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Introduction

Among the five hepatotropic viruses, hepatitis B (HBV) and C (HCV) are those that can lead to chronic hepatitis. Hepatitis A and E viruses cause acute hepatitis but do not lead to chronic infection. Hepatitis D is caused by an incomplete virus that requires the concomitant presence of the hepatitis B virus to be able to cause hepatitis. Other non-hepatotropic viruses that sometimes cause mild-moderate acute hepatitis, such as EBV, CMV or HSV, do not cause chronic hepatitis.

History

Although patients may complain of fatigue, chronic viral hepatitis is largely asymptomatic unless the patient has evolved to decompensated cirrhosis. The patient may have a history of acute hepatitis and establishing an approximate date will be helpful to estimate time of infection. HBV is acquired sexually and parenterally, while HCV virus is acquired parenterally. Therefore it is essential to obtain detailed:

• History of blood transfusion
• Sexual history
• History of drug use (especially IV drugs)

Physical examination

Stigmata of chronic liver disease may be present (palmar erythema, vascular spiders, muscle hypotrophy), particularly in the presence of cirrhosis.

Laboratory investigation

If the possibility of chronic hepatitis B is raised given a positive hepatitis B surface antigen (HBsAg), the next important step is to determine:

• HBV-DNA titer (to determine activity of infection)
• HBeAg and anti-HBe

If the possibility of chronic hepatitis C is raised given a positive anti-HCV, the next important step is to determine:

• HCV-RNA titer (to determine presence of active infection)
• HCV genotype

In addition to laboratory investigations directed at determining a possible etiology of chronic hepatocellular injury, platelets, albumin and prothrombin time/INR should be obtained. The presence of the following is suggestive of cirrhosis:

• Thrombocytopenia, hypoalbuminemia, or prolonged prothrombin time/INR