus. Thus, it must not only be not used by women who are pregnant or planning to be pregnant, but also not by men whose sexual partners are pregnant or planning to be pregnant.

HCV is the most common indication for liver transplantation (30-40%) in the U.S.. Recurrence of HCV occurs in nearly all cases after transplantation, but infection is usually mild.

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Anil Minocha M.D.; FACP; FACG

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