Chronic hepatitis – the inflammatory disease which is characterized by fibrous and necrotic changes of fabric and cells of a liver without violation of structure of segments and symptoms of portal hypertensia. In most cases patients complain of discomfort in the field of the right podreberye, nausea, vomiting, violation of appetite and a chair, weakness, decrease in working capacity, weight loss, yellowness, a skin itch. Diagnostic actions consist in performing biochemical blood test, ultrasonography of abdominal organs, a liver biopsy. Therapy is directed to neutralization of the reason of pathology, improvement of a condition of the patient and achievement of permanent remission.
Chronic hepatitis is the inflammatory defeat of a parenchyma and stroma of a liver developing under the influence of various reasons and continuing more than 6 months. Pathology represents a serious social and economic and clinical problem in connection with the steady growth of incidence. On statistical data, in the world 400 million patients with chronic hepatitis B are recorded and 170 million patients with chronic hepatitis C, at the same time are annually added more than 50 million for the first time the revealed hepatitises B and 100-200 million hepatitises C. All chronic hepatitises occupy about 70% in the general structure of pathological processes of a liver. The disease meets frequency of 50-60 cases at 100 000 population, incidences are more subject men.
For the last 20-25 years many important data on chronic hepatitis are saved up, the mechanism of its development therefore more effective ways of therapy which are constantly improved are developed became clear. Infectiologists, therapists, gastroenterologists and other experts are engaged in studying of a question. The outcome and efficiency of therapy directly depend on a form of hepatitis, the general state and age of the patient.
Classification of chronic hepatitis
Chronic hepatitis is classified by several criteria: etiologies, degrees of activity of pathology, to data of a biopsy. On the causes allocate chronic viral hepatitis B, C, D, A, medicinal, autoimmune and cryptogene (not clear etiology). Degree of activity of pathological processes can be various:
- minimum - nuclear heating plant and ALT is higher than norm by 3 times, increase in timolovy test up to 5 Pieces, growth of gamma globulins up to 30%;
- moderated - concentration of ALT and nuclear heating plant increase at 3-10 times, timolovy test of 8 Pieces, gamma globulins of 30-35%;
- expressed - nuclear heating plant and ALT is higher than norm more than by 10 times, timolovy test is more than 8 Pieces, gamma globulins it is more than 35%.
On the basis of a histologic research and a biopsy allocate 4 stages of chronic hepatitis.
0 stage – fibrosis is absent
1 stage - insignificant periportalny fibrosis (growth of connecting fabric around cells of a liver and bilious channels)
2 stage - moderate fibrosis with porto-portal septa: connecting fabric, expanding, forms partitions (septa) which unite the neighboring portal highways created by branches of a vorotny vein, hepatic artery, bilious channels, lymphatic vessels and nerves. Portal highways are located on corners of a hepatic segment which has the hexagon form
3 stage – severe fibrosis with porto-portal septa
4 stage - signs of violation of very tectonics: considerable growth of connecting fabric with change of structure of a liver.
Reasons and pathogenesis of chronic hepatitis
The pathogenesis of various forms of chronic hepatitis is connected with damage of fabric and cells of a liver, formation of the immune answer, turning on of aggressive autoimmune mechanisms which promote development of a chronic inflammation and support him for a long time. But experts mark out some features of pathogenesis depending on etiologichesky factors.
Most often earlier postponed viral hepatitis B, C, D, sometimes is the reason of chronic hepatitis And. Each activator differently influences a liver: the virus of hepatitis B does not cause destruction of hepatocytes, the mechanism of development of pathology is connected with immune reaction to a microorganism which actively breeds in cells of a liver and other fabrics. Viruses of hepatitis S and D make direct toxic impact on hepatocytes, causing their death.
The organism intoxication caused by influence of alcohol, medicines (antibiotics, hormonal means, antitubercular medicines, etc.), heavy metals and chemicals is considered the second common cause of pathology. Toxins and their metabolites, collecting in cells of a liver, cause failure in their work, accumulation of bile, fats and exchange violations which lead to a necrosis of hepatocytes. In addition, metabolites are anti-genes to which the immune system actively reacts. Also chronic hepatitis can be created as a result of autoimmune processes which are connected with inferiority T-supressorov and formation of T-lymphocytes, toxic for cages.
Irrational food, abuse of alcohol, the wrong way of life, infectious diseases, malaria, endocarditis, various diseases of a liver which cause metabolic violations in hepatocytes can provoke development of pathology.
Symptoms of chronic hepatitis
Symptoms of chronic hepatitis are variable and depend on a pathology form. Signs at low-active (persistiruyushchy) process are poorly expressed or absolutely are absent. The general condition of the patient does not change, but deterioration is probable after abuse of alcohol, intoxication, a vitamin deficiency. Insignificant pains in the field of the right podreberye are possible. During survey moderate increase in a liver is found.
Clinical signs at the active (progressing) form of chronic hepatitis are brightly expressed and are shown in full. At most of patients the dispepsichesky syndrome (a meteorizm, nausea, vomiting, appetite violation, an abdominal distension, change of a chair), an astenovegetativny syndrome (sharp weakness, fatigue, decrease in working capacity, weight loss, sleeplessness, headaches), a syndrome of a liver failure (jaundice, fever, emergence of liquid in an abdominal cavity, bleeding of fabrics), long or periodic pains in a stomach is registered on the right. Against the background of chronic hepatitis the sizes of a spleen and regionarny lymph nodes increase. Because of violation of outflow of bile jaundice, an itch develops. Also on integuments it is possible to find vascular asterisks. During survey increase in the sizes of a liver comes to light (diffusion or taking one share). The liver is dense, painful at a palpation.
Chronic viral hepatitis D proceeds especially hard, the pronounced liver failure is characteristic of it. Most of patients complain of jaundice, an itch of integuments. Besides hepatic signs, extra hepatic are diagnosed: damage of kidneys, muscles, joints, lungs and so forth.
Feature of chronic hepatitis C – a long persistiruyushchy current. More than 90% of acute hepatitises With come to the end with synchronization. At patients the asthenic syndrome and insignificant increase in a liver is noted. The course of pathology wavy, in several decades it comes to an end with cirrhosis in 20-40% of cases.
Autoimmune chronic hepatitis occurs at women of 30 years and is more senior. Weakness, increased fatigue, yellowness of skin and mucous, morbidity in the right side is characteristic of pathology. At 25% of patients pathology imitates an acute hepatitis with a dispepsichesky and astenovegetativny syndrome, fever. Extra hepatic signs occur at every second patient, they are connected with damage of lungs, kidneys, vessels, hearts, a thyroid gland and other fabrics and bodies.
Medicinal chronic hepatitis is characterized by multiple signs, lack of specific symptoms, sometimes pathology masks under sharp process or mechanical jaundice.
Diagnosis of chronic hepatitis
Diagnosis of chronic hepatitis has to be timely. All procedures are carried out in office of gastroenterology. The final diagnosis is made on the basis of a clinical picture, tool and laboratory inspection: blood test on markers, ultrasonography of abdominal organs, a reogepatografiya (a research of blood supply of a liver), a liver biopsy.
Blood test allows to define a pathology form thanks to detection of specific markers is particles of a virus (anti-genes) and antibodies which are formed as a result of fight against a microorganism. Markers only of one type - anti-HAV IgM or anti-HEV IgM are characteristic of viral hepatitis A and E.
At viral hepatitis B it is possible to find several groups of markers, their quantity and a ratio indicate a stage of pathology and the forecast: a superficial anti-gene In (HBsAg), antibodies to a nuclear anti-gene of Anti-HBc, Anti-HBclgM, HBeAg, Anti-HBe (it appears only after completion of process), Anti-HBs (it is formed at adaptation of immunity to a microorganism). The virus of hepatitis D is identified on the basis of Anti-HDIgM, total Anti-HD and RNA of this virus. The main marker of hepatitis C - Anti-HCV, the second – hepatitis C virus RNA.
Functions of a liver are estimated on the basis of the biochemical analysis, to be exact, definition of concentration of ALT and nuclear heating plant (aminotransferase), bilirubin (bilious pigment), alkaline phosphatase. Against the background of chronic hepatitis their quantity sharply increases. Defeat of cells of a liver leads to sharp decrease in concentration of albumine in blood and to significant increase in globulins.
Ultrasonography of abdominal organs – a painless and safe way of diagnostics. It allows to determine the sizes of internals, and also to reveal the happened changes. The most exact method of a research – a liver biopsy, it allows to define a form and a stage of pathology, and also to pick up the most effective method of therapy. On dashing about of results it is possible to judge degree of prevalence of process and weight, and also a probable outcome.
Treatment of chronic hepatitis
Treatment of chronic hepatitis pursues the aim of elimination of the cause of pathology, knocking over of symptoms and improvement of the general state. Therapy has to be complex. To most of patients appoint the basic course directed to decrease in load of a liver. All patients with chronic hepatitis need to reduce physical activities, low-active lifestyle, a semi-bed rest, the minimum quantity of medicines, and also the full-fledged diet enriched with proteins, vitamins, minerals (diet No. 5) is shown them. Quite often apply vitamins B injections: B1, B6, B12. It is necessary to exclude fat, fried, smoked, preserved foods, spices, hard liquors (tea and coffee), and also alcohol.
At emergence of locks soft depletive, for digestion improvement – fermental medicines without the content of bile is shown. For protection of cells of a liver and acceleration of processes of restoration appoint gepatoprotektor. They should be accepted up to 2-3 months, it is desirable to repeat a course of reception of such drugs several times a year. At the expressed astenovegetativny syndrome use polyvitamins, natural adaptogens.
Viral chronic hepatitises badly give in to therapy, the large role is played by immunomodulators which indirectly influence microorganisms, making active immunity of the patient. It is forbidden to use independently these medicines as they possess contraindications and features.
A specific place among such medicines is held by interferona. They are appointed in the form of intramuscular or subcutaneous injections to 3 times a week; at the same time temperature increase of a body therefore before an injection reception of febrifuges is necessary is possible. The positive result after treatment by interferon is observed in 25% of cases of chronic hepatitises. At children's age this group of medicines is used in the form of rectal candles. If the condition of the patient allows, carry out intensive therapy: apply medicines of interferon and antiviral means in big dosages, for example, combine interferon together with ribaviriny and remantadin (especially at hepatitis C).
Constant search of new medicines led to development of pegylated interferon in which the molecule of interferon is connected to polyethyleneglycol. Thanks to it medicine can longer be in an organism and is long to struggle with viruses. Such medicines are highly effective, they allow to reduce the frequency of their reception and to prolong the period of remission of chronic hepatitis.
If chronic hepatitis is caused by intoxication, then it is necessary to carry out dezintoksikatsionny therapy, and also to exclude penetration of toxins into blood (to cancel medicine, alcohol, to leave chemical production, etc.).
Autoimmune chronic hepatitis is treated by glucocorticoids in a combination with azatiopriny. Hormonal means accept inside, after approach of effect lower their dose to minimum admissible. In the absence of results appoint liver transplantation.
Prevention and forecast of chronic hepatitis
Patients and carriers of viruses of hepatitis do not constitute big danger to people around as infection with an airborne and household way is excluded. It is possible to catch only after contact with blood or other biological liquids. To reduce risk of development of pathology, it is necessary to use barrier contraception during sexual intercourse, not to take others sanitary products.
In the first days after possible infection apply human immunoglobulin to the emergency prevention of hepatitis B. Vaccination against hepatitis B is also shown. Specific prevention of other forms of this pathology is not developed.
The forecast of chronic hepatitis depends on a type of a disease. Dosage forms almost completely recover, autoimmune therapies also well give in, virus are seldom allowed, most often they are transformed to cirrhosis. Combination of several causative agents, for example, of a virus of hepatitis V and D, causes development of the most severe form of a disease which quickly progresses. Lack of adequate therapy in 70% of cases leads to cirrhosis.