Which hepatitis has a bad prognosis

Hepatitis A – G (viral hepatitis)

Viral hepatitis: Acute inflammation of the liver caused by viruses, characterized by the death of liver cells, jaundice and mild to very severe flu-like symptoms such as fever, muscle pain and fatigue. Acute viral hepatitis is one of the most common infectious diseases with around 20,000 cases per year in Germany.

Depending on which hepatitis virus is causing the disease, it is hepatitis A, B, C, D or E. All viruses cause similar symptoms, but differ in the type of infection, treatment and consequential damage. Especially in the case of hepatitis B and C, there is a risk of transition into a chronic course with the end stage of liver cirrhosis.

Leading complaints

Initially: I had flu-like symptoms

  • Exhaustion, tiredness
  • Loss of appetite
  • Upper abdominal pain
  • Joint and muscle pain
  • Possibly fever.

Later, but not with all sick people:

  • Yellow discoloration (jaundice) of the skin around the eyes and skin
  • Gray-yellow stool, brown-colored urine
  • Itching of the skin.

When to the doctor

Today at

  • flu-like symptoms associated with yellowing of the skin and / or the sclera
  • severe diarrhea, possibly combined with yellowing of the skin and conjunctiva, especially after stays abroad.

The illness

Depending on the pathogen, a distinction is made between forms of hepatitis A to E. All hepatitis viruses can be detected using blood tests. At the beginning of the disease, however, the blood values ​​are often still normal.

Hepatitis A

Route of infection. Hepatitis A (epidemic hepatitis) is spread all over the world. The virus is transmitted by smear infection through objects contaminated with faeces, contaminated food (mussels) and contaminated drinking water. Two weeks before (i.e. during the incubation period) to 14 days after the onset of the disease, the virus carrier excretes the virus in the stool and is contagious.

Complaints. The first symptoms such as malaise, nausea and fever appear after 2–7 weeks. The disease usually heals in about 4–6 weeks, but it can take 3–4 months (but never becomes chronic). A hospital stay is not necessary if the course is mild. Serious and fatal courses occur in around 0.01–0.1% of patients. These occur mainly in elderly patients and if they are also infected with hepatitis B or C.

Virus detection. The virus DNA appears in the blood and stool just a few days after infection. Antibodies that the organism forms against the virus can be detected after 3–4 weeks.

Hepatitis B.

Routes of infection. The Hepatitis B. is caused by body fluids such as B. blood, semen, vaginal secretions or breast milk are passed on. Because this infection does not take place via the gastrointestinal tract (= enteral), it is also called a parenteral infection. The smallest amounts of virus are sufficient for infection (much less than for infection with the AIDS pathogen HIV). The time between infection and the outbreak is at least one month, but it can also last up to 1 year. On average, it takes about 2 to 4 months for the disease to break out.

Most often, people become infected through unprotected sexual intercourse. The virus is also transmitted from mother to child at birth (perinatal infection). Other ways of getting infected are infected needles or instruments that are used in drug use, tattooing, or piercing. The risk of being infected by blood transfusions has fallen sharply, as nowadays blood is being tested for hepatitis viruses. The infection caused by needle sticks when operating or treating infected patients, previously feared by medical staff, has also become rarer. The reason for this is the introduction of vaccinations (see prevention).

Complaints / course. In addition to the typical flu-like symptoms of acute viral hepatitis, joint pain and skin changes sometimes occur. In addition to mild, almost symptom-free courses, there are also severe liver dysfunction. The disease becomes chronic in 10% of adults and 90% of infected infants.

Virus detection. The laboratory medical detection options for hepatitis B are extremely extensive. Using various antigens of the hepatitis B virus, the antibodies formed by the body and the virus DNA, the stages of the disease and the risk of infection of the virus carrier can be determined.

Hepatitis C.

Routes of infection. The Hepatitis C. is also transmitted parenterally. The most important causes of infection in Germany are shared needles when consuming drugs (so-called needle sharing) and homosexual contacts between men. The disease is also passed on with infected needles when tattooing or piercing. Mothers who have the hepatitis C virus (HCV) can sometimes pass it on to their child during birth. Infection through blood transfusions hardly plays a role in Germany any more, as blood products are now tested for HCV as standard. In developing countries or countries with poor hygienic standards, however, the risk of infection with blood transfusions, medical interventions and treatments is still high.

Complaints / course. As with hepatitis B, joint pain and skin changes sometimes occur with hepatitis C. However, many diseases also run completely without symptoms. In adults, acute hepatitis C becomes chronic in two thirds of cases, but not in children.

Virus detection. In laboratory medicine, 6 hepatitis C virus types (so-called genotypes) are differentiated, the most common HCV type 1 in Europe is at the same time the most dangerous and the most difficult to treat. Antibodies against HCV are found in the blood after 6 weeks at the earliest. The detection of viral RNA in the blood shows whether the person affected is contagious.

Hepatitis D

Transmission path. The hepatitis D virus is also transmitted parenterally. However, only people who have hepatitis B can become infected. The reason for this is that the hepatitis D virus is a "defective" virus without its own shell. In order to reproduce, it is imperative that the hepatitis B virus is present. Hepatitis D infections occur in the Mediterranean region, the Amazon and in the Arab countries; in Germany, hepatitis D is rather rare.

Course. For the prognosis of the disease, it is crucial whether there is a simultaneous infection with hepatitis B and D (simultaneous infection) or an additional infection with hepatitis D if hepatitis B is already present (superinfection). The second case (second hit) is more difficult and more often becomes chronic.

Virus detection. Virus RNA appears in the blood with fresh infection, antibodies against hepatitis D virus can be detected in the course.

Hepatitis E.

Transmission path. The Hepatitis E. is caused by 3 different types of virus.

  • Virus type 3 is particularly important in Germany. It is found in domestic pigs and wild boars, and it is infected through the consumption of undercooked pork. Men over 40 years of age are most often infected. In most cases, those affected have hardly any symptoms and the acute illness heals spontaneously. However, if the liver is previously damaged, severe courses can occur. In addition to the typical hepatitis symptoms with fatigue, loss of appetite and jaundice, brain inflammation or nerve pain are rarely possible.
  • Hepatitis E viruses of types 1 and 2, on the other hand, occur mainly in tropical countries and, like hepatitis A, are fecal-oral, e.g. B. transmitted through contaminated drinking water. Special therapy for the disease is not necessary; in 98% of cases it heals spontaneously. However, particular caution is required with expectant mothers: pregnant women in the last trimester of pregnancy inexplicably often (around 10–20% of those affected) die of hepatitis E and should therefore avoid a trip to the tropics. Vaccination against hepatitis E is available, but studies are still ongoing to verify its application and results.

Virus detection: After about 3–6 months, antibodies appear in the blood and prove the fresh infection. The complicated detection of hepatitis E-RNA in blood or stool mainly serves to clarify sources of infection and epidemics.

Hepatitis F

Hepatitis F. In 1994, virus particles were detected in the stool of people after transfusions that could not be assigned to any known infectious viral disease. Evidence of a previously undiscovered hepatitis virus, so that Hepatitis F virus and toga virus, were not confirmed. Further scientific research did not support the existence of such a virus.

So-called hepatitis G

In 1996, the GB virus was isolated from a patient and linked to hepatitis. In the meantime, however, we know that this virus is not a hepatitis pathogen and that there is therefore no hepatitis G yet. From the GB virus (named after the initials of the original patient) 3 virus types are known (A, B and C), types A and B were found in monkeys. Only GB virus type C occurs in humans, but no disease has yet been linked to it. However, the virus may slow the progression of a co-existing HIV infection.

Course of the disease in the acute phase

The acute phase of viral hepatitis runs in all pathogens of hepatitis in three stages, which differ in intensity:

  • In the preliminary stage (prodromal phase), which lasts 2–7 days, the symptoms are similar to influenza with joint and muscle pain and loss of appetite. In addition, there are often nausea and nausea and increasingly poor general well-being.
  • 50% of patients then develop jaundice (icteric phase) for about 4–8 weeks. During jaundice, the stool is gray-yellow and the urine is brown. Patients complain of itching and yellow skin. The doctor speaks of jaundice, the cause of which lies in the liver (intrahepatic jaundice). Often times, patients feel better when jaundice occurs.
  • In the third phase, the patient begins to recover (convalescence phase). The signs of illness subside. Fatigue and exhaustion can persist for months.

In some cases, serious complications occur in the preliminary stage (prodromal phase). The worst is that fulminant hepatitis, ranging from severe liver dysfunction to fatal liver failure (liver failure).

Chronic hepatitis

Hepatitis B, C and D can develop into chronic viral hepatitis. One speaks of a chronic course if the inflammation that can be detected in the blood or in liver tissue samples has persisted for more than 6 months. Chronic hepatitis, in turn, often leads to cirrhosis of the liver. It often develops into liver cancer many years later.

With chronic hepatitis, patients are often just tired at first and their performance decreases. Often the sick have no symptoms at all and only become noticeable when they have cirrhosis.

It is difficult to predict whether acute hepatitis will develop into chronic hepatitis. Even with a mild course of acute hepatitis, it can later turn into chronic hepatitis.

Diagnostic assurance

The diagnosis of hepatitis - regardless of the form - is possible based on typical changes in the blood, especially bilirubin, GOT and GPT, AP and gamma-GT. A tissue examination of the liver (liver biopsy) is sometimes necessary, especially for the prognosis and therapy.

To clarify which form of hepatitis it is, antibody tests and detection of genetic material of the virus (virus DNA / RNA) in the blood are sometimes necessary.

Differential diagnoses. The acute picture of liver damage is also found in acute toxic hepatitis (poisoning by drugs, alcohol or fungal toxins). Signs of chronic liver dysfunction are e.g. B. in hemochromatosis, Wilson's disease and primary biliary cholangitis.

treatment

General measures

Symptomatic treatment and physical rest are the cornerstones in the treatment of hepatitis. Strict bed rest is not necessary; high-carbohydrate, but low-fat foods are suitable as food. If you have a fever, calf compresses and antipyretic medication such as paracetamol are recommended (see also Self-help with fever).

Harmful influences such as alcohol are to be avoided. To protect the liver, the doctor often stops other drugs (including the "pill") or reduces the dose to an essential level. Sometimes the doctor switches a necessary treatment to drugs that are better tolerated by the liver.

Pharmacotherapy

The antiviral drugs used in hepatitis therapy include:

  • Interferons.Interferons are small proteins that belong to the group of cytokines and support the body's own immune system. For the treatment of hepatitis, pegylated interferons (Pegasys® or PegIntron®) are used. These are bound to a substance (polyethylene glycol) in order to achieve a longer effect. They are injected under the skin (subcutaneously) every 7 days.
  • Antivirals.Virostatics are drugs that inhibit virus replication. The following active ingredients are used in hepatitis:
  • Hepatitis B:
  • Nucleoside analogs (NA) such as entecavir or lamivudine
  • Nucleotide analogs such as tenofovir
  • Hepatitis C:
  • NS5B inhibitors (inhibit the multiplication of HCV viruses), e.g. B. Sofosbuvir, Dasabuvir
  • NS5A inhibitors (inactivating a protein that is needed for virus replication), e.g. B. daclatasvir, ledipasvir, ombitasvir, velpatasvir
  • Protease inhibitors (inhibit the production of important proteins for virus replication), e.g. B. grazoprevir, paritaprevir

Therapy of acute hepatitis

Hepatitis A. There is no specific therapy for acute hepatitis A. Treatment is therefore symptomatic with the general measures mentioned above. In most cases, liver function returns to normal after a few weeks (up to six months).

Hepatitis B. Acute hepatitis B has a high spontaneous healing rate and is therefore treated symptomatically like acute hepatitis A. If there is a so-called fulminant (lightning-fast deterioration) course, antivirals are used. A liver transplant is rarely necessary in such cases.

Hepatitis C. Acute hepatitis C is also initially treated symptomatically due to its high rate of spontaneous healing. If the infection has not healed after 6 months, it is treated as a chronic infection with direct antiviral agents (DAA). In principle, DAAs are also effective in acute hepatitis C. However, the doctors are still discussing their combination and the duration of the therapy. In exceptional cases, however, doctors prescribe them for acute hepatitis C antivirals. These exceptions are

  • Infection after needlestick injuries
  • very strong symptoms (fulminant course)
  • Serious comorbidities
  • Development of the disease outside of the liver (e.g. changes in the blood count, rheumatological diseases, thyroid inflammation)
  • Genotype 1 hepatitis C (ledipasvir / sofosbusvir for 6 weeks)

Therapy of chronic viral hepatitis

Chronic viral hepatitis is a risk factor for developing cirrhosis and liver cell carcinoma. Therefore everything should be tried to avoid chronification or to treat it correctly. Healing is now often possible. In particular, patients with

  • strong virus replication.
  • strong increase in the enzymes GOT, GPT, gamma-GT and AP
  • pronounced inflammatory reaction (possibly even connective tissue remodeling of the liver) in the tissue examination.
  • advanced cirrhosis of the liver.

Chronic hepatitis B. The standard treatment consists of the administration of antivirals such as B. tenovofir or entecavir. The patient takes the tablets until the main virus antigen (HBsAG) has disappeared from the blood. An alternative for patients with mild to moderate progression is treatment with pegylated interferons (Pegasys® or PegIntron®) for 48 months.

Chronic hepatitis C. Depending on the genotype of the virus, the standard therapy consists, for example, of sofosbuvir + ledipasvir (± ribavirin) or sofosbuvir + velpatasvir. The duration of use depends on the extent of the liver changes and the viral load (this is the amount of virus found in the blood) and ranges from at least 8 to about 24 weeks. The healing rates with this new therapy regimen are over 90%. Doctors only resort to the previously used active ingredient interferon if therapy fails.

Before starting treatment with DAA interferon-free therapy, all hepatitis C patients are screened for hepatitis B. If you have or have had a hepatitis B infection, there is a risk that the hepatitis B virus will come back to life. H. is reactivated. Patients with coinfection (hepatitis B and C) must be continuously monitored and the therapy adapted to the individual situation.In some cases, doctors add tenovofir or entecavir to a co-infection in parallel with DAA therapy.

Chronic hepatitis D. The recommended treatment is high-dose therapy with pegylated interferons for up to 48 weeks, but the response is unfortunately poor. In many patients, the viral RNA remains detectable in the blood. If the liver values ​​worsen, the only remaining therapy is liver transplantation. It is still uncertain to what extent patients with chronic hepatitis D will benefit from the administration of DAA.

forecast

The acute hepatitis A usually heals without consequences, the mortality rate is less than 2%.

The acute hepatitis B in most cases heals spontaneously, fulminant courses with liver failure are very rare. Every 10th acute hepatitis B becomes chronic. The doctor can determine whether the chronically ill person is infectious with a special blood test.

The acute hepatitis C If left untreated, it becomes chronic in 60–80% of cases. With consistent therapy, however, chronic hepatitis C has a cure rate of over 90%.

The Hepatitis D infection has a bad prognosis. A superinfection of hepatitis B patients with the hepatitis D virus leads to a chronic course in 90% of cases.

The Hepatitis E. is dangerous for pregnant women: 10–20% of women infected with virus type 1 or 2 in the last trimester of pregnancy die for inexplicable reasons. The type 3 e-hepatitis most common in Germany, on the other hand, is very often asymptomatic and usually heals without consequences.

With all chronic hepatitis the risk is for one Cirrhosis of the liver and one Liver cancer elevated.

Your pharmacy recommends

What you can do yourself

Save the liver.

Even after you leave the hospital, you must avoid anything that puts a strain on the liver. This includes the total renunciation of alcohol and, in women, the renunciation of the pill for contraception. Since many medications are banned for months, sometimes years after surviving hepatitis, it is important that you inform the doctor about your illness every time you visit a (dental) doctor.

Sexual intercourse.

To prevent your partner from becoming infected, you should use condoms during sexual intercourse until the blood test returns normal values ​​and your doctor gives the all-clear.

Hand hygiene. With hepatitis A, strict hand hygiene is particularly important after using the toilet, as the pathogen is excreted in the stool. Try to avoid physical contact with family members during the illness to reduce the risk of infection.

Complementary medicine

Herbal liver therapeutics should only be taken after consulting a doctor. The most frequently recommended medicinal herb is milk thistle, from whose fruits standardized dry extracts are obtained (e.g. Alepa forte capsules, durasilymarin® film-coated tablets, Silibene® 140 film-coated tablets). A liver-protecting effect of milk thistle is supported by many study results, but an actual "antiviral" effect is rather unlikely.

Prevention

Hepatitis B and D. To prevent infections with hepatitis B, vaccines are available that protect against this hepatitis (e.g. Engerix®). A successful hepatitis B vaccination, which is recommended for children and adolescents, long-distance travelers and everyone working in the medical professions, also protects against hepatitis D. The use of condoms is necessary to prevent the sexual transmission of hepatitis B infection.

The sometimes unsanitary working conditions for piercing and tattooing are problematic. Even piercing the earlobe carries a certain risk of hepatitis if the work is carried out improperly.

Hepatitis A. There is also a vaccine for hepatitis A (HAV dead vaccine, e.g. Havrix®). After injection, 95% protection can be achieved within about 2 weeks. Long-term protection over 10 years is achieved after two injections 6–12 months apart. The vaccination against hepatitis A can be combined with a vaccination against hepatitis B (Twinrix®).

When traveling, care should be taken to ensure adequate food hygiene to avoid infection with hepatitis A and E and either cook, fry or peel these before consumption (Cook it, boil it, peel it, or forget it).

Further information

  • www.bag-leber.de - website of the Bundesarbeitsgemeinschaft Leber e. V., Cologne: With information on various liver diseases. The working group includes numerous associations and self-help groups that can be reached from the website.
  • RKI guide to hepatitis A, B, C, and E - https://www.rki.de/DE/Home/homepage_node.html

Authors

Dr. med. Arne Schäffler, Dr. Bernadette Andre-Wallis in: Health Today, edited by Dr. med. Arne Schäffler. Trias, Stuttgart, 3rd edition (2014). Revision and update: Dr. med. Sonja Kempinski | last changed on at 09:02


Important note: This article has been written according to scientific standards and has been checked by medical professionals. The information communicated in this article can in no way replace professional advice in your pharmacy. The content cannot and must not be used to make independent diagnoses or to start therapy.