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HEPATITIS C INTRODUCTION — The term "hepatitis" is used to describe a
common form of liver injury. Hepatitis simply means "inflammation of the liver" (the
suffix "itis" means inflammation, and "hepa" means liver). Hepatitis can be caused
by a number of factors, including alcohol abuse, large doses of certain medications,
poisonous mushrooms, and viruses.
Hepatitis C is caused by a virus that is spread from one person to another in blood
and body fluids, such as by sharing IV drug needles or "works" or during pregnancy
and delivery. Chronic hepatitis C is the most common chronic liver disease and
accounts for 8,000 to 13,000 deaths each year. The majority of liver transplants
performed in the United States are done for people with chronic hepatitis C.
This topic review discusses the symptoms, causes, and long term management of
hepatitis C virus (HCV). Topic reviews that discuss hepatitis A and B are available
separately. (See "Patient information: Hepatitis A" and see "Patient information:
Hepatitis B").
HEPATITIS C SYMPTOMS — When a person is first exposed to the hepatitis C
virus and becomes infected, they are said to have "acute hepatitis C". Most people
have no symptoms of infection during this time.
In 70 to 80 percent of people, the infection becomes chronic. The word "chronic"
implies that the infection will be prolonged, or even lifelong, unless treatment is
given and results in a cure. Chronic infection with hepatitis C has the potential to
cause liver damage, ranging in severity from mild to severe. This is in contrast to
other types of viral hepatitis (such as hepatitis A), which causes symptoms after the
person is infected and then resolve as the virus is cleared from the body. (See
"Patient information: Hepatitis A").
Many people with chronic hepatitis C have no symptoms, even if there is significant
liver damage. Of those who do develop symptoms, the most common symptom is
fatigue; other less common symptoms include nausea, lack of appetite, muscle or
joint aches, weakness, and weight loss. The cause of these symptoms is not entirely
clear. Not having symptoms does not necessarily mean that the infection is under
control.
HOW DID I BECOME INFECTED WITH HEPATITIS C ? — The hepatitis C virus
is spread by contact with blood. Thus, patients with hepatitis should avoid activities
that could expose other people to their blood. Examples include sharing a
toothbrush, nail clippers, razors, and needles (show table 1).
Blood and blood products — Hepatitis C was commonly spread by contaminated
blood transfusions until the early 1990s, when a blood test was developed that could
accurately screen blood donors for hepatitis C infection. As a result, the current risk
of becoming infected with hepatitis C from a blood transfusion is quite small,
estimated at one in 1.9 million. (See "Patient information: Blood donation and
transfusion").
Sexual transmission — The virus can be spread sexually, although the risk is much
smaller than with other types of viruses. The risk of transmission between stable
monogamous sexual partners (ie, between sexual partners who have no other sexual
contacts) is estimated to be approximately one in a thousand per year. Use of a
condom is not routinely recommended due to the very low risk.
People who do not have a stable monogamous sexual partner should use condoms.
This is to protect the person with hepatitis C from new infections (such as HIV or
other sexually transmitted diseases) as well as to protect the partner from acquiring
hepatitis C.
The risk of transmitting the virus is higher in people who are infected with both
hepatitis C and HIV. Furthermore, care of patients who are coinfected with HIV and
hepatitis C often differs from those with hepatitis C alone.
Other transmission — There is no evidence that kissing, hugging, sneezing,
coughing, casual contact, sharing food, water, eating utensils or drinking glasses, or
having other contact without blood exposure can spread the hepatitis C virus.
However, sharing toothbrushes, razors, and other objects that might be
contaminated with blood is NOT recommended. This also applies to implements
(such as straws) used to inhale cocaine and needles and syringes used to inject
drugs. Daily use of marijuana has been associated with worsening liver disease and
is not recommended, particularly for people with hepatitis C.
Transmission during pregnancy — The risk of transmitting hepatitis C during
pregnancy may depend upon the level of virus in the blood stream. In general, the
risk is about 5 to 6 percent (about 1 in 20) but is increased in people who are also
infected with HIV, in whom the risk increases to 12 percent or 1 in 8. Women with
hepatitis C who are pregnant or contemplating pregnancy should speak to their
healthcare provider about these risks.
HEPATITIS C DIAGNOSIS
Blood tests — Hepatitis C is diagnosed with a blood test. In most cases, a screening
blood test (hepatitis C virus antibody) is done because a person has risk factors for
the infection, including the following [4]:
Recent exposure to blood infected with HCV (eg, an accidental needle stick)
Being HIV positive
Past or current sexual partner of a person with HCV
Previous or current use of IV drugs
Previous or current use of hemodialysis for kidney failure
Anyone who was given donated blood or organs before July 1992 or blood
clotting factors before 1987
Less commonly, a screening test is done because a person has symptoms of recent
infection, such as a lack of appetite, nausea, flu-like symptoms, or pain under the
ribs on the right side (where the liver is located).
If the screening test is positive for hepatitis C, further testing is performed to confirm
that the virus is present. Results of these tests are used to guide treatment:
Hepatitis C virus (HCV) RNA is a measure of the amount of virus circulating in
the blood. HCV RNA is detectable in the blood within days to eight weeks
following exposure.
Hepatitis C genotype testing determines the specific type of HCV; most people
in the United States have type I.
Liver biopsy — A liver biopsy is not required to diagnose hepatitis C. However, a
biopsy is often performed if hepatitis C treatment is being considered. Results of the
biopsy can help to determine the stage of the disease and the long-term prognosis.
Liver biopsy is done as a day surgery procedure, and involves taking a tiny sample of
the liver tissue and looking at it under a microscope. The procedure is described in
detail in a separate topic review. (See "Patient information: Liver biopsy").
HEPATITIS C COMPLICATIONS — The hepatitis C virus causes a variable
amount of damage to the liver, although the liver is able to repair itself to some
degree. This damage occurs over many years (show histology 1).
In some people, scar tissue (called fibrosis) accumulates in the liver, which can
eventually become extensive, leading to cirrhosis, in which the liver is severely
scarred (show histology 2). People with cirrhosis are at increased risk for developing
complications because the scarred liver is less able to function normally. (See
"Patient information: Cirrhosis").
One of the most feared complications of cirrhosis is the development of liver cancer
(called hepatocellular carcinoma), which occurs almost exclusively in people with
cirrhosis. About 2 percent of people with cirrhosis (1 in 50) develop hepatocellular
carcinoma each year. Therefore, the majority of people with cirrhosis due to hepatitis
C will not get hepatocellular carcinoma.
Risk factors for complications — Researchers have studied large groups of people
with hepatitis C to find out what happens to them over time. Only about 20 percent
(or one in five) will develop cirrhosis within 20 years of acquiring the infection. Most
others will have some degree of inflammation in the liver, but without a significant
amount of scarring.
Researchers have tried to identify factors that increase the risk of developing
cirrhosis after patients have become infected with hepatitis C. The most important
include:
Consuming alcohol — People with hepatitis C who drink alcohol are at much
greater risk for developing cirrhosis. The amount of alcohol that is safe to consume is
not well established for people with hepatitis C. Even small amounts (social drinking)
have been linked to an increased risk of cirrhosis in people with hepatitis C. Until
more is known, we recommend completely avoiding alcohol.
Amount of liver damage — Increasing amounts of inflammation make it more
likely that the liver will become scarred. There are many tools for determining how
much damage hepatitis C has caused, including blood tests, an ultrasound
examination of the liver, and liver biopsy. Liver biopsy is the "gold standard" test,
although it is not recommended in everyone (see "Liver biopsy" above).
HEPATITIS C TREATMENT OPTIONS — The goal of treating hepatitis C is to
prevent progression of liver disease. As mentioned above, about 20 percent of
people will develop cirrhosis 20 years after becoming infected. Therefore, people with
hepatitis C who are young have a greater chance of developing cirrhosis and
complications of cirrhosis during their lifetime. Unfortunately, it is not always
possible to accurately predict who will develop progressive disease.
Pegylated interferon and ribavirin — The most common treatment for hepatitis C
is a combination of two medications, pegylated interferon and ribavirin. The
recommended duration of treatment with this combination is 48 weeks for genotype
1, and usually 24 weeks for genotype 2 and 3.
During therapy, the level of the virus in the blood (called the viral load) will be
monitored, with the goal of completely eliminating the virus. Therapy may be
stopped early if the virus does not respond or if there are intolerable treatmentrelated side effects.
Side effects occur in almost 80 percent of patients who are given pegylated
interferon and ribavirin. The most common side effects include flu-like symptoms,
low red and white blood cell counts, and fatigue. Treatments to minimize these
symptoms are available.
Should I be treated? — The decision to undergo treatment for chronic hepatitis C
infection is based upon a number of factors, some of which are discussed below.
Treatment for hepatitis C is not recommended for everyone; the patient and
healthcare provider should carefully discuss the potential risks and benefits of
treatment before making a plan to proceed.
Treatment with interferon is not recommended for people whose depression is
not well controlled because this group is at risk for committing suicide during
treatment. Interferon may be used in people with well-controlled depression.
Ribavirin is not recommended in women who are pregnant, contemplating
pregnancy or unable to use a reliable form of birth control.
People with underlying autoimmune disorders (eg, lupus, rheumatoid
arthritis) may be at increased risk of treatment-related complications related
to interferon.
People with normal liver function tests (ALT) who acquired hepatitis C under
the age of 35 years, are women, do not drink alcohol, and have no or minimal
fibrosis on liver biopsy may develop hepatic fibrosis at a slow rate. In such
patients, it is reasonable to delay treatment until fibrosis progresses, liver
function testing becomes abnormal, or clinical trials prove that earlier
treatment is of benefit.
Cure — The chance of being cured depends in part upon the specific type of hepatitis
C virus (ie, the genotype). Overall, the chance is approximately 40 to 50 percent for
genotype 1 and 80 percent or more with genotypes 2 and 3.
To determine if the treatment has cured the infection, the person must wait six
months after therapy is completed since the virus can recur after therapy has been
discontinued. Recurrence happens in about 25 to 30 percent of cases. Cure is defined
as absence of the virus for more than six months after stopping therapy. Follow-up
studies of these patients show no trace of the virus in the blood or liver for over 10
years.
Treatment of non-responders or recurrences — There are several options for
people who do not respond or whose infection recurs after the first round of
treatment. The best option depends upon what medications and doses were used
initially, how well the person tolerated the previous treatment, the current liver
function, and other factors. Options may include observation, retreatment with a
different regimen, or enrollment in a clinical trial (see "Clinical trials" below). These
issues should be discussed with a physician who specializes in liver diseases (a
hepatologist) or infectious diseases.
LONG-TERM MANAGEMENT OF HEPATITIS C
Screening tests — People with hepatitis C who have cirrhosis should have regular
screening tests for hepatocellular carcinoma, which usually includes an ultrasound
examination of the liver plus a blood test (alpha fetoprotein level) every year or
every other year.
In addition, a procedure called an upper gastrointestinal endoscopy may be done to
evaluate for esophageal varices (enlarged veins in the esophagus). Varices develop
in roughly 50 percent of people with cirrhosis. Upper endoscopy uses a thin, flexible
fiberoptic instrument to inspect the esophagus (food pipe) and stomach. (See
"Patient information: Upper endoscopy").
Diet — No specific diet improves signs or symptoms of hepatitis C. The best advice
is to eat a normal, healthy, and balanced diet. It is reasonable to take a multivitamin
without iron. It is safe to drink coffee; in fact some studies suggest that coffee is
good for the liver. Drinking alcohol is strongly discouraged to protect the liver from
further damage.
Vaccines — Anyone who is infected with hepatitis C should be vaccinated against
hepatitis A and B, unless they are already known to be immune. Pneumococcal
vaccine should be given every five years while influenza vaccination should be given
yearly in addition to other routine vaccinations. Routine vaccinations included
diphtheria and tetanus booster immunizations every ten years. Read more about
adult immunizations here. (See "Patient information: Adult immunizations").
Exercise — Exercise is good for overall health and is encouraged, but it has no
effect on the virus.
Prescription and nonprescription drugs — Many drugs are broken down by the
liver. Thus, it is always best to check with a clinician or pharmacist before starting a
new prescription. Most drugs are safe for people with hepatitis C unless the liver is
scarred.
One important exception is acetaminophen (Tylenol); the maximum recommended
dose is no more than 2000 milligrams or 2 grams per 24 hours or 500 mg every 6
hours (four times per day).
Herbal medications — Many herbal products claim to "cure" or improve hepatitis
C; none of these claims has been proven true. In addition, some herbal medications
can seriously injure the liver.
Support — Patients with hepatitis C should not underestimate the value of sharing
their concerns with others who have the same diagnosis. The American Liver
Foundation has helpful advice and list of support groups (www.liverfoundation.org).
If you have recently discovered that you or someone you care about has hepatitis C,
there are many reasons to be optimistic:
Hepatitis C progresses slowly, and many people who harbor the virus will
never get sick.
You are not alone; about 2.7 million people in the United States have
hepatitis C. Treatment is available and researchers are constantly working to
develop new and better therapies.
CLINICAL TRIALS — Even though combination therapy with interferon plus
ribavirin cures about 50 percent of people with hepatitis C (up to 80 percent with
genotype 2 and 3), many are not cured. Thus, new treatments for hepatitis C are
actively being developed. A clinical trial is a carefully controlled way to study the
effectiveness of new treatments or new combinations of known therapies. Ask for
more information about clinical trials or read about clinical trials at
http://clinicaltrials.gov/.