Hepatitis — Differences among the Viruses

“Hepatitis” means liver infection or inflammation; when we talk about germs, it’s infection.ย  There are 5 Hepatitis viruses: A, B, C, D, and E.ย  These are just names; the viruses aren’t related to each other at all, each plays out in its own special way.ย  Actually, other viruses also cause liver injury, like Epstein-Barr (causes Mononucleosis), Cytomegalovirus (very mild, goes away on own), and more.ย 

The most common cause of hepatitis is “Alcoholic Hepatitis,” from heavy binging on (mortality from the inflammation is high enough to worry). Then there are other liver diseases that have nothing to do with viruses. This topic only concerns Viral Hepatitis; see Liver Diseases for a discussion of the others.

If there are symptoms, there’s no way to tell the difference among the viruses without blood tests.  Symptoms of Hepatitis include:

  • Feeling lousy
  • Loss of appetite
  • Maybe upper abdominal pain, especially if you tap on the liver in the upper right
  • Nausea with / without vomiting
  • Jaundice: Eyes & skin turn yellow (urine dark yellow, bowel movements pale gray)

See our topic Acute Hepatitis for a discussion of symptoms.

We diagnose “hepatitis” by finding elevated liver enzymes in a blood test: mainly the ALT and AST (these are also called “transaminases,” or sometimes “Liver Function Tests (LFT’s for short).ย  In acute disease, when a person usually feels sick, the numbers are very high.ย  In chronic forms of hepatitis, the degree of elevation may be small.

Abnormal liver enzymes indicate that something is happening in the liver, but don’t tell us how bad.  The degree of elevation is not a help.  To see if the liver’s working well enough, we measure proteins that the liver puts together (synthesizes): Prothrombin and Albumin.  If these are normal, we say the liver’s “synthetic function” is normal, & thus the liver can do everything it needs to (including detoxifying all food we eat & medications we take).

Here are brief summaries of what the different types of viral hepatitis are:

Hepatitis A  —  Spread from one person’s bowel to another’s mouth, like if an infected food handler doesn’t wash their hands, oral sex (bowel germs are everywhere down there), contaminated water in poor countries, etc.  Symptoms begin 2-6 weeks after getting infected, last around a month, go away on their own (once jaundice occurs, you’ll be better real soon).  Then you’re immune, can never get it again.

Children tend to get few symptoms, maybe a little diarrhea only.  So many immigrants from poor countries already had it as children, & are immune.  Only 1 in 1,000 people with Hep A gets seriously ill (dies or needs transplant), usually someone who has another liver disease to begin with.  There’s no treatment (it’s a virus).  It’s best not to drink alcohol during Hep A, but no need to avoid any pain medicine or birth control pills (the way some people mistakenly advise).

We diagnose Hep A by a blood test for the antibody.  Many clinicians order the wrong test (see Hepatitis Blood Tests to distinguish among the different viruses).

There’s a vaccine to prevent Hep A.  If your roommate or sex partner has the disease, there’s a shot of immune globulin to protect you for a few months.

Hepatitis B  —  Spread by bodily fluids, mainly sex and blood (by injecting).  It’s common among men who have sex with men, anybody with many sex partners, and people who inject drugs.  Hep B is contagious enough that it might also be spread by sharing razors, toothbrushes, washcloths (rubbing hard), anything with even the least bit of unseen blood on it.  It’s very common in Asia and in Africa (south of the Sahara), and increased among first generation Americans whose parents were born there.

Symptoms begin 2-6 months after getting infected.ย  Most people with acute Hep B are hardly sick, often without any symptoms at all.ย  About 90% of people get better on their own, are immune, and can never get it again.ย  But 10% keep the virus forever, becoming “carriers” who can spread it.ย  Half of them develop chronic liver disease (“Active Hep B”), and may develop cirrhosis or liver cancer.ย  About 90% of babies born to mothers with Hep B virus wind up as carriers, & usually get chronic Active Hep B (unless treated at birth).

Diagnosis is made by blood tests for antibodies.ย  There are several to pick from, and many clinicians don’t know which to choose (see Hepatitis Blood Tests to distinguish among the different viruses, and how to tell if Hep B is chronic or not).

We don’t treat acute Hep B, since 90% of the time it goes away on its own.  There’s treatment for Chronic Active Hep B, although not everyone needs it.  We determine who by their liver tests, and by how much virus is in them (Hepatitis B “viral load” for DNA), and a test for “e” antigen.  People who chronically carry virus need regular liver ultrasounds to be sure no cancer is developing, men after age 40, women age 50.

There’s a vaccine for Hep B.ย  Since 1993-4, it’s been given to all newborn babies in the US.ย  People at high risk of Hep B should get antibody tests to see if they need vaccination, including healthcare workers, men who have sex with men, people with many sex partners, people who inject drugs, partners & household members of Hep B carriers, being born in or traveled to high-risk countries, and people who need or may need kidney dialysis.

Hepatitis C  —  The opposite of Hep B, in that only 20% of people with Hep C get cured on their own, while 80% have chronic ongoing infection.  The virus destroys the liver bit by bit, slowly over many years — around 10% of people with Hep C get cirrhosis (liver failure) in 10 years, 30% in 30 years, 50% in 50 years.  So many people infected with Hep C won’t die from it. 

Before the first test was invented in 1992, lots of Hep C was spread by blood transfusion.  Among people born between 1945 – 1965, 2.5% have been infected (1 in 40).  This was thought to be because of the newish “hippie lifestyle,” but a recent study suggests it was because babies got vaccinated & treated with reusable syringes & needles that were hard to sterilize well in those days.  Now Hep C is spread mainly by injecting drugs, and by sex with multiple partners (because other STDs make it easier to transmit).

Most people with Hep C have no symptoms.ย  Some feel ongoing fatigue and achiness, while a minority have joint pains, rashes (with lumps, blisters, bruises, or easy scarring), or decreased kidney function.ย  Treatment for Hep C usually helps.

Treatment has become very easy since 2014.  Before that, it had lots of side effects, and didn’t work well.  Newer drugs have virtually no side effects, and cure almost 100% of people in usually 2-3 months.  There are various ways to determine how much damage has already progressed in the liver — the more damage, the sooner they should be treated.  But it’s also OK to treat everyone.  The problem is that some cost over $150,000 for a full treatment course, so insurances delay approval.

Since most people with Hep C have no idea they’re infected, it’s important to screen high risk people for it.ย  These include anyone who was born 1945-1965, ever injected drugs, had blood transfusions before 1992, was in prison, got kidney dialysis, has HIV, has abnormal liver tests on routine labs, whose partner or mother had Hep C, or who lived in a high-risk country.

Hepatitis Dย  —ย  A virus that can only cause illness if the person also has chronic Hepatitis B.ย  It’s rare in the US, more common in the Mediterranean area and Far East Asia.ย  It causes cirrhosis (liver failure) fairly rapidly.ย  There’s no treatment, although treating chronic Hep B can prevent Hep D complications.ย  See Hepatitis Blood Tests for how to diagnose it.

Hepatitis E  —  This virus is transmitted like Hep A, into the mouth from contaminated water or food (like if a food-handler didn’t wash their hands), maybe from undercooked meat.  It’s common in poor countries, but very rare in the US, only seen among returning travelers.  It causes a somewhat severe illness like Hep A [see above], and gets better on its own.  There’s no chronic ongoing illness like with Hep B or C.

The main danger is for pregnant women, especially in late pregnancy, when maybe 25% might die!!!  As such, we might strongly advise pregnant women against traveling to poor countries.  There’s no blood test for Hep E available in the US, although the CDC could arrange for it if necessary.

Thereโ€™s also a Hepatitis G, a virus which doesnโ€™t cause disease.ย  People used to think that this virus might protect against getting HIV, but it doesnโ€™t.ย  And finally, what happened to โ€œHepatitis Fโ€?ย  Well, a virus was discovered and named, but then found out to be a mistake!ย  So now after โ€œEโ€ comes โ€œGโ€.

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