General
What does the liver do?
The liver is the largest organ inside your body, and is essential to life, carrying out 500 different functions. It is the factory of the body, making proteins, blood clotting factors, and products to help with digestion and energy release. Your body uses it as a store for energy and iron. It also purifies the blood of bacteria, by-products of digestion, alcohol and drugs.
I've just had a liver function test and been told the results are abnormal, what does this mean?
Liver function blood tests, referred to as LFTs, are often ordered by your GP to find out whether you have increased levels of certain enzymes that might indicate a problem with your liver. There are many reasons why you have abnormal results. There is no need to be alarmed, as it is quite common to have an abnormal LFT. Your doctor will probably order further tests to get a fuller picture of your liver health before reaching a conclusion. LFTs are a useful test but are not the only test your doctor will use or rely on to diagnose problems or give you a clean bill of health.
I've been told I have a liver disease. What has caused it?
There are many causes of liver disease:-
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Drinking too much alcohol, usually over many years, is the single largest cause.
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There are also viruses that damage the liver; the most important are the blood-borne viruses hepatitis B and C.
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Some people lay down fat cells in their liver, often connected with being overweight or having diabetes.
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Other people carry genetic or develop autoimmune conditions that can lead to liver damage. It is also possible to suffer adverse reactions to medicines or drugs, resulting in liver failure.
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Cancer is both a cause and a consequence of liver disease. Finding the cause is important in designing the right treatment and stopping the progression of the disease
My brother has been told he has cirrhosis. Does this mean he is an alcoholic?
No, there are many different causes of cirrhosis. Alcohol is only one of these. Cirrhosis may be caused by viruses, iron overload, copper overload, metabolic disease, fat and autoimmune conditions.
What are the symptoms of liver disease?
Liver disease is sometimes referred to as the 'silent killer' as there are often only vague symptoms until liver damage is quite severe. Early symptoms can include feeling generally unwell or tired, having poor appetite, weight loss, a tender abdomen, feeling itchy or vomiting. These are symptoms that are common in other medical conditions as well, however. Most people with liver disease only find out during tests for an unrelated illness or a medical check-up. When liver damage is quite severe, people can experience some of the following symptoms including yellow eyes and skin, called jaundice; bleeding problems; drowsiness and confusion; fever; swollen abdomen and legs; and tarry black stools or vomiting blood. If you have any of the symptoms consult your doctor.
How can liver disease affect quality of life?
Many people with liver disease will feel quite well and even severe symptoms may occur only in episodes that people recover from. However, the symptoms, side-effects of treatment and outlook of liver disease can really affect people with liver disease and their families, causing discomfort, pain, anxiety and depression. Your doctor and the medical team they work with can give you advice on how to manage the symptoms of your disease and direct you to other sources of help, like social services. Many people also find that talking with other people with liver disease can offer practical advice and support.
How common is liver disease?
However, there are many more people living with liver disease and others who have a liver disease but are not aware of it. There are also a large number of people with a liver problem of some description, such as gallstones, and problems that resolve themselves over time without medical treatment.
How can you get infected with hepatitis B and C?
Hepatitis B and C are infectious blood borne viruses which can cause severe liver damage. A tiny amount of blood getting into your bloodstream from an infected person can cause infection, for example through an open wound, cut or scratch. Some of the main routes of transmission are mother-to-baby (during birth); sharing needles and equipment for use in taking drugs, tattoos or piercing; unsafe sex; and from medical treatment in a country with poor hygiene standards. To protect yourself, don't share personal equipment, use a condom and cover all cuts and wounds.
Can you get vaccinated against viral hepatitis?
There is a vaccine against hepatitis A , spread by infected food and water, which it is a good idea to have before travelling abroad outside Europe and the US. There is also a vaccine against hepatitis B which all people in high-risk groups should have. People in high-risk groups include those travelling to visit friends and family for long periods in areas where the infection is common, including South Asia, China and Africa. People receiving blood products, with kidney or liver problems or needing medical treatment abroad should be vaccinated. Some people are at risk because their job puts them in contact with other people's body fluids. Other people at risk are those who change sexual partners frequently; inject drugs or men who have sex with men. Particularly for hepatitis B, it is important to complete the course and if you are having the vaccine before you travel, allow plenty of time to have the course and for it to take effect.
My GP wants to charge me for a hepatitis B vaccine, why?
The NHS only covers the cost of the vaccine for some people, e.g. those at risk as part of their day-to-day lives in the UK (click on hepatitis B prevention for more information). Your employer has a legal obligation to look at the risk of you being infected at work, and if you are, to pay for and arrange vaccination.
What treatments are available for hepatitis B and C?
There are a number of medicines to treat both diseases, many of which are quite new. They generally need to be taken over a period of several months. For hepatitis C, they may help you clear the infection. For hepatitis B, they can stop or delay the progression of the disease. The treatments have side-effects though and so wherever possible, preventing infection is the priority.
Should I see a specialist about my liver disease?
Many people with liver disease benefit from specialist assessment and for a specialist to design a package of ongoing treatment. As a result, we recommend you speak to your GP to request a referral to a specialist, preferably a hepatologist or a gastroenterologist if a hepatologist is not available. After you have seen a consultant, your GP will probably monitor your day-to-day care with review by your consultant.
How can I find out which hospital can best look after liver disease patients?
You have the right to choose which hospital your GP refers you to. Some hospitals have a specialist team dealing with liver patients. You can ask your GP or contact the British Liver Trust to find a hospital with a liver specialist near you.
I've been told I have end-stage liver disease, does this mean I'm going to die ?
No, this means you have advanced disease, but many people live normal lives for many years even with end-stage liver disease. There are different ways of grading how serious your liver disease is, and you can find more information about this in our Cirrhosis publication. It is best to talk with your doctor about your condition, your treatment options and what you can expect.
Can prescription medicines, common pharmacy medicines, herbal remedies and illegal drugs affect my liver disease?
Yes. Most drugs (whether prescription, legal or illegal) are processed and broken down by the liver. In people with liver disease where the liver is already under strain, the extra work in breaking down drugs can be dangerous. Make sure all the health professionals (such as your GP, dentist and pharmacist) know about your liver disease before you are given or buy medicines from them. Even common tablets such as aspirin can be dangerous to people with liver problems. Herbal remedies and illegal drugs are a particular risk, as they are not regulated and can contain impurities that cause liver damage. If in doubt, speak to your liver specialist before taking any medicines or drugs.
I have liver disease, what can I do to keep myself well? Is there a special diet which would help my liver disease?
There are many things you can do to look after yourself. No specific foods are of benefit, but you should however try to have a diet that is well balanced with protein, carbohydrate and plenty of fresh vegetables. Some patients with fatty liver disease will need special dietary advice. You may find it helpful to undertake gentle exercise, without getting yourself over-tired. Alcohol should be avoided as it places an increased burden on your liver and smoking places a burden on your body and can accelerate some conditions. It is also essential to check that any prescription or over-the-counter medicines are safe to take with your liver disease. Plan things that increase your sense of wellbeing, such as a massage, aromatherapy, time with friends, music or relaxation time, but avoid stress and becoming exhausted.
What treatments are there for liver disease?
There are many different liver diseases, and the treatment that is right for you depends on the type of liver disease, its cause and how much damage it has done.
For advanced liver disease, there are a number of treatments aimed at reducing the impact of the symptoms. For example, you might be given diuretics for portal hypertension, lactulose for hepatic encephalopathy and regular drains for ascites. You may be offered surgery such as liver resection for liver cancer. You may be assessed for a liver transplant. There are also a range of lifestyle measures that can help some people, including changes to diet. Your liver specialist will design a package of treatment that is right for you. For more information, see our Cirrhosis publication.
Isn't it true that the liver can regenerate and does this mean I can get better on my own?
Your body can replace old liver cells, called hepatocytes, with new ones. This means that your liver can recover from minor stresses and strains. However, over time damage can cause fibrous scar tissue. This changes the structure of the liver and cannot be repaired. This is why it is so important to spot liver problems before the damage builds up and becomes irreversible.
Can I travel after a transplant?
Having a liver transplant is a major operation and the transplant together with anti-rejection medicines will have a lifelong impact on you. As a result, there are a whole range of things you'll need to consider when travelling, such as how to avoid infection, vaccines, sunscreen, being close to medical help and travel insurance. You'll be advised not to travel long distances away from your transplant centre in the early weeks. After this, speak to your transplant centre about what precautions you should take.
I've been told I have gallstones and suffer pain. What are the possible complications?
Gallstones can cause a condition called a cholangitis attack and also less severe pain and discomfort . Cholangitis is an inflammation of the bile duct system that is usually related to a bacterial infection that can be caused by gallstones blocking the ducts. The main symptom is severe abdominal pain and tenderness, in the 'upper right quadrant' area, although pain can be felt in the chest, upper back or right shoulder. Other symptoms include nausea and vomiting, belching, pale stools and dark urine. You may also have a fever, jaundice, feel lethargic and itchy. An attack of acute cholangitis can make you feel very unwell, so most people will consult a doctor or go to hospital fast. Doctors can treat with antibiotics and painkillers, and schedule an operation to remove the gallbladder to stop the attack happening again.
Should I get the flu vaccination if I have liver disease?
Everyone with liver disease should keep up-to-date with their vaccines, including the annual vaccine against seasonal flu which becomes available in October. This vaccine now also protects against swine flu. Seasonal flu can be particularly dangerous for people with cirrhosis, chronic hepatitis, biliary atresia or those taking immunosuppresants for example, after a liver transplant.
We advise you to get this vaccine as soon as it becomes available. If you have symptoms of flu, stay at home and contact your GP for advice. Do not take over-the-counter flu remedies or painkillers like aspirin unless you have been told by a doctor they are safe for you.
Hepatitis A
What is hepatitis A?
Hepatitis A is a liver disease caused by hepatitis A virus.
How is hepatitis A virus transmitted?
Hepatitis A virus is spread from person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A. This type of transmission is called "fecal-oral." For this reason, the virus is more easily spread in areas where there are poor sanitary conditions or where good personal hygiene is not observed.
Most infections result from contact with a household member or sex partner who has hepatitis A. Casual contact, as in the usual office, factory, or school setting, does not spread the virus.
What are the signs and symptoms of hepatitis A?
Persons with hepatitis A virus infection may not have any signs or symptoms of the disease. Older persons are more likely to have symptoms than children. If symptoms are present, they usually occur abruptly and may include fever, tiredness, loss of appetite, nausea, abdominal discomfort, dark urine, and jaundice (yellowing of the skin and eyes). Symptoms usually last less than 2 months; a few persons are ill for as long as 6 months. The average incubation period for hepatitis A is 28 days (range: 15–50 days).
If you`ve had hepatitis A in the past, can you get it again?
No. Once you recover from hepatitis A you develop antibodies that provide life-long protection from future infections. After recovering from hepatitis A, you will never get it again and you cannot transmit the virus to others.
How do you know if you have hepatitis A?
A blood test (IgM anti-HAV) is needed to diagnose hepatitis A. Talk to your doctor or someone from your local health department if you suspect that you have been exposed to hepatitis A or any type of viral hepatitis.
How can you prevent hepatitis A?
Always wash your hands after using the bathroom, changing a diaper, or before preparing or eating food.
Two products are used to prevent hepatitis A virus infection: immune globulin and hepatitis A vaccine.
1. Immune globulin is a preparation of antibodies that can be given before exposure for short-term protection against hepatitis A and for persons who have already been exposed to hepatitis A virus. Immune globulin must be given within 2 weeks after exposure to hepatitis A virus for maximum protection.
2.
3. . Hepatitis A vaccine has been licensed in the United States for use in persons 12 months of age and older. The vaccine is recommended (before exposure to hepatitis A virus) for persons who are more likely to get hepatitis A virus infection or are more likely to get seriously ill if they do get hepatitis A. The vaccines currently licensed in the United States are HAVRIX® (manufactured by GlaxoSmithKline) and VAQTA® (manufactured by Merck & Co., Inc).
Who Should Get Vaccinated Against Hepatitis A?
How do you kill hepatitis A virus (HAV)?
HAV can live outside the body for months, depending on the environmental conditions. HAV is killed by heating to 185 degrees F. (85 degrees C.) for one minute. However, HAV can still be spread from cooked food if it gets contaminated after cooking. Adequate chlorination of water, as recommended in the US, kills HAV that may get into the water supply.
For information on disinfectants and sterilants used to kill viruses like HAV on hard surfaces (e.g., counter tops, tables, floors) see: http://www.cdc.gov/ncidod/hip/Sterile/sterile.htm.
Can I donate blood if I have had any type of viral hepatitis?
If you had any type of viral hepatitis since aged 11 years, you are not eligible to donate blood. In addition, if you ever tested positive for hepatitis B or hepatitis C, at any age, you are not eligible to donate, even if you were never sick or jaundiced from the infection.
HEPATITIS A VACCINE AND IMMUNE GLOBULIN
Hepatitis A Vaccine
What are the dosages and schedules for hepatitis A vaccines?
Recommended dosages of HAVRIX®¹ |
|
| Vaccinee`s age
(years) |
Dose (EL.U.)² |
Volume (mL) |
No.
doses |
Schedule (mos)³ |
|
12 mos-18 yrs |
720 |
0.5 |
2 |
0,6-12 |
>18 yrs |
1,440 |
1.0 |
2 |
0,6-12 |
|
¹ |
Hepatitis A vaccine, inactivated, GlaxoSmithKline. |
² |
ELISA units. |
³ |
0 months represents timing of the initial dose; subsequent numbers represent months after the initial dose. |
|
Recommended dosages of VAQTA®¹ |
|
| Vaccinee`s age
(months/years) |
Dose(U)² |
Volume (mL) |
No.
doses |
Schedule (mos)³ |
|
12 mos-18 yrs |
25 |
0.5 |
2 |
0,6-18 |
>18 yrs |
50 |
1.0 |
2 |
0,6-12 |
|
¹ |
Hepatitis A vaccine, inactivated, Merck & Co., Inc. |
² |
Units. |
³ |
0 months represents timing of the initial dose; subsequent numbers represent months after the initial dose. |
|
Can a patient receive the first dose of hepatitis A vaccine from one manufacturer and the second (last) dose from another manufacturer?
Yes. Although studies have not been done to look at this issue, there is no reason to believe that this would be a problem.
Can hepatitis A vaccine be given after exposure to hepatitis A virus?
No, hepatitis A vaccine is not licensed for use after exposure to hepatitis A virus. In this situation, immune globulin should be used.
Is it harmful to have an extra dose(s) of hepatitis A or hepatitis B vaccine or to repeat the entire hepatitis A or hepatitis B vaccine series if you have forgotten whether or not you had the vaccine or do not have written documentation that was requested?
No. If necessary, getting extra doses of hepatitis A or hepatitis B vaccine is not harmful.
Should pre-vaccination testing be done?
Pre-vaccination testing is done only in specific instances to control cost (e.g., persons who were likely to have had hepatitis A in the past). This includes persons who were born in countries with high levels of hepatitis A virus infection, elderly persons, and persons who have clotting factor disorders and may have received factor concentrates in the past.
Should post-vaccination testing be done?
No.
Can hepatitis A vaccine be given during pregnancy or lactation?
TWe don`t know for sure, but because vaccine is produced from inactivated hepatitis A virus, the theoretical risk to the developing fetus is expected to be low. The risk associated with vaccination, however, should be weighed against the risk for hepatitis A in women who may be at high risk for exposure to hepatitis A virus.
Can hepatitis A vaccine be given to immunocompromised persons? (e.g., persons on hemodialysis or persons with AIDS)?
Yes.
What is Twinrix®?
It is a combined hepatitis A and hepatitis B vaccine for use in persons aged 18 years and older. Primary vaccination consists of three doses, given on a 0-, 1-, and 6-month schedule, the same schedule as that used for hepatitis B vaccine alone.
Immune Globulin
What is immune globulin?
Immune globulin is a preparation of antibodies that can be given before exposure for short-term protection against hepatitis A and for persons who have already been exposed to hepatitis A virus. Immune globulin must be given within 2 weeks after exposure to hepatitis A virus for maximum protection.
Is immune globulin safe?
Yes. No instance of transmission of HIV (the virus that causes AIDS) or other viruses has been observed with the use of immune globulin administered by the intramuscular route. Immune globulin can be administered during pregnancy and breast-feeding.
Is immune globulin in short supply?
Please click here for immune globulin status.
WHO SHOULD GET VACCINATED AGAINST HEPATITIS A?
Hepatitis A vaccination provides protection before one is exposed to hepatitis A virus. Hepatitis A vaccination is recommended for the following groups who are at increased risk for infection and for any person wishing to obtain immunity.
Persons traveling to or working in countries that have high or intermediate rates of hepatitis A ?
All susceptible persons traveling to or working in countries that have high or intermediate rates of hepatitis A should be vaccinated or receive immune globulin before traveling. Persons from developed countries who travel to developing countries are at high risk for hepatitis A. Such persons include tourists, military personnel, missionaries, and others who work or study abroad in countries that have high or intermediate levels of hepatitis A. The risk for hepatitis A exists even for travelers to urban areas, those who stay in luxury hotels, and those who report that they have good hygiene and that they are careful about what they drink and eat.
Children in states, counties, and communities where rates of hepatitis A were/are at least twice the national average during the baseline period of 1987-1997.
Children living in states, counties, and communities where rates of hepatitis A are at least twice the national average ( ≥ 20 cases/1000,000) in baseline period should be routinely vaccinated beginning at 12 months of age. High rates of hepatitis A have been found in these populations, both in urban and rural settings. In addition, to effectively prevent epidemics of hepatitis A, vaccination of previously unvaccinated older children is recommended within 5 years of initiation of routine childhood vaccination programs. Although rates differ among areas, available data indicate that a reasonable cutoff age in many areas is 10-15 years of age because older persons have often already had hepatitis A. Vaccination of children before they enter school should receive highest priority, followed by vaccination of older children who have not been vaccinated.
Illegal-drug users
Vaccination is recommended for injecting and non-injecting illegal-drug users.
Persons who have occupational risk for infection
Persons who work with hepatitis A virus-infected primates or with hepatitis A virus in a research laboratory setting should be vaccinated. No other groups have been shown to be at increased risk for hepatitis A virus infection because of occupational exposure.
Outbreaks of hepatitis A have been reported among persons working with non-human primates that are susceptible to hepatitis A virus infection, including several Old World and New World species. Primates that were infected were those that had been born in the wild, not those that had been born and raised in captivity.
Persons who have chronic liver disease
Persons with chronic liver disease who have never had hepatitis A should be vaccinated, as there is a higher rate of fulminant (rapid onset of liver failure, often leading to death) hepatitis A among persons with chronic liver disease. Persons who are either awaiting or have received liver transplants also should be vaccinated
Persons who have clotting-factor disorders
Persons who have never had hepatitis A and who are administered clotting-factor concentrates, especially solvent detergent-treated preparations, should be given hepatitis A vaccine.
All persons with hemophilia (Factor VIII, Factor IX) who receive replacement therapy should be vaccinated because there appears to be an increased risk of transmission from clotting-factor concentrates that are not heat inactivated.
WHICH GROUPS DO NOT ROUTINELY NEED HEPATITIS A VACCINE?
Food service workers
Foodborne hepatitis A outbreaks are relatively uncommon in the United States; however, when they occur, intensive public health efforts are required for their control.
Although persons who work as food handlers have a critical role in common-source foodborne outbreaks, they are not at increased risk for hepatitis A because of their occupation. Consideration may be given to vaccination of employees who work in areas where community-wide outbreaks are occurring and where state and local health authorities or private employers determine that such vaccination is cost-effective.
Sewerage workers
In the United States, no work-related outbreaks of hepatitis A have been reported among workers exposed to sewage.
Health-care workers
Health-care workers are not at increased risk for hepatitis A. If a patient with hepatitis A is admitted to the hospital, routine infection control precautions will prevent transmission to hospital staff.
Children under 12 months of age
Because of the limited experience with hepatitis A vaccination among children under 12 months of age, the vaccine is not currently licensed for children below this age group.
Day-care attendees
The frequency of outbreaks of hepatitis A is not high enough in this setting to warrant routine hepatitis A vaccination. In some communities, however, day-care centers play a role in sustaining community-wide outbreaks. In this situation, consideration should be given to adding hepatitis A vaccine to the prevention plan for children and staff in the involved center(s).
Residents of institutions for developmentally disabled persons
Historically, hepatitis A virus infections were common among persons with developmental disabilities living in institutions. Currently, the occurrence of hepatitis A virus infections have diminished.
INTERNATIONAL TRAVEL
Who should receive protection against hepatitis A before travel?
All susceptible persons traveling to or working in countries that have high or intermediate rates of hepatitis A should be vaccinated or receive immune globulin before traveling. Persons from developed countries who travel to developing countries are at high risk for hepatitis A. Such persons include tourists, military personnel, missionaries, and others who work or study abroad in countries that have high or intermediate levels of hepatitis A. The risk for hepatitis A exists even for travelers to urban areas, those who stay in luxury hotels, and those who report that they have good hygiene and that they are careful about what they drink and eat.
How soon before travel should the first dose of hepatitis A vaccine be given?
For optimal protection, at least 4 weeks prior to travel. Check with your doctor about when the next dose is due.
What should be done if a person cannot receive hepatitis A vaccine?
Travelers who are allergic to a vaccine component or who elect not to receive vaccine should receive a single dose of immune globulin (0.02 mL/kg), which provides effective protection against hepatitis A virus infection for up to 3 months. Travelers whose travel period exceeds 2 months should be administered immune globulin at 0.06 mL/kg; administration must be repeated if the travel period exceeds 5 months.
If travel starts sooner than 4 weeks prior to the first vaccine dose, what should be done?
Because protection might not be optimal until 4 weeks after vaccination, persons traveling to a high-risk area less than 4 weeks after the initial dose of hepatitis A vaccine should also be given immune globulin (0.02 mL/kg), but at a different injection site. Therefore, the first dose of hepatitis A vaccine should be administered as soon as travel to a high-risk area is planned.
What should be done for travelers who are less than 12 months of age to protect them from hepatitis A virus infection?
Immune globulin is recommended for travelers less than 12 months of age because the vaccine is currently not licensed for use in this age group
When are persons protected after receiving hepatitis A vaccine?
Protection against hepatitis A begins four weeks after the first dose of hepatitis A vaccine.
How long does hepatitis A vaccine protect you?
A recent review by an expert panel concluded that estimates of antibody persistence derived from kinetic models of antibody decline indicate that protective levels of anti-HAV could be present for at least 25 years in adults and at least 14-20 years in children.
How are hepatitis A vaccines made?
There is no live virus in hepatitis A vaccines. The virus is inactivated during production of the vaccines, similar to Salk-type inactivated polio vaccine.
Is hepatitis A vaccine safe?
Yes, hepatitis A vaccine has an excellent safety profile. No serious adverse events have been attributed definitively to hepatitis A vaccine. Soreness at the injection site is the most frequently reported side effect.
Can other vaccines be given at the same time that hepatitis A vaccine is given?
Yes. Hepatitis B, diphtheria, poliovirus (oral and inactivated), tetanus, oral typhoid, cholera, Japanese encephalitis, rabies, yellow fever vaccine or immune globulin can be given at the same time that hepatitis A vaccine is given, but at a different injection site.
What should be done if the second (last) dose of hepatitis A vaccine is delayed?
The second dose should be administered as soon as possible. There is no need to repeat the first dose.
Hepatitis B
What is hepatitis B?
Hepatitis B is caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death.
How do you know if you have hepatitis B?
Only a blood test can tell for sure.
How is HBV spread?
HBV is spread when blood from an infected person enters the body of a person who is not infected. For example, HBV is spread through having sex with an infected person without using a condom (the efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use might reduce transmission), by sharing drugs, needles, or "works" when "shooting" drugs, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth.
Hepatitis B is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, coughing, sneezing or by casual contact.
How long does it take for a blood test, such as HBsAg, to be positive after exposure to hepatitis B virus?
HBsAg will be detected in an infected person's blood on the average of 4 weeks (range 1-9 weeks) after exposure to the virus. About 1 out of 2 patients will no longer be infectious by 7 weeks after onset of symptoms and all patients, who do not remain chronically infected, will be HBsAg-negative by 15 weeks after onset of symptoms.
If a person has symptoms, how long does it take for symptoms to occur after exposure to hepatitis B virus?
If symptoms occur, they occur on the average of 12 weeks (range 9-21 weeks) after exposure to hepatitis B virus. Symptoms occur in about 70% of patients. Symptoms are more likely to occur in adults than in children.
What are the symptoms of hepatitis B?
Sometimes a person with HBV infection has no symptoms at all. The older you are, the more apt you are to have symptoms. You might be infected with HBV (and be spreading the virus) and not know it.
If you have symptoms, they might include:
What are the risk factors for hepatitis B?
You are at increased risk of HBV infection if you:
-
have sex with someone infected with HBV
-
have sex with more than one partner
-
shoot drugs
-
are a man and have sex with a
-
live in the same house with someone who has chronic (long-term) HBV infection
-
have a job that involves contact with human blood
-
are a client in a home for the developmentally disabled
-
have hemophilia
-
travel to areas where hepatitis B is common (country listing)
Is there a cure for hepatitis B?
There are no medications available for recently acquired (acute) HBV infection. Hepatitis B vaccine is available for the prevention of HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection.
If you are pregnant, should you worry about hepatitis B?
Yes, you should get a blood test to check for HBV infection early in your pregnancy. This test is called hepatitis B surface antigen (HBsAg). If you test HBsAg-negative early in pregnancy, but continue behaviors that put you at risk for HBV infection (e.g., multiple sex partners, injection drug use), you should be retested for HBsAg close to delivery. If your HBsAg test is positive, this means you are infected with HBV and can give the virus to your baby. Babies who get HBV at birth might develop chronic HBV infection that can lead to cirrhosis of the liver or liver cancer.
If your blood test is positive, your baby should receive the first dose of hepatitis B vaccine, along with another shot, hepatitis B immune globulin (called HBIG), at birth. The second dose of vaccine should be given at aged 1-2 months and the third dose at aged 6 months (but not before aged 24 weeks).
Can I donate blood if I have had any type of viral hepatitis?
If you had any type of viral hepatitis since aged 11 years, you are not eligible to donate blood. In addition, if you ever tested positive for hepatitis B or hepatitis C, at any age, you are not eligible to donate, even if you were never sick or jaundiced from the infection.
How long can HBV survive outside the body?
HBV can survive outside the body at least 7 days and still be capable of causing infection.
What do you use to remove HBV from environmental surfaces?
You should clean up any blood spills - including dried blood, which can still be infectious - using 1:10 dilution of one part household bleach to 10 parts of water for disinfecting the area. Use gloves when cleaning up any blood spills.
Hepatitis B Vaccine Information
Who should get vaccinated?
What are the dosages and schedules for hepatitis B vaccines?
The vaccination schedule most often used for adults and children has been three intramuscular injections, the second and third administered 1 and 6 months after the first. Recombivax HB® has been approved as a two dose schedule for aged 11-15 years. Engerix-B® has also been approved as a four dose accelerated schedule.
Can you receive one dose of hepatitis B vaccine from one manufacturer and the other doses from another manufacturer?
Yes. The immune response when one or two doses of a vaccine produced by one manufacturer are followed by subsequent doses from a different manufacturer has been shown to be comparable with that resulting from a full course of vaccination from one manufacturer.
What should be done if there is an interruption between doses of hepatitis B vaccine?
If the vaccination series is interrupted after the first dose, the second dose should be administered as soon as possible. The second and third doses should be separated by an interval of at least 2 months. If only the third dose is delayed, it should be administered when convenient.
Can other vaccines be given at the same time that hepatitis B vaccine is given?
Yes. When hepatitis B vaccine has been administered at the same time as other vaccines, no interference with the antibody response of the other vaccines has been demonstrated.
Are hepatitis B vaccines safe?
Yes. Hepatitis B vaccines have been shown to be safe when administered to both adults and children. Over 4 million adults have been vaccinated in the U.S., and at least that many children have received hepatitis B vaccine worldwide.
Is it harmful to have an extra dose(s) of hepatitis A or hepatitis B vaccine or to repeat the entire hepatitis A or hepatitis B vaccine series if you have forgotten whether or not you had the vaccine or do not have.
Written documentation that was requested?
No. If necessary, getting extra doses of hepatitis A or hepatitis B vaccine is not harmful.
How long does hepatitis B vaccine protect you?
Recent studies indicate that immunologic memory remains intact for at least 23 years and confers protection against clinical illness and chronic HBV infection, even though anti-HBs levels might become low or decline below detectable levels.
Can hepatitis B vaccine be given after exposure to HBV?
Yes. After a person has been exposed to HBV, appropriate treatment, given in an appropriate time frame, can effectively prevent infection. The mainstay of post exposure immunoprophylaxis is hepatitis B vaccine, but in some settings the addition of HBIG will provide some increase in protection.
Should pre-vaccination testing be done?
Pre-vaccination testing is not routinely recommended. The decision to do pre-vaccination testing is usually based on cost. To avoid vaccinating persons who have already had or have HBV infection, testing for prior infection should be considered for adults in risk groups with high rates of HBV infection (e.g., injecting drug users, men who have sex with men and household contacts of persons with chronic HBV infection).
Pre-vaccination testing is not indicated for immunization programs for children or adolescents because of the low rate of HBV infection and the relatively low cost of vaccine.
Who should get post-vaccination testing?
Testing for immunity is advised only for persons whose subsequent clinical management depends on knowledge of their immune status (e.g., infants born to HBsAg-positive mothers, immune compromised persons, healthcare workers, and sex partners of persons with chronic HBV infection).
When should post-vaccination testing be done?
When necessary, post-vaccination testing, using the anti-HBs test, should be performed 1 to 2 months after completion of the vaccine series – EXCEPT for post-vaccination testing of infants born to HBsAg-positive mothers. Testing of these infants should be performed 3 to 9 months after the completion of the vaccination series
Are booster doses of hepatitis B vaccine needed routinely?
No, booster doses of hepatitis B vaccine are not recommended routinely for persons who are not immune compromised. Data show that vaccine-induced anti-HBs levels might decline over time; however, immune memory remains intact indefinitely following immunization. Immune competent people with declining antibody levels are still protected against clinical illness and chronic disease.
Can hepatitis B vaccine be given during pregnancy or when breastfeeding?
Yes, neither pregnancy nor breastfeeding should be considered a contraindication to vaccination of women. On the basis of limited experience, there is no apparent risk of adverse effects to developing fetuses when hepatitis B vaccine is administered to pregnant women. The vaccine contains noninfectious HBsAg particles and should cause no risk to the fetus. HBV infection affecting a pregnant woman might result in severe disease for the mother and chronic HBV infection for the newborn.
Can hepatitis B vaccine be given to immune compromised people?
(e.g., people on hemodialysis or people with AIDS)
Yes, however larger vaccine doses or an increased number of doses are required to induce protective antibody in a high proportion of hemodialysis patients and might also be necessary for other immune compromised people (e.g., those who take immunosuppressive drugs or who have AIDS). For immune compromised people, it is important that post vaccination testing, using the anti-HBs test, be done 1-2 months after the last dose of vaccine to check that the vaccine worked. In addition, immune compromised people need periodic testing and possibly booster doses of hepatitis B vaccine to assure that anti-HBs is still adequate.
Who should not receive the vaccine?
A serious allergic reaction to a prior dose of hepatitis B vaccine or a vaccine component is a contraindication to further doses of hepatitis b vaccine. The recombinant vaccines that are licensed for use in the United States are synthesized by Saccharomyces cerevisiae (common bakers` yeast), into which a plasmid containing the gene for HBsAg has been inserted. Purified HBsAg is obtained by lysing the yeast cells and separating HBsAg from the yeast components by biochemical and biophysical techniques. Persons allergic to yeast should not be vaccinated with vaccines containing yeast.
If You Are Living With Chronic Hepatitis B
What does the term "chronic hepatitis B" mean?
Chronic infection with HBV means that you have a long-term HBV infection; your body did not get rid of the virus when you were first infected with HBV. The risk of progressing to chronic infection is age dependent (i.e., 2% to 6% of people over aged 5 years; 30% of children aged 1-5 years; and up to 90% of infants). People with chronic infection can infect others and are at increased risk of serious liver disease including cirrhosis and liver cancer. In the United States, an estimated 1.25 million people are chronically infected with HBV.
What drugs are used to treat chronic hepatitis B?
There are at least five drugs used for the treatment of people with chronic hepatitis B: Adefovir dipivoxil, interferon alfa-2b, pegylated interferon alfa-2a, lamivudine, and entecavir.
Traveler's Health Information
What is the risk of getting HBV infection while traveling in other countries?
The risk of HBV infection for international travelers is generally low, except for certain travelers in countries where the prevalence of chronic HBV infection is high or intermediate (country listing).
Factors to consider in assessing risk include 1) the prevalence of chronic HBV infection in the local population, 2) the extent of direct contact with blood or other body fluids or of sex contact with potentially infected people, and 3) the duration of travel.
Modes of HBV transmission in areas with high or intermediate prevalence of chronic HBV infection that are important for travelers to consider are contaminated injection and other equipment used for health care-related procedures and blood transfusions from unscreened donors. However, unprotected sex and sharing illegal drug injection equipment are also risks for HBV infection in these areas.
How do I interpret serological lab results?
Interpretation of the Hepatitis B Panel |
Tests |
Results |
Interpretation |
HBsAg
anti-HBc
anti-HBs |
negative
negative
negative |
Susceptible
|
HBsAg
anti-HBc
anti-HBs |
negative
positive
positive |
Immune due to natural infection
|
HBsAg
anti-HBc
anti-HBs |
negative
negative
positive |
Immune due to hepatitis B vaccination |
HBsAg
anti-HBc
IgM anti-HBc
anti-HBs |
positive
positive
positive
negative |
Acutely
infected
|
HBsAg
anti-HBc
IgM anti-HBc
anti-HBs |
positive
positive
negative
negative |
Chronically
infected
|
HBsAg
anti-HBc
anti-HBs |
negative
positive
negative |
Four
interpretations
possible * |
* Four Interpretations:
- Might be recovering from acute HBV infection.
- Might be distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum.
- Might be susceptible with a false positive anti-HBc.
- Might be undetectable level of HBsAg present in the serum and the person is actually chronically infected.
|
What do the different abbreviations on the lab results mean?
-
Hepatitis B Surface Antigen (HBsAg): A serologic marker on the surface of HBV. It can be detected in high levels in serum during acute or chronic hepatitis. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection.
-
Hepatitis B Surface Antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from HBV infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.
-
Total Hepatitis B Core Antibody (anti-HBc): Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous or ongoing infection with hepatitis B virus (HBV) in an undefined time frame.
-
Hepatitis B e Antigen (HBeAg): A secreted product of the nucleocapsid gene of HBV and is found in serum during acute and chronic hepatitis B. Its presence indicates that the virus is replicating and the infected individual has high levels of HBV.
-
Hepatitis B e Antibody (HBeAb or anti-HBe): produced by the immune system temporarily during acute HBV infection or consistently during or after a burst in viral replication. Spontaneous conversion from e antigen to e antibody (a change known as seroconversion) is a predictor of long-term clearance of HBV in patients undergoing antiviral therapy and indicates lower levels of HBV.
-
Hepatitis B Immune Globulin (HBIG): A product available for prophylaxis against HBV infection. HBIG is prepared from plasma containing high titers of anti-HBs and provides short-term protection (3 - 6 months).
-
IgM Antibody to Hepatits B Core Antigen (IgM anti-HBc): Positivity indicates recent infection with HBV (≤6 mos). Its presence indicates acute infection.
Jaundice
What is jaundice?
Jaundice is a condition of excessive build up of a substance called bilirubin in the blood. Bilirubin is a product of break down of red blood cells and is normally processed by the liver and excreted from the body in bile. When the liver malfunctions, bilirubin is not excreted and it gets deposited near the skin surface giving a yellow tinge to the skin, mucous membranes, and eyes.
Jaundice occurs when excess amounts of bilirubin circulating in the blood stream causes a yellowish appearance of the skin and the whites of the eyes. With the exception of physiologic jaundice in the newborn (normal newborn jaundice in the first week of life), all other jaundice indicates overload or damage to the liver, or inability to move bilirubin from the liver through the biliary tract to the gut.
Newborn jaundice is common and unless associated with an abnormal condition will clear without treatment. Another condition called Gilbert`s syndrome is a hereditary condition in which mild jaundice develops during times of stress. This condition, once recognised, requires no further treatment or evaluation. There are also other more rare hereditary causes of elevated bilirubin levels. All other jaundice is the result of an underlying disease, condition, or toxicity.
A yellow-to-orange colour may be imparted to the skin by excessive intake of beta carotene, the orange pigment seen in carrots. People who consume large quantities of carrots or carrot juice or take beta carotene tablets may develop a distinctly yellow-orange cast to their skin. This condition is called hypercarotenemia or just carotenemia. Hypercarotenemia is easily distinguished from jaundice in that the whites of the eye (sclera) remain white, while people with true jaundice have a yellow sclera.
What are the causes?
In children
Newborn jaundice (physiologic jaundice)
Breast feeding jaundice
Viral hepatitis (hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E)
Haemolytic anaemia
Congenital disorders of bilirubin metabolism (Gilbert`s syndrome)
Autoimmune hepatitis
Malaria
In adults
Obstruction of the bile ducts (by infection, tumour or gallstones)
Viral hepatitis (hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E)
Drug-induced cholestasis (bile pools in the gallbladder because of the effects of drugs)
Drug-induced hepatitis (hepatitis triggered by medications, including erythromycin, sulpha drugs, antidepressants, anti-Cancer drugs, rifampicin, steroids, chlorpropamide, tolbutamide, oral contraceptives, testosteronel)
Bile duct stricture
Alcoholic liver disease (alcoholic cirrhosis)
Pancreatic carcinoma (cancer of the pancreas)
Primary biliary cirrhosis
Ischaemic hepatocellular jaundice (jaundice caused by inadequate oxygen or inadequate blood flow to the liver)
Intrahepatic cholestasis of pregnancy (bile pools in the gallbladder because of the pressure in the abdomen with pregnancy)
Haemolytic anaemia
Congenital disorders of bilirubin metabolism
Chronic active hepatitis
What are the symptoms?
Yellow pigmentation of the skin
Inside of the mouth (mucous membranes) turn yellow
Eyes turn yellow
Dark urine
Pale stools
Abdominal pain, systemic symptoms (eg, anorexia, vomiting, fever)
How is it diagnosed?
The medical history is obtained and a physical examination performed.
Medical history questions may include
Is the skin colour yellow (jaundice)?
Is the inside of the mouth (mucous membranes) yellow?
Are the eyes yellow?
When did the jaundice start?
Has the jaundice occurred repeatedly (recurrent)?
What other symptoms are also present?
During a physical examination, the doctor studies one’s body to determine the presence or absence of physical problems.
A typical physical examination includes
inspection (looking at the body)
palpation (feeling the body with hands)
auscultation (listening to sounds)
percussion (producing sounds)
Diagnostic tests that may be performed include
serum bilirubin
hepatic (liver) enzymes (see liver function tests) and cholesterol
prothrombin time
complete blood count
ultrasound of the abdomen
liver biopsy
urine and faecal urobilinogen
What causes jaundice?
Bilirubin comes from red blood cells. When red blood cells get old, they are destroyed. Hemoglobin, the iron-containing chemical in red blood cells that carries oxygen, is released from the destroyed red blood cells after the iron it contains is removed. The chemical that remains in the blood after the iron is removed becomes bilirubin.
The liver has many functions. One of the liver’s functions is to produce and secrete bile into the intestines to help digest dietary fat. Another is to remove toxic chemicals or waste products from the blood, and bilirubin is a waste product. The liver removes bilirubin from the blood. After the bilirubin has entered the liver cells, the cells conjugate (attaching other chemicals, primarily glucuronic acid) to the bilirubin, and then secrete the bilirubin/glucuronic acid complex into bile. The complex that is secreted in bile is called conjugated bilirubin. The conjugated bilirubin is eliminated in the feces. (Bilirubin is what gives feces its brown color.) Conjugated bilirubin is distinguished from the bilirubin that is released from the red blood cells and not yet removed from the blood which is termed unconjugated bilirubin.
Jaundice occurs when there is 1) too much bilirubin being produced for the liver to remove from the blood. (For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood), 2) a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile, or 3) blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. (For example, the bile ducts can be blocked by cancers, gallstones, or inflammation of the bile ducts). The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.
What problems does jaundice cause?
Jaundice or cholestasis, by themselves, causes few problems (except in the newborn, and jaundice in the newborn is different than most other types of jaundice, as discussed later.) Jaundice can turn the skin and sclerae yellow. In addition, stool can become light in color, even clay-colored because of the absence of bilirubin that normally gives stool its brown color. The urine may turn dark or brownish in color. This occurs when the bilirubin that is building up in the blood begins to be excreted from the body in the urine. Just as in feces, the bilirubin turns the urine brown.
Besides the cosmetic issues of looking yellow and having dark urine and light stools, the symptom that is associated most frequently associated with jaundice or cholestasis is itching, medically known as pruritus. The itching associated with jaundice and cholestasis can sometimes be so severe that it causes patients to scratch their skin “raw,” have trouble sleeping, and, rarely, even to commit suicide.
It is the disease causing the jaundice that causes most problems associated with jaundice. Specifically, if the jaundice is due to liver disease, the patient may have symptoms or signs of liver disease or cirrhosis. (Cirrhosis represents advanced liver disease.) The symptoms and signs of liver disease and cirrhosis include fatigue, swelling of the ankles, muscle wasting, ascites (fluid accumulation in the abdominal cavity), mental confusion or coma, and bleeding into the intestines.
If the jaundice is caused by blockage of the bile ducts, no bile enters the intestine. Bile is necessary for digesting fat in the intestine and releasing vitamins from within it so that the vitamins can be absorbed into the body. Therefore, blockage of the flow of bile can lead to deficiencies of certain vitamins. For example, there may be a deficiency of vitamin K that prevents proteins that are needed for normal clotting of blood to be made by the liver, and, as a result, uncontrolled bleeding may occur.
What diseases cause jaundice?
Increased production of bilirubin
There are several uncommon conditions that give rise to over-production of bilirubin. The bilirubin in the blood in these conditions usually is only mildly elevated, and the resultant jaundice usually is mild and difficult to detect. These conditions include: 1) rapid destruction of red blood cells (referred to as hemolysis), 2) a defect in the formation of red blood cells that leads to the over-production of hemoglobin in the bone marrow (called ineffective erythropoiesis), or 3) absorption of large amounts of hemoglobin when there has been much bleeding into tissues (e.g., from hematomas, collections of blood in the tissues).
Acute inflammation of the liver
Any condition in which the liver becomes inflamed can reduce the ability of the liver to conjugate (attach glucuronic acid to) and secrete bilirubin. Common examples include acute viral hepatitis, alcoholic hepatitis, and Tylenol-induced liver toxicity.
Chronic liver diseases
Chronic inflammation of the liver can lead to scarring and cirrhosis, and can ultimately result in jaundice. Common examples include chronic hepatitis B and C, alcoholic liver disease with cirrhosis, and autoimmune hepatitis.
Infiltrative diseases of the liver
Infiltrative diseases of the liver refer to diseases in which the liver is filled with cells or substances that don’t belong there. The most common example would be metastatic cancer to the liver, usually from cancers within the abdomen. Uncommon causes include a few diseases in which substances accumulate within the liver cells, for example, iron (hemochromatosis), alpha-one antitrypsin (alpha-one antitrypsin deficiency), and copper (Wilson’s disease).
Inflammation of the bile ducts
Diseases causing inflammation of the bile ducts, for example, primary biliary cirrhosis or sclerosing cholangitis and some drugs, can stop the flow of bile and elimination of bilirubin and lead to jaundice.
Blockage of the bile ducts
The most common causes of blockage of the bile ducts are gallstones and pancreatic cancer. Less common causes include cancers of the liver and bile ducts.
What is neonatal jaundice (jaundice in newborn infants)?
Neonatal jaundice is jaundice that begins within the first few days after birth. (Jaundice that is present at the time of birth suggests a more serious cause of the jaundice.) In fact, bilirubin levels in the blood become elevated in almost all infants during the first few days following birth, and jaundice occurs in more than half. For all but a few infants, the elevation and jaundice represents a normal physiological phenomenon and does not cause problems.
The cause of normal, physiological jaundice is well understood. During life in the uterus, the red blood cells of the fetus contain a type of hemoglobin that is different than the hemoglobin that is present after birth. When an infant is born, the infant’s body begins to rapidly destroy the red blood cells containing the fetal-type hemoglobin and replaces them with red blood cells containing the adult-type hemoglobin. This floods the liver with bilirubin derived from the fetal hemoglobin from the destroyed red blood cells. The liver in a newborn infant is not mature, and its ability to process and eliminate bilirubin is limited. As a result of both the influx of large amounts of bilirubin and the immaturity of the liver, bilirubin accumulates in the blood. Within two or three weeks, the destruction of red blood cells ends, the liver matures, and the bilirubin levels return to normal.
There is another uncommon syndrome associated with neonatal jaundice, referred to as breast-milk or breast feeding jaundice. In this syndrome, jaundice appears to be caused by or at least accentuated by breast feeding. Although the cause of this type of jaundice is unknown, it has been hypothesized that there is something in breast milk that reduces the ability of the liver to process and eliminate bilirubin. With breast-milk jaundice, the bilirubin levels rise and reach peak levels in approximately two weeks, remain elevated for a week or so, and then decline to normal over several weeks or months. This timing of the elevation in bilirubin and jaundice is different than normal physiological jaundice described previously and allows the two causes of jaundice to be differentiated. The real importance of the more prolonged jaundice associate with breast-milk jaundice is that it raises the possibility that there is a more serious cause for the jaundice that needs to be sought, for example, biliary atresia (destruction of the bile ducts). Breast-milk jaundice alone usually does not cause problems for the infant.
Physiologic jaundice and breast-milk jaundice usually do not cause problems for the infant; however, there is a concern that high or prolonged elevations in levels of unconjugated bilirubin (the type of bilirubin that is not attached to glucuronic acid and the main type of bilirubin that is present in physiologic and breast-milk jaundice) will cause neurologic damage to the infant. Therefore, when unconjugated bilirubin levels are high or prolonged, treatment usually is started to lower the levels of bilirubin. Treatment may be started earlier in infants who are born prematurely since their livers take longer to mature, and the risk of higher and more prolonged elevations of bilirubin is greater. Treatment involves phototherapy with artificial or natural sunlight and, if phototherapy is not successful, exchange transfusion in which the infant’s blood is exchanged for normal blood from blood donors.
The benign nature of physiologic and breast-milk allergy need to be distinguished from hemolytic disease of the newborn, a much more serious, even life-threatening cause of jaundice in newborns that is due to blood group incompatibilities between mother and fetus, for example Rh incompatibility. The incompatibility results in an attack by the mother’s antibodies on the babies red blood cells leading to hemolysis. Fortunately, because of modern management of pregnancy, this cause of jaundice is rare.
How is the cause of jaundice diagnosed?
Many tests are available for determining the cause of jaundice, but the history and physical examination are important as well.
History
The history can suggest possible reasons for the jaundice. For example, heavy use of alcohol suggests alcoholic liver disease, whereas use of illegal, injectable drugs suggests viral hepatitis. Recent initiation of a new drug suggests drug-induced jaundice. Episodes of abdominal pain associated with jaundice suggests blockage of the bile ducts usually by gallstones.
Physical examination
The most important part of the physical examination in a patient who is jaundiced is examination of the abdomen. Masses (tumors) in the abdomen suggest cancer infiltrating the liver (metastatic cancer) as the cause of the jaundice. An enlarged, firm liver suggests cirrhosis. A rock-hard, nodular liver suggests cancer within the liver.
Blood tests
Measurement of bilirubin can be helpful in determining the causes of jaundice. Markedly greater elevations of unconjugated bilirubin relative to elevations of conjugated bilirubin in the blood suggest hemolysis (destruction of red blood cells). Marked elevations of liver tests (aspartate amino transferase or AST and alanine amino transferase or ALT) suggest inflammation of the liver (such as viral hepatitis). Elevations of other liver tests, e.g., alkaline phosphatase, suggest diseases or obstruction of the bile ducts.
Ultrasonography
Ultrasonography is a simple, safe, and readily-available test that uses sound waves to examine the organs within the abdomen. Ultrasound examination of the abdomen may disclose gallstones, tumors in the liver or the pancreas, and dilated bile ducts due to obstruction (by gallstones or tumor).
Computerized tomography (CT or CAT scans)
Computerized tomography or CT scans are scans that use x-rays to examine the soft tissues of the abdomen. They are particularly good for identifying tumors in the liver and the pancreas and dilated bile ducts, though they are not as good as ultrasonography for identifying gallstones.
Magnetic resonance imaging (MRI)
Magnetic Resonance Imaging scans are scans that utilize magnetization of the body to examine the soft tissues of the abdomen. Like CT scans, they are good for identifying tumors and studying bile ducts. MRI scans can be modified to visualize the bile ducts better than CT scans (a procedure referred to as MR cholangiography), and, therefore, are better than CT for identifying the cause and location of bile duct obstruction.
Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound
Endoscopic retrograde cholangiopancreatography (ERCP) provides the best means for examining the bile duct. For ERCP an endoscope is swallowed by the patient after he or she has been sedated. The endoscope is a flexible, fiberoptic tube approximately four feet in length with a light and camera on its tip. The tip of the endoscope is passed down the esophagus, through the stomach, and into the duodenum where the main bile duct enters the intestine. A thin tube then is passed through the endoscope and into the bile duct, and the duct is filled with x-ray contrast solution. An x-ray is taken that clearly demonstrates the contrast-filled bile ducts. ERCP is particularly good at demonstrating the cause and location of obstruction within the bile ducts. A major advantage of ERCP is that diagnostic and therapeutic procedures can be done at the same time as the x-rays. For example, if gallstones are found in the bile ducts, they can be removed. Stents can be placed in the bile ducts to relieve the obstruction ca used by scarring or tumors. Biopsies of tumors can be obtained.
Ultrasonography can be combined with ERCP by using a specialized endoscope capable of doing ultrasound scanning. Endoscopic ultrasound is excellent for diagnosing small gallstones in the gallbladder and bile ducts that can be missed by other diagnostic methods such as ultrasound, CT, and MRI. It also is the best means of examining the pancreas for tumors and can facilitate biopsy through the endoscope of tumors within the pancreas.
Liver biopsy
Biopsy of the liver provides a small piece of tissue from the liver for examination under the microscope. The biopsy most commonly is done with a long needle after local injection of the skin of the abdomen overlying the liver with anesthetic. The needle passes through the skin and into the liver, cutting off a small piece of liver tissue. When the needle is withdrawn, the piece of liver comes with it. Liver biopsy is particularly good for diagnosing inflammation of the liver and bile ducts, cirrhosis, cancer, and fatty liver.
