Hepatitis - viral
Hepatitis is a serious inflammation of the liver, usually due to a virus. It can also be caused by an overactive immune system, and from drugs, alcohol, chemicals, and environmental toxins. In the United States, viral hepatitis usually appears as type A, B, or C. Two other types, D and E, are rare in the U.S.
Type A is the most common form of viral hepatitis. It often affects school-aged children. The disease is usually transmitted when someone ingests fecal matter through contaminated food or water. You can also get hepatitis A by having sex with someone who has the virus. A person who has hepatitis A can be contagious before they even know they have the disease. Unlike other forms of viral hepatitis, the virus does not stay in your body once you recover. The best way to prevent hepatitis A is with a vaccine and good hygiene.
Hepatitis types B and C affect people of all ages. Most people who become infected with hepatitis B get rid of the virus within 6 months. This type of short infection is known as an "acute" case of hepatitis B. About 10% of people infected with the hepatitis B virus develop a chronic, life-long infection. People with chronic infection may or may not have symptoms. Those who do not develop symptoms are referred to as carriers. You can get hepatitis B through contact with infected blood and body fluids. Having chronic hepatitis B increases your chance of permanent liver damage, including cirrhosis (scarring of the liver) and liver cancer. There is a vaccine to prevent hepatitis B.
Anyone who has chronic hepatitis B is also susceptible to infection with another strain of viral hepatitis known as hepatitis D (formerly called delta virus). Hepatitis D virus can only infect cells if the hepatitis B virus (HBV) is present. People who use IV drugs are at greatest risk. Being infected with both hepatitis B and D raises the risk of developing cirrhosis or liver cancer.
Hepatitis C is usually spread through contact with infected blood, as when IV drug users share needles. It can be either acute (a short-term infection) or become chronic and even life threatening. There is no vaccine for hepatitis C.
Hepatitis E is rare in the United States. It is spread through ingesting food or water contaminated with feces. There is no vaccine for hepatitis E. The only way to prevent the disease is to reduce the risk of exposure to the virus.
Signs and Symptoms
- Flu-like symptoms including fever, as well as aching or painful muscles and joints
- Jaundice (yellow discoloration of both your skin and the whites of your eyes)
- Abdominal pain
- Weight loss
- Loss of appetite
- Nausea, vomiting
- Dark urine, colorless stool
- Whole body itching (called pruritus)
- Mild anemia
- Enlarged, tender liver
People with chronic hepatitis do not always have the symptoms of acute hepatitis. Some people with hepatitis C feel only mild ongoing fatigue and, perhaps, whole body itching. The virus is often discovered by a blood test.
Hepatitis A is usually transmitted by someone touching feces and then not washing their hands before putting them in their mouth or touching food. It can be transmitted by ingesting contaminated food and water (for example, seafood from sewage contaminated water). It can also be transmitted through close contact with someone who has the virus.
Hepatitis B and C are transmitted through contact with infected blood. These viruses are usually transmitted by contaminated needles (in the case of IV drug users). Having unprotected sex with someone who is infected can also pass on the hepatitis B virus (it is rarer for hepatitis C to be transmitted through sexual activity). In as many as 40% of the cases of hepatitis C, the specific cause of transmission is unknown. Before scientists developed better testing, you could get hepatitis B or C from a blood transfusion. Now blood and blood products that are used for transmission can be tested for both hepatitis B and C.
Many viruses can cause hepatitis, including herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and others.
- Being in an institution (such as a nursing home or rehabilitation center)
- Daycare employees or children who attend daycare
- Recent hepatitis A infection in a family member
- Recent travel or immigration from Asia, South, or Central America
- Food industry workers
- Sewage workers
- Contact with blood in work setting: health care providers are at particular risk
- Unprotected sex with multiple partners
- History of blood transfusion prior to the early 1990s
- Receiving a tattoo with contaminated instruments
- IV drug use with sharing of contaminated needles
- Birth to a hepatitis B-infected mother
- Travel to underdeveloped nations and immigrants from areas where disease rates are high (the Asia Pacific and Mediterranean regions and southern Africa)
- Having the human immunodeficiency virus (HIV) puts you at greater risk for chronic hepatitis and its potential complications
- Blood transfusion prior to July 1992
- Solid organ transplantation from a donor who has hepatitis C
- IV drug use and sharing of contaminated needles
- Long-term kidney dialysis
- Contact with blood in work setting: health care providers are at particular risk
- Sex with a person who has hepatitis C
- Birth to a hepatitis C-infected mother, particularly if she has HIV
- Having HIV or hepatitis B puts you at greater risk for chronic hepatitis C and its potential complications
First, your doctor will ask questions to assess your risk for the different types of viral hepatitis. Questions will include whether you:
- Work in health care setting, including either a medical laboratory or a dialysis unit
- Have a parent, sibling, or child infected with hepatitis
- Engage in unprotected sex or have a sexual partner with either hepatitis B or C
- Use IV drugs
- Live in or are exposed to unsanitary conditions
- Consume possibly contaminated food or water
- Eat or handle raw shellfish
Next, your doctor will examine your abdomen carefully to see whether your liver or spleen are enlarged or tender. A blood test will check your liver function and test for antibodies against the specific hepatitis viruses. Your doctor will likely do a urine test as well. For chronic hepatitis, you may need a liver biopsy, which must be done under general anesthesia. A liver biopsy is important if you have chronic hepatitis C because this test checks the degree of liver damage, which can occur even if you do not have symptoms.
- Avoid unclean food and water.
- Wash hands thoroughly after using the toilet or changing a diaper, as well as before serving food.
- Clean yourself thoroughly if you come into contact with any type of body fluid from an infected person (such as blood and feces).
- Those with the virus should not prepare food for others.
- People at risk should receive the hepatitis A vaccine (see below).
Hepatitis B and C
- Avoid contact with blood or blood products whenever possible.
- DO NOT use IV drugs, and do not share needles.
- Avoid having multiple sexual partners.
- DO NOT have unprotected sex.
- Go to a reputable shop for tattoos and body piercing.
- Health care workers should practice universal precautions when handling blood and bodily fluids. This includes wearing gloves when performing any procedure with blood exposure, disposing of needles properly, and other precautions.
- Children should receive the hepatitis B vaccine (see below).
- Avoid sharing personal items, such as razors and toothbrushes.
People who should receive the hepatitis A vaccine include:
- Anyone who lives or works in a community where outbreaks occur (such as a daycare center)
- Those who travel frequently or have long overseas stays in high risk areas
- Sexually active homosexual men
- People who already have a chronic form of hepatitis should be vaccinated before the chronic form reaches late stages of liver disease.
- Health care workers
- People living in high risk U.S. states, including Alaska, Arizona, Arkansas, California, Colorado, Idaho, Missouri, Montana, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, Washington, and Wyoming
- People with intimate exposure to someone with hepatitis A. In this case, your doctor will decide if the vaccine or immunoglobulin (an immunizing agent) is best for you.
Immunization provides the only true protection against hepatitis B. The hepatitis B vaccine is now part of routine pediatric care in the United States. Adults who are at higher risk should also be vaccinated:
- Those who live with someone who has hepatitis B
- Health care workers
- Travelers to high risk areas
- Sexually active people who have multiple partners
- People on kidney dialysis
- People who have suppressed immune systems (such as HIV)
- High-risk pregnant women
- People who have inflammatory bowel disease (IBD)
There is no vaccine for hepatitis C, but immunoglobulin helps protect against it after blood transfusions. Receiving immunoglobulin in periodic doses may also help protect someone who has sex with an infected partner.
The goals for treating acute viral hepatitis include:
- Supporting the person with nutrition and fluids
- Preventing further damage to the liver by avoiding alcohol and taking other preventive measures
- Avoiding transmission of the virus to others
There are no medications to treat acute hepatitis, although your doctor may recommend drugs to treat some of the symptoms. Most cases of acute hepatitis are mild. Only people who are at high risk for complications, such as pregnant women, the elderly, people with serious underlying medical conditions, or those who become dehydrated from nausea and vomiting, need to be hospitalized. In very rare cases, acute hepatitis can lead to liver failure (called fulminant acute hepatitis) that requires liver transplantation.
The goals for treatment of chronic viral hepatitis include:
- Preserving liver function and preventing liver damage
- Boosting the immune system to help fend off damage from the virus
Your doctor may choose from several medications to help treat chronic hepatitis. Many people also use CAM therapies that may help boost your immune function, and help make you feel stronger and less tired while taking conventional medications, including herbal and vitamin supplements, homeopathy, acupuncture, and massage therapy. Make sure your health care providers know that you have hepatitis so that precautions can be taken to avoid spread of the virus.
Your doctor will talk with you about steps you can take to avoid spreading the virus. For hepatitis A, these include:
- Washing clothes thoroughly with hot water
- Washing your hands after using the toilet
- Heating contaminated articles for one minute, which should kill the virus
- Using household bleach to disinfect hard surfaces
- Keeping any eating and cooking utensils used by someone infected with the virus separate from other utensils
- Abstaining from sex during an acute infection
For hepatitis B and C, these measures include:
- Avoiding sharing personal items, such as toothbrushes and razors.
- Abstaining from sexual activity, or taking strict precautions, such as always using a condom. Women should not have sex during menstruation.
- Handling objects contaminated with blood with special care, like wearing gloves when drawing blood if you work in a hospital.
- Not sharing drug needles if you use IV drugs and making sure that tattoo and piercing artists and acupuncturists use sterile needles. Note: there have been no reports of hepatitis infection from acupuncture therapy in the United States.
If you are traveling to a high-risk country, take the following precautions:
- Get vaccinated against hepatitis A and possibly hepatitis B.
- Use bottled water for drinking and brushing teeth.
- Eat heated food promptly. Heated food should be hot to the touch.
- DO NOT buy food from street vendors.
- Avoid sliced fruit. It may have been washed in contaminated water.
- DO NOT eat raw or undercooked fish and shellfish.
- DO NOT drink alcohol during the acute phase of hepatitis, or if you become a carrier of types B or C.
- Quit smoking. Evidence suggests that cigarette smoking is associated with more severe infection.
Interferons. Interferon is produced by the body to fight viruses. Taking man-made interferons may help stimulate your immune system against the hepatitis B and C viruses. Examples of interferon medications include Roferon-A, Intron-A, Rebetron, Alferon-N, and Peg-Intron. These drugs do not work for everyone who takes them, but the possible benefits include:
- Lower viral levels of hepatitis B and C
- Fewer symptoms
- Better survival rates
- These drugs are given by injection
- Hepatitis B and C can become resistant to the medication; in other words, the drugs become less effective over time.
- Side effects can be unpleasant, including flu-like symptoms with fever, chills, and muscle aches. Additional side effects include depression, hair loss, weight loss, and a drop in white blood cells (the cells in the body that help fight infection).
Ribavirin (Rebetol). Often used in combination with interferon for chronic hepatitis C. Side effects can include anemia (low red blood cell count), fatigue, skin irritation, insomnia, and depression. Side effects are usually most severe during the first weeks of treatment, and improve after that.
Lamivudine (Epivir-HBV). An oral medication used to stop the hepatitis B virus from reproducing in the body. It has fewer side effects, but some people's symptoms get significantly worse when they stop taking it.
Adefovir dipivoxil (Hepsera). An oral medication used to stop the hepatitis B virus from reproducing in the body, given the people who did not respond to Epivir. Like Epivir, side effects are mild but some people's symptoms get significantly worse when they stop taking it.
Entecavir (Baraclude). An antiviral drug taken as a pill once a day to treat hepatitis B. Studies comparing it with Epivir show Baraclude is more effective. As with Epivir, some people's symptoms get significantly worse when they stop taking it.
Surgery and Other Procedures
People with the following conditions may need a liver transplant:
- Life-threatening cirrhosis and life expectancy is more than 12 years
- Liver cancer that remains confined to the liver
- Fulminant acute hepatitis (liver failure)
Five year survival rate after liver transplantation is 60 to 80%. In about 50% of people with chronic hepatitis who receive a liver transplant, the infection recurs.
Nutrition and Dietary Supplements
Although no special diets have been shown to help treat acute hepatitis, eating small snacks during the day, with larger ones in the morning, may be recommended to prevent weight loss and reduce nausea. Generally, eating a healthy diet, lots of fruits and vegetables high in antioxidants, can help most people who are battling a chronic disease.
DO NOT drink alcohol, especially if you have chronic hepatitis.
Tell your health care provider about any supplements you are thinking about taking.
- Vitamin C, as an antioxidant and for immune support. Your provider may recommend high-dose intravenous vitamin C to treat hepatitis C. Speak with your physician.
- Coenzyme Q10 (CoQ10), for antioxidant, immune, and muscular support. CoQ10 may interact with blood-thinning medications, such as warfarin (Coumadin) and aspirin by decreasing their effectiveness.
- Acetyl-L-carnitine, for antioxidant and antiviral activity. People who have a history of seizures should not take Acetyl-L-carnitine. It may interfere with thyroid hormone and potentially increase the blood-thinning effects of certain medications.
- Probiotic supplement (containing Lactobacillus acidophilus), for maintenance of gastrointestinal and immune health. Some probiotic supplements need refrigeration. People who are immune compromised, or who take immune-suppressive drugs, should only take probiotics under the direction of a physician.
- N-acetyl cysteine (NAC), for liver and antioxidant support. NAC can potentially interact with nitroglycerin.
- SAMe (s-adenosylmethionine), for liver and antioxidant support. If you have bipolar disorder your doctor should monitor you closely for signs of mania if taking SAMe. SAMe may interfere with some antidepressants and may potentially worsen Parkinson disease.
Herbs are one way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting treatment. Some herbs may interact with medications, so ask your doctor before taking any herb. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.
Cordyceps (Cordyceps sinensis): is a type of mushroom used in traditional Chinese medicine to support the liver. Preliminary studies show it may help improve liver and immune system function in people with hepatitis B. People who have autoimmune disease should not take Cordyceps. Cordyceps may slow down the blood's clotting ability, so people who take blood-thinning medications should use caution.
Milk thistle (Silybum marianum): Milk thistle has been used since Greco Roman times to treat liver problems. Several scientific studies support this traditional use. They suggest that a substance in milk thistle (silymarin) can protect the liver from damage caused by viruses, toxins, alcohol, and certain drugs, such as acetaminophen. However, studies are mixed as to whether milk thistle improves liver function tests or quality of life for people with chronic active hepatitis B or C. People who are allergic to ragweed may have an allergic reaction to milk thistle. Milk thistle may have estrogen-like effects, so people with hormone-sensitive conditions should use this herb with caution. Because it acts on the liver, Milk thistle can theoretically interact with several medications that are processed through the liver.
Milk thistle may help protect the liver against damage from exposure to industrial toxins.
In a comprehensive review of studies on milk thistle by the U.S. Agency for Healthcare Research and Quality (AHRQ), milk thistle improved liver function in people with mild liver disease but did not work as well for those with severe liver disease, such as cirrhosis.
Licorice root (Glycyrrhiza glabra): Licorice root has been used in both Eastern and Western medicine to treat a variety of illnesses, including liver disease. Preliminary data from Japanese researchers suggests that taking glycyrrhizin (an active component of licorice root) along with cysteine and glycerine might help reduce the risk of cirrhosis if you have hepatitis C and B. However, the formula was delivered intravenously (IV). It is not known whether taking these substances by mouth would have any effect. More studies are needed. People with high blood pressure, or those who take steroids, digoxin (Lanoxin), diuretics (water pills), or anticoagulants (blood thinners, such as warfarin (Coumadin), should not take licorice. Pregnant women should avoid licorice. Licorice interacts with many medications, and can raise blood pressure. Use licorice only under the direction of your physician. People with hormone-sensitive conditions, kidney disease, bleeding disorders, or who are taking blood-thinning medications should be particularly cautious with licorice.
Reishi mushroom (Ganoderma lucidum): for chronic hepatitis B. A preliminary study showed it decreased levels of the hepatitis B virus. More research is needed. Reishi may lower blood pressure and interact with blood-thinning medications; speak with your physician.
While research in China has shown some promise in treating hepatitis B, not many acupuncturists in the United States provide treatment for hepatitis. In China, acupuncture is generally used to boost the immune system of those with hepatitis.
There has been some concern that people could contract hepatitis from dirty needles or infected practitioners. However, there have been no reports of infection in the U.S. In many states acupuncturists are required to use sterile needles, and there is virtually no risk of contracting hepatitis from acupuncture therapy here or in other countries with similar standards and safe practices.
Therapeutic massage may help boost the immune system.
Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for viral hepatitis based on his or her knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.
- Aconitum. Used during initial phases of hepatitis when the person has a fever, jaundice, and sharp pains in the liver; can be used in newborns.
- Belladonna. Used in early stages of hepatitis when the person has occasional liver pains that are worsened by inhalation and movement.
- Chelidonium. For people with pain that originates in the liver and extends to the back and right shoulder; this remedy is most appropriate for individuals who have gray or yellow loose stools, fever, and jaundice. A craving for milk may be present. Lying on the left side and ingesting hot food or drink may bring some relief.
- China. For people with a tender liver and a sensation of fullness in the stomach. The individual may burp frequently although it provides no relief. The individual may also have cravings for sweets, cold drinks, or coffee.
- Lycopodium. One of the primary remedies for hepatitis in children and adults. This remedy is most appropriate for people who feel tension in the liver area, have difficulty standing up, and feel full after eating only small amounts of food.
- Mercurius. For people with a swollen, tender liver, and jaundice; the tongue may also be yellow and swollen. This remedy is most appropriate for individuals with clammy perspiration, excessive salivation, sensitivity to temperature variations, and bleeding gums. Lying on the right side is painful and stools may be light gray or green.
- Phosphorus. For people with burning pains under the right rib cage and in the back between the shoulder blades that are relieved by cold drinks. This remedy may be used in newborns with jaundice.
Traditional Chinese Medicine (TCM)
Traditional Chinese Medicine (TCM) is a range of traditional medical practices originating in China that developed over several thousand years. When assessing a person with hepatitis, a TCM practitioner might make one of the following diagnoses:
- Hepatic qi (energy) stagnation
- Hepatic yang excess with yin deficiency (balance)
- Hepatic yin insufficiency
Once the diagnosis is established, the practitioner is likely to use acupuncture, moxibustion (a burning of an herb called mugwort over acupuncture sites), and herbal remedies to address the imbalances of hepatic qi (energy) and yin yang (balance).
If you are at high risk of contracting hepatitis, or if have already been infected with any form of the hepatitis virus, your doctor will recommend the hepatitis B vaccine. A vaccine is also available for hepatitis A.
Food handlers should be extremely careful of contracting hepatitis A, and health care workers should always exercise universal precautions to avoid contracting or transmitting hepatitis B or C.
Support groups are available for people with chronic hepatitis B or C. It is often difficult to cope with this disease. Talking with people who also have this condition is often very helpful. Check with your doctor or hospital to locate a support group near you.
Hepatitis B and C can be transmitted during pregnancy or childbirth. Women who are pregnant, or planning to become pregnant soon, cannot take interferon or nucleoside analogues.
Warnings and Precautions
Because the liver processes many types of medications, your doctor may tell you to stop taking drugs other than those recommended for treatment of hepatitis. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), used to relieve pain, can raise your risk for serious liver damage.
Some herbs and supplements are known to cause harm to the liver:
- Kava kava (Piper methysticum). An herb used to relieve anxiety and tension, may be toxic to the liver and cause severe hepatitis, and even liver failure, if you take large doses or take it for a long time. Those risks have prompted regulatory agencies in other countries, including Germany, Switzerland, France, Canada, and the United Kingdom, to warn consumers about the potential risks associated with kava use and to remove kava-containing products from the marketplace. The U.S. Food and Drug Administration issued an advisory in March of 2002 about the potential risk of liver failure associated with kava, but this herb has not been taken off the market in this country.
- Vitamin A in large quantities can be toxic to the liver. Vitamin A is often found in cod liver oil supplements. Some manufacturers remove the vitamin A; read the labels carefully or ask a health care provider.
DO NOT take over-the-counter drugs that contain acetaminophen (Tylenol) if you have hepatitis without first talking to your doctor. Acetaminophen can be toxic to the liver, even in people with healthy livers.
Prognosis and Complications
With acute hepatitis, jaundice generally disappears in 2 to 8 weeks. Sometimes you may need to be hospitalized, for example, if you become dehydrated, but most people recover completely. It can take several months for your liver function to test normal.
Rare yet serious complications of acute hepatitis include aplastic anemia (when the bone marrow makes no new cells), pancreatitis, very low blood sugar, and polyarteritis (inflammation of blood vessels). Also quite rare is liver failure (called fulminant hepatitis), with bleeding from the gastrointestinal tract and brain damage, known as hepatic encephalopathy. Sometimes the acute phase of hepatitis B or C is milder but longer, with recovery taking up to 1 year. Some 5 to 10% of people who have a longer acute phase go on to develop chronic hepatitis.
Once the acute phase is over, long-term prognosis depends on several things: what caused the hepatitis, whether you become a carrier of hepatitis B or develop chronic hepatitis, and whether you have other medical conditions. About 5 to 10% of people with hepatitis B become carriers, and about 25% of carriers develop chronic hepatitis. Most people infected with hepatitis C become carriers, and anywhere from 50 to 90% of them eventually develop chronic hepatitis.
Chronic hepatitis can cause scar tissue to form in the liver (known as cirrhosis) and lead to liver failure. There are 2 types of chronic hepatitis, chronic active and chronic persistent. Chronic persistent hepatitis is mild and either doesn't get worse or only does so very slowly. Chronic active hepatitis, on the other hand, is much more likely to lead to permanent damage to the liver. Cirrhosis occurs in 5 to 10% of people with chronic hepatitis from hepatitis B, and as many as 20 to 30% of those with chronic hepatitis from hepatitis C. About 14% of people with cirrhosis develop liver cancer.
Akyuz F, Kaymakoglu S, Demir K, et al., Lamivudine monotherapy and lamivudine plus interferon alpha combination therapy in HBeAg negative chronic hepatitis B not responding to previous interferon alpha monotherapy. Acta Gastroenterol Belg. 2007;70(1):20-24.
Cohen MR. Herbal and complementary and alternative medicine therapies for liver disease. A focus on Chinese traditional medicine in hepatitis C virus. Clin Liver Dis. 2001;5(2):461-78, vii.
Dhiman RK, Chawla YK. Herbal medicines for liver diseases. Dig Dis Sci. 2005;50(10):1807-12.
El-Kamary SS, Shardell MD, Abdel-Hamid M, et al. A randomized controlled trial to assess the safety and efficacy of silymarin on symptoms, signs and biomarkers of acute hepatitis. Phytomedicine. 2009;16(5):391-400.
Ferrucci LM, Bell BP, Dhotre KB, et al. Complementary and alternative medicine use in chronic liver disease patients. J Clin Gastroenterol. 2010;44(2):e40-e45.
Ferenci P, Scherzer TM, Kerschner H, et al. Silibinin is a potent antiviral agent in patients with chronic hepatitis C not responding to pegylated interferon/ribavirin therapy. Gastroenterology. 2008;135(5):1561-7.
Firpi RJ, Nelson DR. Current and future hepatitis C therapies. Arch Med Res. 2007;38(6):678-90.
Gish RG. Improving outcomes for patients with chronic hepatitis B. Hepatol Res. 2007;37(s1):S67-S78.
Goldman. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders. 2011.
Gorban EM, Orynchak MA, Virstiuk NG, Kuprash LP, Panteleimonov TM, Sharabura LB. [Clinical and experimental study of spirulina efficacy in chronic diffuse liver diseases.] Lik Sprava. 2000(6):89-93.
Honer zu Siederdissen C, Manns MP, Cornberg M. Which treatment options are validated for chronic viral hepatitis? Internist (Berl). 2013;54(12):1427-8.
Hou JK, Velayos F, Terrault N, Mahadevan U. Viral hepatitis and inflammatory bowel disease. Inflamm Bowel Dis. 2010;16(6):925-32.
Huang TS, Shyu YC, Chen HY, Yuan SS, Shih JN, Chen PJ. A systematic review and meta-analysis of adjuvant interferon therapy after curative treatment for patients with viral hepatitis-related hepatocellular carcinoma. J Viral Hepat. 2013;20(10):729-43.
Isaguliants MG. Functionality of the immune system in patients with chronic hepatitis C: trial by superinfections and vaccinations. Expert Rev Vaccines. 2007;6(4):527-37.
Koshy A, Marcellin P, Martinot M, Madda JP. Improved response to ribavirin interferon combination compared with interferon alone in patients with type 4 chronic hepatitis C without cirrhosis. Liver. 2000;20(4):335-9.
Lai MY. Firstline treatment for hepatitis C: combination interferon/ribavirin versus interferon monotherapy. J Gastroenterol Hepatol. 2000;15(Suppl):E130-E133.
Langmead L, Rampton DS. Herbal treatment in gastrointestinal and liver disease--benefits and dangers. Aliment Pharmacol Ther. 2001;15(9):1239-52.
Leung NW. Management of viral hepatitis C. J Gastroenterol Hepatol. 2002;17(Suppl):S146-S154.
Li YM, Yang HZ, Guan WB, et al. Therapeutic effect of traditional Chinese medicine on coagulation disorder and accompanying intractable jaundice in hepatitis B virus-related liver cirrhosis patients. World J Gastroenterol. 2008;14(39):6060-4.
Liaw YF, Leung NW, Chang TT, et al. Effects of extended lamivudine therapy in Asian patients with chronic hepatitis B. Asia Hepatitis Lamivudine Study Group. Gastroenterology. 2000;119(1):172-80.
Liu JP, Manheimer E, Tsutani K, Gluud C. Medicinal herbs for hepatitis C virus infection. Cochrane Database Syst Rev. 2001;(4):CD003183.
Liu JP, McIntosh H, Lin H. Chinese medicinal herbs for asymptomatic carriers of hepatitis B. Cochrane Database Syst Rev. 2001;(2):CD002231.
Ma K, Xie YM, Yang W, Wang YY, Yi DH, Zhuang Y. Analysis of characteristics of traditional Chinese medicine and western medicine clinical use in patients with viral hepatitis based on real world hospital information system data. Zhongguo Zhong Yao Za Zhi. 2014; 39(18):3535-40.
Martin KW, Ernst E. Antiviral agents from plants and herbs: a systematic review. Antivir Ther. 2003;8(2):77-90.
Mayer KE, Myers RP, Lee SS. Silymarin treatment of viral hepatitis: a systematic review. J Viral Hepat. 2005;12(6):559-67.
McCulloch M, Broffman M, Gao J, Colford JM Jr. Chinese herbal medicine and interferon in the treatment of chronic hepatitis B: a meta-analysis of randomized, controlled trials. Am J Public Health. 2002;92(10):1619-28.
Milliman WB, Lamson DW, Brignall MS. Hepatitis C; a retrospective study, literature review, and naturopathic protocol. Altern Med Rev. 2000;5(4):355-71.
Morishima C, Shuhart MC, Wang CC, et al. Silymarin Inhibits in vitro T cell proliferation and cytokine production in hepatitis C virus infection. Gastroenterology. 2010;138(2):671-81, 681.e1-e2.
Pellicano R, Fagoonee S, Repici A, Rizzetto M. Hepatitis C virus and human immunodeficiency virus: a dangerous dealing. Panminerva Med. 2007;49(2):79-82.
Pessione F, Ramond MJ, Njapoum C, et al. Cigarette smoking and hepatic lesions in patients with chronic hepatitis C. Hepatology. 2001;34(1):121-5.
Pianko S, McHutchison JG. Treatment of hepatitis C with interferon and ribaviron. J Gastroenterol Hepatol. 2000;15(6)581-6.
Rambaldi A, Jacobs BP, Iaquinto G, Gluud C. Milk thistle for alcoholic and/or hepatitis B or C liver diseases -- a systematic cochrane hepato-biliary group review with meta-analyses of randomized clinical trials. Am J Gastroenterol. 2005;100(11):2583-91.
Saller R, Meier R, Brignoli R. The use of silymarin in the treatment of liver diseases. Drugs. 2001;61(14):2035-63.
Seeff LB, Lindsay KL, Bacon BR, Kresina TF, Hoofnagle JH. Complementary and alternative medicine in chronic liver disease. Hepatology. 2001;34(3):595-603.
Shahidah KN, Merican I. Chronic hepatitis B and herbal therapy. Med J Malaysia. 2005;60(Suppl B):35-38.
Shimizu I. Antifibrogenic therapies in chronic HCV infection. Curr Drug Targets Infect Disord. 2001;1(2):227-40.
Singal AK, Fontana RJ. Meta-analysis: oral anti-viral agents in adults with decompensated hepatitis B virus cirrhosis. Ailment Pharmacol Ther. 2012;35(6):674-89.
Takagi H, Nagamine T, Abe T, et al. Zinc supplementation enhances the response to interferon therapy in patients with chronic hepatitis C. J Viral Hepat. 2001;8(5):367-71.
Tamayo C, Diamond S. Review of clinical trials evaluating safety and efficacy of milk thistle (Silybum marianum [L.] Gaertn.). Integr Cancer Ther. 2007;6(2):146-57.
Wang BE. Treatment of chronic liver diseases with traditional Chinese medicine. JGastroenterol Hepatol. 2000;15(Suppl):E67-E70.
Wohlfarth C, Efferth T. Natural products as promising drug candidates for the treatment of hepatitis B and C. Acta Pharmacol Sin. 2009;30(1):25-30.
Yazigi N, Balistreri W. Kliegman: Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier Saunders. 2011.
Zeisel MB, Lupberger J, Fofana I, Baumert TF. Host-targeting agents for prevention and treatment of chronic hepatitis C - perspectives and challenges. J Hepatol. 2013;58(2):375-84.
Zoulim F, Locarnini S. Management of treatment failure in chronic hepatitis B. J Hepatol. 2012;56(Suppl 1):S112-S122.