Hepatitis C

Hepatitis C is a viral infection that causes liver inflammation, sometimes leading to serious liver damage. The hepatitis C virus (HCV) spreads through contaminated blood.

Until recently, hepatitis C treatment required weekly injections and oral medications that many HCV-infected people couldn't take because of other health problems or unacceptable side effects.

That's changing. Today, chronic HCV is usually curable with oral medications taken every day for two to six months.

Still, about half of people with HCV don't know they're infected, mainly because they have no symptoms, which can take decades to appear. For that reason, the U.S. Preventive Services Task Force recommends that all adults ages 18 to 79 years be screened for hepatitis C, even those without symptoms or known liver disease. The largest group at risk includes everyone born between 1945 and 1965 — a population five times more likely to be infected than those born in other years.

Symptoms

Long-term infection with the hepatitis C virus is known as chronic hepatitis C. Chronic hepatitis C is usually a "silent" infection for many years, until the virus damages the liver enough to cause the signs and symptoms of liver disease.

Signs and symptoms include:

• Bleeding easily
• Bruising easily
• Fatigue
• Poor appetite
• Yellow discoloration of the skin and eyes (jaundice)
• Dark-colored urine
• Itchy skin
• Fluid buildup in your abdomen (ascites)
• Swelling in your legs
• Weight loss
• Confusion, drowsiness and slurred speech (hepatic encephalopathy)
• Spiderlike blood vessels on your skin (spider angiomas)

Every chronic hepatitis C infection starts with an acute phase. Acute hepatitis C usually goes undiagnosed because it rarely causes symptoms. When signs and symptoms are present, they may include jaundice, along with fatigue, nausea, fever and muscle aches. Acute symptoms appear one to three months after exposure to the virus and last two weeks to three months.

Acute hepatitis C infection doesn't always become chronic. Some people clear HCV from their bodies after the acute phase, an outcome known as spontaneous viral clearance. In studies of people diagnosed with acute HCV, rates of spontaneous viral clearance have varied from 15% to 25%. Acute hepatitis C also responds well to antiviral therapy.

Causes

Hepatitis C infection is caused by the hepatitis C virus (HCV). The infection spreads when blood contaminated with the virus enters the bloodstream of an uninfected person.

Globally, HCV exists in several distinct forms, known as genotypes. Seven distinct HCV genotypes and more than 67 subtypes have been identified. The most common HCV genotype in the United States is type 1.

Although chronic hepatitis C follows a similar course regardless of the genotype of the infecting virus, treatment recommendations vary depending on viral genotype.

Risk factors

Your risk of hepatitis C infection is increased if you:

• Are a health care worker who has been exposed to infected blood, which may happen if an infected needle pierces your skin
• Have ever injected or inhaled illicit drugs
• Have HIV
• Received a piercing or tattoo in an unclean environment using unsterile equipment
• Received a blood transfusion or organ transplant before 1992
• Received clotting factor concentrates before 1987
• Received hemodialysis treatments for a long period of time
• Were born to a woman with a hepatitis C infection
• Were ever in prison
• Were born between 1945 and 1965, the age group with the highest incidence of hepatitis C infection

Complications

Hepatitis C infection that continues over many years can cause significant complications, such as:

• Scarring of the liver (cirrhosis). After decades of hepatitis C infection, cirrhosis may occur. Scarring in your liver makes it difficult for your liver to function.
• Liver cancer. A small number of people with hepatitis C infection may develop liver cancer.
• Liver failure. Advanced cirrhosis may cause your liver to stop functioning.

Prevention

Protect yourself from hepatitis C infection by taking the following precautions:

• Stop using illicit drugs, particularly if you inject them. If you use illicit drugs, seek help.
• Be cautious about body piercing and tattooing. If you choose to undergo piercing or tattooing, look for a reputable shop. Ask questions beforehand about how the equipment is cleaned. Make sure the employees use sterile needles. If employees won't answer your questions, look for another shop.
• Practice safer sex. Don't engage in unprotected sex with multiple partners or with any partner whose health status is uncertain. Sexual transmission between monogamous couples may occur, but the risk is low.

Diagnosis

Screening for hepatitis C

The U.S. Preventive Services Task Force recommends that all adults ages 18 to 79 years be screened for hepatitis C, even those without symptoms or known liver disease. Screening for HCV is especially important if you're at high risk of exposure, including:

• Anyone who has ever injected or inhaled illicit drugs
• Anyone who has abnormal liver function test results with no identified cause
• Babies born to mothers with hepatitis C
• Health care and emergency workers who have been exposed to blood or accidental needle sticks
• People with hemophilia who were treated with clotting factors before 1987
• People who have undergone long-term hemodialysis treatments
• People who received blood transfusions or organ transplants before 1992
• Sexual partners of anyone diagnosed with hepatitis C infection
• People with HIV infection
• Anyone born from 1945 to 1965
• Anyone who has been in prison

Other blood tests

If an initial blood test shows that you have hepatitis C, additional blood tests will:

• Measure the quantity of the hepatitis C virus in your blood (viral load)
• Identify the genotype of the virus

Tests for liver damage

Doctors typically use one or more of the following tests to assess liver damage in chronic hepatitis C.

• Magnetic resonance elastography (MRE). A noninvasive alternative to a liver biopsy (see below), MRE combines magnetic resonance imaging technology with patterns formed by sound waves bouncing off the liver to create a visual map showing gradients of stiffness throughout the liver. Stiff liver tissue indicates the presence of scarring of the liver (fibrosis) as a result of chronic hepatitis C.
• Transient elastography. Another noninvasive test, transient elastography is a type of ultrasound that transmits vibrations into the liver and measures the speed of their dispersal through liver tissue to estimate its stiffness.
• Liver biopsy. Typically done using ultrasound guidance, this test involves inserting a thin needle through the abdominal wall to remove a small sample of liver tissue for laboratory testing.
• Blood tests. A series of blood tests can indicate the extent of fibrosis in your liver.

Treatment

Antiviral medications

Hepatitis C infection is treated with antiviral medications intended to clear the virus from your body. The goal of treatment is to have no hepatitis C virus detected in your body at least 12 weeks after you complete treatment.

Researchers have recently made significant advances in treatment for hepatitis C using new, "direct-acting" antiviral medications, sometimes in combination with existing ones. As a result, people experience better outcomes, fewer side effects and shorter treatment times — some as short as eight weeks. The choice of medications and length of treatment depend on the hepatitis C genotype, presence of existing liver damage, other medical conditions and prior treatments.

Due to the pace of research, recommendations for medications and treatment regimens are changing rapidly. It is therefore best to discuss your treatment options with a specialist.

Throughout treatment your care team will monitor your response to medications.

Liver transplantation

If you have developed serious complications from chronic hepatitis C infection, liver transplantation may be an option. During liver transplantation, the surgeon removes your damaged liver and replaces it with a healthy liver. Most transplanted livers come from deceased donors, though a small number come from living donors who donate a portion of their livers.

In most cases, a liver transplant alone doesn't cure hepatitis C. The infection is likely to return, requiring treatment with antiviral medication to prevent damage to the transplanted liver. Several studies have demonstrated that new, direct-acting antiviral medication regimens are effective at curing post-transplant hepatitis C. At the same time, treatment with direct-acting antivirals can be achieved in appropriately selected patients before liver transplantation.

Vaccinations

Although there is no vaccine for hepatitis C, your doctor will likely recommend that you receive vaccines against the hepatitis A and B viruses. These are separate viruses that also can cause liver damage and complicate the course of chronic hepatitis C.

Lifestyle and home remedies

If you receive a diagnosis of hepatitis C, your doctor will likely recommend certain lifestyle changes. These measures will help keep you healthy longer and protect the health of others as well:

• Stop drinking alcohol. Alcohol speeds the progression of liver disease.
• Avoid medications that may cause liver damage. Review your medications with your doctor, including over-the-counter medications you take as well as herbal preparations and dietary supplements. Your doctor may recommend avoiding certain medications.
• Help prevent others from coming in contact with your blood. Cover any wounds you have and don't share razors or toothbrushes. Don't donate blood, body organs or semen, and advise health care workers that you have the virus. Also tell your partner about your infection before you have sex, and always use condoms during intercourse.

Preparing for an appointment

If you think you may have a risk of hepatitis C, see your family doctor. Once you've been diagnosed with a hepatitis C infection, your doctor may refer you to a specialist in liver diseases (hepatologist) or infectious diseases.

What you can do

Because appointments can be brief and because there's often a lot to discuss, it's a good idea to be well prepared. To prepare, try to:

• Review your medical record. This is particularly important if you are seeing a liver specialist (hepatologist) for the first time after finding out you have hepatitis C. If you had a liver biopsy to check for damage from chronic infection and a blood test to determine which hepatitis C genotype you have, make sure you know the results so you can share them with your specialty care team.
• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Make a list of all medications, vitamins or supplements you're taking.
• Consider taking a family member or friend. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

To make the most of your time with your doctor, take along a list of questions you want to ask. Put your most important questions at the top of your list, in case time runs out. For a hepatitis C infection, some basic questions to ask your doctor include:

• Should I be tested for other causes of liver disease, such as hepatitis B?
• Has the hepatitis C virus damaged my liver?
• Do I need treatment for a hepatitis C infection?
• What are my treatment options?
• What are the benefits of each treatment option?
• What are the potential risks of each treatment option?
• Is there one treatment you think is best for me?
• I have other medical conditions. How will these affect my hepatitis C treatment?
• Should my family be tested for hepatitis C?
• Is it possible for me to spread the hepatitis C virus to others?
• How can I protect the people around me from hepatitis C?
• Should I see a specialist? Will my insurance cover it?
• Are there brochures or other material that I can take with me? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?
• Is it safe for me to drink alcohol?
• What medications should I avoid?

Don't hesitate to ask any other questions that occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you some of the following questions. If you've thought about your answers beforehand, this part of the visit may go more quickly than usual, leaving you more time to address your concerns.

• Have you ever had a blood transfusion or an organ transplant? If so, when?
• Have you ever used self-injected drugs not prescribed by your doctor?
• Have you ever been diagnosed with hepatitis or jaundice?
• Does anyone in your family have hepatitis C?
• Is there a history of liver disease in your family?

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