Introduction

Hepatitis E is a disease of the liver caused by a viral infection, and it is currently the most common cause of short-term Hepatitis in the UK.¹ The Hepatitis E virus has been associated mainly with the overconsumption of raw pork. Although it only causes mild disease, it can be more serious in people who have a weakened immune system.¹ 

Cirrhosis is scarring, also known as fibrosis of the liver, which is caused by long-term liver damage. Cirrhosis is often referred to as “end-stage liver disease” as it happens following other liver conditions, such as Hepatitis.² This article will explore how Hepatitis E can interact with pre-existing liver conditions, such as cirrhosis.

Overview of Hepatitis E and Cirrhosis

As previously mentioned, Hepatitis E is a viral infection most commonly associated with contaminated water and raw pork.¹ The symptoms of Hepatitis E are: dark urine, feeling tired, fever, joint pain, loss of appetite, jaundice, and stomach pain.³ 

Although Hepatitis E tends to cause a mild form of the disease, there are certain groups of people who are at risk of developing a more severe form of the disease. People who have recently had an organ transplant, who are pregnant, or who have a weakened immune system should be wary, as they can develop liver failure.³ 

In the UK, Hepatitis E is contracted when consuming raw or undercooked pork, however, in most of the world, it is contracted by drinking water contaminated with stool or the virus itself.⁴ According to the WHO, Hepatitis E causes around 20 million infections a year and leads to 55,000 deaths globally, mainly affecting Central America, Africa and Asia.⁴ 

As previously mentioned, cirrhosis refers to fibrosis of the liver and is known as “end-stage liver disease”. As cirrhosis worsens, your liver fails. Cirrhosis has a range of symptoms and signs as the liver has many functions, and symptoms may not appear until cirrhosis is advanced.⁵ Cirrhosis is mainly caused by chronic Hepatitis B or C, alcohol, and non-alcoholic fatty liver disease.⁵ 

As of today, cirrhosis has no cure, but the underlying causes of cirrhosis can be addressed and treated—this may help prevent liver failure and halt the progression of the disease.⁵ 

Cirrhosis is most prevalent in men in the UK, with cases on the rise since 2019.⁶ Although cirrhosis cannot be directly passed down genetically, some of the conditions that can cause cirrhosis can be inherited, such as disorders of metabolism, cystic fibrosis, and haemochromatosis.⁷ 

How does Hepatitis E interact with liver conditions?

Hepatitis E causes mild disease, however, patients with pre-existing liver disease will suffer worse symptoms than someone with a healthy liver.⁸ Patients with pre-existing liver disease, such as cirrhosis, may experience symptoms of ascites, jaundice, encephalopathy and ruptured varices.⁹ The Hepatitis E virus can induce the decompensation of liver disease,⁸ which means that the liver is no longer able to carry out its function, and the body starts to fail. 

In a paper published in 2022,¹⁰ it is shown that Hepatitis E can cause a syndrome called acute on chronic liver failure (ACLF), most commonly in endemic areas¹⁰ where Hepatitis E is more common than in the UK. The distinguishing feature of ACLF is the sudden deterioration of liver function in cirrhotic patients.¹⁰ However, ACLF does not limit itself to the liver, and it may involve other organs and cause multi-organ failure.¹⁰ 

The 180-day mortality was shown to be higher in patients with pre-existing liver disease who contracted Hepatitis E, compared to the patients who didn’t get the virus,¹⁰ so we can safely assume that Hepatitis E may induce liver failure and be deadly in patients who already have a liver condition, such as cirrhosis.

Hepatitis E can also affect patients who have just received a transplant. After a transplant, the body will often be subject to immunosuppressant drugs, which will weaken your immune system to reduce the risk of your body rejecting the new liver.¹¹ With a weakened immune system, you have a higher chance of catching an infection, such as Hepatitis E, and the said infection can cause a more severe form of the disease. For example, Hepatitis E almost always causes an acute infection, but in immunocompromised patients or patients with another liver condition, it can cause chronic Hepatitis, with some systemic manifestations.¹² 

There are some studies that have linked Hepatitis E infection and a more severe form of non-alcoholic fatty liver disease (NAFLD).¹³ Developing the infection can also cause metabolic and inflammatory processes if patients have pre-existing non-alcoholic fatty liver disease, which can cause severe symptoms. 

It has also been proven that Hepatitis E infection can either cause or worsen autoimmune diseases of the liver, such as autoimmune Hepatitis and primary biliary cholangitis.¹⁴ It is hypothesised that contracting the Hepatitis E infection can make any symptoms caused by autoimmune liver disease worse, and can also deteriorate the state of the liver and lead to a more severe form of the disease.¹⁴

Overall, Hepatitis E can interact with pre-existing liver disease in many ways, and can also contribute to liver disease later.

Management of Hepatitis E in patients with liver disease

Although the deterioration of the liver is rapid and sudden in patients who contract Hepatitis E and have a pre-existing liver condition, some things can be done. 

The most important thing is to diagnose Hepatitis E early. Two serology tests can be performed to detect Hepatitis E: IgM antibodies, which signify acute infection, and PCR tests for the virus’s RNA.¹⁵ Liver tests must also be performed to assess the functioning of the liver.

Patients with a pre-existing liver condition who contract Hepatitis E will need to be hospitalised and monitored to ensure they do not develop ACLF.¹⁶ Healthcare professionals should watch out for clinical signs that the liver’s function is worsening, such as ascites and hepatic encephalopathy. 

Another important step in the management of patients is to give patients supportive care, such as fluids and electrolytes, diuretics for ascites and medications for their symptoms of liver failure.¹⁷ 

As of 2024, there is no specific drug or treatment for Hepatitis E, as the infection usually resolves on its own. However, in patients with pre-existing liver disease, an antiviral drug called Ribavirin is used to alleviate symptoms.⁸ This drug is regularly used to treat chronic Hepatitis C. Giving it to patients with cirrhosis and Hepatitis E for 3 months at a high dose according to the patient’s body weight can yield some positive results for patients.⁸

Overall, most of the management of patients with both cirrhosis and acute Hepatitis E includes preventing liver failure and alleviating symptoms.

FAQs

How do I avoid catching Hepatitis E?

• Avoid travelling to areas where it is prevalent
• Ensure you drink clean water
• Practise safe cooking methods
• Avoid raw dairy products³

Can I get vaccinated against Hepatitis E?

Currently, the only vaccine available for Hepatitis E is in China and Pakistan.¹⁸ If you live outside of China or Pakistan, you may not be vaccinated against Hepatitis E. 

How do I keep my liver healthy?

• Eat well
• Limit alcohol intake
• Exercise
• Avoid taking toxins
• Get vaccinated against Hepatitis A and B

Summary

Hepatitis E is a viral infection that usually causes mild disease, however, in patients with pre-existing liver conditions, such as cirrhosis, it can cause much more severe symptoms. For example, it can lead to acute or chronic liver failure and death. However, if managed and diagnosed in time, liver failure can be avoided and patients can be saved. Patients with pre-existing liver conditions and a weakened immune system should avoid eating poorly cooked pork and should not travel to areas where Hepatitis E is endemic. If you have a liver condition and develop symptoms of Hepatitis E, see your doctor as soon as possible.