Hepatitis C

Answer 1

Definition

Hepatitis C is a viral disease that leads to swelling (inflammation) of the liver.

Alternative Names

Non-A or non-B hepatitis

Causes, incidence, and risk factors

Hepatitis C infection is caused by the hepatitis C virus (HCV). People who may be at risk for hepatitis C are those who:

• Have been on long-term kidney dialysis
• Have regular contact with blood at work (for instance, as a health care worker)
• Have unprotected sexual contact with a person who has hepatitis C (this is less common, but the risk increases for those who have multiple sex partners, already have a sexually transmitted disease, or are infected with HIV)
• Inject street drugs or share a needle with someone who has hepatitis C
• Received a blood transfusion before July 1992
• Received a tattoo or acupuncture with contaminated instruments (the risk is very low with licensed, commercial tattoo facilities)
• Received blood, blood products, or solid organs from a donor who has hepatitis C
• Share personal items such as toothbrushes and razors with someone who has hepatitis C (less common)
• Were born to a hepatitis C-infected mother (this is less common than with hepatitis B)

Hepatitis C has an acute and chronic form. Most people who are infected with the virus develop chronic hepatitis C.

Other hepatitis virus infections include hepatitis A and hepatitis B. Each viral hepatitis infection is caused by a different virus.

Symptoms

Many people who are infected with hepatitis C do not have symptoms.

If the infection has been present for many years, the liver may be permanently scarred, a condition called cirrhosis. In many cases, there may be no symptoms of the disease until cirrhosis has developed.

The following symptoms could occur with hepatitis C infection:

• Abdominal pain(right upper abdomen)
• Ascites
• Bleeding varices (dilated veins in the esophagus)
• Dark urine
• Fatigue
• Generalized itching
• Jaundice
• Loss of appetite
• Low-grade fever
• Nausea
• Pale or clay-colored stools
• Vomiting

Signs and tests

The following tests are done to help diagnose hepatitis C:

• ELISA assay to detect hepatitis C antibody
• Hepatitis C genotype. Six genotypes exist. Most Americans have genotype 1 infection, which is the most difficult to treat.
• Hepatitis C RNA assays to determine virus levels (called viral load)

The following tests are done to identify and monitor liver damage from hepatitis C:

• Liver function tests
• Albumin level
• Prothrombin time

Liver biopsy can show how much damage has been done to the liver.

Treatment

There is no cure for hepatitis C, but medications in some cases can suppress the virus for a long period of time.

Some patients with hepatitis C benefit from treatment with medications. The most common medications are a combination of interferon alpha and ribavirin, an antiviral medication.

• Most patients receive weekly injections just under the skin with a form called pegylated interferon alpha.
• Ribavirin is a capsule taken twice daily. The major side effect is low red blood cells (anemia). Ribavirin also causes birth defects. Women should avoid getting pregnant during, and for 6 months after, treatment.
• Treatment is given for 24 - 48 weeks.

These medications have a number of side effects, including:

• Depression
• Fatigue
• Fever
• Flu-like symptoms
• Headache
• Irritability
• Loss of appetite
• Low white blood cell counts and platelets
• Nausea
• Thinning of hair
• Vomiting

See: Cirrhosisfor information about treating more severe liver damage caused by hepatitis C.

Patients who develop cirrhosis or liver cancer may be candidates for a liver transplant.

People with hepatitis C should also:

• Be careful not to take vitamins, nutritional supplements, or new over-the-counter medications without first discussing it with their health care provider.
• Avoid any substances that are toxic to the liver (hepatotoxic), including alcohol. Even moderate amounts of alcohol speed up the progression of hepatitis C, and alcohol reduces the effectiveness of treatment.
• Get vaccinated against hepatitis A and B.

Support Groups

You can often ease the stress of illness by joining a support group of people who share common experiences and problems. See liver disease - resources.

Expectations (prognosis)

Most people with hepatitis C infection have the chronic form.

In people who are treated with medications, a "sustained response" means that the patient is free from the hepatitis C virus 6 months after stopping treatment. This does not mean that the patient is cured, but that the levels of active hepatitis C virus in the body are very low and are probably not causing more, or as much damage.

Patients with genotypes 2 or 3 are three times more likely to respond to treatment than patients with genotype 1.

Hepatitis C is one of the most common causes of chronic liver disease in the United States today. People with this condition may have:

• Cirrhosis of the liver
• Liver cancer(may develop in a small number of people with liver cirrhosis)

Hepatitis C usually comes back after a liver transplant, which can lead to cirrhosis of the new liver.

Calling your health care provider

Call your provider if:

• You develop symptoms of hepatitis
• You believe you have been exposed to the hepatitis C virus

Prevention

Avoid contact with blood or blood products whenever possible. Health care workers should follow precautions when handling blood and bodily fluids.

Do not inject illicit drugs, and especially do not share needles with anyone. Be careful when getting tattoos and body piercings.

Sexual transmission is low among stable, monogamous couples. A partner should be screened for hepatitis C. If the partner is negative, the current recommendations are to make no changes in sexual practices.

People who have sex outside of a monogamous relationship should practice safer sex behaviors to avoid hepatitis C as well as sexually transmitted diseases, including HIV and hepatitis B.

Currently there is no vaccine for hepatitis C.

References

Ghany MG, Strader DB, Thomas DL, Seeff LB. American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335-1374.

Jou JH, Muir AJ. In the clinic. Hepatitis C. Ann Intern Med. 2008;148:ITC6-1-ITC6-16.

Answer 2

Definition

Hepatitis C is a viral disease that leads to swelling (inflammation) of the liver.

Alternative Names

Non-A hepatitis; Non-B hepatitis

Causes, incidence, and risk factors

Hepatitis C infection is caused by the hepatitis C virus (HCV). People who may be at risk for hepatitis C are those who:

• Have been on long-term kidney dialysis
• Have regular contact with blood at work (for instance, as a health care worker)
• Have unprotected sexual contact with a person who has hepatitis C (this risk is much less common than hepatitis B, but the risk is higher for those who have many sex partners, already have a sexually transmitted disease, or are infected with HIV)
• Inject street drugs or share a needle with someone who has hepatitis C
• Received a blood transfusion before July 1992
• Received a tattoo or acupuncture with contaminated instruments (the risk is very low with licensed, commercial tattoo facilities)
• Received blood, blood products, or solid organs from a donor who has hepatitis C
• Share personal items such as toothbrushes and razors with someone who has hepatitis C (less common)
• Were born to a hepatitis C-infected mother (this occurs in about 1 out of 20 babies born to mothers with HCV, which is much less common than with hepatitis B)

Symptoms

Most people who were recently infected with hepatitis C do not have symptoms. About 1 in 10 have yellowing of the skin (jaundice) that gets better.

Of people who get infected with hepatitis C, most develop a long-term (chronic) infection. Usually there are no symptoms. If the infection has been present for many years, the liver may be permanently scarred. This is called cirrhosis. In many cases, there may be no symptoms of the disease until cirrhosis has developed.

The following symptoms could occur with hepatitis C infection:

• Abdominal pain(right upper abdomen)
• Abdominal swelling (due to fluid called ascites)
• Clay-colored or pale stools
• Dark urine
• Fatigue
• Fever
• Itching
• Jaundice
• Loss of appetite
• Nausea
• Vomiting

Signs and tests

Blood tests are done to check for hepatitis C:

• EIA assay to detect hepatitis C antibody
• Hepatitis C RNA assays to measure virus levels (viral load)

Genetic testing is done to check for the hepatitis C genotype. Six genotypes exist. Test results can help your doctor better choose your treatment.

• Most Americans have genotype 1 infection, which is the hardest to treat.
• Genotypes 2 and 3 are also common, and respond better to treatment.

The following tests are done to identify and monitor liver damage from hepatitis C:

• Albumin level
• Liver function tests
• Prothrombin time

Liver biopsy can show how much damage has been done to the liver.

Treatment

The goals of HCV treatment are to remove the virus from the blood and reduce the risk of cirrhosis and liver cancer that can result from long-term HCV infection.

Many patients with hepatitis C benefit from treatment with medications. The most common medications are a combination of pegylated interferon alfa and ribavirin, an antiviral medication.

• Most patients receive weekly injections of pegylated interferon alfa.
• Ribavirin is a capsule taken twice daily. Ribavirin can cause birth defects. Women should avoid getting pregnant during, and for 6 months after treatment.
• Treatment is given for 24 - 48 weeks.
• Telaprevir and boceprevir are newer drugs which may be used for patients with genotype 1.

These medications have a number of side effects, and patients must be watched closely. See: Cirrhosis for information about treating more severe liver damage caused by hepatitis C.

Patients who develop cirrhosis or liver cancer may be candidates for a liver transplant.

People with hepatitis C should also:

• Be careful not to take vitamins, nutritional supplements, or new over-the-counter medications without first discussing it with their health care provider.
• Avoid any substances that are toxic to the liver, including alcohol. Even moderate amounts of alcohol speed up the progression of hepatitis C, and alcohol reduces the effectiveness of treatment.
• Get vaccinated against hepatitis A and B.

Support Groups

You can often ease the stress of illness by joining a support group of people who share common experiences and problems. See liver disease - resources.

Expectations (prognosis)

Most people with hepatitis C infection have the chronic form.

Patients with genotypes 2 or 3 are more likely to respond to treatment than patients with genotype 1. Newer drugs may improve the response of those with genotype 1.

Many doctors use the term "sustained virologic response" rather than "cure" when the virus is removed from the blood, because it is not known whether this will last a person's entire life. Even if treatment does not remove the virus, it can reduce the chance of severe liver disease.

Hepatitis C is one of the most common causes of chronic liver disease in the United States today. People with this condition may have:

• Cirrhosis of the liver
• Liver cancer(also called hepatocellular cancer) -- may develop in a small number of people with liver cirrhosis

Hepatitis C usually comes back after a liver transplant, which can lead to cirrhosis of the new liver.

Calling your health care provider

Call your health care provider if:

• You develop symptoms of hepatitis
• You believe you have been exposed to the hepatitis C virus

Prevention

Avoid contact with blood or blood products whenever possible. Health care workers should follow precautions when handling blood and bodily fluids.

Do not inject illicit drugs, and especially do not share needles with anyone. Be careful when getting tattoos and body piercings.

Sexual transmission is very low among stable, monogamous couples. A partner should be screened for hepatitis C. If the partner is negative, the current recommendations are to make no changes in sexual practices.

People who have sex outside of a monogamous relationship should practice safer sex behaviors to avoid hepatitis C as well as sexually transmitted diseases, including HIV and hepatitis B.

Currently there is no vaccine for hepatitis C.

References

Ghany MG, Strader DB, Thomas DL, Seeff LB. American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335-1374.

Jou JH, Muir AJ. In the clinic. Hepatitis C. Ann Intern Med. 2008;148:ITC6-1-ITC6-16.

O'Leary JG, Davis GL. Hepatitis C. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 79.

Rosen HR. Clinical practice. Chronic hepatitis C infection.N Engl J Med. 2011 Jun 23;364(25):2429-38.

Reviewed By

Review Date: 10/16/2011

David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. and George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California.