Passive and active hepatitis C. Chronic active hepatitis of alcoholic etiology. CVH with low activity

Chronic hepatitis is an inflammatory-dystrophic lesion of the liver, leading to disruption of its functionality and lasting more than six months. With this pathology, the lobular structure of the organ is preserved, but inflammatory-dystrophic changes occur in it, and without treatment the disease develops into cirrhosis, which can cause death. That is why treatment of chronic hepatitis C and other forms should be carried out under the close supervision of a doctor, who individually selects the dosage of medications and complements the therapy with traditional medicine.

Symptoms

Most often, this disease has a hidden course, that is, the symptoms of the pathology are extremely vague and do not give an accurate idea of ​​​​the nature of the disorders in the body. Early symptoms include:

• weakness;
• slight increase in body temperature;
• mild nausea;
• irritability;
• decreased appetite;
• decreased mood;
• general malaise and increased fatigue.

Rarely, such symptoms of muscle pain may occur or even develop against the background of a person’s aversion to familiar food.

As the pathology progresses, patients complain of pain under the ribs with right side, which first appear only after eating food, especially fried and fatty foods, and then become permanent.

Due to the fact that symptoms are often absent or unexpressed, it can be extremely difficult to make a timely diagnosis, because patients attribute these symptoms to other diseases or even blame stress and poor ecology. Therefore, it is so important to consult a doctor at the slightest suspicion of liver dysfunction for diagnosis.

Varieties

It should be said that in the medical classification, hepatitis is divided into six main types. Of these, two, A and E, never develop into a chronic form. The most common form of the disease is chronic hepatitis C, which is also the most complex pathology, because it is asymptomatic with the development of severe complications.

The disease is caused by which people are often infected in medical institutions, including in dental offices. To become infected with this virus, it is necessary that the biological fluids of the patient or virus carrier enter the human body, which is possible during various medical procedures, for example, injections into a vein or blood transfusion.

The most common ways of becoming infected with viral hepatitis C are as follows:

• unprotected sexual contact;
• failure to maintain personal hygiene (using other people's towels, toothbrushes, manicure tools);
• transmission of infection from mother to child during childbirth;
• use of the same disposable syringe by drug addicts;
• visits to dental offices and nail salons, in which insufficient attention is paid to the sanitary processing of instruments.

Chronic viral hepatitis C can be asymptomatic for 10 or even 15 years, but strange symptoms that should alert a person are still present. In particular, he may suffer from constant allergic reactions, often suffer from infectious and colds, experience headaches, and even. In addition, with pathology, symptoms of disturbances in the gastrointestinal tract are noted:

• nausea;
• loss of appetite;
• gagging;
• liver enlargement;
• weight loss, etc.

If we talk about chronic hepatitis B, then it is most often infected through the parenteral route, that is, through intravenous injections or blood transfusion. There is also a route of transmission of the virus from mother to fetus.

According to ICD 10, chronic hepatitis B is designated in the classification system by the numbers 18.0 and 18.1. The course of the disease is multivariate - it is quite possible that a person, if the virus enters his body, will not suffer from its negative effects, but will still be a virus carrier. The second variant of the course leads to the development of acute, and the third - to the development of cirrhosis and even a cancerous tumor.

Very dangerous option is a combination of virus B and D, which causes the development of co-infection. If virus D joins virus B, which is already developing in the body, doctors talk about superinfection. With this development of events, a lightning-fast form of the disease is observed, and the person dies in the shortest possible time. The most poorly studied is the G virus, which in its clinical picture similar to virus C.

There is also autoimmune chronic hepatitis, which is a consequence of autoimmune processes, which more often affects women. Drug-induced hepatitis It also often progresses - the liver is affected due to excessive use of medications.

In medical practice, there is such a thing as cryptogenic chronic hepatitis, which is spoken of in cases where the causes of inflammatory and degenerative changes in the organ are not clear.

It is necessary to talk about chronic toxic hepatitis - a disease characterized by an acute onset and a rapid course. Pathology develops due to the effects of various drugs on the body, chemical substances, industrial poisons and other toxic substances harmful to the human body.

If we talk about the forms of pathology, chronic viral hepatitis C and B can be active and persistent. Chronic active hepatitis is a disease in which there is a pronounced tendency to develop hepatitis. This pathology can have both hepatic and extrahepatic manifestations, depending on what virus the disease is caused by. In particular, chronic active hepatitis C and B is characterized by severe symptoms characteristic of this pathology, but autoimmune or cryptogenic hepatitis is hidden behind the symptoms of other gastrointestinal diseases.

If we talk about chronic persistent hepatitis, then this pathology is the mildest form of the disease, with mild symptoms. With timely treatment and compliance with doctor's recommendations, chronic persistent hepatitis is completely curable.

Causes

As has already become clear from the above information, different forms of hepatitis develop due to certain reasons.

Of course, the main thing is the entry of a particular virus into the body of a healthy person. In addition, certain types of pathology can be caused by factors such as:

• unfavorable environment;
• alcohol and drug abuse;
• working in unfavorable conditions;
• uncontrolled use of medications;
• autoimmune pathologies;
• decline protective functions body;
• regular stress and other negative factors.

Treatment

To detect chronic viral hepatitis, it is necessary to conduct a complete examination of the patient. First of all, anamnesis is collected, and the person’s complaints are listened to. Next is carried out visual inspection and palpation of the liver, after which the doctor prescribes the necessary tests and instrumental methods diagnostics Currently with diagnostic purpose They use ELISA methods to accurately determine the presence of a pathogen of one or another form of viral hepatitis in the body. An accurate diagnosis is established when HCV RNA markers are detected in a person’s blood for six months.

Ultrasound examination and computed tomography play an important role in diagnosis. These studies make it possible to clarify the degree of inflammatory-dystrophic disorders in the affected organ.

Today, chronic hepatitis can be successfully treated, but the treatment is long-term and requires a responsible approach. All patients who have been diagnosed with chronic hepatitis C, B and other viral hepatitis are prescribed antiviral therapy. To achieve success in treatment, it is recommended to treat viral hepatitis B and C in a medical facility so that the doctor can control the dosage of medications taking into account the dynamics of the pathology.

There is no single treatment regimen for such a pathology as chronic hepatitis, because everything depends on the form of the disease and its stage. In particular, chronic viral hepatitis C is treated antiviral drugs, preventing the progression of the disease, and chronic viral hepatitis B requires both antiviral and symptomatic therapy to maintain liver function and improve its functional state. Detoxification therapy is also prescribed.

If we talk about chronic persistent hepatitis, then in the remission stage the disease does not require treatment - you just need to follow the doctor’s recommendations regarding nutrition for this pathology. If a period of exacerbation occurs, then chronic persistent hepatitis is treated in a hospital - detoxification therapy is indicated by intravenous administration of saline, glucose and hemodesis.

Chronic active hepatitis, in which the manifestations of the disease are pronounced, requires large-scale therapy with antiviral drugs and medications that relieve local symptoms. Since chronic active hepatitis often causes serious complications, it is necessary to support the body by taking medications that protect certain internal organs from damage.

Diet plays an important role in treatment. It is prohibited to consume foods harmful to the body, including fatty and fried foods, sausages and canned food, chicken eggs in any form and much more - it is recommended to adhere to diet No. 5.

The following products are allowed for consumption:

• vegetables and fruits;
• natural honey;
• dried fruits;
• dietary varieties of fish and meat;
• vegetarian soups;
• porridge;
• herbal teas.

A complex combination of medications and traditional methods. In particular, chronic viral hepatitis C can be successfully cured with lingonberry infusion or regular consumption of birch sap. However, it should be remembered that such treatment is effective only if modern medications are taken simultaneously, and in itself cannot cure this disease.

Is everything in the article correct from a medical point of view?

Answer only if you have proven medical knowledge

Chronic active hepatitis is a disease that develops in the liver. It can manifest as chronic viral active hepatitis or.

Symptoms of the disease

Chronic active hepatitis is most often observed in childhood. In most cases, it affects females. It is almost impossible to diagnose the disease at an early stage, since it is characterized by the absence of symptoms. Low-level hepatitis in some cases can develop as regular acute hepatitis.

As this disease develops, patients may experience specific symptoms. Asthenia is most often observed in patients. In adult females, libido may decrease with hepatitis. Patients also often experience symptoms such as spider veins on the body or hyperemia of the palms. Active hepatitis C in most cases is accompanied by a slight increase in body temperature.

A pronounced symptom of this disease, which is determined during examination of the patient, is liver enlargement. During the period of remission, this organ returns to normal. With low activity hepatitis, the papillae on the tongue are smoothed out. The organ itself takes on a bright pink color. With the development of this disease, symptoms such as asthenovegetative or edematous-asthenic syndrome may also be observed. In the first case, there is a decline in the detoxification function of the organ.

Chronic active hepatitis may also cause symptoms such as:

• fatigue;
• unmotivated weakness;
• sleep disturbance;
• psycho-emotional lability.

Very often, patients complain of decreased performance. They get tired even when performing familiar everyday tasks. In some cases, this disease may be accompanied by an enlarged spleen. If chronic active hepatitis develops in men, it may be accompanied by gynecomastia. When this disease appears, males and females may experience hair loss in the pubic and armpit areas.

Like inactive hepatitis, this disease is in most cases accompanied by fever. Very often the disease is accompanied by cutaneous vasculitis:

• erythema;
• hives;
• purples.

When this disease appears, patients are often diagnosed with glomerulonephritis, which is characterized by a chronic course. Also, the pathological condition may be accompanied by multiple migrating arthralgias in large joints. At the same time, there is no deformation.

When the disease appears, many patients complain that their urine becomes significantly darker. Its color resembles dark beer or tea. The feces of patients, on the contrary, lighten and acquire a cream color. The disease in most cases is accompanied by subrenal jaundice. In this case, brown pigmentation of the skin is observed.

Hepatitis can present differently among patients. Symptoms directly depend on the degree of disease activity.

If the patient knows what signs accompany hepatitis and observes them in himself, then he must definitely seek help from a doctor. The specialist will prescribe appropriate tests for the patient, and based on their results, rational treatment.

Features of disease diagnosis

To make a correct diagnosis, the patient is prescribed tests. They consist, first of all, in a functional study of the liver. It is observed that bilirubin is increased in moderate amounts. Analyzes also show that the number of transaminases has increased significantly - from 5 to 10 times.

During laboratory tests, during the development of this disease, it is observed that gamma globulins almost double. Tests also show that albumin levels are normal. In some cases, their decrease may be diagnosed.

To make a correct diagnosis, the patient is in most cases prescribed laparoscopy. During this procedure, an enlargement of the liver is observed. The organ is characterized by the presence of a rounded lower edge. It has a smooth or furrowed surface, which is characterized by a red color. The liver is also characterized by a fairly dense consistency.

The main significance of histological examination for hepatitis is to identify the degree of disease activity.

With the development of chronic active hepatitis, extrahepatic manifestations may occur. When examining a patient, tests may show that he has varying degrees arthralgia, as well as poly- or monoarthritis. The patient may also exhibit signs of diseases such as:

• amenorrhea;
• skin rash;
• pulmonary infiltrate;
• pleurisy;
• pericarditis, etc.

As a result, in some cases an erroneous diagnosis is made.

In order to correctly diagnose the patient, appropriate tests are prescribed. Patients should tell the doctor what signs of illness concern them. This will allow you to make the most accurate diagnosis.

Course of the disease and diagnosis

Chronic active hepatitis in most cases is characterized by a severe course. In this case, the patient experiences frequent exacerbations pathological condition, in which a variety of clinical and laboratory manifestations are enhanced.

In some cases, the process stabilizes, but is accompanied by exacerbations. Death may also occur. In this case, signs of a disease such as progressive liver failure appear.

In most cases, with the development of active hepatitis, cirrhosis gradually develops. It is very often observed during the first examination of the patient. The course of this disease is quite dangerous, since against its background hepatocellular failure and portal hypertension can develop. The second of them reduces the possibility of surgical intervention to almost zero, as it is accompanied by gastrointestinal bleeding.

Diagnosis of the disease, regardless of what form it occurs, can be simple or difficult. Difficulties may arise because it is not over yet. Histological changes may be characterized by aggressiveness. Difficulties in diagnosing the disease also lie in the fact that it has similar symptoms with other diseases. This makes it impossible to make a correct diagnosis.

The course of hepatitis of varying degrees of activity in most cases occurs in severe form. To make a diagnosis, it is necessary to conduct a series of studies.

Features of treatment of the disease

If the disease of any degree of activity progresses, the patient is recommended to rest in bed. He must also adhere to a diet. Table No. 5 is most often used for this purpose.

If the viral etiology of the disease is proven, then the patient is prescribed interferon-based medications. If a patient is diagnosed with hepatitis B, then he is prescribed Intron A or Reaferon. A single dose of the drug is 5 million IU. The drug is administered 5 to 7 times a week. The course of treatment for the disease using these medications is at least six months.

When a patient is diagnosed with a disease that has arisen as a result of hepatitis C, he is also prescribed interferons. A single dose of the drug is 3 million IU. The medication is prescribed three times a week. The course of treatment is 1-1.5 years.

If the patient has interferon resistance, then the use of the antiviral drug Lamivudine is required.. The daily dose of the drug is from 150 to 300 milligrams. The course of treatment with this medication can last from 1 to 6 months.

With hepatitis, which has high replicative activity, the patient's subpopulation increases. That is why the disease is classified as autoimmune. Since a deficiency of suppression is observed during the development of the disease, it is necessary to treat the disease using immunocorrective therapy. For low activity diseases, steroid hormones, cytostatics and thymic drugs are used for treatment.

In most cases, treatment of the disease involves the use of complex therapy, which includes taking Prednisolone and Laferon. Prednisolone is taken at a dose of 45 milligrams per day. A single dose of Laferon is 4 million IU. This drug is prescribed to patients intramuscularly. The duration of treatment with the drug is 3 weeks. When taking these drugs in combination, ALT levels stabilized in most patients.

To obtain a clinical effect, patients must be treated with Timalin. Most often, the drug is prescribed to patients who have a low Tx/Tc ratio. When the disease worsens, patients are prescribed cytostatics. Discontinuation of the drug is carried out when the patient experiences a relapse. Otherwise, during remission of the disease, inhibition of the synthesis of normal antibodies will be observed.

At the stage of exacerbation of the disease, it is necessary to treat the patient with immunosuppressants, which disrupt cooperative intercellular processes. Doctors say that patients should be given Azathioprine. Patients are prescribed 2.5 milligrams of the drug per kilogram of body weight per day. In case of individual intolerance to this drug, patients are prescribed Prednisolone. The daily dose of the drug is 1-2 milligrams per kilogram of weight. The course of treatment using this medicine is one week.

Background therapy for low disease activity requires the use of multivitamin preparations or flavonoids. In some cases, patients are infused with amino acid mixtures intravenously. If the disease of low activity is in remission, then to treat it it is necessary to use Neovir, multivitamins or glycyrrhizic acid drugs.

Treatment of low-level hepatitis and other forms requires an integrated approach. Medicines are prescribed depending on the course of the disease, as well as individual characteristics patient.

Prevention measures

To avoid the occurrence of hepatitis, it is necessary to apply preventive measures in a timely manner. If a patient has even mild liver disease, he must be provided with complete rest. This will improve blood flow in the liver and also limit the possibility of developing the disease. It is also recommended to prevent and promptly treat Botkin's disease.

During the cold season, people are recommended to take vitamin complexes. It is also recommended to take them if intestinal diseases develop. The most commonly recommended intake is vitamin K, Ascorutin, lipoic acid, Undevit.

To eliminate the possibility of hepatitis developing in patients, it is recommended that medical instruments be thoroughly cleaned before using them in hospitals. People who take drugs intravenously are at risk of developing the disease. This is why drug addiction treatment is necessary. Before blood transfusion, it is necessary to carry out tests for infection.

Males are strictly prohibited from using the same razors. The virus can also be transmitted through sexual contact. That is why it is necessary to exclude unprotected sexual intercourse.

The occurrence of chronic active hepatitis can occur due to various reasons. When the first signs of this disease appear, you must contact a medical center for diagnosis and effective treatment. To avoid the occurrence of the disease, it is necessary to follow preventive measures.

Quite often in modern medical practice, chronic hepatitis B is registered. How long do people live with it and what are the prognosis for patients? What symptoms are accompanied by the disease? The answers to these questions are of interest to many people, because this disease is today considered one of the most common on the planet. Moreover, if diagnosed untimely and untreated, hepatitis often ends in death.

What is hepatitis B?

To begin with, it is worth considering the main characteristics and features of the disease. The term “chronic hepatitis B” is used to combine a group of diseases that affect hepatocytes. Of course, pathological changes in the liver tissues affect the functioning of the whole organism.

In most cases, such liver damage occurs when viruses enter the body. It is believed that almost a third of the world's population is sick or has previously had this infection. In approximately 7% of cases, acute hepatitis becomes chronic, which is difficult to treat. By the way, development of this disease may be associated with other factors.

Viral hepatitis and its features

What is chronic hepatitis B? How long do they live with him? Are there effective methods treatment? These questions are certainly important, but first it’s worth considering the causes and mechanism of development of the disease.

As already mentioned, such liver damage is most often associated with the penetration of specific viral particles into the body. The hepatitis B virus is released along with biological fluids - this applies not only to blood, but also to semen, vaginal secretions and saliva. Accordingly, it is very easy to catch the infection through contact with an infected person. According to studies, in families in which a person with viral hepatitis lives, after 5-10 years everyone becomes infected - viral particles are spread through household means.

Previously, you could catch an infection during an injection or blood transfusion, visiting a dentist's office, or even getting a manicure. Today, such a spread of the virus is rarely observed, since disposable instruments have become commonplace, as well as effective sterilization equipment. However, the risk group includes people from socially disadvantaged groups of the population, as well as workers in the intimate services sector, drug addicts, and people with promiscuous sex lives. The infection can also be passed from mother to child during pregnancy.

Other forms of chronic hepatitis B

Not only a viral infection can cause the development of hepatitis B. There are other known forms of this disease:

• Autoimmune chronic hepatitis is a disease associated with genetic disorders at work immune system, as a result of which it begins to attack its own cells. As a rule, an autoimmune reaction is provoked by the same hepatitis viruses, as well as herpes and some other groups of infections.
• Alcoholic hepatitis develops against the background of constant, long-term alcohol abuse. Observed in patients with chronic alcoholism.
• Drug-induced chronic hepatitis develops as a side effect of uncontrolled use of large doses certain drugs, for example, antibiotics, isoniazid, powerful painkillers, anticoagulants, etc.

Stages of development of viral hepatitis

What does chronic hepatitis B look like? Symptoms of the disease depend primarily on the stage of development of the disease, of which four are usually distinguished:

• The stage of immune tolerance is observed if the patient is infected at a very young age. During this period, there are no manifestations of the disease. By the way, it can be long-lasting - up to 15-20 years.
• This is followed by the active stage, in which rapid multiplication of viral particles is observed, which is accompanied by massive death of liver cells. Sometimes this course leads to the rapid development of liver cirrhosis. If this does not happen, the disease enters the phase of inactive virus carriage - this is a transition to the chronic form of hepatitis.
• The stage of relative calm, in which the patient is only a carrier of the virus, can also last several years. Active reproduction of viral particles is not observed.
• Despite the fact that during the inactive period no serious disorders are observed, the human body is weakened and more susceptible to various infections. Infection with viruses, be it herpes simplex or even a cold, can provoke reactivation of the disease, or rather, an exacerbation of chronic hepatitis B, in which increased reproduction of viruses and death of liver cells begins again.

What symptoms accompany the disease?

Manifestations of the disease largely depend on the stage of its development and the degree of liver damage. How to determine hepatitis B? The symptoms that primarily concern patients are fatigue and constant weakness. As the disease progresses, sleep problems appear, as well as frequent migraines.

Pain due to hepatitis is also present - it is localized in the area of ​​the right hypochondrium. Patients also complain of dyspeptic symptoms, in particular, nausea, bloating, heaviness in the abdomen, bitterness in the mouth, lack of appetite, dry mucous membranes of the oral cavity.

Itching, redness and rash may also occur. Often a person experiences bleeding gums, small hemorrhages under the skin that occur even after a slight blow or pinch, as well as the appearance of so-called spider veins.

Extrahepatic manifestations of hepatitis

Chronic hepatitis B is a disease in which liver cells are destroyed. Violation of the normal functioning of this organ affects the functioning of the entire body. For example, against the background of hepatitis, strong changes in the level of hormones in the blood are often observed.

Persistent arterial hypertension, purpura, arthralgia, and polyneuropathy may develop. Many patients experience damage to the muscles, organs of vision, and endocrine glands, which may be accompanied by amenorrhea, thyroid disease, or even diabetes. Complications of hepatitis include malignant degeneration of cells.

Chronic hepatitis B: tests and diagnosis

Of course, for the decision accurate diagnosis you need to undergo a series of examinations. First of all, carry out biochemical analysis blood, which allows the doctor to judge the functioning of the liver. A special blood test for markers allows you to confirm the presence of antibodies to the hepatitis virus in the patient’s body.

Ultrasound examination of organs is mandatory abdominal cavity is a safe, painless and informative diagnostic method that allows you to identify changes in the size and structure of organs. Patients are often prescribed a liver biopsy. Laboratory research liver tissue samples help determine the severity of the disease, the extent of its spread, and even the expected outcome for the patient.

Hepatitis treatment regimen

Therapy for this disease largely depends on its origin. For example, the autoimmune form of hepatitis is treated with corticosteroids. In the presence of viral infection Taking immunomodulators is important. These drugs inhibit the proliferation of viruses. In case of severe intoxication of the body, appropriate measures are taken to cleanse the body of toxic substances. You should also avoid potentially dangerous drugs and alcohol.

Further treatment is aimed at relieving the load on the liver and gradually restoring its function. Therapy must be comprehensive. During the acute phase of the disease, bed rest and a minimum of physical activity are very important. For the patient they make up proper diet, rich in proteins, minerals and vitamins. Spicy and salty foods, canned food, fatty and fried foods, as well as alcohol should be excluded from the menu. To improve digestion, special enzyme preparations can be used, which should not contain bile. If the patient suffers from constipation, the problem is solved with the help of mild laxatives. It is important to take medications - hepatoprotectors, which protect liver cells from harmful effects and promote tissue repair processes. Sometimes patients are additionally prescribed injections of B vitamins.

Chronic hepatitis B: how long do people live with it? Prognosis for patients

We have already considered questions about what provokes the development of this disease and what disorders it is accompanied by. So how dangerous is chronic hepatitis B? How long do patients live with him?

There is no clear answer to this question. The outcome of chronic hepatitis B depends on its origin and the severity of liver damage. For example, if the disease is caused by taking medications, then liver function can be almost completely restored. Autoimmune hepatitis is also quite treatable. As for chronic viral hepatitis, there is a very high probability the appearance of complications in the future, including cirrhosis.

That is why people are recommended to get vaccinated against hepatitis, avoid contact with the blood of infected people, and use protective equipment during sexual intercourse. A healthy lifestyle is important not only for preventing infection - it should also be followed by people who have already had hepatitis, as proper nutrition, therapeutic exercises, physical activity, proper sleep and rest patterns reduce the likelihood of relapse.

Chronic hepatitis (classification described below) is a disease that has necrotic changes in the tissue of liver cells, without disturbing the structure of the organ itself and signs of hypertension. Patients often complain of pain in the right hypochondrium, nausea, vomiting, poor appetite, upset stomach, general weakness, rapid weight loss, jaundice and itching of the skin. This disease can be diagnosed using an ultrasound of the abdomen, liver biopsy, and blood tests. The disease cannot be completely cured; therapy is aimed at eliminating the causes of this pathology, generally improving the person’s condition and achieving long-term remission. But we must remember that it is much easier to kill hepatitis from the infection route.

Chronic hepatitis

Chronic hepatitis is inflammation of the parenchyma and stroma of the liver. This disease develops for various reasons and lasts more than 6 months. The pathology is serious clinical problem, given that the disease progresses very quickly.

If you believe the statistics, more than 400 million people in the world suffer from chronic hepatitis, just under 200 million patients complain that they are struggling with hepatitis C. Moreover, every year 50 million people are added with the disease of the first type and 100-200 million - second.

It should be noted that active chronic hepatitis is much more common than any other similar liver disease. The disease occurs quite often, and, as a rule, men are susceptible to it. Over the past 30 years, scientists have been able to identify many important information about this disease, it became clear how it develops and its causes. Therefore, the most effective treatment methods have been developed. Every year they improve. It should be noted that this issue is dealt with not only by medical specialists, but also by therapists, infectious disease specialists, gastroenterologists, and so on. The outcome of a person’s life directly depends on what form of hepatitis is present, how advanced it is, and the patient’s age also plays a significant role.

Classification of chronic hepatitis

This disease is classified according to several criteria. We are talking about the etiology, the degree of growth of the pathology. And also according to biopsy data. There are chronic hepatitis B, C, D, A, in addition to them there are also medicinal, cryptogenic and autoimmune. However, the degree of development of the disease may vary. There are minimal, moderate, pronounced. We'll talk about them a little below. In addition, based on histological studies of biopsies, hepatitis is divided into 4 stages. They are called 0, 1, 2, 3, 4, respectively.

Classification by process activity

• Minimum level of activity: ALT is 3 times higher than normal. The thymol test increases to 5E, and gamma globulin increases to almost 30%.
• Moderate: the concentration of the above enzymes increases 10 times, the thymol test is 8 units. Gamma globulin increases to 35%.
• Pronounced is characterized by the fact that enzymes increase by more than 10 times, the sample increases by more than 8. Globulin increases by more than 35%.

Stages of hepatitis

At zero stage fibrosis is absent. In this form, the activity of chronic hepatitis is practically not detected.

The first stage is characterized by the fact that slight decomposition of the tissue occurs. The connecting surface grows near the liver and bile. The second stage is characterized by the fact that fibrosis is already moderate. Appearing in the septum, the tissue unites the tracts, forms branches of veins, arteries, ducts, and nerves. When connected, it forms a hexagon.

During the third stage, severe fibrosis is observed. The fourth stage is characterized by the fact that the connective tissue grows, and the structure of the liver changes as much as possible.

Causes of hepatitis

Chronic hepatitis (the classification can be read above) is most often the result of a transmitted virus. We are talking about hepatitis B, C, D bacteria, the least common is A. Each pathogen acts differently on the liver of any person. For example, the hepatitis B virus does not damage hepatocytes, and the development of pathology is directly related to the reaction of the immune system to this virus. Hepatitis C and D bacteria are toxic. They affect the liver and cause inflammation.

The second common cause is intoxication of the body. Diagnosis of chronic hepatitis is much easier. As a rule, this is affected by alcohol, medications, heavy metals and chemicals. Over time, toxins accumulate in the liver, causing organs to malfunction, bile and other substances to accumulate, and metabolic disorders to occur. Because of this, necrosis occurs.

Metabolites are considered antigens to which the immune system reacts violently. The development of hepatitis can also be provoked due to poor nutrition, alcohol abuse, and leading an unhealthy lifestyle. The causative agents are infectious diseases: malaria and other diseases. They can cause metabolic disorders.

Pathogenesis of the disease

The pathogenesis of the disease is due to the fact that liver cell tissue is damaged. The immune system reacts very actively, an aggressive autoimmune mechanism appears, and chronic inflammation develops. They last quite a long time.

Symptoms of the disease

The symptoms of chronic hepatitis (the classification of which is quite complex) vary quite greatly for each person, moreover, they directly depend on the form of the disease. Signs at the inactive stage are weakly expressed, they may not even appear. The patient does not feel unwell, but after he drinks alcohol or develops vitamin deficiency, he immediately feels severely unwell. In the area of ​​the right hypochondrium possible lungs pain. During the examination, the doctor may detect significant enlargement of the liver.

Clinical signs of an already active form of this disease are quite pronounced, and they manifest themselves to the maximum. Patients complain of flatulence, nausea, bloating, diarrhea, and poor appetite. In addition, asthenovegetative syndrome occurs, that is, we are talking about fatigue, poor concentration, weight loss, headaches, and liver failure syndrome may also play a role. A person complains of jaundice, constant fever, tissues constantly bleed, and fluid forms in the abdominal cavity. Abdominal pain is prolonged and severe.

Chronic hepatitis causes problems with the spleen and lymph nodes. They increase significantly in size. Bile has a very weak outflow, which is why jaundice develops. Itching may occur. Special spider veins can be found on the skin. During the disease, the liver enlarges. At the same time, palpation is quite painful, the organ is very dense.

Symptoms of hepatitis D

Viral chronic hepatitis is difficult to diagnose. It is the most severe and is usually characterized by liver failure, which is expressed in its maximum form. Most patients complain of jaundice and very severe itching. In addition to these signs, damage to muscles, joints, lungs and other organs can be diagnosed.

Symptoms of hepatitis C

Hepatitis C has its own characteristics. This disease is quite long-term, and more than 90% of cases of acute forms of this disease end with it becoming chronic. Patients often complain of a slight enlargement of the liver, as well as general malaise. Unfortunately, the course of the pathology is wavy: a person may not pay attention to pain that goes away after some time. But several years after infection, in 40% of cases this disease ends in cirrhosis.

Symptoms of autoimmune hepatitis

The disease chronic hepatitis of the autoimmune form occurs, as a rule, in women who are already over 30. They complain that they feel weak, get tired quite quickly, the skin becomes yellow, and there is constant pain in the right side. It should be noted that this disease is quite insidious. In 25% of patients, this disease is hidden under acute hepatitis C with the manifestation of certain syndromes and fever. In every second patient, extrahepatic signs can be detected; damage to the lungs, blood vessels, heart, thyroid gland, and tissues may occur.

Symptoms of drug-induced chronic hepatitis

This disease has a very large number of signs, but there are no specific symptoms. Sometimes the disease can masquerade as obstructive jaundice.

Diagnosis of hepatitis

In order to have a positive result after treatment of chronic persistent hepatitis, it is necessary to diagnose this disease in time. All procedures are performed under the supervision of a gastroenterologist. This diagnosis placed only after examination. We are talking about a blood test, an ultrasound of the abdominal cavity, and a study of the blood supply to the liver, and a biopsy. Thanks to a blood test, it is possible to identify the form of this disease if there are specific markers - viruses or antigens that fight microorganisms. It is so easy to identify the stage of chronic hepatitis. The pathogenesis is complex.

Viral hepatitis A or E is characterized by markers of certain types. When it comes to hepatitis B, several groups of markers are identified during diagnosis. Moreover, their number and ratio clearly indicate the state of developmental pathology. Moreover, thanks to this analysis, a forecast can already be made.

The hepatitis D virus is detected using certain markers, we are talking about Anti-HD. Liver functions are assessed using a special biochemical analysis. In this case, the organ is checked for the state of transferase, bilirubin, and alkaline phosphatase. The signs of hepatitis are very pronounced. With chronic hepatitis, their number will increase several times. If liver cells are damaged, the concentration of albumin in the blood will sharply decrease, and globulin will increase.

Next, you need to perform an ultrasound of the abdominal cavity - this is the most painless and safe way. Thanks to it, you can find out the size of the internal organs, and accordingly, find out the changes that have occurred. The most precise method The research will include a biopsy. Thanks to it, you can find out the form and stage of this disease. After it is carried out, you can accurately diagnose and prescribe treatment. Thanks to comprehensive research, as well as their results, it is already possible to judge how common the process is and the likely outcome of a person.

Treatment of the disease

Treatment of chronic toxic hepatitis is carried out in order to eliminate the causes of the pathology, relieve symptoms and improve the person’s condition. It should be noted that therapy should be as comprehensive as possible. Most patients undergo a basic course, which allows to reduce the load on the liver as much as possible. If a person has constipation, he is prescribed mild laxatives that help improve digestion. As a rule, these are preparations without bile content. All patients should reduce physical activity. They must maintain a sedentary lifestyle and semi-bed rest.

Medicines are prescribed in minimum quantity because they can provide strong influence to the liver. This is dangerous when treating chronic toxic hepatitis. Moreover, a complete diet No. 5 is prescribed. It is maximally enriched with proteins and vitamins, all essential minerals.

Injections are often prescribed. We are talking about vitamins B1, B6, B12. Fatty, fried and other foods that are heavy, as well as strong drinks (alcohol) are prohibited. In order to protect liver cells, it is necessary to use hepaprotectors. They are taken for two to three months, the course of treatment is repeated once a year.

Viral chronic hepatitis, unfortunately, is quite difficult to treat, so patients are prescribed immunomodulators. They affect microorganisms, so the human immune system becomes more active. It is prohibited to use these drugs on your own, as they have a huge list of contraindications and side effects.

We also need to talk about interferons. They are often prescribed to be taken up to three times a week. Because of them, the temperature can rise, so before you give the injection, you need to take an antipyretic drug. It should be noted that in 25% of chronic hepatitis diseases, these treatments bring positive results. If a child suffers from hepatitis, then this group of drugs is prescribed as rectal suppositories. In this case, the signs of hepatitis decrease.

In order to improve a person's condition, intensive therapy can be performed. It is allowed to use interferon and antiviral drugs at the same time, and in large dosages.

Due to the fact that doctors are constantly looking for new drugs, special pegylated interferons were invented. Thanks to them, you can fight viruses much more effectively; this drug stays in the body much longer. These medications are considered highly effective; they do not need to be used as often as the remedies described above. If chronic hepatitis is caused by intoxication, then special therapy is carried out, which removes all unnecessary substances from the body. Moreover, it is necessary to exclude any source of toxins entering the blood. Among other things, it is necessary to exclude any drug if it is included in such a risk group, and to leave work if it is related to chemical production.

If chronic hepatitis (cirrhosis - the final stage of the disease) is associated with the autoimmune system, then it is necessary to use special hormonal agents. They are taken internally. After the effect occurs, their intake is reduced to a minimum. If there are no results, then doctors prescribe a liver transplant.

Prevention

Patients and carriers of the virus do not pose a great danger to people around them. It should be noted that infection by airborne droplets and household methods is impossible. You can become infected only after contact with blood or any other biological fluids.

In order to reduce the risk of developing this disease, it is necessary to use contraceptive methods during sexual intercourse, and also not to use other people’s hygiene items. Hepatitis is difficult to treat. It’s quite easy to get away from the path of infection, more late stages- difficult. In order to prevent hepatitis B, it is necessary to use human immunoglobulin on the first day after infection. In addition, you can also get vaccinated against this type of disease. Unfortunately, no other prevention has been developed for forms of this disease.

Forecast

The prognosis for chronic hepatitis (the etiology of the disease is complex) depends on what form and type it is present. If we are talking about the dosage form, then it is almost completely curable. The autoimmune form also responds well to therapy. A viral infection can be cured only in 5% of cases; in the rest it transforms into cirrhosis.

If several pathogens are combined, that is, several hepatitis is present in the body at once, then a rather severe form of the disease occurs, which progresses as quickly as possible. If adequate therapy is absent, then quite quickly in 70% of cases this disease will develop into cirrhosis. The ICD code for chronic hepatitis is B12.

In modern society, people are often interested in the following question: “Hepatitis B - what is it?” Everything is explained by the widespread spread of this disease and the increased risk of infection.

Hepatitis B is a serious disease that attacks liver cells and can be fatal. It is caused by the HBV virus. Hepatitis B poses the greatest danger in the long term, since in most cases it occurs without obvious signs. Every modern person needs to know the symptoms and treatment of hepatitis B. The disease is difficult to treat, but if a person with hepatitis B manages to recover, he develops the necessary antibodies that provide lasting immunity.

In this article we will consider the following issues related to the disease called “hepatitis B”:

How is it transmitted?

Prevention of disease.

Treatment of hepatitis B.

How does infection occur?

The hepatitis B virus is extremely viable. Factors such as boiling, freezing, and treatment with highly toxic chemicals are not harmful to it. At room temperature, the virus can survive for a very long time. It poses a danger even if it is in a dried, old stain of blood or saliva. It is hundreds of times more infectious than the AIDS virus.

The most frequently asked question is: “How is hepatitis B transmitted?” To get sick, a small amount of the virus enters a person’s bloodstream. Routes of infection are also mucous membranes and damaged skin. Through the blood, this virus reaches liver cells, where it settles and multiplies. In this case, a change occurs in the tissues of this organ. The sick person’s own lymphocytes begin to attack and damage the altered cells, having a detrimental effect on the condition of the liver.

The main danger is the blood of a sick person. Hepatitis B is most often transmitted in the following ways:

1. In beauty salons (manicure, pedicure, piercing).

2. In tattoo parlors (including when permanent makeup is performed).

3. During the process of blood or serum transfusion.

4. During the hemodialysis procedure through machines.

5. When using other people's razors, toothbrushes, towels and other personal hygiene items.

6. Through instruments in medical institutions (dental offices, operating rooms, dressing rooms, donor stations, etc.).

7. Through non-sterile syringes (risk group - drug addicts).

8. Sexual contact with a sick person (any unprotected relationships).

9. From mother to child (infection occurs when passing through the birth canal).

Infection is almost impossible (but possible) through kissing, sneezing, breastfeeding, sharing utensils, and shaking hands. Next, we will look at the symptoms and treatment of hepatitis B.

What are the signs of infection

The main danger of this disease is that at first the symptoms are not pronounced. Minor signs begin to appear only when the virus has already multiplied and is actively operating in the body. The asymptomatic incubation period takes on average 2-6 months. Warning signs that may indicate a developed disease:

• Fatigue and fatigue.
• Loss of appetite, weight loss.
• Nausea.
• Feeling of discomfort in the liver area (right hypochondrium).
• Darkening of urine (the color of brewed tea).
• Lightening of feces.
• Yellowness of the sclera of the eyes and skin.
• Joint pain.
• A biochemical blood test shows signs of liver dysfunction.

It should also be noted that in adults these symptoms are more pronounced than in children. If these signs are detected, it is necessary to take a blood test for hepatitis B antigen, which will confirm or deny the presence of the disease.

Carriage of hepatitis

One of the forms of viral hepatitis B disease is carriage. In this case, it manifests itself depending on personal immunity and is asymptomatic. The course of this disease often does not become chronic due to the vitality of the body, its strength and endurance. Most often, carriage develops into a chronic form of hepatitis B after 15-20 years.

Just 10 years ago, carriage was not perceived as hepatitis B disease. Currently, many infectious disease doctors insist that this form of the disease is the beginning of chronic hepatitis B. Specific treatment there is no virus for carriers, so for prevention it is necessary to carry out immunostimulating and restorative courses. However, you need to know that the carrier poses a danger to others due to its contagiousness.

Forms of the disease

The most severe form of viral hepatitis B is the fulminant onset of the disease, when symptoms develop very quickly. Brain swelling occurs within a few hours, followed by coma and death. Cases of patient survival after such a disease are very rare.

Acute hepatitis B is also isolated. In this case, the following variants of the disease are possible:

• subclinical (symptoms appear moderately, there is no jaundice, minor changes in the biochemical blood test);
• icteric (jaundice, intoxication, bright pronounced changes in biochemical analysis);
• protracted (considerable duration of the disease, lasting from 3 to 12 months, most often manifested in elderly people);
• cholestatic (features of inflammation are moderately expressed, signs of damage to biliary excretion dominate).

The most common question that comes up is: “What are the causes, symptoms and treatment of hepatitis B?” Signs of the acute form of the disease at the initial stage can be compared with the manifestations of a cold: general weakness, fatigue, nausea, sweating, sore throat, headaches, runny nose, fever, cough. Later, external signs of a viral disease appear (jaundice, darkening of urine, lightening of stool, etc.).

One of the most common forms of the disease is the chronic form of hepatitis B. In this case, the incubation period lasts from a month to six months. This disease is insidious in that it is asymptomatic at the initial stage. Only after serious changes in the liver do signs of hepatitis begin to appear. There have been cases when the virus was detected in a person’s blood completely by accident, and the patient was unaware of his illness and did not experience any discomfort.

Hepatitis B: diagnosis

Most often people are interested in information about what tests for hepatitis and HIV infection need to be taken. Hepatitis B is diagnosed using the following tests:

1. Biochemical blood test (shows the condition of the liver, a diagnosis can only be made indirectly).

2. Blood test for the “Australian” HBSAg antigen. It should be noted that a negative result this survey cannot exclude carriage of the virus or an inactive form of hepatitis B.

3. Blood test for IgM antibodies (their presence confirms the acute form of the disease).

4. Blood test for IgG antibodies(their presence will allow us to speak about the chronic form of hepatitis B and carriage of the virus). If you suspect you have HIV infection, you must take a special blood test. ELISA can detect the virus only after 1.5-3 months after infection. PCR analysis confirms infection 2-3 weeks after infection.

Chronic hepatitis: treatment

In the chronic form of hepatitis B, an infectious disease hepatologist prescribes a course of antiviral drugs:

• nucleide analogues help reduce the reproduction activity of this virus in the blood;
• interferons reduce pathological changes in the liver.

In addition, regular maintenance therapy is recommended. For this purpose, hepatoprotectors are prescribed, which contribute to the resistance of liver cells to the penetration of viruses; immunomodulatory drugs that increase the body's overall resistance to infection.

It is also possible to carry out detoxification when, thanks to special drugs the blood is cleansed of various toxins. For general maintenance of the body, it is recommended to take vitamins in courses, as well as strictly follow a diet.

In case of serious liver dysfunction, it is possible surgical intervention. In this case, a liver transplant is performed from a donor.

Treatment of acute forms of the disease

If hepatitis B is mild, antiviral treatment is not prescribed. Patients are shown:

• detoxification (taking large quantity water to reduce symptoms and restore fluid levels in the body);
• strict diet (without alcohol and taking toxic medications).

Cure

Full recovery is possible. With proper treatment, lifestyle and medical supervision, it occurs within several years. If you have an acute form of hepatitis B, there is a chance that it will become chronic. Asymptomatic carriage can persist throughout life without causing serious complications or liver disease.

If necessary treatment is not produced, hepatitis B can lead to serious diseases such as cirrhosis or liver cancer.

Prevention

If the question of hepatitis B - what it is - is more or less clear, then let’s clarify how to avoid this disease. To reduce the likelihood of becoming infected with the hepatitis B virus, the following recommendations should be followed:

• Timely vaccination against hepatitis B.
• Protected sexual intercourse.
• Maintaining hygiene rules.
• Undertaking preventive medical examinations.

Graft

Vaccination against hepatitis B is carried out during the first day of a baby's life. Often women ask the following question: “Why vaccinate your child so early?” The fact is that when infected with hepatitis B in the first 12 months after birth, the baby becomes a carrier of the virus for the rest of his life. If we take into account the asymptomatic course of the disease, then we can seriously fear for the future health of the child. Untreated hepatitis B often causes complications such as cirrhosis or liver cancer.

This vaccination is carried out for all children, since sometimes it is impossible for a mother to detect that she is a carrier of hepatitis B during pregnancy. The fact is that the test that is prescribed during pregnancy confirms only the chronic or acute form of the disease.

In the Russian Federation, vaccinations against hepatitis B are carried out according to the 0-1-6 scheme. This means that vaccination occurs in three doses: at birth, at 1 month and at six months. If the woman in labor is a carrier of the virus, vaccination is carried out according to the scheme: 0-1-2-12. The vaccine is injected into the front of the thigh intramuscularly.

An adult also needs to be vaccinated against hepatitis B. This is due to the wide spread of this disease in Russia and around the world. Vaccination is carried out in three doses according to the 0-1-6 scheme. It must be carried out within a certain time frame without delay, otherwise the body will not develop effective immunity against this disease.

Contraindications to vaccination against hepatitis B are the following:

• Allergy to baker's yeast.
• Acute respiratory diseases.
• Meningitis.
• Autoimmune diseases.
• Diabetes mellitus type 1.

A little about hepatitis C

The likelihood of infection with hepatitis C and B viruses occurs under the same circumstances. Symptoms appear only during the acute course of the disease and manifest themselves in the form of general fatigue, weakness, joint pain, and digestive disorders. Jaundice with hepatitis C develops very rarely. After suffering from acute hepatitis C, the patient may recover completely, as well as the disease becoming chronic or carrier state.

The symptoms and treatment of hepatitis B and C are similar in many ways. The probability of cure is possible in 60-80% of cases, provided timely appeal to a medical facility.

There is currently no vaccination against viral hepatitis C, so to prevent infection it is necessary to follow the recommendations of doctors.

Types of illness

Viral hepatitis is a very insidious disease. Its danger lies in its asymptomatic course, while one of the vital organs - the liver - is destroyed. It is his condition that is directly affected by hepatitis.

The types of this disease are as follows: viral hepatitis A, B, C, D, E, F (G). They have different courses, and infection also occurs for different reasons. The only thing they have in common is the similarity of symptoms and the detrimental effect on the human liver. For diagnosis and treatment, you must go to a medical facility and get tested.

Conclusion

With timely diagnosis, you can achieve full recovery from a disease such as hepatitis. There are different types of this virus. Some require expensive and lengthy treatment, while others can be eliminated without special therapy.

Many people with hepatitis B do not receive the necessary treatment because antiviral drugs are quite expensive. The minimum price for a one-month course is 10,000 rubles, and you must take medications for a year or more. If cure does not occur, then after a break the necessary medications will be prescribed again.

Is it possible to overcome chronic hepatitis? Treatment depends on timely access to a medical facility. If this disease is detected in time, the symptoms will not complicate your life, and therapy will be faster, more effective and cheaper.

Rice. 20. Chronic active viral hepatitis (NV) Bridging necrosis of hepatocytes with the development of extensive infiltrates is presented. Staining with hematoxylin and eosin, * 100.
It is believed that stepwise necrosis is a consequence of the cytopathic effect of T-lymphocytes and lymphotoxic activity of T-killers, as well as antibody-dependent cytolysis carried out by K-lymphocytes. With an insignificant degree of activity, peri-portal stepwise necrosis is limited to segments of the periportal zone, only part of the portal tracts are affected. Moderate degree activity is characterized by the same changes, but the damage covers almost all portal tracts, inflammatory infiltrates and stepwise necrosis penetrate to the middle of the lobule.
Along with the described typical picture, there are more severe histological subtypes of CAH with bridging and multilobular necrosis. The appearance of bridge-like necrosis is characteristic of the pronounced activity of the process.
In CAH with bridging necrosis (subacute hepatitis, subacute liver necrosis), areas of parenchymal necrosis, stromal collapse and an inflammatory reaction are detected. It should be emphasized that the necrotic hepatocytes themselves may not be visible, and the bridges between the portal tracts and the central veins are made up of extensive lymphoid cell infiltrates and collagen fibers that dissect the lobules [Loginov A.S., AruinL. I., 1985].
CAH with multilobular necrosis is the most severe form (sharply expressed degree of activity) and is characterized by massive necrosis of the parenchyma, spreading beyond the boundaries of the lobules, total destruction of several adjacent lobules, sometimes with a strong inflammatory reaction or collapse. In biopsy specimens, as a rule, stepwise necrosis is also visible.
The structural restructuring of the liver tissue, observed in some patients, gives reason to talk about the transition of chronic hepatitis to cirrhosis of the liver. In 25% of the patients with chronic active viral hepatitis we observed, the lobular architecture was noticeably disturbed in punctates; some portal tracts were elongated and connected to each other by thin fibrous bridges. Thin connecting layers, often extending from the portal tracts, divide some of the lobules into small fragments.
In chronic viral hepatitis C, histological changes are less pronounced than in hepatitis B. They are characterized predominantly by hydropic degeneration and focal microvesicular fatty degeneration of hepatocytes. A distinctive feature is the presence of acidophilic necrosis of single hepatocytes in the central areas of the lobule. In active forms, extended inflammatory infiltration and fibrosis of the portal tracts with partial destruction of the border plate and “stepped” necrosis of the peri-portal hepatic parenchyma are noted. In repeated liver punctures of patients with chronic hepatitis C, changes can vary between the histological findings of chronic active and chronic persistent hepatitis (the so-called fluctuating type of chronic hepatitis C).
Morphological markers of the hepatitis B virus. The viral etiology of CAH can be established not only by electron microscopic or immunomorphological detection of Dane particles, HB&A& and HBCA&, but also using publicly available methods. Viral liver damage can be suspected by the presence of frosted glassy hepatocytes when examining preparations stained with hematoxylin and eosin or using the Van Gieson method. These are large hepatocytes with pale eosin-stained cytoplasm. Opaque glassy hepatocytes are found not only in the presence of HB&Ag, but also in drug-induced and alcohol-induced lesions. However, in the presence of HB&A§, frosted glassy hepatocytes are stained with orcein and aldehyde-fuchsin. Liver cells containing HB&Ag are stained in paraffin sections with aldehyde fuchsin and orcein (Shikata reaction). The specificity of orcein staining was confirmed by parallel studies of HB8A§ in liver tissue using immunofluorescence and electron microscopy.
Clinical picture. In a number of patients with CAH of viral etiology, a direct connection can be traced with acute viral hepatitis, but in most cases, the acute phase of hepatitis and the appearance of clinical symptoms of chronic hepatitis are separated by 3-5 years or more. The disease begins gradually and is manifested by repeated episodes of mild jaundice, liver enlargement and a number of nonspecific symptoms.
Asthenovegetative syndrome is extremely characteristic: weakness, severe fatigue, sometimes so strong that patients are forced to spend 5 to 7 hours in bed daytime. There are often complaints of poor performance, nervousness, and a depressed state of mind (hypochondria). Characterized by a sharp weight loss (5-10 kg).
Pain in the liver area is a fairly common symptom of the disease; it can be constant, aching, and sometimes very intense. Sharply intensifies after physical activity. The pain appears to be associated with pronounced inflammatory infiltration in the connective tissue (rich in nerves), in the portal and periportal zones, especially in the liver capsule. Some patients do not pain syndrome, but there is a feeling of heaviness and fullness in the right hypochondrium, independent of food intake; many patients complain of the unpleasant taste of food products.
Dyspeptic syndrome rarely reaches significant severity; constant, painful nausea, aggravated by food and medications, accompanies exacerbation of the disease in most patients. Dyspeptic syndrome in patients with CAH can be associated with impaired detoxification function of the liver and concomitant damage to the pancreas.
The syndrome of “small” liver failure, manifested by drowsiness, severe bleeding, jaundice and ascites, is observed in patients with severe necrotizing forms of CAH.
Cholestasis syndrome can be observed along with asthenovegetative disorders or dyspeptic syndrome. It is expressed by transient skin itching, increased levels of bilirubin, cholesterol, alkaline phosphatase activity, and GGTP in the blood serum.
During the period of exacerbation, there are such extrahepatic manifestations of the disease as pain in the joints and muscles with an increase in temperature to subfebrile levels, but there is no swelling or deformation of the joints. Patients report amenorrhea, decreased libido, and gynecomastia.
Extrahepatic signs (spider veins, hyperemia of the palms - “liver palms”) are often detected in this form of hepatitis. Their appearance coincides with biochemical and morphological signs of the activity of the process and is not, as is often believed, an indication of liver cirrhosis. If clinical improvement is accompanied by a noticeable decrease or disappearance of spider veins, then hyperemia of the palms remains for a long time, often until “biochemical remission”.
Hepatomegaly is detected in most patients with CAH. During the period of severe exacerbation, the liver protrudes 3-7 cm from under the costal arch, is moderately dense, the edge is pointed, palpation is painful. Remission is accompanied by a noticeable shrinkage of the liver: in many patients it protrudes by 2-3 cm or is palpated at the edge of the costal arch. Moderate enlargement of the spleen is common, but significant enlargement is rare. The onset of remission is accompanied by a decrease in the spleen. The activity of the reticuloendothelial tissue of the spleen in patients with CAH may be increased, therefore, when studying with "shTs", the accumulation of colloid in the spleen is often increased, but to a lesser extent than in liver cirrhosis.
“Asymptomatic” CAH occurs latently in 25% of patients with complaints of intolerance to fatty and fried foods and alcohol. The examination reveals hepatomegaly, normal or slightly increased bilirubin levels, and an increase in aminotransferase activity by 3-5 times. At histological examination a picture characteristic of CAH of moderate or insignificant degree of activity is revealed. Liver cirrhosis develops latently, although it develops less frequently than with other course options.
Functional state of the liver. Exacerbation of CAH of viral etiology is characterized by hypergammaglobulinemia, hypoalbuminemia, increased thymol test values ​​and aminotransferase activity. The activity of serum ALT is usually greater than that of AST. In most cases, the content of total protein and bilirubin in the blood serum increases. In remission of chronic active hepatitis, indicators of gamma globulins, functional tests and enzyme activity are rarely completely normalized; in most patients they only improve.
Serological indicators. The identification of hepatitis B markers in blood serum is of diagnostic importance.
Hepatitis B virus markers in the blood serum of patients with chronic active hepatitis of viral etiology: HB&A& is positive in most cases; anti-HB8 negative; anti-HBc are usually positive in high titers, some are positive for ap1t-HBC1&M; NVSA& positive or negative; DNA polymerase positive or negative; anti-HBe negative or positive.
The presence of HBeA& and/or anti-HBc class 1&M in the blood serum, as well as DNA polymerase, indicates replication of the hepatitis B virus; detection of anti-HBe may indicate favorable prognosis diseases.
Availability of HB&A& in various combinations with anti-HBc class 1§M and anti-HBe characterizes the phase of integration of the hepatitis B virus into the hepatocyte genome.
Features of the flow. CAH of viral etiology can have a continuously relapsing course or occur with alternating exacerbations and distinct clinical and sometimes biochemical remissions.
A continuously relapsing course of viral CAH can be observed for several years with very short clear intervals lasting up to a month.
In CAH with alternating exacerbations and remissions, exacerbations are usually frequent and long-lasting. Clinical remission occurs after 3-6 months, and improvement in biochemical parameters occurs after 6-12 months. IN in some cases functional tests are completely normalized during remission, although for a short period of time - usually up to 2-3 months. Some patients have several exacerbations within one year.
The prognosis of CAH depends on the stage of the disease at the time of diagnosis and histological signs of process activity, primarily the type of necrosis. SN. Nagtl (1986) defines a favorable prognosis for CAH primarily by the absence of signs of cirrhosis at the time of observation, while 5-year survival is observed in 80% of patients. In the presence of signs of cirrhosis, the 5-year survival rate is determined to be only 50%.
The possibility of a complete recovery is low. Stabilization of CAH is diagnosed by persistent clinical remission and improvement of biochemical parameters for at least 1/2-2 years, i.e., with weak or moderate activity of the process. It is important to emphasize the possibility of spontaneous remissions in 10-25% of patients.
According to the literature, 30-50% of all CAH develop into cirrhosis.
We conducted clinical follow-up for a period of 4 to 18 years in 66 patients with chronic active viral hepatitis. Stabilization of the process with weak or moderate activity was detected in 38 patients, 28 developed cirrhosis of the liver, of whom died
sick.
The disease had a significant duration in many patients with CAH: from 5 to 10 years in 13 patients, from 10 to 15 years in 6 patients, and more than 15 years in 4 patients.
In some patients, when the process with weak activity stabilizes, the disease acquires the morphological features of chronic persistent hepatitis.
Long-term clinical observation shows that determining the variants of this form of hepatitis (chronic active hepatitis with exacerbations followed by clear remissions, or continuously relapsing) helps in choosing treatment tactics, but does not determine the outcome of the disease. The prognosis largely depends on how early treatment is started. Medical examination of patients at an early stage significantly improves the prognosis.
The results of dispensary observation, indicating stabilization and ongoing activity of the process without signs of cirrhosis, refute the opinion about the fatal inevitability of the transition of this form of hepatitis to cirrhosis of the liver.
Chronic active viral hepatitis C, like its acute form, is much milder and has a more favorable prognosis than hepatitis B. Clinical symptoms are nonspecific, autoimmune manifestations are not observed. Apparently, the significant tolerance of the patient’s immune system to the pathogen determines the slow, erased course of the disease and minor biochemical changes in this form of chronic hepatitis. There is a tendency towards long-term remissions with complete normalization of biochemical test data, which leads to an erroneous conclusion about recovery. After a long-term remission, spontaneous increases in aminotransferase activity are observed, indicating the onset of an exacerbation. According to SN. At 221 (1986), the transition of hepatitis to cirrhosis is observed in 20-30% of patients, in most cases there is a tendency to transition to chronic persistent hepatitis.
Chronic autoimmune hepatitis
This variant of CAH is accompanied by significant immune disorders. Clinical variants of similar pathological process have been described under various names: active juvenile cirrhosis, lipoid hepatitis, acute hepatitis, autoimmune hepatitis, plasma cell hepatitis, liver disease in young women with hypergammaglobulinemia, progressive hypergammaglobulinemic hepatitis. Each of these names dogmatizes one symptom of the disease. The term “autoimmune hepatitis”, emphasizing the uniqueness of the pathogenesis and clinical manifestations of the disease and the most common one, was chosen by us to designate this variant of CAH, which occurs with the most striking extrahepatic manifestations and often with a pronounced activity of the process.
Morphological characteristics. These are lymphomacrophagic elements, plasma cells, and in smaller numbers segmented nuclear leukocytes.
A distinctive feature of this form of hepatitis is the identification of a large number of plasma cells at an early stage of the disease. In our observations, the transition to cirrhosis did not indicate an inactive stage of the disease. The formation of cirrhosis was detected in patients with undiminished activity of the process and a malignant course during the first and second years of the disease.
Clinical picture. The incidence of chronic autoimmune hepatitis is unknown, although most diseases are described in the
¦
Western Europe and the USA, and in our country - in the European part, but there are reports of cases of detection of HB&A&-negative chronic active hepatitis with autoimmune manifestations in India. Among those sick with this form of hepatitis, the majority were girls and young women aged 10-30 years, less often women in menopause.
The ratio of women to men in autoimmune hepatitis is 3:1, while chronic viral hepatitis is more often observed in men. We observed 28 women with chronic autoimmune hepatitis aged 11-52 years and two men aged 14 and 42 years, while 10 patients were under 20 years old at the onset of the disease.
The onset of autoimmune hepatitis. In some patients, the initial symptoms are indistinguishable from those of acute viral hepatitis. Periods of weakness, anorexia, and dark urine were preceded by intense jaundice with an increase in bilirubin content to 100-300 µmol/l (6-17%) and aminotransferase activity more than 200 units, which became the reason for hospitalization with a diagnosis of “acute viral hepatitis”. In only one patient, the bilirubin level did not exceed 20.5 µmol/l (1.2 mg%) and the onset of the disease was regarded as an anicteric form of acute viral hepatitis. However, in contrast acute hepatitis the disease progressed, and over the next 1-6 months, symptoms of CAH began to appear.
Another variant of the onset of autoimmune hepatitis is characterized by extrahepatic manifestations, fever. Moreover, the disease for 1-5 years is mistakenly regarded as SLE, rheumatism, rheumatoid polyarthritis, myocarditis, etc. Thus, in one of the patients we observed, 14-year-old S., the disease began with intense pain in the knee joints, heel bones, and after 2 months, hemorrhagic rashes appeared on the legs. Only six months later, icteric sclera and enlarged liver and spleen were discovered. In another observation for 3 years, the patient had low-grade fever, tachycardia, an increase in ESR to 50 mm/h, which served as a reason for the erroneous diagnosis of thyrotoxicosis and specific therapy.
The clinical picture in the late stages of autoimmune hepatitis is varied: slowly progressive jaundice, fever, arthralgia, myalgia, abdominal pain, itching and hemorrhagic rashes, hepatomegaly. Individual manifestations This symptom complex reaches varying intensities.
Fever was often combined with arthralgia and was present in all the patients we observed, and in most of them the temperature reached febrile levels. In some patients, an increase in temperature from 37.5 to 39 ° C, combined with increase in ESR up to 40-60 mm/h, dominated the clinical picture, and liver disease was not initially diagnosed. The galloping course of the disease with fever and pronounced dysproteinemia forced differential diagnosis with reticulosis and liver cancer.
Arthralgia is one of the most common and persistent extrahepatic manifestations of the disease in patients with chronic autoimmune hepatitis. Mainly the large joints of the upper and lower limbs, in some cases - the joints of the spine. 3. G. Aprosina described polyarthritis in patients with chronic active hepatitis. The configuration of the joints changed mainly as a result of periarticular inflammation and tendon-muscular syndrome.
Recurrent purpura is the most frequent defeat skin. It is characterized by hemorrhagic exanthems in the form of sharply defined dots or spots that do not disappear with pressure. Purpura often leaves behind a brownish-brown pigmentation. In some cases, there are lupus erythema, erythema nodosum, psoriasis, focal scleroderma. All patients had endocrine disorders: amenorrhea, acne and stretch marks on the skin, hirsutism.
Jaundice in patients with autoimmune hepatitis is intermittent, noticeably increasing during periods of exacerbation. Spider veins and hyperemia of the palms, expressed to varying degrees, are often visible. The liver in most patients is enlarged, painful on palpation, and its consistency is moderately dense. Transient splenomegaly occurs only in some patients; ascites is observed very rarely - during periods of pronounced activity of the process. Despite numerous clinical symptoms, patients often remain in good general health, unlike patients with all other forms of chronic hepatitis.
CAH is a systemic disease affecting the skin, serous membranes and internal organs; pleurisy, myocarditis, pericarditis, ulcerative colitis, glomerulonephritis, iridocyclitis, Sjogren's syndrome are detected, thyroid lesions, secondary amenorrhea, Cushing's syndrome, diabetes, generalized lymphadenopathy are described, hemolytic anemia, various pulmonary and neurological diseases. However, these processes rarely predominate in the clinical picture; the most serious of them, including glomerulonephritis, often develop in the terminal stage of the disease.
Hepatic encephalopathy is observed in patients with lupoid hepatitis only in the terminal stage, but some patients, especially during periods of exacerbation, experience episodes of reversible “minor” liver failure.
Features of the flow. Most patients with autoimmune hepatitis experience a continuous course of the disease from the first symptoms to death. Exacerbations of the disease are manifested by jaundice, anorexia, abdominal pain, fever, hemorrhagic syndrome, hepatomegaly, sometimes splenomegaly and other symptoms.
During clinical observation of 25 patients for 3-18 years, we noted a continuously relapsing course in 12 patients; 6 of them died, respectively, 10, 12, 20 months, 21/2, 5 and 8 years after the onset of clinical symptoms during the events liver failure. In 3 patients, hepatic coma developed after bleeding from dilated veins of the esophagus and stomach; 6 other patients are alive, and after 2-3 years, 5 patients developed cirrhosis of the liver. In 4 patients with macronodular cirrhosis, severe hepatocellular failure with encephalopathy and ascites was observed. Improvements in well-being are very short-term and depend on the dose of glucocorticoid drugs. Only one patient from this group had highly active chronic hepatitis.
In 13 patients with autoimmune hepatitis, clinical remission was obtained 11/2-4 years after its first manifestations. Stabilization of the process with weak or moderate activity was observed in 10 patients, transition to the inactive stage - in 3. In 9 of these patients, signs of transition to liver cirrhosis were found. In most patients, clinical remission is accompanied by improvement, but not normalization of biochemical parameters. Repeated exacerbations in patients with long-standing autoimmune hepatitis are milder with less severe symptoms and smaller deviations in biochemical parameters. Repeated exacerbations are stopped much faster than the first. In accordance with this, in the first acute period of the disease, patients require long-term hospital treatment. In the patients we observed, the duration of the first hospitalization ranged from 4 to 14 months with short breaks. Repeated hospitalizations were significantly shorter and did not exceed 2 months.
Functional state of the liver. In all patients during periods of exacerbation of lupoid hepatitis, an increase in bilirubin content, aminotransferase activity, as well as disturbances in protein metabolism were detected. Less pronounced changes in these indicators were also observed in the majority of patients in remission. The serum bilirubin content in the observed patients did not exceed 188 µmol/l (11 mg%) and most often increased to 85.5 µmol/l (5 mg%). Hypergammaglobulinemia during periods of exacerbation reaches high numbers (35-48.7%). The diagnostic significance of increased gamma globulin levels for chronic autoimmune hepatitis is widely discussed in the literature. The great significance of the indicator is evidenced by one of the names of this form of hepatitis - “progressive hypergammalobulinemic hepatitis”. It is fair to limit the value of this indicator due to the fact that other liver diseases may be accompanied by hypergammaglobulinemia. Hypoalbumicemia (below 40%) is observed during periods of pronounced activity of the process and does not indicate the formation of cirrhosis. The activity of aminotransferases increases significantly more than in all other forms of chronic hepatitis - in most patients it exceeds the norm by 7-10 times. In some patients, an increase in enzyme activity corresponds to the development of liver necrosis, but a clear parallelism between the severity of the disease and the activity of aminotransferases is not found. The increase in ALT is usually more pronounced than AST, so the De Ritis coefficient is less than one. Note that exacerbations of the disease are characterized by a pronounced deviation in the thymol test and a sharp slowdown in the retention of bromsulfalein.
The most pronounced changes in biochemical parameters are observed at the onset of the disease and during the period of exacerbation. In some patients, during periods of remission, biochemical parameters deviate slightly from normal values.
Serological tests and tests that detect tissue antibodies are very often positive in CAH. These include the L-cell phenomenon, antinuclear factor, complement fixation reactions.
In the observed patients, LE cells and antinuclear factor were detected in 50% of cases at a serum dilution of 1:32. In some patients, antinuclear factor is detected with a negative reaction to LE cells. Chronic autoimmune hepatitis is characterized by a high frequency of detection of tissue antibodies in smooth muscles, gastric mucosa, thyroid gland, renal tubular cells, and liver parenchyma. Own experience in studying smooth muscle antibodies (together with
E.L. Nasonov) allowed us to conclude that they are most often detected in CAH: their detection in high titers (1:160, 1:320 and above) is pathognomonic for the lupoid variant of CAH. It is important to emphasize their absence in SLE, chronic persistent hepatitis, and alcoholic liver damage. Determination of smooth muscle antibodies is essential for differential diagnosis CAH with these diseases.
Forecast. Observations have shown that in chronic autoimmune hepatitis, the frequency of transition to cirrhosis is higher, and the prognosis is more serious than in patients with chronic viral hepatitis.
In more than a third of the observed patients, the formation of cirrhosis was latent against the background of stabilization of the process. Mortality is higher in patients with hepatitis-like onset, persistent cholestasis, ascites, episodes of hepatic coma, as well as necrosis in the liver punctures. From our own observations and literature data it follows that the highest mortality occurs in the early, most active period of the disease. Patients who have survived critical period, have a significantly better prognosis. Among the patients we observed, 4 live more than 15 years after the onset of clinical symptoms.
Diagnostics various forms HAG. A feature of chronic autoimmune hepatitis is the predominantly plasma cell nature of the inflammatory infiltration in the portal tracts and intralobular stroma, and in chronic viral hepatitis it is lymphoid.
Functional liver tests and changes in enzyme activity are unidirectional, but when comparing the degree of deviations, a significant difference in their values ​​is determined.
Violation of protein synthetic, pigment, excretory-absorbent functions and increased activity of aminotransferases are much more pronounced in chronic autoimmune hepatitis. Significant differences are detected when studying immunological parameters. According to our data, with CAH of viral etiology, the content of 1&M and 1^0 was normal in 20%, and 1&A - in 40% of patients. In autoimmune hepatitis, an increase in the amount of immunoglobulins was detected in all patients. A comparative study of the content of immunoglobulins showed that the difference is statistically significant (Table 17). It should be emphasized that there is a significant increase in IgM content in autoimmune hepatitis.
High titers of antibodies to smooth muscle and specific hepatic lipoprotein are detected in all patients with chronic autoimmune hepatitis before treatment with glucocorticosteroid hormones. It is these indicators that can serve as reliable diagnostic criteria for autoimmune hepatitis with the morphological picture of CAH. The high frequency of detection of antibodies to smooth muscles in autoimmune hepatitis and their absence in SLE are essential in distinguishing
Table 17. Indicators of immune status and markers of viral replication in patients with autoimmune and viral chronic active hepatitis (active stage), M±t
HAG
Indicator Complement titer, units.
1&A, g/l 1§M, g/l 1§C, g/l
Antibodies to smooth muscle
Antibodies to liver-specific nocturnal lipoprotein
The ratio of helper and suppressor activity
T-suppressor defect Deficiency of suppressor activity
Immunodeficiency
Markers of viral replication in blood serum and liver tissue
Frequency of HLA-B8 genotypes 35.15±5.15 23.6±1.32 5.09±6.79 8.48±2.39 11.04±1.33 23.86±6.71 13.42 ±1.26 19.47±2.36 Rarely in low titer Always in high titer Same Same Low due to the predominance of T-suppressors High due to the predominance of T-helpers Possible in severe forms Always To HB5A5 , НВСА$ To a specific hepatic lipoprotein Pronounced Moderate Often present Always absent Less constant Pronounced autoimmune
viral

These diseases. Difficulties usually arise in the initial stage of autoimmune hepatitis with pronounced systemic manifestations, as well as in the presence of kidney damage in a number of patients with CAH. Clinical data on glomerulitis in some patients with lupoid hepatitis from an immunological point of view have shown that serum containing antibodies to smooth muscles reacts with the cytoplasm of cells of the renal glomeruli, spleen, thymus, lymph nodes. Moreover, the reaction of these antibodies with kidney glomeruli can cause their damage. This appears to lead to kidney damage in some patients with lupoid hepatitis.
The diagnosis of chronic active viral hepatitis is based on identifying markers of viral replication in blood serum and liver tissue and the results of a puncture biopsy, which gives an idea of ​​the form of hepatitis and histological criteria for the activity of the process. Antigenic markers of hepatitis B in blood serum are HB8A&, HBeA&, anti-HBe, anti-HBc, in liver tissue - HBCA&.
The characteristic features of hepatitis B that distinguish it from hepatitis C are the possibility of developing del
ta-superinfections. It is delta-infected and c that leads to the development of “unmotivated” exacerbations with pronounced cytolytic and cholestatic syndrome and significantly accelerates the progression of the disease with transition to cirrhosis of the liver.
Another feature inherent in hepatitis B is seroconversion, i.e. the disappearance of HBeA^ and the appearance of antibodies to it. The long-term version develops spontaneously or after sudden withdrawal of large doses of glucocorticosteroids prescribed for a short period of time. Elimination of the pathogen by immunocompetent cells leads to lysis of affected hepatocytes and a severe exacerbation of the disease, sometimes with the development of hepatic coma. In most cases, after seroconversion, long-term remission occurs.
The diagnosis of hepatitis C is based on the detection of a marker (anti-HSU), as well as on a complex of anamnestic, clinical, biochemical and histological data. In this case, it is essential to exclude markers of hepatitis B and other etiological factors causing CAH.
Treatment. The regimen is the most important factor in maintaining compensation of liver function. It is necessary to timely eliminate hepatotoxic hazards: contact with hepatotropic poisons at work, lack of hygiene skills, alcohol consumption, unbalanced diet. Patients with CAH outside periods of exacerbation in the compensation stage should be recommended a lighter regimen. It is prohibited to work with physical and nervous overload. A short rest is indicated in the middle of the day. When the process is exacerbated, bed rest creates more favorable conditions for liver function as a result of an increase in hepatic blood flow in the horizontal position of the patient and the elimination of physical and mental stress. It is necessary to remove the drug burden, drugs that are slowly neutralized by the liver are not indicated - tranquilizers, sedatives, analgesics, strong laxatives for constipation, physiotherapeutic procedures for the liver area, balneotherapy are contraindicated. During the period of exacerbation of the disease, surgical operations and vaccinations can be performed only for health reasons.
Diet. In Russia, diet No. 5 according to the scheme of M.I. Pevzner has been adopted for patients with chronic hepatitis. It is energetically full, but with a limitation of extractive and cholesterol-rich substances (fatty meats and fish, spicy snacks, fried foods, salty, smoked foods). The amount of plant fiber is slightly increased. The daily diet contains 100-200 g of protein, 80 g of fat, 450-600 g of carbohydrates, which is 3000-3500 kcal.
In case of exacerbation of the process, as well as with concomitant diseases gastrointestinal tract Diet No. 5a is prescribed, which is mechanically and chemically gentle. Vegetables and herbs are given in pureed form, meat - in the form of meatballs, quenelles, and steamed cutlets. Coarse vegetable fiber (rye bread, cabbage) and snacks are excluded. The amount of fat is limited to 70 g, including 15-20 g of vegetable fat. It is important to consider the amount of fat. For example, butter does not cause any unpleasant effects in patients with liver diseases. Pork, lamb and goose lard is prohibited.
Eating heavily can reflexively cause intense contraction of the muscles of the biliary tract and pain, so patients should eat at least 4-5 times a day.
It is advisable to use therapeutic factors aimed at normalizing hydrolysis and absorption, eliminating intestinal dysbiosis [Grigoriev P. Ya., Yakovenko E. P., 19901. Detoxification therapy includes intravenous drip administration of hemodeza (200-400 ml No. 3-8 ); orally - lactulose 30-60 ml 1-2 times a day.
Drug therapy for chronic active viral hepatitis.
In the treatment of chronic active hepatitis of viral etiology, the use of two groups of drugs is justified: immunostimulants and antivirals.
Immunostimulants. A group of drugs, which include transfer factor, SCD vaccine, thymus preparations, zhvamizole, prodigiosan, laser beams, sodium nucleinate, etc.
The premise for the use of immunostimulants was the assumption of R. U. EisNeu et al. (1972) about a defect in the immune system in response to the hepatitis B virus, as a result of which its elimination is impaired. Their use is based on two mechanisms drug effects- increased cellular immunoreactivity and decreased viral replication. A prerequisite for eliminating the virus is the destruction of hepatocytes containing the hepatitis B virus by cells of the lymphoid system. This explains the development of cytolysis syndrome during treatment with immunostimulants.
Most researchers note that the cytolysis syndrome observed at the beginning of taking levamisole is replaced by normalization of aminotransferase activity, improvement in the condition of patients, as well as a decrease in viral replication in a number of patients. This is manifested by the disappearance of HBeA^ from the blood serum, a decrease in the level of DNA polymerase activity, as well as a decrease in the number of hepatocytes containing HBeA^ and HBCA^.
However, in some cases, despite a certain immunostimulating effect, the virus remains in the body.
Levamisole (Decaris) has the greatest use in clinical practice. The drug is a nonspecific immunostimulant that improves the functional state of immune T cells and macrophages, reduces viral replication, and accelerates the lysis of some affected hepatocytes.
Studying immune mechanisms The action of this anthelmintic drug began after the report of the French researcher S. Xpoich (1971) about the increase in the protective properties of a bacterial vaccine under its influence. Levamisole stimulates all subpopulations of T-lymphocytes, primarily T-suppressors, normalizes the interaction of T- and B-lymphocytes, and helps reduce the imbalance of T-helpers and T-suppressors. A. S. Loginov et al. (1983) observed a decrease in the biochemical and immunological activity of the process under the influence of decaris, but did not reveal a significant effect on the persistence of HBeAg.
The use of levamisole for CAH can contribute to the development of severe forms of liver damage, including fulminant hepatitis [TNotaz N.S. e! a1., 1979], in this regard, the prescription of immunostimulants requires strict indications. It should be considered that the presence of severe hepatocellular failure is a contraindication to the use of levamisole.
Taking into account literature data and our own experience, we formulated the following indications (criteria) for prescribing levamisole: clinical - absence of signs of severe disease; biochemical - bilirubin level is below 100 µm/l, ALT activity does not exceed the norm by 5 times; immunological - immunodeficiency in the cellular immunity system, impaired immunoregulation (deficiency of suppressor activity), the presence of markers of the hepatitis B virus replication phase in blood serum or liver tissue.
Various treatment regimens with levamisole are used: 1) 150-100 mg/day 3 days a week; 2) 150-100 mg/day every other day; a total of 7-10 doses are prescribed.
Maintenance doses are 100-50 mg per week. Course duration is from 1 month to 1 year or more*
To prevent pronounced syndrome cytolysis in some patients, decaris is used in combination with small doses of prednisolone.
Taking levamisole may be accompanied by the development of the following complications: 1) allergic; 2) neurological reactions; 3) changes in the gastrointestinal tract; 4) hematological - agranulocytosis (more often in women with HLA-B27), neutropenia, thrombocythemia.
Thymus preparations (thymalin, thymosin, T-activin) have the same indications as levamisole.
The use of thymus preparations in the treatment of chronic active liver diseases leads to an improvement in clinical, biochemical parameters in patients, which is apparently due to the immunoregulatory effect of these drugs: an increase in the number of T-lymphocytes, an improvement in the function of macrophages, a decrease in cytopathic action of lymphocytes, increased suppressive activity of cells. It is possible that these drugs will occupy a significant place in the treatment of active liver diseases.
E-penicillamine. A positive effect was noted during long-term treatment with E-penicillamine for chronic active liver diseases, which was manifested in an improvement in general well-being, normalization of functional indicators, and removal of signs of activity of the pathological process during histological examination. It is important to emphasize that O-penicillamine is effective in cases of early fibrosis; the effect of the drug on mature connective tissue in cirrhosis is ineffective.
In CAH of viral etiology, O-penicillamine has a collagen-inhibiting and immunoregulatory effect. The effect of the drug on the immunoregulatory system is to increase the number of T-suppressors and reduce the T-helper/T-suppressor ratio, inhibition of autoimmune reactions, which helps to reduce the activity of the pathological process.
Indications for use are the presence of young collagen in liver tissue, autoimmune reactions against the background of an imbalance of immunoregulatory cells. The dose of the drug is 600-900 mg/day. Duration of treatment is 1-6 months.
Antiviral drugs. In case of CAH of viral etiology, the study continues therapeutic effect a number of antiviral drugs that suppress the replication of viral particles: interferon, adenin arabinoside and its derivative - arabinoside monophosphate, acyclovir, vidarabine.
Interferon is a drug with a wide range of actions, affecting not only the replication of the virus, but also the cells of the immune system. Along with the inhibitory effect of human leukocyte interferon on virus reproduction [Cops1o M. e! a!., 1980] noted its regulatory effect on T-lymphocytes, NK cells, spontaneously lysing infected with virus cells [Rare S.K. & X a1., 1980]. The effectiveness of therapy is determined by its timeliness; Early treatment helps to completely eliminate the virus. A number of studies have noted an unstable antiviral effect of interferon, so its combination with immunostimulating drugs is advisable [Caragara et al., 1984].
Successful results have been obtained in the treatment of not only chronic active hepatitis B, but also C with injections of lymphoblastic alpha-interferon. Beta-interferon is able to suppress the replication of not only viruses B and C, but also delta infection, although the effectiveness of the drug against LEU is clearly low. Adenine arabinoside and its soluble form for intramuscular injections, adenine arabinoside-5 monophosphate, like interferon, have an unstable antiviral effect. During treatment, there is a decrease in the level of hepatitis B virus DNA and DNA polymerase activity, less often a decrease in HB&A^ and HBeAe seroconversion, however, after discontinuation of the drugs, markers of viral replication reappear. Antiviral therapy is effective only in patients with a high level of viral reproduction. Treatment with adenine arabinoside and adenine arabinoside γ-monophosphate may be complicated by the development of pain, pain and neuropathies, dysfunction of the gastrointestinal tract, and thrombocytopenia.
Immunosuppressive drugs. Most controversial issue in the treatment of CAH of viral etiology is the use of glucocorticosteroid hormones. Proponents of prescribing prednisolone are based on the positive effect of immunosuppressants on immunopathological reactions involved in the pathogenesis of the disease. Firstly, the production of factors by lymphocytes that inhibit the migration of leukocytes in response to liver-specific lipoprotein and HB&Ag decreases. Taking prednisolone leads to a decrease in the activity of K-cells, which are important in the pathogenesis of the disease. There are reports of a decrease in hepatitis B virus replication under the influence of prednisolone. A decrease in the level of HBeA§ and DNA polymerase activity in the blood serum and the disappearance of HBeA§ from liver tissue is accompanied by an improvement in histological parameters
[OaU18 S. L. e(a!., 1981; Kishada N., 1982; M1uaka^a N. e!a!., 1983].
The greatest effectiveness of immunosuppressive therapy was observed in patients with the presence of antibodies to HBe (anti-HBe-positive),
A significant number of studies note the negative effect of therapy with immunosuppressive drugs in patients with CAH: increased replication of the hepatitis B virus, unfavorable course of the disease, and lack of improvement in morphological examination of liver punctures were revealed. Attention should also be paid to the fact that glucocorticoid hormones suppress the function of macrophages, which delays the elimination of the virus from the body.
Considering the well-founded danger of delayed persistence of the hepatitis B virus under the influence of prednisolone therapy, we believe that the indications for prescribing immunosuppressants in these patients should be sharply limited.
The indication for prescribing prednisolone is only a severe clinical course of the disease with sharp changes in functional tests and enzyme activity, and the detection of bridging or multilobular necrosis of hepatocytes during histological examination.
N. S. Asfandiyarova (1988) noted the inducing effect on suppressor cells of medium doses of prednisolone in patients with chronic viral hepatitis with a high degree of activity. These data make it possible to explain the decrease in the activity of the pathological process by the suppression of immunopathological reactions.
The dose of prednisolone is 20-30 mg/day. The absence of a clear effect within 3-4 weeks from the use of medium doses of prednisolone serves as an indication for a gradual dose reduction and subsequent discontinuation of the drug. If the patient's condition improves, treatment can be continued from 6 months to 2 years.
With moderate and low activity of the pathological process, accompanied by significant immunodeficiency with increased suppressor function, the administration of prednisolone, delagil, azathioprine is not indicated, since this leads to a further deepening of the immunoregulation defect and, consequently, potentiation of virus activation and the activity of the pathological process. The use of prednisolone is also contraindicated for CAH caused by the C virus.
Patients with chronic viral hepatitis are advised to periodically prescribe drugs that increase the body's nonspecific immune resistance (vitamin therapy, sodium nucleinate, complevit, flakozid), which give a pronounced tonic effect.
At present, the attitude towards the prescription of hepatoprotective drugs (Essentiale, Legalon, Karsil, Aika-phosphate, Katergen) for chronic viral hepatitis has been revised. These drugs do not reduce inflammatory activity; in addition, they can contribute to the intensification or appearance of intrahepatic cholestasis, therefore their use in CAH is not indicated.
Clinical examination of patients forms the basis of treatment of this form. Medical examinations are carried out regularly, at least once every six months, with the determination of the most informative biochemical liver tests.
The appearance of increasing weakness and decreased performance, even in the absence of significant changes in biochemical blood tests, is an indication for hospitalization and the issuance of a certificate of incapacity for work. Patients with a highly active form of CAH of viral etiology are essentially group III disabled people. Employment is required, providing work that is not associated with heavy labor physical activity, frequent and long business trips, driving. It is advisable to provide work with a shortened working day.
Treatment of chronic autoimmune hepatitis. Perennial clinical experience the use of glucocorticosteroids (GC) and new data on the pathogenesis of the disease allow us to consider them the drugs of choice for the treatment of chronic active autoimmune hepatitis.
One of the main drugs of glucocorticoid hormones - prednisolone - has a wide spectrum of action, affecting all types of metabolism; it has a pronounced anti-inflammatory effect.
The decrease in the activity of the pathological process under the influence of prednisolone is due not only to its direct immunosuppressive effect on K cells. Of decisive importance, apparently, is the inducing effect of the drug on the suppressor activity of T-lymphocytes, which contributes to the inhibition of immune reactions. K. Yoip et al. (1982), adding prednisolone, noted the restoration of T-suppressor function in patients with autoimmune CAH and the absence of this effect in viral lesions. The immunoregulatory effect of prednisolone is manifested when a high dose of the drug is prescribed.
K. Alanas1$ (1975), b. M. Bee et al. (1975) revealed a decrease in the frequency and intensity of immunopathological reactions directed against the liver tissue’s own antigens during treatment with prednisolone. A decrease in the frequency and degree of sensitization of lymphocytes to specific hepatic lipoprotein, a decrease in the titer of antibodies to specific hepatic lipoprotein and the level of 1^0 were established.
Azathioprine. Two mechanisms of influence of azathioprine on the immune response have been registered: suppression of an actively proliferating clone immunocompetent cells and elimination of specific inflammatory cells.
The effect of azathioprine on the primary and secondary immune response in experimental animals and humans has been noted. Azathioprine causes a decrease in the number of B-lymphocytes, the level of 1§C and T-lymphocytes with helper activity.
The insufficient effect of treatment with azathioprine is associated with impaired activation of azathioprine or acceleration of its destruction in liver diseases. Prednisolone may promote activation of azathioprine; Azathioprine at a dose of 100 mg may be completely ineffective, but if it is prescribed along with prednisolone, even at a dose of 50 mg it gives a therapeutic effect. Currently, the combined administration of azathioprine with prednisolone is preferred for CAH.
The following indications (criteria) for prescribing immunosuppressive therapy can be formulated: clinical - severe course of the disease with pronounced symptoms (jaundice, systemic manifestations, precoma, coma); biochemical - an increase in the content of gamma globulins above 30-40%, an increase in the activity of aminotransferases by more than 5 times, an increase in the thymol test by more than 3 times; immunological - increased 1§C content above 2000 mg/100 ml, high titers of antibodies to 8MA, impaired immunoregulation (increased helper activity, defective suppressor activity); morphological - the presence of stepped, bridge-like or multiform necrosis.
Use one of two schemes.
Scheme 1. High initial daily dose of prednisolone, 30-40 mg (rarely 50 mg) for autoimmune hepatitis. The duration of treatment is 4-10 weeks, followed by a reduction to a maintenance dose of 20-10 mg.
The dose of the drug is reduced slowly under the control of biochemical indicators of activity by 2.5 mg of prednisolone every
2 weeks before the maintenance dose, which the patient takes until complete clinical, laboratory and histological remission is achieved. If, when trying to reduce the dose, signs of relapse of the disease appear, the dose is increased again. Therapy with maintenance doses of GC should be long-term - from 6 months to 2 years, and in some patients with autoimmune hepatitis - up to 4 years or throughout life. When a maintenance dose of prednisolone is reached, according to A. S. Loginov, Yu. E. Blok (1987), alternating therapy is advisable, i.e., taking the drug every other day in a double dose, which prevents the development of adrenal insufficiency.
When prescribing other GCs, you can use the following equivalent: 5 mg prednisolone (1 tablet) - 4 mg triamsinolone (1 tablet) = 4 mg methylprednisolone (1 tablet) = 0.75 mg dexamethasone (1.5 tablets).
When choosing a dose of GC, it is advisable to take into account the serum albumin content. A close relationship has long been noted between the incidence of side effects of GCs and serum protein levels. When the albumin content is less than 25 g/l side effects develop 2 times more often when prescribing the same dose of the drug. This is because usually more than 55% of the hormone in the blood is bound to albumin. With hypoalbuminemia, most of it remains free.
The side effects of GCs are well documented in the literature. As the dose of the drug and the duration of treatment increase, the risk of developing ulcerations of the digestive tract, corticosteroid diabetes, osteoporosis, Cushing's syndrome, and decreased resistance to infections increases. With a rapid decrease in the daily dose of GC, especially at the end of long courses, the development of “withdrawal syndrome” is possible. It is believed that the “withdrawal syndrome” is associated with the development of insufficiency of the adrenal cortex and impaired autoimmune reactions. According to our observations, their combination with azathioprine or delagil, which allows the use of smaller doses of GC, is essential for preventing “withdrawal syndrome”, as well as other side effects of GCs.
There are no absolute contraindications for the use of GCs in chronic autoimmune hepatitis. Relative contraindications are severe forms of renal failure, focal infection, diabetes mellitus, peptic ulcer, decompensated hypertension, severe (2-3rd degree; see above) varicose veins of the stomach and esophagus, osteoporosis, spontaneous bacterial peritonitis.
Regimen 2: Prednisolone can be given in combination with azathioprine from the beginning of treatment or when the dose of prednisolone is reduced to prevent side effects of steroids. Prednisolone is prescribed at the beginning of the course at a dose of 15-25 mg/day, azathioprine - at a dose of 50-100 mg/day.
The maintenance dose of azathioprine is 50 mg, prednisolone is 10 mg. The duration of treatment is the same as when using prednisolone alone.
Both treatment regimens are equally effective, however, the incidence of complications with the combined use of prednisolone and azathioprine is 4 times less than with the use of prednisolone alone. With this combination, cosmetic defects develop in most patients by 2 years of treatment. More severe complications develop in 50%, and according to our data, in 20% of cases after 5 years from the start of therapy. It should be remembered that azathioprine has a depressant effect on Bone marrow. The incidence of cytopenia is 11% at usual therapeutic doses. However, unlike cyclophosphamide and methotrexate, azathioprine never causes generalized depression of bone marrow hematopoiesis. At the beginning of treatment, the number of leukocytes, especially neutrophils, often decreases. When the number of leukocytes decreases to 4*10 -3*10 /l, the dose is reduced, and at 3*10 -2*109/l the drug is discontinued. In addition, during treatment with azathioprine, side effects may develop such as skin rashes, gastrointestinal disorders, activation focal infection, liver damage.
The hepatotoxic effect is manifested by transient nausea, loss of appetite, and a slight increase in bilirubin levels. However, compared to other immunosuppressants, the hepatotoxic effect of azathioprine is much less pronounced. The combination of azathioprine with prednisolone, according to our observations, reduces the toxic effect of azathioprine.
It has been noted that long-term use of immunosuppressants can contribute to the occurrence of malignant neoplasms, mainly of the lymphoproliferative type. The oncogenic effect of immunosuppressants, in particular azathioprine, has been demonstrated in a number of experimental models. Thus, in mice treated with azathioprine, lymphomas were detected in 80% of cases, and in untreated mice - extremely rarely. No complications have been described for liver diseases. However, the potential for tumor development is now increasing due to the duration of treatment and the increased use of immunosuppressive drugs.
Clinical improvement, according to our observations, develops in the majority of patients in the first weeks of treatment, biochemical remission - in /4 patients by the end of the 1st year. Histological remission with transition to inactive CAH or chronic persistent hepatitis develops later and is detected in / z patients after 2 years.
Observations of recovered patients who had chronic autoimmune hepatitis showed that good biopsy results are difficult to expect unless aminotransferase activity levels have decreased or normalized. Half of the patients who responded to treatment relapsed within 6 months after stopping therapy. Liver cirrhosis is detected in cases where complete remission is not achieved during treatment, and sometimes even after successful treatment, accompanied by clinical and laboratory remission. Therapy with azathioprine in combination with prednisolone is most promising in the early stages of the disease.
Failures in the treatment of chronic autoimmune HB^A^negative hepatitis develop in 20% of patients; 15-20% experience improvement without developing complete remission, and patients require maintenance therapy.
The lack of effect when using GC can be explained by insufficient doses of the drug. It is important to note that the adverse effects were reported specifically by researchers using 10-20 mg prednisolone.
Delagil (chloroquine, hingamine, rezoquine, aralen) has a pronounced nonspecific anti-inflammatory effect.
It inhibits the synthesis of nucleic acids, the activity of certain enzymes, and immunological processes. This served as the basis for the use of delagil for acute and chronic viral hepatitis.
Delagil is prescribed for mildly expressed activity of chronic autoimmune hepatitis. A daily dose of delagil of 0.25-0.5 g is combined with 10-15 mg of prednisolone. Subsequently, the dose of prednisolone is reduced to 5 mg, and then only delagil is prescribed.
The duration of treatment is from 1/2 to 6 months, and in some patients - up to 1/2-2 years.
Combination therapy with prednisolone and delagil, according to available observations, has a much better effect on biochemical parameters than treatment with prednisolone alone. When assessing the long-term results of treatment, it turned out that the process stabilizes much more often in patients receiving combination therapy.
Delagil allows you to use lower doses of prednisolone. Patients usually tolerate taking delagil orally in the indicated doses well. The literature describes the following side effects with long-term use of delagil: dermatitis, dizziness, headache, nausea, sometimes vomiting, tinnitus, impaired accommodation, decreased visual acuity, leukopenia. Typically, these phenomena resolve on their own when the dose is reduced or the drug is discontinued. Combination therapy with prednisolone and delagil at a dose of 0.25-0.5 g did not cause deterioration in liver function.
Clinical examination. Patients with chronic autoimmune hepatitis are subject to dispensary observation, which includes monitoring the correct regimen with limitation of physical and emotional stress, employment taking into account the clinical form of the disease and the nature of production activities.
Most patients with chronic autoimmune hepatitis in the remission stage retain limited ability to work and can continue to work.
Drug therapy includes maintenance courses of immunosuppressive drugs not only for severe, but also for moderate and mild degrees of process activity. Courses of treatment with B vitamins and lipamide are prescribed 2-3 times a year. Control examinations and laboratory examinations are carried out every
4 months, and with continued immunosuppressive therapy - 1-2 times a month.
The appearance of signs of relapse (jaundice, systemic manifestations, increased aminotransferase activity, hyperbilirubinemia, hypergammaglobulinemia) indicates the need to resume therapy according to the above regimens in a hospital setting.
The problem of pregnancy and childbirth in patients with chronic autoimmune hepatitis cannot be solved unambiguously. There are reports that pregnancy and childbirth worsen the course of autoimmune chronic hepatitis, and immunosuppressive therapy does not significantly affect the fate of the fetus.
The point of view of A. S. Loginov and Yu. E. Blok (1987), who believe that pregnancy in patients with chronic autoimmune hepatitis can be allowed only after achieving stable remission and in the absence of clinically pronounced signs of portal hypertension, seems more justified and acceptable. Our experience shows that pregnancy poses a huge risk for the fetus and mother suffering from chronic autoimmune hepatitis.

This disease is associated with inflammation of the liver. The consequences of chronic hepatitis depend on the degree and activity of damage to the body’s main “filter,” which is not always indicated by symptoms and signs. With terrible consequences The disease is cirrhosis of the liver and the development of tumors. You can avoid this by learning the causes, types and methods of treatment.

What is chronic hepatitis

The disease is characterized by the presence of diffuse inflammatory diseases in the liver (the body's filter) for a period of 6 months or more. Often this is asymptomatic, so a person may not be aware of the presence of parenchymal hepatocyte damage. If this is not diagnosed in time, liver cells are replaced by connective tissue. Cirrhosis appears, acute oncological and biliary disorders develop. Not all types of the disease develop into chronic stage, for example, type A. Infectious variations B and C can become like this.

Causes

If reactive hepatitis B, C, D, G is treated inappropriately, the disease becomes chronic. Type A is usually treated within a few weeks, and the body develops lasting immunity for the rest of its life. It is also called Botkin's disease - jaundice. The main danger is fraught with type C (80%). In addition, the disease develops due to the following factors:

• metabolic disease;
• autoimmune hepatitis – transmitted hereditarily, failures in protective processes;
• toxic – the body is exposed to harmful substances for a long time: alcohol, medications (tetracyclines, drugs, anti-tuberculosis, sedatives), salt, benzenes, heavy metals, radioactive elements.

Classification

The three main types of liver damage are A, B, C. The first is common, similar to the flu at first. After 2-4 days, the feces become colorless, and the urine, on the contrary, darkens. Prevention – compliance with hygiene standards. Variety E is similar to A, but the severe form affects the liver and kidneys. Type F has been little studied. With the viral etiology of hepatitis D, acute extrahepatic symptoms are observed: damage to the lungs, kidneys, joints, and muscles. Type G is similar to C, but does not lead to cancer or cirrhosis. Acute form affects the body quickly. Classification of chronic hepatitis:

• cryptogenic – the triggering mechanisms have not been studied;
• chronic persistent (low-active) – develops with drug, alcohol and toxic liver damage;
• lobular - a variant of the first with localization of pathologies in the hepatic lobules;
• aggressive hepatitis (chronic active) - characterized by necrosis, there is a tendency to the occurrence of cirrhosis, occurs due to hepatitis B viruses, rarely C, may have a drug, chronic alcoholic etiology (nature of origin).

Diagnostics

To identify the pathogenesis of a chronic disease, the doctor conducts an initial examination. An infected person develops a pinpoint rash, yellowish color skin, crimson tongue, red palms, spider veins. Along with the examination, palpation is performed in the area of ​​the spleen and liver: if they are enlarged, there will be unpleasant sensations when pressed. Then an ultrasound of these organs is prescribed to determine the heterogeneity of their structure. Diagnosis of chronic hepatitis includes in some cases:

• liver biopsy to determine the type of disease, whether there is cirrhosis/fibrosis or not;
• general analysis blood, which confirms the presence of inflammatory processes;
• laboratory serological test - identifies certain markers of viral antigens;
• biochemical blood test - determines the level of bilirubin, liver enzymes, which cause the skin to change color;
• immunological examination– detection of antibodies to liver cells.

Symptoms of chronic hepatitis

These are complaints of bitterness in the mouth due to cholestasis, bowel movements, headaches, bleeding with bruises, a feeling of weakness, fatigue. There is a feeling of heaviness and discomfort in the liver area - under the right hypochondrium. The aching pain intensifies after eating fried, fatty foods. It is possible to develop asthenovegetative syndrome - decreased mental concentration, performance, and drowsiness. Clinical manifestations sometimes include weight loss due to metabolic disorders and cholestatic syndrome.

Treatment of chronic hepatitis

Therapy is developed taking into account the individual characteristics of each patient. The treatment complex is determined by the degree of disease activity and the causes of its occurrence. Drug therapy is complemented by a special diet and exercise regimen. Interferon preparations are used to suppress chronic viral hepatitis C. The liver is protected by hepatoprotectors, which restore tissue structure in combination with vitamins and antioxidants, and relieve immune inflammation. The goal is remission of the disease (weakening).

Hepatitis B

It is also called serum type. Infection occurs through blood, seminal fluid during sexual intercourse, and during labor. Immunostimulants are prescribed (for example, Timalin, Methyluracil), vitamins B and C, folic acid, nicotinic acid. The liver is restored by anabolic, corticosteroid hormones. Treatment of chronic hepatitis of this type is supplemented with medications to protect the liver. After discharge from the hospital, you need to undergo annual rehabilitation in a sanatorium and adhere to diets throughout your life.

Hepatitis C

After analyzing the degree of liver damage, the stage of cirrhosis, cancer, and assessing concomitant diseases, a individual course long-term therapy. In modern practice, interferon and Ribavirin are used, which are effective against all genotypes of the disease. The main problem of a patient with HCV infection (type C) is poor tolerability of drugs and their high cost.

Active

Treatment should begin after full confirmation of the correct diagnosis of the chronic form. After waiting 3-6 months, histological control is repeated. The main elements of therapy are immunosuppressants and corticosteroids. If treatment is interrupted before all clinical symptoms are eliminated, a relapse with an exacerbation of the disease is possible. Therapy should be carried out under the strict supervision of a physician.

Persistent

Chronic viral hepatitis with a minimal degree of activity is treated by reducing physical and nervous stress. Ensures healthy sleep, a calm environment, and proper nutrition. If the course of the disease is favorable, special medication assistance need not. Antiviral and immunomodulatory drugs are used. Medical examination is necessary as a preventive measure.

Prevention of chronic hepatitis

Replication does not occur by airborne droplets and in a household way, therefore, carriers of disease viruses do not pose a danger. To protect yourself, it is important to use barrier contraception and not take other people’s hygiene items. Emergency prevention of type B – use of human immunoglobulin, vaccines. Drug-induced lesions and autoimmune forms are curable, and viral chronic hepatitis transforms into cirrhosis. Eliminating alcohol from your diet will help you avoid alcohol-related injuries.

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