Hepatitis C – Diagnosis, Symptoms, and Treatment

What is Hepatitis C?

Hepatitis C is a virus that can cause chronic liver disease, cirrhosis, and liver cancer.  The virus is usually transmitted through exposure to infected blood or sexual contact.  This virus most commonly causes acute hepatitis (inflammation of the liver).  In a moderate number of patients, the immune system fails to clear the initial infection and chronic hepatitis C infection results.  Chronic hepatitis C has a significant risk of liver cirrhosis and failure if left untreated.  The risk of liver cancer is also increased.

The long-term consequences of liver cirrhosis from hepatitis C includes esophageal varices, gastrointestinal bleeding, ascites, confusion, lower extremity swelling, liver cancer, and death.  Patients with end-stage liver disease that meet certain criteria may be candidates for liver transplantation.

What Causes Hepatitis C?

Hepatitis C is a virus that is spread through exposure to blood or via sexual contact.  A number of individuals over the age of 50 have unrecognized hepatitis C infection due to the use of medical blood products before the virus was discovered and screened for.  Younger patients tend to acquire hepatitis C from unprotected sexual intercourse and sharing needles during IV drug use. Lastly, healthcare workers are at risk for hepatitis C transmission from  accidental needle stick injuries. 

Once the virus is acquired, it may lead to acute hepatitis (inflammation of the liver) characterized by low-grade fever, malaise, abdominal discomfort, jaundice, and nausea/vomiting.  In some individuals this acute infection resolves and does not lead to life-long infection.  However,50%-85% of patients never clear the infection and develop chronic hepatitis C.  This leads to chronic liver inflammation and injury. This inflammation can lead to fibrosis and scarring of the liver that is referred to as cirrhosis. 

The progression to liver cirrhosis is more common in the elderly, male, and patients who use alcohol.  In cirrhosis the normal liver tissue gets replaced by non-functional scar tissue.  When a significant amount of the liver is scar tissue signs of liver failure such as yellow-colored skin (jaundice), fluid accumulation in the abdomen (ascites), and lower extremity swelling (edema) develop.

How Common is Hepatitis C?

The U.S. Centers for Disease Control estimate that 2.4 million Americans are living with hepatitis C. Over half of these infections are suspected to be asymptomatic with those infected unaware that they have the disease. Chronic hepatitis C related cirrhosis is the most common cause of death from this condition. Chronic liver disease is one of the leading causes of death in the United States with approximately 50,000 deaths in a given year. 

Signs and Symptoms

Most individuals with chronic hepatitis C infection have no symptoms, others may only have mild fatigue as a symptom.  Those who go on to develop liver cirrhosis typically present with the following complications:

• Confusion – hepatic encephalopathy
• Easy bleeding & bruising – coagulopathy
• Jaundice – yellow discoloration of skin
• Swelling in the legs – lower extremity edema
• Ascites – accumulation of fluid within the abdomen 
• Spontaneous bacterial peritonitis (SBP) - Infection of the abdominal fluid
• Bad breath – fetor hepaticus
• Increased risk for infection
• Gynecomastia and loss of pubic hair
• Upper gastrointestinal bleeding – esophageal varices
• Liver cancer
• Death

Diagnosis

The vast majority of hepatitis C infections have no symptoms and will not be detected. In some cases these asymptomatic infections may be detected by abnormal liver enzymes on routine yearly labs. Individuals that are at risk of hepatitis C based on their age may also be routinely screened once in their lifetime. If a patient presents with liver failure they are often tested for hepatitis C.

Basic lab tests are always obtained in patients suspected of having hepatitis. These include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and coagulation studies (PT/INR, PTT).  Patients with chronic liver disease may have elevated AST, ALT, and alkaline phosphatase levels.  Albumin is usually low and PT/INR levels are generally high.  Patients commonly have elevated total and occasionally direct bilirubin levels.

Testing for hepatitis C involves checking for hepatitis C antibodies in your blood.  Positive antibody tests are usually confirmed with molecular RNA testing.  Genotype testing may also be obtained to help select the most effective treatments.

Your doctor will likely also test you for HIV, hepatitis B, and hepatitis A.  In addition, other causes of chronic liver disease (eg, hemochromatosis, autoimmune hepatitis) are generally tested for as well.

If you have signs and symptoms of cirrhosis or liver failure your physician may obtain imaging of the liver with an abdominal ultrasound or CT scan. Your doctor may order an MRI of the abdomen if more detail about the structure of the liver is required. In some cases, your doctor may recommend a liver biopsy, this is more common if the cause of your liver failure is unclear. Patients with severe cirrhosis often receive routine upper endoscopies to screen for esophageal varices (dilated esophageal veins) that can bleed without warning and lead to severe blood loss.

Hepatitis C Treatment and Medication

In the past decade the development of several extremely successful anti-viral agents allow certain chronic hepatitis C infections to be eliminated entirely. The most commonly used of these medications are: 

• Harvoni (Ledipasvir-sofosbuvir)
• Epclusa (Sofosbuvir-velpatasvir)
• Zepatier (Elbasvir-grazoprevir) with or without Virazole (ribavirin)

These anti-virals have been shown to have high safety, tolerability, and efficacy.  Ribavirin can cause birth defects and is contraindicated in women who are pregnant and in the male partners of women who are pregnant.

Another type of therapy for chronic hepatitis C infection includes PEG-interferon and Virazole (ribavirin). This regimen is less commonly used due to increased side effects and a longer duration of treatment. In some cases this therapy is preferred based on the genotype of the hepatitis C virus in a given patient. Antiviral therapies reduce viral levels and frequently eradicate the disease in the majority of patients.  Patients are closely monitored and hepatitis C RNA levels are periodically checked to evaluate treatment response.  Patients with hepatitis C should be immunized against hepatitis B and hepatitis A.

References:

1. Younossi Z, Henry L. Systematic review: patient-reported outcomes in chronic hepatitis C--the impact of liver disease and new treatment regimens. Aliment Pharmacol Ther 2015; 41:497. - https://www.ncbi.nlm.nih.gov/pubmed/25616122
2. Recommendations for Testing, Managing and Treating Hepatitis C. Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. http://www.hcvguidelines.org/ (Accessed on July 08, 2016). - https://www.hcvguidelines.org/