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Chronic Viral Hepatitis. Bethesda, MD: American Gastroenterological Association (AGA). 2001. [4 p.].
Hepatitis is an inflammation of the liver which usually produces swelling, tenderness, and sometimes permanent damage. Hepatitis is caused by a number of things including alcohol, drugs, chemicals, and viral infections. If the inflammation of the liver continues at least six months or longer, it is called chronic hepatitis. This brochure reviews chronic hepatitis, including the five different viruses known to cause viral hepatitis, the symptoms of viral hepatitis, diagnostic tests used to confirm hepatitis, the differences between acute and chronic hepatitis, carrier status, treatment options, transmission and its prevention (including immunization where available), and the physiology and anatomy of the liver. The brochure concludes with a brief glossary of related terms. 1 figure. 2 references.
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Approach to the Patient with Abnormal Liver Tests and Fulminant Liver Failure. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 283-292.
This chapter on managing patients with abnormal liver tests and fulminant liver failure is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. This chapter includes a general discussion of commonly used liver tests; the differential diagnosis and discussion of diseases characterized by an increase in hepatocellular enzyme levels; differential diagnosis and discussion of diseases characterized by an increase in cholestatic enzyme levels; the evaluation of patients who have jaundice; and the management of patients who have fulminant liver failure. In general, a patient with liver test abnormalities that are less than twice normal may be followed as long as the patient is asymptomatic and the albumin level, prothrombin time, and bilirubin concentration are normal. Clinical syndromes that contribute to abnormal liver tests include acute hepatitis, chronic hepatitis, cholestasis without hepatitis or jaundice, jaundice, and cirrhosis or portal hypertension. Fulminant liver failure can be defined as the presence of acute liver failure, including the development of hepatic encephalopathy, within 8 weeks after the onset of jaundice in a patient without a previous history of liver disease. Liver transplantation has revolutionized the management of fulminant liver failure, which without transplantation has a low survival rate. The author stresses that transplantation should be performed when a poor outcome is anticipated, before the patient has uncontrolled sepsis or prolonged periods of increased intracranial pressure. The chapter includes diagnostic algorithms for evaluating patients who have abnormal liver tests. 4 figures. 6 tables. 7 references.
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Chronic Hepatitis C Infection is Associated With Higher Hemoglobin Levels in Hemodialysis Patients, but Hepatitis B Infection is Not. Dialysis and Transplantation. 37(1): 12, 14, 16-17. January 2008.
Chronic hepatitis is associated with increased hemoglobin levels in patients with end-stage renal disease (ESRD). This article reports on a study undertaken to define the individual and combined influence of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections on red blood cell status. The retrospective study included 524 chronic hemodialysis patients at five hemodialysis centers whose charts were reviewed for the period March 1 to June 31, 2005. The results showed that 345 patients, or 65.8 percent, had neither HBV nor HCV; 55 patients, or 10.5 percent, had HBV; 108 patients, or 20.6 percent, had HCV; and 16 patients, or 3.1 percent, had concurrent HBV and HCV infection. The authors report the hemoglobin and hematocrit of patients in each status group, as well as the erythropoietin (EPO) dose given to patients with HCV. The authors found that erythropoietin dose, elevated liver function test results, and HCV infection are major factors affecting red blood cell production. HCV infection was associated with an increased number of red blood cells, which led to a lowering of the necessary EPO dose. HCB infection was not similarly associated with changes in red blood cells. 3 tables. 11 references.
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Chronic Hepatitis C Infection Is Associated with Higher Hemoglobin Levels in Hemodialysis Patients, but Hepatitis B Infection Is Not. Dialysis and Transplantation. 37(1): 12-17. January 2008.
This article reports on a study undertaken to determine the individual and combined influence of chronic hepatitis B and C infections—HBV and HCV, respectively—on red blood cell status. The authors note that chronic hepatitis is associated with increased hemoglobin level in patients with end-stage renal disease (ESRD). The retrospective review study, conducted from March through June 2005, included 524 chronic hemodialysis (HD) patients at five hemodialysis centers. Screening tests on these patients showed that 345 patients, or 65.8 percent, had neither HBV nor HCV; 55 patients, or 10.5 percent, had HBV; 108 patients, or 20.6 percent, had HCV; and 16 patients, or 3.1 percent, had concurrent HBV and HCV infection. The hemoglobin and hematocrit of patients with HCV were significantly higher than those patients with neither infection. The erythropoietin dose given to patients with HCV was significantly lower than that for those with neither infection. Analyses showed that erythropoietin dose, elevated liver functional test results, and HCV infection were major factors affecting red cell production. The authors conclude that hepatitis C virus infection in hemodialysis patients not only influenced red blood cell production but affected serum transaminase activity, platelet count, and intact-PTH, iron, and TSAT levels. However, similar findings were not seen in patients with hepatitis B infection. 3 tables. 11 references.
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Chronic Viral Hepatitis. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 293-306.
This chapter on chronic viral hepatitis is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. The author notes that viral infections are major causes of liver disease worldwide. The five primary hepatitis viruses that have been identified are A, B, C, D (or delta), and E. This chapter focuses on the primary hepatitis viruses, covering epidemiology, clinical presentation and natural history, diagnostic tests, treatment, and prevention of each type. The major routes of transmission of hepatitis A virus are ingestion of contaminated food or water and contact with an infected person. The treatment of acute hepatitis A is supportive; a vaccine is available and should be offered to travelers to areas with an intermediate or high prevalence of hepatitis A, intravenous drug users, and other selected populations. Hepatitis B is usually transmitted through sexual activity or intravenous drug use. Hepatitis B infection is treated with interferon or an oral agent. Hepatitis B vaccine is given to infants and previously unvaccinated young adolescents. Hepatitis C is a factor in 40 percent of all cases of chronic liver disease and is the leading indication for liver transplantation. Most people with hepatitis C present with chronic hepatitis, with a mild-to-moderate increase in ALT levels. Treatment is successful in many patients with hepatitis C infection and can be useful to prevent complications, notably cirrhosis. A final section of the chapter considers the interplay between viral hepatitis and human immunodeficiency virus (HIV) infection. Patient care algorithms are provided. 6 figures. 7 tables. 7 references.
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Cirrhosis. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 8 p.
This fact sheet describes cirrhosis, a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. In cirrhosis, scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. Scarring impairs the liver’s ability to control infections, remove bacteria and toxins from the blood, process nutrients and drugs, make proteins that regulate blood clotting, and produce bile to help absorb fats and fat-soluble vitamins. Written in nontechnical language, the fact sheet describes the causes of cirrhosis, symptoms, complications, diagnosis, measurement of severity, treatment options, and indications for liver transplantation. In the United States, heavy alcohol consumption and chronic hepatitis C have been the most common causes of cirrhosis. Obesity is becoming a common cause of cirrhosis, either as the sole cause or in combination with alcohol, hepatitis C, or both. Other causes of cirrhosis include hepatitis B, hepatitis D, and autoimmune hepatitis; diseases that damage or destroy bile ducts; inherited diseases; nonalcoholic fatty liver disease; drugs; toxins; and infections. Many people with cirrhosis have no symptoms in the early stages of the disease. As the disease progresses, symptoms may include weakness, fatigue, loss of appetite, nausea, vomiting, weight loss, abdominal pain and bloating, itching, and spiderlike blood vessels on the skin. The goals of treatment are to stop the progression of scar tissue in the liver and prevent or treat complications. Treatment for cirrhosis includes avoidance of alcohol and other drugs, nutrition therapy, and other therapies that treat specific complications or causes of the disease. A liver transplant may be considered when complications of cirrhosis cannot be controlled by treatment. Readers are referred to three resource organizations for more information: the American Liver Foundation (www.liverfoundation.org and 1–800–465–4837), Hepatitis Foundation International (www.hepfi.org or 1–800–891–0707), and the United Network for Organ Sharing (www.unos.org or 1–888–894–6361). The fact sheet briefly describes the work of the National Digestive Diseases Information Clearinghouse, which provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. 1 figure.
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Impact of Non-Alcoholic Fatty Liver Disease on Chronic Hepatitis B and C. Practical Gastroenterology. 32(7): 14-28. July 2008.
This article reviews the impact of nonalcoholic fatty liver disease (NAFLD) on chronic hepatitis B and C. The authors note that the prevalence of NAFLD is increasing due to the worldwide epidemic of obesity and diabetes. Metabolic conditions such as central obesity, insulin resistance, dyslipidemia, and hypertension are strongly associated with NAFLD. The article covers the pathogenesis of NAFLD; NAFLD, insulin resistance, and hepatitis C; hepatitis C and hepatic steatosis interaction; host and viral-induced steatosis in patients with hepatitis C virus (HCV); mechanisms underlying the interaction of these conditions and disease progression; the impact of hepatic steatosis on fibrosis progression; the impact of NAFLD on HCV treatment options and results; NAFLD and hepatitis B virus (HBV); and the impact of treating components of the metabolic syndrome on outcomes related to hepatitis B and C. Nonalcoholic steatohepatitis (NASH) is defined as a histologic subtype of NAFLD that may progress to cirrhosis, advanced liver disease, or hepatocellular carcinoma (HCC). Although simple hepatic steatosis may not lead to progressive liver disease, it increases the risk of coronary artery disease. In addition, hepatic steatosis and conditions associated with metabolic syndrome seem to aggravate other liver diseases such as hepatitis B and C. The authors conclude by calling for a better definition and understanding of the impact of superimposed NAFLD and its risk factors on HBV and HCV, which is particularly crucial as the rates of obesity and NAFLD continue to increase. 1 table. 57 references.
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Liver Disease and Pregnancy. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 419-430.
This chapter on liver disease and pregnancy is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. The author notes that because most pregnant women are young and healthy, liver disease is uncommon in this patient population. The presence of liver disease should not be confused with some of the physiologic changes of pregnancy that mimic features commonly associated with liver dysfunction. The chapter divides liver diseases during pregnancy into three categories: chronic liver disease and portal hypertension, liver disease coincidental with pregnancy, and liver disease unique to pregnancy. Specific conditions covered include chronic hepatitis B, hepatitis C, autoimmune disease, Wilson’s disease, cirrhosis of any cause, extrahepatic portal hypertension, acute viral hepatitis, Budd-Chiari syndrome, gallstones, drug-induced liver disease, intrahepatic cholestasis of pregnancy, hyperemesis gravidarum, preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy. For each condition, particularly those in the last category, the author discusses clinical features and diagnosis, incidence and cause, and patient care management, including concerns for both mother and fetus. 2 figures. 4 tables. 7 references.
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Submassive Hepatic Necrosis in a Patient With AIDS. Practical Gastroenterology. 32(9): 54-62. September 2008.
This article reports the case of drug-induced hepatitis, resulting in submassive hepatic necrosis, in a patient with AIDS. The 43-year-old man presented with fever, chills, and a generalized rash of 2 weeks duration. He had chronic nonproductive cough and shortness of breath, generalized fatigue, malaise, and a 20-pound weight loss over 1 month. He had AIDS for 8 years, chronic hepatitis C infection, and previous hepatitis B infection. The patient had been taking nelfiniavir, zidovudine, and lamivudine for his HIV infection for 5 years. Three months before admission, the patient was started on dapsone for pneumonia prophylaxis. He was admitted to the hospital with a presumed diagnosis of adverse drug reaction to dapsone. The authors describe the diagnosis process that he underwent, with an explanation of a set of features suggesting adverse reaction to dapsone known as dapsone syndrome. Dapsone syndrome is a manifestation of the drug rash with eosinophilia and systemic symptoms (DRESS syndrome). The case exhibited most of the key features of dapsone syndrome, including exfoliative dermatitis, fever, hemolytic anemia, and hepatitis, as evidenced by liver biopsy and improvement in the patient’s condition after discontinuation of dapsone. 4 figures. 3 tables. 21 references.
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Viral Hepatitis: A Through E And Beyond. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 6 p.
This fact sheet reviews the different types of viral hepatitis, defined as inflammation of the liver caused by a virus. Several different viruses, named the hepatitis A, B, C, D, and E viruses, cause viral hepatitis. These viruses all cause acute, or short-term, viral hepatitis. The hepatitis B, C, and D viruses can also cause chronic hepatitis, in which the infection is prolonged, sometimes lifelong. Chronic hepatitis can lead to cirrhosis, liver failure, and liver cancer. This fact sheet answers common questions about viral hepatitis, discussing the symptoms of the disease, and, for each type, how it is spread, who is at risk for contracting the disease, how it can be prevented, and treatment options. Depending on the type of virus, viral hepatitis is spread through contaminated food or water, contact with infected blood, sexual contact with an infected person, or from mother to child during childbirth. Vaccines can offer protection from hepatitis A and hepatitis B; no vaccines are available for hepatitis C, D, and E. Reducing exposure to the viruses offers the best protection. The fact sheet concludes with a brief note about research studies in this area and a list of resource organizations through which readers can get additional information. The back cover of the fact sheet provides information about the goals and activities of the National Digestive Diseases Information Clearinghouse (NDDIC).
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Acute Hepatitis C: Diagnosis And Management. Practical Gastroenterology. 31(9): 66-72, 77. September 2007.
This article brings readers up-to-date on the diagnosis and management of acute hepatitis C virus (HCV). After a review of transmission and diagnostic approaches, the authors focus on the issue of differentiating acute HCV from reactivation of chronic disease, particularly in patients with unknown past antibody status. The next section focuses on answering five questions about patient management: who should be treated, how acute HCV should be treated, when treatment should begin, how long treatment should continue, and how to monitor patients after treatment. The authors conclude by reiterating the importance of early detection of acute hepatitis to help prevent the occurrence of chronic hepatitis. The identification of patients at risk and appropriate serological testing is key to discovering the infection in its early stage. Pegylated interferon monotherapy appears to be highly effective in achieving a sustained response; the addition of ribavirin does not seem to add much to effectiveness in most cases. In patients that respond to treatment, appropriate follow-up must be continued to detect relapse. 1 table. 27 references.
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Alopecia Universalis Following Interferon Alfa-2b And Ribavirin Treatment for Hepatitis C. Gastroenterology and Hepatology. 3(8): 644-647. August 2007.
There are many cutaneous side effects associated with the use of combination pegylated interferon alfa-2b (PEG-IFN) and ribavirin (RBV) therapy, which are used to treat hepatitis C. The cutaneous side effects commonly include local reactions at the injection site and development of worsening lichen planus, psoriasis, and vitiligo. This article describes a case report of alopecia universalis (AU) following hepatitis C treatment with PEG-IFN and RBV. The case patient was a 45-year-old Caucasian woman with chronic hepatitis C (CHC) whose past medical history was significant only for hypothyroidism and whose physical examination was unremarkable before starting treatment with PEG-IFN/RBV. After 12 weeks of treatment, her hepatitis C virus RNA level was undetectable and her treatment course was rather typical, although she developed mild anemia. At 45 weeks, the patient reported a significant amount of hair loss from her scalp, which progressed to include her eyebrows and hair on her upper and lower extremities, followed by hair loss in axillary and pubic areas at the end of treatment at 48 weeks. A dermatologist who evaluated the patient diagnosed her condition as AU, confirmed by skin biopsy that showed multiple hair bulbs surrounded and focally infiltrated by a chronic inflammatory cell reaction. Even 1 year after therapy discontinuation, there was no hair regrowth in this patient. The authors briefly discuss the pathogenesis and etiology of AU, noting that their patient started to have hair regrowth after 1 year, without specific treatment for her AU. They conclude that, considering the benign and reversible nature of AU associated with PEG-IFN/RBV treatment, patients should not be discouraged to initiate or complete their treatment for CHC. Appended to the article is a commentary written by Taliani and Biliotti; they echo the conclusions reached by the reporting authors. 32 references.
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Asian Pacific Association for the Study of the Liver Consensus Statements on the Diagnosis, Management and Treatment of Hepatitis C Virus Infection. Journal of Gastroenterology and Hepatology. 22(5): 615-33. May 2007.
This article presents the consensus statements of the Asian Pacific Association for the Study of the Liver (APASL) on the diagnosis, management, and treatment of hepatitis C virus (HCV) infection. Sections cover laboratory testing for HCV infection, prevention of HCV infection, natural history of the disease, treatment approaches, HCV infection in liver transplant candidates, HCV infection in end-stage renal disease, HCV infection in thalassemia and hemophilia, HCV infection in children, HCV and HIV coinfection, HCV and hepatitis B virus (HBV) coinfection, and HCV infection and extrahepatic manifestations. In each section, the consensus statements are listed in a sidebar and then practical clinical points are discussed. 277 references.
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Business Response to Hepatitis B: An Action Guide For Managers. Stanford, CA: Asian Liver Center. 2007. 6 p.
This brochure describes hepatitis B, a viral infection of the liver and the leading cause of liver cancer. This brochure is designed to help employers understand hepatitis B and undertake measures to protect their workforce. The brochure explains that hepatitis B is common worldwide and chronic infection can put people with hepatitis B at risk for chronic liver disease and liver cancer. Readers are advised to review their corporate policies regarding testing job applicants for hepatitis B virus (HBV) status, implement an action plan that promotes HBV education and eliminates discrimination, review coverage available through the company's health plan, provide hepatitis B vaccination, and provide employee education. The brochure emphasizes that people with chronic hepatitis B can lead active lives, interact with co-workers, travel, and be productive employees. Hepatitis B cannot be spread to others through casual contact in the workplace.
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Characteristics of Persons with Chronic Hepatitis B: San Francisco, California, 2006. Morbidity and Mortality Weekly Report. 56(18): 446-448. May 11, 2007.
This article reports characteristics of people in San Francisco with chronic hepatitis B virus (HBV) infection as of 2006. Nearly one fourth of the population of San Francisco was born in Asia and the Pacific Islands, places where HBV infection is endemic. In 2006, the San Francisco Department of Public Health (SFDPH) received reports consistent with probable chronic HBV infection for 2,238 persons; the SFDPH collected additional data on a subset of 567 cases reported to their registry. Eighty-four percent of the persons were Asians or Pacific Islanders, 80 percent of whom were foreign born. Fewer than half had been referred to a gastroenterologist or hepatologist for evaluation. The authors stress that people with chronic HBV can benefit from medical care by providers with expertise in viral hepatitis. Culturally appropriate counseling for and follow-up of persons with chronic HBV infection and their contacts could help reduce the transmission of HBV infection. Appended to the report is an editorial commentary that addresses concerns about the accuracy and completeness of registry data. 2 tables. 7 references.
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Chronic Hepatitis B. Hepatology. 45(2): 507-539. February 2007.
This article presents the practice guideline from the American Association for the Study of Liver Diseases (AASLD) on the care of patients with chronic hepatitis B. These recommendations are based on a formal review and analysis of the published literature on the topic; several consensus conferences among experts; the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines; guideline policies produced by professional organizations, including the AASLD and the American Gastroenterological Association; and the authors’ experiences managing hepatitis B. Topics include screening high-risk populations to identify hepatitis B virus (HBV) infected persons, counseling and the prevention of hepatitis B, hepatitis B vaccination, terminology and natural history of chronic HBV infection, the evaluation and management of patients with chronic HBV infection, treatment options for chronic HBV, whom to treat and with what antiviral agent, the management of special populations with HBV infection, and antiviral prophylaxis of hepatitis B carriers who receive immunosuppressive or cytotoxic chemotherapy. Forty-one specific patient care recommendations are provided. 13 tables. 275 references.
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Chronic Hepatitis B: Who And How to Treat. Practical Gastroenterology. 31(11): 25-30, 35-40. November 2007.
This article reports on the use of drug therapies for hepatitis B and how to determine which patients can and should be treated. The author considers factors such as the natural history of hepatitis B, the variability in disease progression, variable individual patient response, and the advantages and disadvantages of each treatment modality. Patient selection is the key to having the best chance at a remission or cure with treatment. Specific topics include patient evaluation, the immune tolerant phase of the disease, the immune reactive phase of the disease, the inactive carrier phase, the e-antigen negative reactivation phase, treatment goals, treatment options currently approved by the Food and Drug Administration (FDA), and choosing a therapy for an individual patient. The six treatment approaches discussed are interferon alfa-2b, pegylated interferon alfa, lamivudine, adefovir dipivosil, entecavir, and L-deoxythymidine (telbivudine). The author concludes that the goal of treatment for chronic hepatitis B virus (HBV) is to prevent progressive liver disease, cirrhosis, and hepatocellular carcinoma. These goals are achieved through suppression of viral replication. An individual approach should be taken with each patient, and biopsy should be considered in some patients to evaluate for inflammation and fibrosis. 5 tables. 37 references.
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Clinical Update: Hepatitis B. Gastroenterology and Hepatology. 3(7): 538-545. July 2007.
This article provides readers with a clinical update on the diagnosis, epidemiology, and management of chronic hepatitis B (CHB). The author notes that CHB remains a global health problem, with disproportionately high prevalence rates approaching 10 to 15 percent in the Asian population worldwide, and in Asian immigrants in the United States. Chronic infection complications, including cirrhosis and hepatocellular carcinoma, occur in 15 to 40 percent of infected individuals. High viral replication, independent of other factors, may have an impact on long-term disease outcomes. The author discusses each of the current therapies for hepatitis B treatment, including interferon, lamivudine, adefovir, entecavir, and telbivudine. Some of these more recent treatment options have been shown to be very effective at viral suppression, with lower rates of viral resistance compared with lamivudine. Recently updated guidelines and algorithms use viral replication, alanine aminotransferase levels, and severity of histologic disease as the determining factors for treatment. The author concludes by reminding readers that hepatitis B is a disease that is preventable by vaccine, and continued implementation of screening and vaccination programs is essential in the hopes of eradicating this virus. 1 figure. 3 tables. 42 references.
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Factors Contributing to Failure When Treating Patients With Chronic Hepatitis C Virus Infection. Gastroenterology and Hepatology. 3(6): 4-11. June 2007.
This article is from a special issue about the practical management of treatment failure in patients with chronic hepatitis C viral (HCV) infections. The author outlines factors contributing to failure when treating patients with this disease. Combination therapy with peginterferon and ribavirin is the current standard of care for patients with chronic HCV, a treatment that yields sustained virologic response (SVR) in about 50 percent of patients. Certain demographic characteristics and medical comorbidities are associated with treatment failure, including noncompliance, alcohol and drug use, prior treatment with less effective medications, adverse events leading to dose reductions, coinfection with HIV, advanced age, race, advanced fibrosis and cirrhosis, obesity, and insulin resistance and diabetes mellitus. The author recommends measuring HCV RNA frequently during the course of treatment to allow the various patterns of virologic response and nonresponse to be recognized. The treating physician can then more effectively manage the adverse events of therapy and optimize treatment duration. Aggressive management of adverse events may reduce the frequency of null response, partial response, and virologic breakthrough. 3 figures. 1 table. 70 references.
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Hepatitis B: What You Need to Know About This Serious Liver Disease And How to Prevent it. New York, NY: American Liver Foundation. 2007. 2 p.
This brochure from the American Liver Foundation reviews hepatitis B, a disease of the liver that is caused by the hepatitis B virus (HBV). Written in a question-and-answer format, the brochure discusses the causes and transmission of HBV, the typical course of the disease, the symptoms of HBV infection, diagnostic tests that may be used to confirm the presence of HBV, risk factors for getting hepatitis B, chronic hepatitis B and its complications, treatment options, and prevention strategies. HCB is transmitted through body fluids such as blood, semen, and vaginal secretions. Many hepatitis B patients have no symptoms. In a small percentage of patients, hepatitis B persists as a chronic condition that can lead to more serious liver diseases, including cirrhosis, liver failure, and liver cancer. Vaccination is recommended as the best way to prevent hepatitis B. The back cover of the brochure lists facts about hepatitis B in a summarized format. Contact information for the American Liver Foundation is provided.
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Liver Cancer: What You Need to Know if You Have Liver Cancer or Are at Increased Risk. New York, NY: American Liver Foundation. 2007. 2 p.
This brochure from the American Liver Foundation reviews liver cancer. Written in a question-and-answer format, the brochure discusses the causes of liver cancer; the symptoms; the typical course of the disease; diagnostic tests that may be used to confirm the presence of liver cancer; treatment options, including transplantation, surgery, chemotherapy, and radiation therapy; prognosis; prevention strategies; and the management of patients who have liver cancer. The biggest risk factors for primary liver cancer are other liver diseases––mainly cirrhosis and chronic hepatitis B––and obesity. Treatment options are quite limited for liver cancers, except for those that are discovered early. Three websites and a reference book are suggested for readers who wish to obtain more information about liver cancer. The back cover of the brochure lists facts about liver cancer in a summarized format. Contact information for the American Liver Foundation is provided.
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Management of Alcoholic Hepatitis. Gastroenterology and Hepatology. 3(2): 97-99. February 2007.
This article answers common questions physicians may have about the management of alcoholic hepatitis. Topics covered include the pathophysiology of alcoholic hepatitis, the presenting symptoms and attributes of patients with alcoholic hepatitis, the typical course of treatment in these patients, the impact of cessation of drinking alcohol on the course and effects of alcoholic hepatitis, concerns regarding liver transplantation for patients with severe alcoholic hepatitis, and new research in this area. The hallmark of alcoholic hepatitis is jaundice. Most clinicians in the United States do not perform a liver biopsy to make the diagnosis; rather, they base diagnosis on a long history of alcohol use, elevated bilirubin, characteristic AST and ALT values, and no evidence of other liver diseases. The author cautions that approximately 20 to 50 percent of people who have alcoholic hepatitis also have chronic hepatitis C infection. After diagnosis, most patients are treated with oral prednisolone or pentoxifylline. Abstinence from alcohol is required for long-term survival. 6 references.
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Management of Chronic Hepatitis B: Consensus Guidelines. Canadian Journal of Gastroenterology. 21(Suppl C): 5C-24C. June 2007.
This article presents the proceedings of a consensus development conference about the management of viral hepatitis B, held in January 2007, sponsored by the Canadian Association for Study of the Liver and the Association of Medical Microbiology and Infectious Disease Canada. This update is particularly vital because several new drug agents have become available since the last consensus guidelines were published in 2004. In addition, new information has become available to help assess the risk of adverse outcomes of chronic hepatitis B and who should be treated. The participants identified a number of structural barriers that exist uniquely in Canada that prevent physicians from properly managing their patients. Topics include the selection of patients for treatment, the drugs that can and should be used for these patients, screening for liver cancer, and the treatment of hepatitis B in special populations, including pregnant women and people with kidney failure. Thirty-three specific recommendations are provided. 6 figures. 7 tables. 161 references.
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Management of Chronic Hepatitis C: Consensus Guidelines. Canadian Journal of Gastroenterology. 21(Suppl C): 25C-34C. June 2007.
This article presents the proceedings of a consensus development conference about the management of viral hepatitis C, held in January 2007, sponsored by the Canadian Association for Study of the Liver and the Association of Medical Microbiology and Infectious Disease Canada. This article highlights the presentations and discussion about chronic hepatitis C virus. The authors review the epidemiology of hepatitis C in Canada, treatment of acute hepatitis C, the use of hematopoietic growth factors, and new algorithms in chronic hepatitis C, including one for retreatment of previous treatment failures. The authors consider the management of hepatitis C in special populations such as pregnant women, children, and injection drug users. Twenty-six specific recommendations are provided. 3 figures. 5 tables. 97 references.
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Managing Side Effects Related to Treatment for Chronic Hepatitis C. Gastroenterology and Hepatology. 3(6): 12-21. June 2007.
This article is from a special issue about the practical management of treatment failure in patients with chronic hepatitis C viral (HCV) infections. The author outlines approaches to managing side effects related to treatment for chronic HCV. Many reasons explain the lack of enduring response to treatment that occurs in approximately half of all patients treated with interferon-based therapy, including both viral and host factors. Adverse effects to antiviral therapy, including hematologic and neuropsychiatric effects, are important contributors to dose reduction and treatment discontinuation and contribute to poor adherence. The author describes common treatment-related adverse effects, including flu-like syndrome, dermatologic symptoms, hematologic complications, anemia, neutropenia, thrombocytopenia, fatigue, neuropsychiatric effects, and depression. Proper patient selection is an important first step in minimizing the possibility of treatment failure, and patients who undergo treatment should be educated on the nature and frequency of common side effects. A patient care algorithm for managing interferon-induced depression is included. 5 figures. 5 tables. 90 references.
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Mechanism of Action of Ribavirin in the Treatment of Chronic Hepatitis C. Gastroenterology and Hepatology. 3(3): 218-225. March 2007.
The current standard treatment for chronic hepatitis C consists of the combination of pegylated interferon and ribavirin. Although interferon is known to have potent antiviral, immunomodulatory, and anti-inflammatory activities against hepatitis C, the mechanism of ribavirin action against the virus is not clearly understood. This article reviews proposed mechanisms of ribavirin activity, along with their supporting data. The authors discuss ribavirin’s roles in the direct inhibition of hepatitis C virus replication, the inhibition of inosine monophosphate dehydrogenase, the induction of mutagenesis to the threshold of error catastrophe, and immunomodulation. The authors note that the immunomodulatory effect of ribavirin cannot account for its antiviral activity in cell cultures, and direct effects on HCV RNA levels are not observed in patients on ribavirin alone. The authors hypothesize that the success of ribavirin is attributable to its multivalent nature as a purine analogue involved in multiple cellular pathways. 2 figures. 71 references.
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Prospective Evaluation of FIBROSpect II for Fibrosis Detection in Hepatitis C and B Patients Undergoing Laparoscopic Biopsy. Gastroenterology and Hepatology. 3(5): 367-376. May 2007.
This article reports on a study undertaken to validate a serum marker of liver fibrosis through the use of laparoscopic biopsy, which decreases sampling error and increases the reliability of histopathologic assessment. The authors prospectively evaluated the FIBROSpect II serum marker test for viral liver fibrosis against laparoscopic biopsies by studying 145 patients with chronic hepatitis B or C who underwent laparoscopy in a tertiary care setting. Results showed that the FIBROSpect II test was able to rule in significant fibrosis (stages 2 to 4) with a likelihood rate of 2.6. The test correctly indicated absence of diseases in 74 percent of stages 0 to 1 patients and correctly predicted significant disease in 67 percent of stages 2 to 4 patients. Multiple biopsies from 52 percent of patients differed by at least one stage. In 13 patients (9 percent), cirrhosis was detected by laparoscopy but not histologically. The authors conclude that FIBROSpect II provides valuable additional information for assessing fibrosis. 3 figures. 4 tables. 26 references.
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Role Of Innate Immunity in Chronic Hepatitis C Viral Infection. Gastroenterology and Hepatology. 3(9): 683-684. September 2007.
This article from a series on advances in hepatology answers common clinical questions about the role of innate immunity in chronic hepatitis C viral (HCV) infection. Topics include the rationale for research on the innate immune response to chronic viral infections, how the innate and adaptive immune systems affect one another in the setting of chronic HCV infection, how this research could be useful in the treatment regimens currently in use, how the HCV core protein interacts with the innate immune system, recent research on the NS3/4A protease and how it relates to currently developing protease-inhibitor therapies for HCV, and how this understanding of the innate immune response may help in devising more effective treatment regimens for eradicating HCV infection. The author notes that therapeutic interferon works via both direct viral suppression and enhancement of immune system T-cell action. If medical science can determine that the subset of genes that are turned on by interferon are the genes that can control HCV infection, it may be possible to modify the therapy to enhance the expression of that set of genes. 7 references.
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ABC's of Hepatitis. Silver Spring, MD: Hepatitis Foundation International. 2006. 1 p.
This fact sheet summarizes the different types of human viral hepatitis. Hepatitis viruses cause inflammation of the liver. There are five types commonly considered: hepatitis A, B, C, D or delta, and E. The fact sheet briefly defines each type, noting incubation period, how the virus is transmitted, the symptoms, treatment of chronic versions of the disease (where applicable), vaccination if available, risk factors, and prevention strategies. The contact information for the Hepatitis Foundation International is also provided.
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Consensus Interferon: Practical Management of Treatment Failures in Chronic Hepatitis C. Gastroenterology and Hepatology. 3(6): 22-30. June 2006.
This article is from a special issue about the practical management of treatment failure in patients with chronic hepatitis C viral (HCV) infections. The author considers treatment guidelines published by professional medical associations. These guidelines are only updated periodically, so they cannot always incorporate the full range of available treatment options. The author notes that independently developed guidelines may close these gaps by incorporating more up-to-date treatment regimens. Options available for the retreatment of patients who failed earlier interferon-based therapy include retreatment with a different pegylated interferon at a higher dose or as induction therapy, longer duration therapy, maintenance therapy, a watch-and-wait strategy, or retreatment with consensus interferon and ribavirin. The goal of all of these retreatment options is to decrease the burden of hepatitis C virus-related morbidity and to eradicate the virus. Consensus interferon is a synthetic agent used to treat chronic hepatitis C; it has been shown in some studies to increase rates of sustained virologic response in patients who failed previous therapy when compared with conventional therapy. The author calls for the inclusion of consensus interferon into the current treatment guidelines to provide another effective treatment option for patients who have failed the current standard of care. 1 figure. 2 tables. 48 references.
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End-Stage Liver Disease. IN: Nilsson, K.R.; Piccini, J.P., eds. Osler Medical Handbook. Philadelphia, PA: Saunders. 2006. pp. 402-417.
Chronic liver disease includes a broad differential diagnosis of infectious, autoimmune, inherited, metabolic, toxic, and acquired origins. This chapter on end-stage liver disease is from a handbook that provides the essentials of diagnosis and treatment, as well as the latest in evidence-based medicine, for residents working bedside, in-patient care. The chapter begins with a presentation of essential Fast Facts and concludes with Pearls and Pitfalls useful to the practicing internist. The body of the chapter is divided into sections: Epidemiology, Clinical Presentation, Diagnosis, and Management. Specific topics covered include the most common causes of cirrhosis in the United States, notably alcoholic liver disease and chronic hepatitis C infection; nonalcoholic fatty liver disease (NAFLD); the causes of the clinical problems associated with cirrhosis; the risk factors for hepatic encephalopathy, including infection, dehydration, hypokalemia, alkalosis, and sedating medications; the risk of liver cancer in patients with cirrhosis; autoimmune hepatitis; the diagnostic tests used to confirm metabolic and inherited causes of chronic liver disease; and the use of the Model for End-Stage Liver Disease (MELD) score to predict mortality, particularly for those patients waiting for a liver transplantation. The chapter concludes with a list of references, each labeled with a 'strength of evidence' grade to help readers determine the type of research available in that reference source. 1 figure. 2 tables. 35 references.
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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.
In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.
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Liver Disease in Patients with Diabetes Mellitus. Journal of Clinical Gastroenterology. 40(1): 68-76. January 2006.
In addition to the well-known cardiovascular, renal, and ophthalmologic complications of diabetes, liver-related complications occur commonly and are often underrecognized. This article reviews the relationship between diabetes mellitus and two common liver diseases: chronic hepatitis C and nonalcoholic fatty liver disease. The author also discusses the association of diabetes and cirrhosis, acute liver failure, hepatocellular carcinoma, and outcomes following orthotopic liver transplantation. The liver plays a significant role in energy homeostasis and glucose metabolism; insulin enhances glycogen synthesis within the liver and prevents glucose production. These normal physiologic processes become dysregulated with insulin resistance and type 2 diabetes mellitus. Insulin resistance may work synergistically with hepatitis C infection to make changes in the liver, in the form of steatosis, inflammation, and fibrosis development. Once this occurs, progression to diabetes may occur in patients with underlying genetic susceptibility. Current treatment for preventing liver complications is focused on therapies that improve underlying insulin resistance, including weight loss or drug therapy. 1 figure. 2 tables. 158 references.
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Natural History of Nonalcoholic Steatohepatitis. Journal of Clinical Gastroenterology. 40(Suppl 1): S11-S16. March 2006.
This review article covers the natural history of nonalcoholic steatohepatitis, a variation of nonalcoholic fatty liver disease (NAFLD). NAFLD is being increasingly recognized as one of the most common chronic liver diseases. The authors note that the natural history of this liver disease remains unclear due to its indolent nature, the paucity of prospective studies, and the lack of consensus regarding the various forms of this disorder. Patients with nonalcoholic steatohepatitis (NASH) appear to have a higher likelihood of progression to cirrhosis. Obesity and possibly type 2 diabetes appear to be associated with an increased risk of fibrosis. There is also an increased risk of liver cancer and end-stage liver disease among patients with NASH-related cirrhosis and those with cryptogenic cirrhosis, which likely represents a late stage of NAFLD. The authors also briefly review the recurrence of NASH in patients who have undergone liver transplantation for NASH-related end-stage liver disease. They conclude that long-term survival in patients with NAFLD may be slightly worse than survival from all-cause chronic liver disease, although survival appears to be higher than among patients with fatty liver from alcohol abuse, and is comparable to patients with chronic hepatitis C infection. 6 figures. 19 references.
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New Treatments for Chronic Hepatitis C. Gastroenterology and Hepatology. 1(2): 97-98. September 2006.
This article answers clinical care questions on new treatments for chronic hepatitis C (HCV). Topics include the standard treatment approach for chronic HCV, the side effects of treatment with interferon and ribavirin, patient candidacy for drug therapy, new types of interferon currently under study, new varieties of ribavirin, four other categories of treatment for HCV (using antibodies, augmenting the patient’s immune response to the virus, ways to block inflammation and formation of fibrosis and scar tissue, and drugs that inhibit the ability of HCV to replicate), the use of protease inhibitors, and strategies to improve acute hepatitis C treatment as a way to prevent chronic hepatitis C. 5 references.
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Viral Hepatitis. IN: Nilsson, K.R.; Piccini, J.P., eds. Osler Medical Handbook. Philadelphia, PA: Saunders. 2006. pp. 389-401.
This chapter on viral hepatitis is from a handbook that provides the essentials of diagnosis and treatment, as well as the latest in evidence-based medicine, for residents working bedside, in-patient care. The chapter begins with a presentation of essential Fast Facts and concludes with Pearls and Pitfalls useful to the practicing internist. The body of the chapter is divided into sections: Epidemiology, Clinical Presentation, Diagnosis, and Management. Specific topics covered in this chapter include hepatitis A through C; the diagnosis of acute hepatitis A (HAV), which is usually transmitted via the fecal-oral route; the problem of patients with hepatitis B virus (HBV) infection converting to chronic carrier state; markers used to assess disease severity; the risk of acute exposure to hepatitis C converting to chronic hepatitis C (HCV) infection; and the use of HCV genotype studies to help determine those patients more likely to achieve a sustain virological response to drug therapy for their disease. The chapter concludes with a list of references, each labeled with a 'strength of evidence' grade to help readers determine the type of research available in that reference source. 7 figures. 31 references.
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Diagnosis and Treatment of Viral Hepatitis. Silver Spring, MD: Hepatitis Foundation International. 2005. 2 p.
This fact sheet summarizes the diagnosis and treatment recommended for different types of human viral hepatitis. Hepatitis viruses cause inflammation of the liver. There are five types commonly considered: hepatitis A, B, C, D or delta, and E. Blood tests are used to diagnose all types of hepatitis. For hepatitis A virus (HAV) infections, 99 percent of those infected will recover without treatment. Immunization against hepatitis A is available and recommended for individuals planning international travel or those in households with other people who have hepatitis A. Hepatitis B also resolves in most patients within 6 months, however, there is also a chronic type. There are four approved treatments for chronic hepatitis B virus (HBV): interferon alfa-2b, lamivudine, entecavir, and adefovir dipivoxil. Safe and effective vaccines provide protection against hepatitis B and are universally recommended. Hepatitis C virus (HCV), a sexually transmitted disease, results in chronic infection in 55 to 85 percent of patients diagnosed with acute infection. Treatment options include interferon combined with ribavirin. Currently, nearly half of all liver transplants in the U.S. are performed for end-stage hepatitis C. Hepatitis D virus (HDV) is only encountered in patients already infected with HBV; vaccination against HBV will therefore also protect against HDV. The contact information for the Hepatitis Foundation International is also provided.
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Evaluation of the Patient for Liver Transplantation. Hepatology. 41(6): 1-26. June 2005.
Liver transplantation is the most effective treatment for many patients with acute or chronic liver failure resulting from a variety of causes. This article presents the practice guideline from the American Association for the Study of Liver Diseases (AASLD) on the evaluation of patients for liver transplantation. These recommendations are based on a formal review and analysis of the published literature on the topic; several consensus conferences among experts; the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines; guideline policies produced by professional organizations, including the AASLD and the American Gastroenterological Association; and the authors’ experience in the specified topic. Topics include the indications of liver transplantation, when evaluation for transplantation should be considered, determining the need for liver transplantation, and recipient evaluation at the transplant center. The article offers recommendations for patients with the hepatopulmonary syndrome, portopulmonary hypertension, obesity, cigarette smoking, kidney failure, extrahepatic malignancies, osteoporosis, HIV infection, surgical contraindications, and psychosocial problems. The authors discuss specific indications for liver transplantation, including chronic noncholestatic liver disorders, chronic hepatitis C, chronic hepatitis B, autoimmune hepatitis, alcoholic cirrhosis, cholestatic liver disorders, primary biliary cirrhosis, primary sclerosing cholangitis, childhood cholestatic diseases, metabolic diseases, alpha-1-antitrypsin disease, Wilson disease, nonalcoholic steatohepatitis and cryptogenic cirrhosis, hereditary hemochromatosis, neonatal hemochromatosis, tyrosinemia and glycogen storage disease, metabolic diseases with severe extrahepatic manifestations, amyloidosis and hyperoxaluria, urea cycle and branched-chain amino acid disorders, hepatic malignancies, hepatocellular carcinoma, hepatoblastoma, fibrolamellar hepatocellular carcinoma and hemangioendothelioma, cholangiocarcinoma, and fulminant hepatic failure. The article includes 76 specific recommendations for the evaluation of the patient for liver transplantation. 3 tables. 328 references.
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Hepatitis and Liver Disease in the United States. New York, NY: American Liver Foundation. 2p.
This fact sheet offers basic information and statistics about hepatitis and liver disease in the United States. Twenty-five million Americans, or one in every 10, are or have been afflicted with a liver, biliary, or gallbladder disease. Alcoholic liver disease and chronic hepatitis C are the leading causes of cirrhosis (scarring of the liver that reduces or prevents proper functioning of the organ). The Centers for Disease Control and Prevention (CDC) estimate that the number of annual deaths from hepatitis C will triple in the next 10 to 20 years. Data for hepatitis B show that 78,000 people are infected with the virus each year; 1.25 million people are chronically infected. The estimated medical and work loss cost per year for hepatitis B is over $700 million' for hepatitis C it is over $600 million. Approximately 5,600 liver transplants were performed in 2003; however, because of the organ shortage, it is estimated that over 1,800 people died that year while waiting for a liver transplant. There are currently 17,700 people waiting for a liver transplant. The fact sheet concludes with listing the risk factors for hepatitis B and those for hepatitis C. A brief description of the American Liver Foundation (ALF) is also provided, along with the Foundation's contact information.
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Importance and Benefits of Hepatitis A Prevention in Chronic Liver Disease Patients. Journal of Gastroenterology and Hepatology. Volume 19 Supplement. S17-S20. March 2004.
This review article considers the importance and benefits of hepatitis A prevention in chronic liver disease patients. The author discusses the global prevalence of hepatitis A, the impact of hepatitis A on chronic hepatitis B, the Shanghai epidemic, hepatic necrosis (liver tissue death), hepatitis A infection superimposed on hepatitis C infection, and hepatitis A virus (HAV) vaccination, including strategies, benefits, and cost-effectiveness. The author concludes that the evidence suggests that patients with chronic liver disease (CLD) have a worse outcome if infected with hepatitis A. In the Shanghai epidemic, mortality was five time higher in those with chronic hepatitis B. Vaccination against HAV has been successful in CLD patients, but it must be ensured that patients complete a full course of vaccination. 1 figure. 14 references.
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Silent Celiac Disease in Chronic Hepatitis C: Impact of Interferon Treatment on the Disease Onset and Clinical Outcomes. Journal of Clinical Gastroenterology. 38(10): 901-905. November-December 2004.
This article reports on a study undertaken to assess the impact of interferon treatment on celiac disease (CD) in hepatitis C patients and to clarify clinical relevance and outcome. CD is an autoimmune enteropathy characterized by inappropriate immune responses to dietary wheat gluten. Hepatitis C is associated with autoimmunity, which can be worsened by interferon treatment. Cases of celiac disease activation during interferon treatment have been reported. The authors conducted a retrospective evaluation of 534 hepatitis C patients with or without symptoms compatible with CD onset during interferon treatment and 225 controls. Results showed that 86 percent of patients with anti-transglutaminase antibodies showed activation of celiac disease while on interferon. Symptoms ranged from mild to severe, and interferon had to be discontinued in 2 of 7 (29 percent) patients. Symptoms subsided in 6 of 7 patients after interferon withdrawal. The authors conclude that, in hepatitis C patients, the activation of silent celiac disease during interferon treatment should be suspected, but rarely requires treatment discontinuation. Is rarely required. 3 tables. 29 references.
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Therapeutic Advances in Chronic Hepatitis B. Journal of Gastroenterology and Hepatology. Volume 19 Supplement. S5-S9. March 2004.
This review article considers therapeutic advances in chronic hepatitis B (CHB). The author first discusses the outcome of lamivudine therapy, including the results from a 1-year study of this drug, long-term lamivudine therapy, the durability of treatment response, and HBeAg-negative disease (and treating it with lamivudine). The author also considers decompensated cirrhosis and the lamivudine safety profile. The author concludes that most patients with CHB have their disease controlled by lamivudine therapy, and those with elevated ALT respond well. Lamivudine has shown efficacy in HBeAg-negative patients and those with decompensated cirrhosis. In long-term use, lamivudine has been found to be well tolerated. In patients with decompensated CHB, the combination of lamivudine and adefovir dipivoxil showed significant efficacy. 3 figures. 11 references.
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Viral Hepatitis. IN: U.S. Department of Health and Human Services. Action Plan for Liver Disease Research. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2004. pp. 61-70.
At least five different hepatitis viruses (hepatitis A to E) cause liver disease in humans. All five cause acute disease, while hepatitis B, C, and D viruses can also lead to a persistent infection and chronic hepatitis. This chapter on viral hepatitis is from the Action Plan for Liver Disease Research that was developed to advance research on liver and biliary diseases. The Action Plan was undertaken to identify areas of scientific opportunity to help direct research resources at the National Institutes of Health (NIH) toward practical goals in the prevention, diagnosis, and management of liver and biliary diseases. In this chapter, the authors first review the different types of hepatitis viruses, their epidemiology and treatment strategies. The authors then outline recent research advances in each of the different types of hepatitis, noting that all five viruses have been identified and defined by molecular and immunological means; safe and effective vaccines are available for hepatitis A and B; and therapies for chronic hepatitis B and C have been approved and are in general use. Specific research goals in each area are then proposed, with the overarching goal of developing practical, safe, and effective means of prevention, treatment, and control of the five forms of viral hepatitis. One chart summarizes the short (0 to 3 years), intermediate (4 to 6 years), and long-term (7 to 10 years) goals of research on these topics. 1 figure. 1 table.
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