Hepatitis—the types (hepatitis A and B) and other common forms of liver inflammation

Hepatitis can be viral or non-viral, and a distinction is made between acute and chronic hepatitis. The condition is considered chronic if it lasts longer than 6 months. The liver is the largest and most important metabolic organ in the human body. It is also the largest gland in our body. Located in the upper right abdomen, its surface borders directly on the diaphragm.

Of particular importance is the portal vein system of this organ. Before substances can spread throughout the body, they first enter the liver via the portal vein. This “first-pass effect” means that medications can be metabolized there, and their effects can be enhanced or reduced. At the same time, the body’s cells are protected, for example, from ingested alcohol. Alcohol also first passes from the intestines to the liver for breakdown.

The liver’s metabolic functions depend heavily on the function of its cells. However, these cells can become infected by various viruses via the bloodstream. This results in severe inflammation and, consequently, impaired liver metabolism. Such inflammation of the liver is referred to as hepatitis.

The colloquial term “jaundice” is, strictly speaking, inaccurate. The noticeable yellowing (= jaundice) of the skin and the whites of the eyes does not occur in all cases of liver inflammation. Furthermore, jaundice can also result from a blockage of the bile ducts. This is usually caused by gallstones or tumors.

Regardless of the exact cause, every case of hepatitis always begins with damage to and destruction of liver cells. Proteins and enzymes—known as transaminases—are released from these cells. If these liver transaminases rise in the blood, this is an indication during diagnosis that hepatitis may be present.

During acute hepatitis, various inflammatory mediators are released. They lead to the observed general symptoms such as fever and flu-like symptoms.

In many cases, liver inflammation first becomes apparent through the resulting disturbances in liver function.

Disruptions in hemoglobin and bile acid metabolism lead to an increase in bilirubin. This is a breakdown product of the red blood pigment hemoglobin. Bilirubin in the blood causes

• the typical yellowing of the skin and the whites of the eyes,
• dark-colored urine, and
• the pale color of the stool and
• itching

. Since energy metabolism is disrupted, patients often feel weak. In cases of very severe hepatitis, other functions are impaired, such as the production of clotting factors or the detoxification of the blood.

An overview of typical symptoms of hepatitis:

• Fatigue
• Headaches
• Loss of appetite
• A feeling of pressure in the upper right abdomen
• Vomiting
• Itching
• Fever
• Dark-colored urine
• Light-colored stools
• Yellowing of the skin, mucous membranes, or eyes (known as jaundice).

To make a diagnosis, a doctor can quickly rule out hepatitis by taking a blood sample and conducting a subsequent test. If the doctor detects specific antibodies against the respective hepatitis virus in the blood, a diagnosis of hepatitis is confirmed.

If chronic hepatitis is suspected, further tests, such as a tissue sample (liver biopsy), are necessary.

As soon as hepatitis A, B, C, D, or E is diagnosed, the treating physician must report it to the public health department in accordance with Section 6 of the Infection Protection Act.

Hepatitis either resolves without complications after the acute phase has passed, or it progresses to chronic hepatitis.

In the chronic course of the disease, a condition known as cirrhosis of the liver develops over the long term. In this process, functional connective tissue is irreversibly converted into non-functional tissue (fibrosis).

In the terminal stage of this liver inflammation, the liver becomes largely non-functional. As a result, blood backs up through the entire circulatory system before reaching the liver. Consequently, collateral circulation develops, manifesting as an increased formation of internal varicose veins (varices).

Due to the lack of clotting factors caused by hepatitis, patients become increasingly prone to bleeding and coagulation disorders. In addition, fluid very often accumulates in the abdominal cavity—a condition that doctors refer to as ascites (abdominal fluid accumulation).

Liver dysfunction leads to further symptoms such as

• malnutrition,
• increased susceptibility to infection,
• increased tendency to bleed,
• confusion (= “hepatic encephalopathy”), and
• metabolic disorders.

In addition, liver cirrhosis resulting from chronic hepatitis increases the risk of hepatocellular carcinoma.

Hepatitis can have a wide variety of causes, including

• alcohol,
• toxins, and
• bile stasis resulting from a tumor or gallstones.

In addition, viruses play a particularly significant role. Those that cause liver inflammation are currently classified into five groups:

• Hepatitis A viruses (HAV), which are mainly transmitted through contaminated food.
• Hepatitis B viruses (HBV), which, as a sexually transmitted infection, use the bloodstream to infect new hosts.
• The hepatitis D virus (HDV) is closely linked to hepatitis B. This defective virus is a common co-infection with hepatitis B and requires the hepatitis B virus’s envelope to infect new cells.
• Hepatitis C is caused by the hepatitis C virus (HCV) and is arguably the most dangerous form of hepatitis in this group. If left untreated, it always leads to chronic hepatitis with cirrhosis of the liver and ultimately results in liver cancer.
• Hepatitis E viruses (HEV) are transmitted primarily through drinking water contaminated with feces. They are particularly widespread in Africa and Asia.

Hepatitis viruses are therefore transmitted either through the bloodstream (B, C, and D) or through so-called contact transmission (A and E). This means that, in the case of a viral infection, there has been oral or fecal contact. This can occur through sexual contact or through contact with shared household items.

In general, unsanitary facilities pose a risk. Contaminated food can be a source of epidemic infection. This includes vegetables or shellfish fertilized with feces, and occasionally drinking or bathing water. In such cases, many people fall ill at the same time. In general, countries in the developing world are considered high-risk areas for hepatitis. Travelers, in particular, should therefore always keep the following saying in mind: “Boil it, peel it, or leave it.” This means that all foods that have not been cooked or peeled should be avoided.

However, special caution is also warranted in the case of hepatitis B and C with regard to sexual contact and casual vacation acquaintances. If left untreated, both diseases can progress to a chronic form of liver inflammation and severely impair the rest of a person’s life. In addition to general precautions, however, vaccination is available for some hepatitis viruses. The following section will therefore focus on transmission routes and preventive measures.

Hepatitis A (HAV) is widespread worldwide. However, infections are particularly common in southern countries. The virus is characterized by its extreme resilience even outside the human body.

Because of this characteristic, the hepatitis A virus survives when it is flushed into the sea via feces. Shellfish and other marine animals absorb it from the water and unintentionally accumulate it through filtration mechanisms. Anyone enjoying a seafood pizza on vacation can easily become infected with the virus.

That is why hepatitis A is now considered one of the classic illnesses that can occur while traveling (“travelers’ hepatitis”).

The time from infection to the onset of symptoms (incubation period) is very long, ranging from 15 to 50 days. In many cases, the vacation is already over by then, making hepatitis A more difficult to detect. To complicate matters, children in particular are usually asymptomatic—that is, they show no signs of illness at all.

If symptoms do occur, the main diagnostic indicators are:

• Gastrointestinal symptoms
• Feeling of fullness
• Nausea
• General feeling of illness
• Mild fever
• Yellowing (= jaundice) of the skin and whites of the eyes

Hepatitis A is always acute and, unlike hepatitis B and C, does not develop into a chronic condition. Once a person has recovered from the infection, they are immune for life, so reinfection is impossible.

However, this form of liver inflammation can be completely prevented through prior vaccination. Travelers to Southern Europe, Africa, or Asia in particular should keep this in mind before departure. Depending on the health insurance provider, such a vaccination may even be reimbursed as a preventive measure for travel protection. In any case, children up to age 18 receive the vaccine free of charge in combination with the hepatitis B vaccine.

Hepatitis B virus (HBV) is transmitted through blood and other bodily fluids, including

• semen,
• tears,
• saliva, and colostrum.

For this reason, the disease is classified as a sexually transmitted infection (STI).

In acute cases, symptoms first appear 60 to 120 days after exposure and include

• nausea,
• vomiting,
• joint pain,
• fever, and
• fatigue.

Later on, the characteristic yellowing of the skin also occurs in hepatitis B. About one percent of those affected die from acute hepatitis, especially if the liver is already damaged by cirrhosis or other conditions. Another ten percent eventually develop chronic hepatitis.

The situation is different for children: In this group, 90 percent of infections progress to a chronic form. People with chronic hepatitis B remain a source of infection for life and are not permitted to work in the food service or healthcare industries, for example. As a result, hepatitis B also has a profound impact on the lives of those affected.

Between 0.7 and 1 percent of people in Germany are chronically infected. The best protection is provided by the three-dose vaccination series, which is free of charge if administered during childhood.

Are you unsure whether you should get vaccinated? The following list shows the groups of people for whom vaccination is currently recommended:

• All infants and young children can receive the hepatitis B vaccine. In addition, all adolescents between the ages of 9 and 17 who have not yet been vaccinated should get vaccinated.
• If the mother is infected with hepatitis B, newborns should also be vaccinated (passively immunized) immediately after birth as a precaution.
• People who are already weakened by other chronic illnesses should also receive the vaccine. This group includes, for example, people
  • those with chronic kidney disease,
  • dialysis patients,
  • people who frequently receive transfusions of blood or blood components,
  • patients undergoing major surgery, and
  • people who primarily live or work in psychiatric or other care facilities, as well as in workshops for people with disabilities.
• In addition, people with chronic liver disease and those who are HIV-positive but have not yet been infected with hepatitis B benefit from this.
• Healthcare workers, including
  • trainees and students,
  • laboratory and cleaning staff,
  • staff at psychiatric facilities, asylum seeker shelters, and workshops for people with disabilities, and
  • other individuals at risk of infection through blood exposure (e.g., first responders, police officers, sanitation workers)
• People who travel frequently to tropical and subtropical regions where hepatitis B is common should also get vaccinated. The same applies if close contact (including sexual contact) is expected during a vacation.

The vaccine provides long-lasting protection against infection with the hepatitis B virus. However, regular booster shots are recommended after 15 years, depending on the antibody titer in the blood. Following high-risk exposure or for individuals working in the healthcare sector, booster shots may be advisable as early as 10 years after the initial vaccination.

Hepatitis C (HCV) is the most insidious of all human hepatitis infections. After a relatively short acute phase, the hepatitis progresses to a chronic form. The acute phase is often asymptomatic. Over the course of 15 to 30 years, liver cirrhosis slowly develops, which can progress to liver cancer.

The incubation period until the first symptoms appear is usually six to eight weeks. Flu-like symptoms are very common and eventually lead to jaundice. Chronic hepatitis C is usually asymptomatic and therefore often goes unnoticed.

However, there are a number of other symptoms that may indicate such a persistent infection:

• Fatigue
• Loss of energy
• Upper abdominal discomfort
• Itchy skin
• Joint pain and other rheumatic conditions
• Kidney disease
• Depression

Unfortunately, unlike with hepatitis B, D, and A, there is no vaccine available for hepatitis C. Therefore, the only way to protect yourself is to avoid blood-to-blood contact, as blood remains the primary route of transmission.

The following groups are therefore particularly at risk

• Injecting drug users
• Tattoo enthusiasts who get new tattoos abroad, as well as
• People who engage in risky sexual practices. 

Until the early 1990s, contaminated blood units or blood products were the main cause of new infections. The virus was not identified until 1989. Since then, blood units have been screened for hepatitis viruses using a test.

In general, however, hepatitis C is now considered curable. We owe this in particular to new medications approved in 2014 that inhibit viral replication in the liver.

The prognosis for a complete cure ranges from 60 to 95%. Factors influencing this include

• the viral genotype (1–6),
• the stage of liver cirrhosis,
• the presence of concurrent infections with other pathogens, such as HIV or hepatitis B.

Therefore, early diagnosis and treatment should always be the goal.

The hepatitis D virus (HDV) is what is known as a defective virus. This means that it cannot replicate on its own in liver cells. For its replication cycle, hepatitis D requires a concurrent infection of the cells with hepatitis B. It essentially uses the envelope of the hepatitis B virus as a “helper virus” to infect new liver cells.

Transmission occurs in the same way as with hepatitis B. Thus, in cases of frequent changes in sexual partners, dual infections with both viruses can occur. Such co-infections with hepatitis B and D are generally even more severe than infections with hepatitis B alone.

If a D variant develops, it is therefore important for the patient to know whether

• they were infected with both B and D at the same time (simultaneous infection) or
• the D variant developed later (superinfection).

The liver suffers significantly more in the case of a superinfection. However, the course of the disease is also much slower compared to the B variant.

Up to 90 percent of those affected then develop a chronic liver infection, which can lead to cirrhosis and liver cancer. Therefore, especially in cases of dual infection with hepatitis B and D, it is very important to begin treatment with antiviral medications early on. This offers the best chance of slowing the progression of the disease or reducing the viral load. The best protection against hepatitis D infection is also provided by the hepatitis B vaccine.

This form of liver inflammation caused by hepatitis E (HEV) is a disease found worldwide. It occurs primarily in Asia, Africa, and developing countries. Similar to hepatitis A, it is transmitted to humans through contaminated water.

In Europe, the risk of infection arises from consuming uncooked pork or contaminated wild boar meat. The Federal Institute for Risk Assessment recommends meticulous hygiene when preparing wild boar meat. Anyone who butchers a wild boar or parts of it themselves should always wear gloves.

People with acute or chronic immunodeficiency are among the residual risk groups. In these individuals, the hepatitis E virus is more likely to cause hepatitis E.

Approximately 40 days after infection, typical symptoms develop, including yellowing of the skin and eyes. Since the disease is usually asymptomatic in children, there is a lack of reliable data in this age group.

Hepatitis E usually resolves on its own after about two to three weeks. There are no known cases of the disease becoming chronic. There is neither a treatment specifically targeting the virus nor a vaccine approved in Europe to prevent the infection.

What general steps can be taken to avoid contracting hepatitis? Here are some tips that are particularly useful when traveling abroad and in potentially risky everyday situations:

• When traveling to distant countries, peel or cook fruits and vegetables before eating them.
• Do not use ice cubes in Asia, Africa, or South America (the water should be boiled).
• Only eat meat products—and especially offal—from pigs, wild boars, deer, or roe deer if they are thoroughly cooked. 
• Protect yourself by using a condom during sexual intercourse, especially when changing partners.
• When using sharp objects such as scissors, needles, or knives (at nail salons, for manicures and pedicures, and at tattoo parlors), ensure that proper hygiene standards are maintained.