Hepatitis A and hepatitis E viruses cause acute hepatitis and therefore they have no effective treatment; management involves relieving the symptoms. A few cases of hepatitis A (0.5%) develop into severe hepatitis and liver failure; however, despite the symptoms, patients usually have a favourable evolution and the infection is cured without any lasting damage. Hepatitis A never develops into a chronic disease. Similarly, it is rare for hepatitis E to produce severe hepatitis (1%), with the exception of pregnant women where the risk of severe hepatitis and liver failure can ascend to 20% of cases. Hepatitis E never becomes chronic in healthy people, but the virus can produce a chronic infection in immunosuppressed individuals such as transplant patients.
In the case of hepatitis B, the age of acquisition of the infection influences whether it evolves into a chronic condition: 90% of patients if shortly after birth; 30% if infected between the ages of 1 and 5 years; and less than 15% in healthy adults.
In hepatitis C the acute infection is usually asymptomatic and very rarely associated with severe hepatitis. In 15–45% of people infected with hepatitis C the virus is eliminated spontaneously in the first 6 months following infection. The rest of this group develops a chronic infection and of these 15–30% are at risk of cirrhosis of the liver. Patients with cirrhosis have a 5‑year cumulative incidence of hepatocellular carcinoma of 5%.
Acute complications of Viral Hepatitis
Acute hepatitis has a wide range of repercussions. It can clear up completely and course without any symptoms and without the patient noticing its presence, but in some instances, it can also have complications, in which case it is classed as severe hepatitis. In these cases, the patient suffers from liver failure. The inflammation causes the liver to stop functioning correctly and coagulation disorders arise, which can evolve into hepatic encephalopathy (drowsiness, stupor, disorientation) and even hepatic coma. This is known as acute liver failure and a liver transplant is the only treatment available at the present time.
Chronic complications of Viral Hepatitis
In some cases, infection persists over time and develops into chronic hepatitis, which is when the inflammation of the liver lasts for more than 6 months. Chronic hepatitis can evolve into fibrosis (when the liver cells are inflamed they produce a more fibrous tissue similar to scarring) and eventually cirrhosis (which is when the liver is so damaged and full of scar tissue that it progressively suffers a loss of function) or liver cancer.
Fibrosis. When the liver cells suffer chronic inflammation (e.g., due to a viral infection or alcohol consumption) they develop into a more fibrous tissue similar to scar tissue. As the liver cells are replaced by scar tissue, the liver loses elasticity and its capacity for normal function. The prognosis and severity of the liver disease depend on the degree of fibrosis.
Cirrhosis. Cirrhosis is the most advanced stage of liver disease, when the organ is very damaged, and is characterised by a decrease in its elasticity. Healthy liver tissue is replaced by scar tissue, which partially obstructs the blood flow through the liver. The scarring also reduces other functions such as the elimination of bacteria and toxins from the blood, bile production or the processing of nutrients, hormones and medications.
Portal hypertension. This corresponds to high blood pressure in the portal vein (the vein which transports blood from the digestive system to the liver). The increase in pressure is a result of obstructed blood flow through the liver because cirrhosis produces scarring and therefore reduces the liver’s elasticity. An increase in portal vein pressure may cause the veins in the oesophagus to dilate (varicose veins). The oesophageal varicose veins are fragile and may bleed more easily.
Compensated cirrhosis. Although the liver is damaged, it can still perform the most important functions if the patient has not suffered cirrhosis-related complications. The patient must undergo regular monitoring to detect if the disease progresses or any complications arise.
Decompensated cirrhosis. In this stage, the liver cannot perform its most important functions and the patient already has symptoms and complications associated with the cirrhosis and portal vein hypertension such as:
Ascites. Retention and accumulation of fluid in the abdomen, producing an increase in the abdominal circumference. This becomes apparent when the patient needs, for example, more holes in their belt or their weight increases notably. They may also notice fluid retention in the dependent parts of the body, such as legs, wrists, ankles, hands, leading to cutaneous oedemas.
Hepatic encephalopathy. A severe complication of cirrhosis due to poor hepatic function; the liver does not eliminate toxic substances from the blood and these subsequently reach the brain. If the patient develops encephalopathy they will be drowsy or confused, they may be disoriented (they do not know where they are, what day it is or do not recognise their relatives) and suffer speech, writing and gait disturbances because of a lack of coordination in their movements. The encephalopathy could progress into a decreased level of consciousness and coma.
Upper gastrointestinal bleeding. This is a very severe complication that occurs when a dilated vein (varix) in the oesophagus or stomach ruptures and bleeds. In the most striking cases the patient may vomit blood and therefore they must be taken to hospital immediately. In other cases, the patient has black, sticky and foul-smelling stools (tar-like), which indicates they are suffering from gastrointestinal bleeding.
Other complications. In this stage the disease affects several areas of the body with a wide range of manifestations, including kidney, heart or lung problems associated with the cirrhosis. Poor kidney function can cause blood coagulation disorders and a decrease in platelets, so the patient has weaker skin and therefore a greater risk of haematomas (bruises) and skin lesions. Patients also experience a loss of muscle mass and appear thinner. In addition, they could have reproductive problems such as male and female sterility, as well as impotence and reduced sexual desire. Finally, the body’s altered immune function (low defences) combined with the liver’s poor capacity to filter blood from the intestine means that patients with decompensated cirrhosis have a very high risk of infections, e.g., urine infections, pneumonia or infected ascites (known as spontaneous bacterial peritonitis).
Due to all the complications described above, patients with decompensated cirrhosis have a reduced life expectancy and should therefore be assessed by a hepatologist specialising in these complications and undergo regular medical checkups. Some patients with decompensated cirrhosis are indicated for a liver transplant, which is the only cure for this disease.
Liver cancer. Liver cancer or hepatocellular carcinoma is the most common type of liver tumour. An early diagnosis of the tumour is very important as the smallest growths can receive curative treatments. Therefore, all patients with cirrhosis undergo a liver ultrasound every 6 months.