Hepatitis C

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 blood or sexual contact.  Some patients acquire the virus and develop acute hepatitis (inflammation of the liver).  In a subset of patients, the initial infection fails to clear and individuals advance to chronic hepatitis C infection.  Chronic hepatitis C significantly increases the risk of progressive liver fibrosis (cirrhosis) and failure if left untreated.  The risk of liver cancer is also increased.

The long-term consequences of chronic hepatitis C and cirrhosis include 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.  Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.  By the end of this article, you will have the answers to these essential questions

What causes Hepatitis C?

Hepatitis C is a virus that is spread through the blood or via sexual contact.  Individuals who share needles for intravenous drug abuse and those who have sex with multiple partners are at increased risk.  The risk of infection is also increased in men who have sex with men.  Lastly, healthcare workers are at increased risk due to the possibility of needle-stick injury.

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 a subset of individuals, this resolves and they never develop long-term sequela.  However, about 50%-85% of patients never clear the infection and go on to develop chronic hepatitis C.  This leads to chronic liver inflammation and injury.  The liver may eventually begin the process of fibrosis (scarring) – this occurs in about 5%-30% of individuals over 20-30 years.

The progression to liver cirrhosis is more commonly seen in elderly, male, and patients who use alcohol.  Normal liver tissue ultimately gets replaced by scar tissue and is non-functional.  In late stages, patients may develop signs of liver failure such as yellow-colored skin (jaundice), fluid accumulation in the abdomen (ascites), and lower extremity swelling (edema).

How common is Hepatitis C?

Hepatitis C virus infection is the most common cause of chronic liver disease in the United States.  It is also the most common indication for liver transplantation.  The condition usually requires referral to an infectious disease and hepatology specialist.

In 2008, liver disease caused approximately 66,000 deaths – about 18,000 of these deaths were related to hepatobiliary malignancy.  Chronic liver disease was the 8th leading cause of death in 2010 - responsible for about 50,000 deaths.  Approximately 20,000 of these deaths were caused by hepatic malignancy (liver cancer).

What are the symptoms and signs of Hepatitis C?

Most individuals with chronic hepatitis C infection have no symptoms besides fatigue.  Those who go on to develop liver cirrhosis may have the following complications:

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

How is Hepatitis C diagnosed?

The diagnosis of hepatitis C is suggested based on symptoms and physical examination, but typically confirmed with laboratory studies.  Your doctor will typically measure hepatitis C antibodies in your blood.  Positive antibody tests are usually confirmed with molecular RNA testing.  Genotype testing may also be obtained to guide therapy.

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 worked up.

Your doctor will normally order basic blood tests including 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.

Your doctor will also obtain imaging of the liver with abdominal ultrasound or CT scan.  Occasionally, your doctor with order an MRI of the abdomen.  Sometimes, your doctor may recommend a liver biopsy.  Patients with advanced liver disease may require routine upper endoscopies to screen for esophageal varices.

How is Hepatitis C treated?

Patients with chronic hepatitis C are typically treated with antiviral therapy.  Individuals with genotype 1 hepatitis C infection can benefit from the following drug regimens:

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

These 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 may include PEG-interferon and Virazole (ribavirin).  Antiviral therapies reduce viral levels and frequently eradicate the disease.  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.

Hepatitis C Patient Summary:

  • Hepatitis C is a virus that can cause chronic liver disease, cirrhosis, and liver cancer.
  • It is spread through the blood or via sexual contact. Individuals who share needles for intravenous drug abuse and those who have sex with multiple partners are at increased risk. 
  • 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 a subset of individuals, this resolves and they never develop long-term sequela. However, about 50%-85% of patients do not clear the infection and go on to develop chronic hepatitis C - this leads to chronic liver inflammation and injury.
  • The liver may eventually begin the process of fibrosis (scarring).
  • The diagnosis of hepatitis C is typically confirmed by measuring antibodies in your blood. Positive antibody tests are usually confirmed with molecular RNA testing.  Genotype testing may also be obtained to guide therapy.
  • Patient with chronic hepatitis C are typically treated with antiviral therapy. Individuals with genotype 1 hepatitis C infection can benefit from the following drug regimens: Harvoni (Ledipasvir-sofosbuvir), Epclusa (Sofosbuvir-velpatasvir), and Zepatier (Elbasvir-grazoprevir) with or without Virazole (ribavirin).
  • Another type of therapy may include PEG-interferon and Virazole (ribavirin).
  • Ribavirin can cause birth defects and is contraindicated in women who are pregnant and in the male partners of women who are pregnant.
  • 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.
  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).

Popular Hepatitis C Medications

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.