Chronic hepatitis

　　The pathogenesis of various chronic hepatitis is different, summarized as follows:

　　1. Chronic hepatitis B (CHB):It is generally believed that HBV does not directly damage liver cells, but rather causes damage and destruction of liver cells through host immune responses and reactions, leading to corresponding clinical manifestations. Due to the different immune responses of the host, including individual genetic and metabolic differences, the clinical manifestations and symptoms of HBV infection may also vary. The period of immune tolerance is basically without immune response, with a high viral load in the blood, but basically no liver damage. The immune activator is the appearance of a partial immune response, causing liver damage leading to active hepatitis, with a reduction in viral load, but incomplete immune response, so the virus cannot be cleared. If the immune response reaches a dynamic balance with viral replication, it manifests as a decrease in the activity of hepatitis and a decrease in viral load. If the viral gene undergoes mutations in the pre-C region and the basic core promoter (BCP), it results in HBeAg-negative chronic hepatitis B, with HBV DNA positivity.

　　2. Chronic hepatitis C (CHC):The pathogenesis of hepatitis C is very complex, and the interaction between the virus and the human immune system determines the occurrence, development, and outcome of the disease.

　　3. Autoimmune hepatitis (AIH):The basic pathogenesis is that the body's tolerance to self-antigens is broken, thereby triggering an immune response to self-antigens, with immune cells attacking the corresponding target antigens, causing cell apoptosis, necrosis, and inflammatory reactions.

　　4. Chronic alcoholic liver disease (ALD):The occurrence and development of ALD are at least related to the following mechanisms: ① Oxidative stress: A large amount of reactive oxygen species (ROS) produced during ethanol metabolism, the toxic reaction of oxygen free radicals, causes oxidative stress in the human body, which is one of the key mechanisms for the occurrence and development of alcoholic liver disease. ② The toxic effect of acetaldehyde: Acetaldehyde is an intermediate product of ethanol metabolism and one of the main factors causing chronic progressive liver damage. ③ Endotoxins: The production and absorption of endotoxins in the intestines of ALD patients are increased, while the liver's clearance of endotoxins is insufficient, forming endotoxemia, which aggravates liver inflammation and injury through various mechanisms. ④ The toxicity of ethanol: During ethanol metabolism, a large amount of NAD+ is consumed, causing a series of biochemical and metabolic disorders, triggering hypoglycemia, lactic acidosis, and fatty liver due to the accumulation of fatty acids; ethanol also interferes with protein and nucleic acid metabolism. In addition, long-term intake of ethanol can directly or indirectly cause malnutrition. In summary, ALD caused by excessive drinking is the result of a sequential or superimposed action of multiple mechanisms, which are intercausal, mutually induced, and mutually promoted, forming a vicious cycle.

　　5. Drug-induced liver injury (DILI):Hepatotoxicity of drugs is divided into two types: predictable and unpredictable hepatotoxicity. The former is related to the dose of medication and has a dose-effect relationship, which can be replicated in animal experiments. The latter is related to the specific quality of the body and has no obvious dose-effect relationship, making it difficult to predict and not easily replicable in animal experiments. Most DILI in clinical practice is of this latter type. The pathogenesis of DILI is the direct action of the drug itself or its toxic metabolites on liver cells, or the pathological changes caused by the immune mechanism. The immune mechanism is that the drug acts as a hapten to form new antigens in the body, stimulate T cells and B cells through antigen-presenting cells, and lead to immune injury dominated by immune reactions.

　　Chronic hepatitis has more common complications, such as chronic cholecystitis, hepatic diabetes, and hepatitis B-related nephropathy. Controlling liver disease to maintain stability is helpful for the stability of complications. On the basis of chronic hepatitis, when there are triggering factors such as patients overworking, excessive drinking, or co-infection with other hepatitis viruses, the condition can rapidly worsen and develop into chronic severe hepatitis. In addition, if the condition of chronic hepatitis gradually develops, it can lead to liver cirrhosis. Chronic severe hepatitis and liver cirrhosis both arise from chronic hepatitis. In severe cases, they can even be life-threatening, but they are not strictly speaking complications of chronic hepatitis.

　　For many people, chronic hepatitis can bring harm. Hepatitis is divided into acute and chronic types, generally acute hepatitis has a rapid onset, and people can quickly discover it. Chronic hepatitis has no obvious symptoms in the early stage, so many people ignore this disease. What are the symptoms of chronic hepatitis?

　　Mild and moderate chronic hepatitis: The early symptoms of typical chronic hepatitis are mild and lack specificity, showing fluctuating intermittent, even without any symptoms for many years. The most common is easy fatigue and stomach discomfort, which is often ignored and is easily mistaken for stomach disease; clinical cases of occult liver cirrhosis are often seen, before the occurrence of liver cirrhosis, there is no obvious discomfort, nor routine physical examination, and gradually develop into liver cirrhosis without realizing it; occasionally, some patients may have nausea, abdominal distension, jaundice, and deep urine, but according to the symptoms, it is not possible to judge the severity of chronic hepatitis.

　　Chronic hepatitis with severe and chronic severe hepatitis: When the color of urine deepens progressively, the yellowing of the skin and conjunctiva deepens progressively, and fatigue and decreased appetite become more and more obvious, it indicates that the condition is worsening, especially to be vigilant about the occurrence of chronic severe hepatitis. Chronic severe hepatitis is a manifestation of liver failure, which can be manifested as severe fatigue, severe abdominal distension, severe jaundice, and severe anorexia; it can appear hypoproteinemia, ascites, pleural effusion, abdominal infection, decreased coagulation function, upper gastrointestinal bleeding, hepatic encephalopathy, etc. The mortality rate is relatively high in clinical practice, and active treatment is needed.

　　Hepatitis B virus and hepatitis C virus are the main causes of chronic hepatitis. To prevent chronic hepatitis, it is necessary to start with the prevention of hepatitis B and C.

　　I. Prevention of hepatitis B and C

　　Hepatitis B can be prevented by producing hepatitis B surface antibody through injection of hepatitis B vaccine, and the higher the level of hepatitis B surface antibody, the stronger the protective ability to the human body. Before injection of the hepatitis B vaccine, it is necessary to check liver function and hepatitis B five items. Generally, hepatitis B virus is not transmitted through respiratory tract and digestive tract, so daily contact such as study, work, or life without blood exposure usually will not transmit hepatitis B virus. There is currently no effective vaccine to prevent hepatitis C.

　　Strictly implement the

　　III. Prevention of transmission through percutaneous and mucosal routes

　　Promote safe injections. Medical instruments such as dental instruments and endoscopes should be strictly disinfected. Medical personnel should wear gloves when in contact with patients' blood and body fluids. Counseling and safety education should be provided to intravenous drug users to persuade them to quit drug use. Razors and toothbrushes should not be shared, and hairdressing tools, puncture, tattooing, and beauty tools should be strictly disinfected.

　　IV. Prevention of sexual transmission

　　People with a history of sexual promiscuity should have regular checks and strengthen management. It is recommended that people infected with HBV or HCV use condoms during sexual intercourse during the period of viral replication. Appropriate sex education should be provided to adolescents.

　　V. Prevention of maternal and infantile transmission

　　For pregnant women with positive HBV DNA, they should go to specialized medical institutions for maternal and infantile blockage, with a success rate of more than 95%; for pregnant women with positive HCV RNA, amniocentesis should be avoided, and the delivery time should be shortened as much as possible to ensure the integrity of the placenta and reduce the chance of neonates being exposed to maternal blood.

　　Chronic hepatitis requires the following examinations:

　　1. Liver function:Including serum ALT, AST, total bilirubin, direct bilirubin, indirect bilirubin, albumin, globulin, cholinesterase, alkaline phosphatase, transpeptidase, etc., to understand the degree of liver injury.

　　2. Prothrombin time (PT) and PTA:PT is an important indicator reflecting the synthesis function of liver coagulation factors, and PTA is a commonly used method to express PT values, which has great value in judging the progression and prognosis of the disease. A progressive decrease in PTA to below 40% in recent days is one of the important diagnostic criteria for liver failure. Some also use the international normalized ratio (INR) to express this indicator, and the increase in INR is equivalent to the decrease in PTA value.

　　3. Hepatitis virus markers:Hepatitis B five items, hepatitis C antibody, to understand whether there is hepatitis virus infection.

　　4. Tumor markers:Such as alpha-fetoprotein (AFP), CA199, AFU, etc., to detect liver cancer early.

　　5. Imaging:Including abdominal color Doppler ultrasound of liver, gallbladder, and spleen, to understand whether there is chronic liver injury and early screening for liver cancer. Abdominal enhanced CT or MRI may be performed if necessary to understand the degree of chronic liver injury.

　　6. Liver elastography:It is a non-invasive examination that can be used to assess the degree of liver fibrosis in chronic hepatitis patients. Assessing the degree of liver fibrosis in chronic hepatitis patients is very important for determining the treatment plan.

　　7. Liver biopsy:It is still the gold standard for evaluating the degree of liver damage in patients, including inflammation grading and fibrosis staging.

　　There are no special dietary requirements for chronic hepatitis, pay attention to a balanced diet, eat more fresh vegetables and fruits, try to eat less fried food, quit smoking and drinking, maintain a normal weight, ensure sleep time, pay attention to the combination of work and rest, and keep a peaceful mood. Medicines rich in various vitamins and minerals, such as propolis, spirulina, royal jelly, Cordyceps preparations, etc., are also helpful for improving liver nutrition and enhancing the immune function.

　　The treatment of chronic hepatitis includes many aspects, such as liver protection, antifibrosis, antiviral removal of etiology, prevention of liver cancer, etc. Among them, the removal of etiology according to different etiologies is the most important principle in the treatment of chronic hepatitis.

　　1. Liver protection therapy

　　There are many types of drugs, including glycyrrhizin preparations, silymarin preparations, Schisandra chinensis preparations, etc., suitable for all chronic hepatitis patients.

　　2. Antifibrotic therapy

　　Mostly traditional Chinese medicine oral preparations, also suitable for all chronic hepatitis patients.

　　3. Injection of interferon antiviral treatment

　　Including interferon (2a, 2b, and 1b) and pegylated interferon (2a and 2b), which are suitable for patients with chronic hepatitis B and chronic hepatitis C, with a treatment course of at least 1 year. The combination of interferon and ribavirin is the standard treatment for chronic hepatitis C, and the efficacy depends on the HCV genotype and the speed of response to treatment. Patients with hepatitis C virus below the detection limit within 4 weeks of treatment (commonly known as negative conversion) are called rapid virological response (RVR), and this group has the best response to interferon treatment, with a cure rate of up to 87%.

　　4. Oral nucleoside analog antiviral treatment

　　These drugs are only suitable for the treatment of Hepatitis B, including chronic Hepatitis B and Hepatitis B cirrhosis. In mainland China, there are the following four drugs: lamivudine (lamivudine, LAM), adefovir dipivoxil (ADV), telbivudine (telbivudine, LdT), entecavir (entecavir, ETV); internationally, there is also a fifth drug: tenofovir disoproxil fumarate (TDF), used to treat patients who are resistant to the above four drugs. The advantages of nucleoside analogs are good antiviral efficacy, few side effects, and convenient administration, with one tablet per day, widely used in clinical practice, extending the survival period of patients with liver cirrhosis and significantly improving the quality of life of patients with liver cirrhosis. The disadvantages are that they need to be taken for a long time and there is a risk of resistance. As a special medicine for the treatment of chronic Hepatitis B, it must be used under the guidance of a doctor and regular reexamination of Hepatitis B virus quantification is required. Taking medication and stopping medication arbitrarily will promote the occurrence of drug resistance of Hepatitis B virus, lead to the aggravation of the condition, and even death.

　　5. Immunosuppressants

　　When autoimmune hepatitis recurs with difficulty in controlling liver function with liver-protecting drugs, if liver biopsy indicates significant liver inflammation activity, then corticosteroids or another immunosuppressant azathioprine should be used in combination to promote the recovery of the condition.

　　6. Prevent the occurrence of tumors

　　Chronic hepatitis has a long history, and the risk of developing liver cancer increases. Supplementing trace element selenium helps enhance anti-cancer ability; in addition, injecting thymosin improves immune function, which is also beneficial to enhance the ability to prevent tumors.

　　7. Eliminate the cause

　　Abstain from alcohol, stop taking drugs that damage the liver: It is especially important for patients with alcoholic liver disease and drug-induced liver disease. It is also of great significance for chronic hepatitis caused by other reasons.