First-line Blood Tests
🧬 Viral: Hepatitis B surface Ag, Hepatitis C antibodies 🧪 Autoimmune: ANA, Smooth Muscle Ab, Anti-Mitochondrial Ab (PBC) 🧫 Immunoglobulins: IgA (Alcohol/NAFLD), IgM (PBC), IgG (Autoimmune hepatitis) 🔩 Metabolic: Ferritin (Haemochromatosis), Alpha-1 antitrypsin, Caeruloplasmin (Wilson’s disease)

🧭 History & Risk Factors

Symptoms: Fatigue, jaundice, abdominal discomfort, pruritus, dark urine, pale stools.
Duration: ≥ 6 months of liver inflammation = chronic hepatitis.
Risk Factors:
- 💉 Blood transfusion before 1992 (Hep C risk)
- 💊 IV drug use / unsafe injections
- ❤️ Unsafe sexual practices
- 🩺 Occupational exposure (e.g. healthcare)
- 🍷 Alcohol excess
- 🧬 Family history (autoimmune / metabolic)
- 💊 Hepatotoxic drugs (paracetamol, methotrexate, amiodarone)
- ✈️ Travel to Hep B/C endemic areas

👩‍⚕️ Physical Examination

General: Jaundice, cachexia, lethargy
Abdomen: Hepatomegaly, RUQ tenderness, splenomegaly, ascites
Skin signs: Spider angiomas, palmar erythema, caput medusae, bruising/petechiae

🦠 Aetiology

Alcoholic liver disease
Autoimmune hepatitis
Non-alcoholic fatty liver disease (NAFLD/NASH)
Chronic viral hepatitis (B, C; less common CMV/EBV)
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Wilson’s disease
Haemochromatosis
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs: amiodarone, methotrexate, nitrofurantoin
Type IV glycogen storage disease
Sarcoidosis, Budd–Chiari syndrome, right heart failure
Idiopathic

👩‍⚕️ Clinical Features

Hands: Leukonychia, palmar erythema, clubbing, Dupuytren’s contracture
Skin: Spider naevi (>3 in SVC distribution), “paper money skin”, bruising
Endocrine: Testicular atrophy, gynaecomastia (alcohol, spironolactone)
Face: Parotid swelling, fetor hepaticus
Abdomen: Hepatomegaly or small shrunken liver, splenomegaly, ascites, caput medusae
Other clues: Tattoos (HBV), anaemia (chronic disease, variceal bleeding)

🔎 Causes of Chronic Hepatitis

Cause	Typical Presentation	Investigations	Treatment
Hepatitis B	Fatigue, jaundice, arthralgia → cirrhosis/HCC	HBsAg, HBeAg, HBV DNA, LFTs, Fibroscan	Antivirals (tenofovir, entecavir); transplant if end-stage
Hepatitis C	Often asymptomatic; later cirrhosis/HCC	Anti-HCV, HCV RNA PCR, genotype, LFTs, Fibroscan	Direct-acting antivirals (DAAs) tailored to genotype
Autoimmune Hepatitis	Fatigue, jaundice, arthralgia, hepatomegaly	ANA, SMA, LKM1, IgG, biopsy	Prednisolone ± Azathioprine
Alcoholic Hepatitis	Jaundice, hepatomegaly, ascites	AST:ALT > 2, bilirubin ↑, biopsy if unclear	Abstinence, nutrition, steroids if severe
NAFLD / NASH	Often asymptomatic; hepatomegaly, cirrhosis	Ultrasound, Fibroscan, biopsy if uncertain	Weight loss, exercise, control DM/dyslipidaemia
Drug-Induced	Fatigue, jaundice, variable course	Drug history, LFTs, biopsy if unclear	Stop drug, supportive care
Wilson’s Disease	Hepatic + neuro/psychiatric symptoms	Low ceruloplasmin, urinary copper, biopsy, genetics	Penicillamine, zinc; transplant if failure
Haemochromatosis	Fatigue, bronze skin, diabetes, cirrhosis	Ferritin, transferrin saturation, HFE genotype	Venesection; chelation if not tolerated

🧬 Laboratory Investigations

LFTs: ALT, AST, ALP, bilirubin; Albumin + PT/INR (synthetic function)
Viral markers: HBsAg, HCV Ab; HBV DNA, HCV RNA PCR
Autoimmune: ANA, SMA, LKM1
Metabolic: Ferritin, transferrin saturation, ceruloplasmin

🖼️ Imaging & Non-invasive Tests

Ultrasound: size, cirrhosis, focal lesions
Fibroscan/elastography: fibrosis/cirrhosis staging
CT/MRI: suspected HCC or complications

🧪 Liver Biopsy

Indicated if diagnosis unclear or to stage fibrosis
Essential for autoimmune hepatitis confirmation

💊 Management Principles

HBV → antivirals (tenofovir/entecavir)
HCV → DAAs (curative)
Autoimmune → steroids + azathioprine
Alcoholic → abstinence, nutrition, steroids if severe
NAFLD/NASH → lifestyle, metabolic control
Wilson’s → chelators/zinc
Haemochromatosis → venesection
Supportive: avoid alcohol/NSAIDs, vaccinate for HAV/HBV, regular monitoring

⚠️ Screening for Complications

Cirrhosis & liver failure
Portal hypertension: varices, ascites
Hepatocellular carcinoma (HCC): Ultrasound + AFP every 6–12 months

💡 Exam tip: In OSCEs, mention that all CLD patients need HCC surveillance and variceal screening once cirrhosis develops.

Cases - Chronic Hepatitis

Case 1 - Chronic viral hepatitis B 🦠: A 32-year-old man from China is found to have persistently raised ALT on routine bloods. He denies alcohol use. Serology: HBsAg positive >6 months, HBeAg positive, high HBV DNA load. Ultrasound: normal liver. Diagnosis: chronic hepatitis B (active replication phase). Managed with antiviral therapy (tenofovir) and regular HCC surveillance.
Case 2 - Chronic hepatitis C 🎗️: A 45-year-old man with history of IV drug use presents with fatigue and mild jaundice. LFTs: raised ALT/AST. HCV RNA positive, genotype 3. Fibroscan: significant fibrosis. Diagnosis: chronic hepatitis C. Managed with direct-acting antivirals (sofosbuvir/velpatasvir) and hepatology follow-up.
Case 3 - Autoimmune hepatitis 🧬: A 28-year-old woman presents with fatigue and arthralgia. Exam: hepatomegaly. LFTs: ALT 350, AST 320, raised bilirubin. Immunology: ANA and anti-smooth muscle antibody positive, IgG elevated. Liver biopsy: interface hepatitis with plasma cell infiltrates. Diagnosis: autoimmune hepatitis. Managed with corticosteroids and azathioprine.
Case 4 - Metabolic (Wilson’s disease) 🧑‍⚕️: A 21-year-old student presents with abnormal LFTs, tremor, and dysarthria. Exam: Kayser–Fleischer rings on slit lamp. Serum caeruloplasmin low, 24-hour urinary copper high. Diagnosis: chronic hepatitis due to Wilson’s disease. Managed with copper chelators (penicillamine) and liver specialist referral.
Case 5 - Drug-induced (methotrexate) 💊: A 54-year-old woman with rheumatoid arthritis on long-term methotrexate presents with fatigue. LFTs: persistently raised transaminases. Imaging: hepatomegaly. Biopsy: fibrosis with chronic hepatitis features. Diagnosis: chronic drug-induced hepatitis. Managed by stopping methotrexate, monitoring fibrosis, and supportive care.

Teaching Point 🩺: Chronic hepatitis is defined as persistent liver inflammation ≥6 months. Causes include viral (HBV, HCV), autoimmune, metabolic (Wilson’s, haemochromatosis), and drugs. Complications: cirrhosis and HCC. Diagnosis requires serology, autoantibodies, genetic/metabolic tests, and biopsy. Management is cause-specific, with surveillance for complications.

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Causes of Chronic Hepatitis

🧪 Screening Investigations for Chronic Liver Disease