Chronic hepatitis is defined as persistent hepatic inflammation for longer than 6 months, as evi-denced by elevated serum aminotransferases. Patients can usually be classified as having one of three distinct syndromes based on a liver biopsy: chronic persistent hepatitis, chronic lobular hepati-tis, or chronic active hepatitis. Patients with chronic active hepatitis have chronic hepatic inflammation with destruction of normal cellular architecture (piecemeal necrosis) on the biopsy. Evidence of cir-rhosis is either present initially or eventually devel-ops in 20% to 50% of patients. Although chronic active hepatitis seems to have many causes, it occurs most commonly as a sequela of hepatitis B or hepa-titis C. Other causes include drugs (methyldopa, isoniazid, and nitrofurantoin) and autoimmune disorders. Both immunological factors and a genetic predisposition may be responsible in most cases. Patients usually present with a history of fatigue and recurrent jaundice; extrahepatic mani-festations, such as arthritis and serositis, are not
uncommon. Manifestations of cirrhosis eventually predominate in patients with progressive disease.
In evaluating patients for chronic hepatitis, laboratory test results may show only a mildelevation in serum aminotransferase activity and often correlate poorly with disease severity. Patients without chronic hepatitis B or C infection usually have a favorable response to immunosuppressants and are treated with long-term corticosteroid ther-apy with or without azathioprine.
Patients with chronic persistent or chronic lobular hepatitis should be treated similarly to those with acute hepatitis. In contrast, those with chronic active hepatitis should be assumed to already have cirrho-sis and should be treated accordingly . Patients with autoimmune chronic active hepatitis may also present with problems related to other autoimmune manifestations (such as diabetes or thyroiditis) or long-term corticosteroid therapy that they have likely received.