An Integrative Medicine Approach to Autoimmune Hepatitis

When the immune system affects the liver tissue, an inflammatory condition known as autoimmune hepatitis may occur; this immune response can lead to chronic inflammation and impact liver tissue and function over time. While you may not notice symptoms early in the disease course, autoimmune hepatitis might eventually lead to symptoms like abdominal pain, an enlarged liver, fatigue, yellowing of the skin and eyes, itchy skin, nausea, and potential scarring of the liver or cirrhosis. 

While the exact prevalence of this condition is uncommon, studies suggest between .010% and .025% of the European population is affected. Autoimmune hepatitis is more common among Alaska Natives, impacting around .043% of that population and in women by a ratio of 4:1.

Corticosteroids are often given to help manage the inflammation that occurs in autoimmune hepatitis, but long-term use can have side effects. Fortunately, an integrative medicine approach to autoimmune hepatitis may help support the body's balance by addressing imbalances in the gut and immune system.

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What is Autoimmune Hepatitis?

The liver is an organ found in the upper right quadrant of your abdomen that plays vital roles in detoxifying harmful substances, metabolizing nutrients, regulating blood clotting, and producing bile, proteins, and cholesterol. Autoimmune hepatitis is a chronic inflammatory condition of the liver that occurs when the immune system mistakenly affects liver tissue. 

There are two main types of autoimmune hepatitis that involve different types of autoantibodies that affect different types of cells in your liver.

In type 1 autoimmune hepatitis, anti-smooth muscle antibodies (ASMA) affect the smooth muscle cells in your liver. This “classic” type is the most common subtype, impacting around 80% of people with this autoimmune hepatitis, and can occur at any age, although it is most common in early to middle adulthood. This type of autoimmune hepatitis shares similar symptoms with systemic lupus erythematosus (SLE) and is, therefore, sometimes referred to as “lupoid hepatitis.” 

In type 2 autoimmune hepatitis, two types of autoantibodies may be involved.  Anti-liver-kidney microsome type 1 antibodies (anti-LKM-1), which target a protein in your liver cells called cytochrome P450-2D6 (CYP2D6), and anti-liver cytosol type 1 antibodies (anti-LC1), which are specific to type 2 autoimmune hepatitis. This subtype is less common and often causes more severe damage with a more quickly progressive course than type 1. It often begins during childhood.

Some people with autoimmune hepatitis may also develop autoimmune-induced inflammation in the bile ducts. This can result in primary biliary cholangitis (PBC), which causes inflammation of the portal vein and gradual changes in the liver’s internal bile ducts, or primary sclerosing cholangitis (PSC) that involves inflammation, fibrosis, and narrowing of the liver’s interior and exterior bile ducts. These autoimmune conditions are considered variants of autoimmune hepatitis.

People with autoimmune hepatitis may not have many noticeable symptoms early on in the disease. Some early symptoms include abdominal pain, an enlarged liver, fatigue, joint pain, and skin rashes, including acne. As the condition progresses, and liver function changes, bile can start to build up in the blood, causing yellowing of the skin and eyes (jaundice), dark urine, pale stools, itchy skin (pruritus), and nausea. Over time, liver dysfunction can contribute to enlarged veins in the esophagus (varices), spider angiomas, easy bruising, fluid collecting in the abdomen (ascites), edema, and confusion (hepatic encephalopathy). If the inflammation persists over time, scarring of the liver or cirrhosis can occur, resulting in liver failure.

What Are The Possible Causes of Autoimmune Hepatitis?

Like in other autoimmune conditions, in autoimmune hepatitis, the immune system mounts an errant response against the body’s own tissues instead of its usual targets of pathogens. When the body produces antibodies targeted against liver tissue, this results in inflammation and changes to the liver over time. 

Many factors contribute to the development of autoimmune diseases. These conditions involve the interplay of environmental factors, including diet, toxin exposure, and stress, in genetically susceptible individuals, with the integrity of the gut and the balance of microbes in the microbiome playing a key role. 

Common triggers associated with autoimmune hepatitis include certain drugs such as nitrofurantoin (for urinary tract infections), minocycline (for acne), atorvastatin (for high cholesterol), and isoniazid (an antibiotic), and viral infections, including viral hepatitis (A, B, C, D or E), mononucleosis (Epstein-Barr virus), measles, and herpes. Those with other autoimmune diseases are also at a higher risk of disease.

Your digestive tract is inhabited by trillions of microbes that make up the gut microbiome. In addition, 70% of immune cells are present in the digestive tract. These variables interact in an extensive communication network that also coordinates with your brain bidirectionally. In addition, the gut communicates with and impacts the liver via the liver-gut axis. 

Since the liver receives almost 75% of its blood supply from the intestine via the portal vein, it is readily exposed to products that enter the gut, such as food elements, bacteria, and their metabolites. Therefore, dietary factors, microbe balance, microbial metabolites, and bile acids all help to regulate immunity and function of the gut and liver. 

To keep the environment and immune system in the liver balanced, a healthy intestinal barrier is required. If this barrier is disturbed (leaky gut), bacteria, metabolites, and other substances can burden the liver and trigger the immune system to create excess inflammation and potential autoimmunity. 

Studies show that there is increased intestinal permeability, imbalances in the microbiome, and crossing of bacteria across the intestinal barrier into the bloodstream in autoimmune hepatitis, which is correlated with the severity of the condition.

Functional Medicine Labs to Test for Root Cause of Autoimmune Hepatitis

Functional medicine laboratory testing can help uncover factors contributing to the autoimmunity and chronic inflammation that underlies autoimmune hepatitis. 

Antibody Testing

Different types of autoantibodies can be seen in patients with autoimmune hepatitis. Patients with type 1 autoimmune hepatitis have anti-smooth muscle antibodies (ASMA), while those with type 2 autoimmune hepatitis can have two types of autoantibodies, anti-liver-kidney microsome type 1 antibodies (anti-LKM-1) and anti-liver cytosol type 1 antibodies (anti-LC1), which are specific to type 2 autoimmune hepatitis. Other autoantibodies that may also be seen include anti-mitochondrial antibodies and antinuclear antibodies. 

The Autoimmune Liver Disease Panel measures antibodies that are often seen early in the course of autoimmune hepatitis, as well as mitochondrial dysfunction, primary biliary cirrhosis, and certain skin conditions. This test detects antibodies against actin, which are found in 52-85% of patients with autoimmune hepatitis, as well as antibodies against mitochondrial M2 antigen, which is part of the pyruvate dehydrogenase (PDH) complex of polypeptides commonly seen in patients with primary biliary cirrhosis.

Liver Function Testing

The function of the liver can be evaluated with blood testing such as Access Medical Labs' Hepatic Function Panel, which identifies liver function markers. Patients with autoimmune hepatitis have elevated levels of serum transaminases in addition to autoantibodies and hypergammaglobulinemia.

Comprehensive Stool Test

To evaluate many of the underlying contributors of autoimmunity, including microbial imbalances, factors with inflammation, digestion, and immune function, the GI-MAP with Zonulin from Diagnostic Solutions can be used. This test includes zonulin, a marker associated with a leaky gut.

Additional Labs To Test 

In addition to blood testing to look at liver function and antibodies, a liver biopsy may be done to confirm the diagnosis of autoimmune hepatitis and assess the degree of liver changes. This involves taking a small tissue sample of the liver to examine under a microscope.

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Conventional Treatment for Autoimmune Hepatitis

The conventional treatment approach to autoimmune hepatitis involves high doses of steroids, such as prednisone or budesonide, to help manage inflammation and suppress the autoimmune response on the liver. 

Since steroids can have significant side effects when used long term, including weight gain, mood disorders, glaucoma, weakening of the bones, diabetes, and high blood pressure, an immunosuppressant like azathioprine may be added for long-term maintenance therapy. 

If autoimmune hepatitis does not respond to conventional medication and advanced liver disease develops, a liver transplant may be needed.

Functional Medicine Treatment for Autoimmune Hepatitis

Functional medicine can help to optimize digestive health and support liver functioning to balance liver-gut communication and manage the inflammation and autoimmunity that occur in autoimmune hepatitis.

Nutritional Recommendations

An anti-inflammatory diet can help balance the inflammation, support gut health, and manage autoimmunity in people with autoimmune hepatitis. For example, the Mediterranean diet with a focus on whole fresh fruits and vegetables, polyphenols, fatty fish, and olive oil and limiting ultra-processed foods, processed meats, sweets, sugary beverages, inflammatory fats, refined grains, and alcohol has been shown to support liver health. 

Focusing on plenty of nourishing, anti-inflammatory foods like a variety of colorful fruits, vegetables, beans, nuts, seeds, whole grains, herbs and spices, tea, fish, and healthy fats nourishes the microbiome and balances inflammation. 

In some cases, a more restrictive elimination diet, like the autoimmune protocol diet, may help to support the body's balance. This modification to the Paleo diet is used to support gut health and manage inflammation in those with autoimmune conditions or symptoms. Like the Mediterranean diet, it focuses on incorporating plenty of nutrient-dense foods while eliminating inflammatory processed foods.

Supplements & Herbs

In addition to balancing the body and addressing the factors of autoimmunity with a nutrient-dense anti-inflammatory diet, targeted individualized supplements can support gut health and inflammation in patients with autoimmune hepatitis.

Probiotics

Probiotics are key supplements to help maintain a healthy gut microbiome and intestinal barrier, providing an anti-inflammatory benefit in the gut and beyond. In addition, probiotics help to decrease the crossing of a key bacterial toxin, lipopolysaccharides (LPS), from the gut to the liver to reduce the immune system burden and lower inflammation.

A small clinical trial found that six weeks of oral probiotics increased blood flow through the liver and portal vein, improving symptoms of cirrhosis.

Ginger

Ginger is a natural anti-inflammatory herb that can modulate the immune system response and limit inflammatory pathways. Studies suggest that it has anti-inflammatory effects similar to non-steroidal anti-inflammatory drugs and can support gut health by inhibiting pro-inflammatory responses in the intestines.

Glutamine

L-glutamine is an amino acid that serves as a primary fuel source for the cells that line the small intestine. Studies show that L-glutamine can help support intestinal health and improve leaky gut. 

Vitamin D

Vitamin D deficiency is associated with permeability of the intestinal barrier and autoimmunity. Vitamin D supplementation can support immune function and decrease markers of intestinal permeability. 

Omega-3 Fatty Acids

Omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) can support the balance of microbes in the gut, significantly lower inflammation in the body, and act as prebiotics to feed healthy gut bacteria. These essential fatty acids must be consumed in the diet or via supplementation. Foods that are rich in omega-3s include fatty fish such as salmon, mackerel, herring, trout, sardines, walnuts, and algae.

Complementary and Integrative Medicine

Complementary and lifestyle approaches help to establish a foundation for balanced health and improved quality of life. 

Stress Management and Rest

Leaky gut can worsen due to chronic stress, lack of sleep, and over-exercising. On the other hand, regular moderate exercise can help to decrease excess inflammation and improve intestinal permeability.

Incorporate meaningful stress management practices like yoga, meditation, prayer, time in nature, and breathwork to manage stress in daily life. Be sure to get adequate daily rest with at least a full 7-9 hours of sleep a night.

Traditional Chinese Medicine

In traditional Chinese medicine, autoimmune conditions like autoimmune hepatitis involve Yin deficiency. Such a Yin deficiency can occur from genetic inheritance, dietary imbalances, chronic emotional distress, or after an illness treated by a medication that affects Liver Yin. A case study used this concept to support the body's balance with Chinese Medicine treatments, including auricular acupuncture and Chinese dietary therapy with the avoidance of dairy products, fried foods, eggs, chocolate, honey, coconut, alcohol, soda, and mate tea, resulting in improvements in autoimmune hepatitis. 

Several studies suggest that several natural products used in Traditional Chinese Medicine may help manage autoimmune hepatitis by balancing the immune response and supporting liver tissue, including phenols, glycosides, flavonoids, polysaccharides, and alkaloids. 

Ayurvedic medicine

Ayurvedic Medicine originated in India and utilizes lifestyle interventions and natural therapies to bring balance to the body, mind, spirit, and the environment. A case study showed significant improvements in liver function in a patient with autoimmune hepatitis when utilizing an Ayurvedic approach of nutritional supplements and Ayurvedic treatments to help support glutathione in an effort to manage oxidative stress-related liver changes involved in this condition.

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Summary

Autoimmune hepatitis is a chronic and progressive condition where the immune system affects the liver, resulting in chronic inflammation and changes in the important processes of the liver. This condition can arise at any age and is most common in women and those with other autoimmune conditions. This autoimmune process can be influenced by environmental factors, viral infections, certain medications, and imbalances in the gut, including dysbiosis and increased intestinal permeability. 

Patients with autoimmune hepatitis may be mostly without symptoms or have abdominal pain, yellowing of the skin, itching, nausea, and potential scarring and changes in liver function if not managed. 

Conventional treatment usually focuses on managing the immune response and inflammation with prednisone and azathioprine. A functional medicine approach to autoimmune hepatitis targets the inflammation and gut imbalances that underlie autoimmunity using an anti-inflammatory nutrient-dense diet to help support gut health and balance inflammation, targeted supplements like probiotics and ginger, and lifestyle approaches such as stress management and moderate exercise to support the body's balance.