Hepatitis C Virus

Acute hepatitis C refers to the presence of HCV immediately following incubation (usually 2–6 weeks) to within six months of acquiring infection. Most people are asymptomatic

Chronic hepatitis C refers to the continued presence of HCV six months or more after acquiring infection.

Transmission is via percutaneous exposure to infected blood. Following acute exposure, about 55% to 85% of patients develop chronic hepatitis C.

Presentation

Following exposure to the virus, the majority of patients are asymptomatic

Symptoms that may occur in acute HCV

  • General malaise
  • Mild flu-like illness

Symptoms that may occur in chronic HCV

  • Non-specific fatigue
  • Myalgia
  • Anxiety
  • Depression
  • Poor memory or concentration

Other symptoms that may indicate hepatitis

  • Nausea and vomiting
  • Right upper quadrant abdominal pain.
  • Jaundice (with dark urine and/or pale stools if cholestasis)
  • Signs of chronic liver disease (e.g hepatomegaly)

History

Presence of risk factors

  • Unsafe medical practices and needlestick injury
  • IV or intranasal drug use
  • Sharing of needles
  • Blood transfusion or organ transplant
  • Tattoos or body piercings
  • Heavy alcohol use
  • HIV
  • Travel history - Especially where hepatitis C is endemic

Examination

No abnormal findings on examination unless the patient has developed portal hypertension or decompensated liver disease

  • Hand signs - Palmar erythema, Dupuytren contracture, asterixis, leukonychia, clubbing
  • Gynecomastia, small testes
  • Abdominal signs - ascites, caput medusae, hepatosplenomegaly, abdominal bruits
  • Skin signs - Spider nevi, petechiae, excoriations due to pruritus

Laboratory investigations

HCV antibody test

Indicates if a person has ever been infected with HCV
Offer screening for the following individuals:

  • Asymptomatic who are at high risk of hepatitis C infection
  • Individuals with symptoms suggesting acute or chronic HCV

HCV RNA and genotype analysis

1) If the HCV antibody test is positive, or in immunocompromised people, send a blood sample for HCV RNA to check if HCV infection is active and a genotype analysis.

2) If the HCV RNA test is positive, send a repeat sample for confirmation. A positive HCV RNA result means the person has current infection with active hepatitis C

3) If the HCV RNA result is negative, repeat the test after a period of 6 months. If the negative result is confirmed, this means the person has a previously resolved HCV infection, but they are not immune to future HCV infection

4) Chronic infection is confirmed if HCV RNA is positive 6 months after the first positive test

Other tests

  • Full blood count (to check for anaemia, neutropenia, and thrombocytopenia).
  • Urea and electrolytes, creatinine, estimated glomerular filtration rate (eGFR).
  • ALT and GGT - these do not accurately indicate the extent of liver damage or severity of hepatitis C infection.
  • Clotting screen - clotting may be affected if there is significant liver damage
  • HbA1c level
  • Thyroid function tests (TFTs) — antiviral therapy can cause thyroid dysfunction, therefore a baseline value is necessary
  • Ferritin level — to assess iron stores which can be elevated in chronic hepatitis C
  • Hepatitis B surface antigen (HBsAg) or antibody to hepatitis B core antigen (anti-HBc) to check hepatitis B status
  • Hepatitis A immunoglobulin M (HAV-IgM) to check hepatitis A status
  • HIV test and other sexually transmitted infections
  • Liver biopsy - May be considered to assess the extent of liver damage caused by inflammation, fibrosis or cirrhosis and to exclude other causes of liver damage.

Radiological investigations

Liver ultrasound

  • To screen for hepatocellular cancer in patients with advanced fibrosis or cirrhosis

Management

Lifestyle advice to reduce the risk of disease progression

  • Stop alcohol consumption - alcohol is the most important predictor of disease progression
  • Lose weight if necessary and maintain a healthy diet — obesity increases the risk of fatty liver disease and progression to cirrhosis.
  • Advise the person about the risk of sexual transmission

Antiviral combination therapy

Combination dual drug therapy

  • Pegylated interferon alpha (weekly self-administered subcutaneous injections)
  • Ribavirin (daily oral doses)

Triple therapy may be considered for those with HCV genotype 1 because of their worse prognosis

  • Dual drug therapy with the addition of a protease inhibitor

Immunisation

  • Offer immunization against hepatitis A and B - co-infection with hepatitis A can increase the risk of acute fulminant hepatitis, and co-infection with hepatitis B can lead to hepatic decompensation

Follow up

Regular clinical and blood monitoring is needed to check for adverse effects and response to treatment.

Prognosis

The long-term prognosis of HCV varies greatly and depends on the severity of liver fibrosis. Symptoms can take decades to occur.

  • About 25–50% of people will spontaneously clear the virus without treatment (but are not immune to future HCV infection).
  • About 50–80% of people will develop chronic hepatitis C.
  • 5–15% may progress to develop liver cirrhosis over a period of 20 years

Risk factors for a poor prognosis and progressive liver disease include

  • HCV genotype — genotypes 1, 4, 5, and 6 are less responsive to antiviral treatments than genotypes 2 and 3.
  • Excessive alcohol consumption - previous or current
  • Older age at infection
  • Male
  • Black African American and Hispanic patients
  • Co-infection with HIV, hepatitis A, and/or hepatitis B.

Complications

Actue HCV

  • Mortality (very low)
  • Acute fulminant hepatitis (rare)

Chronic HCV

  • Fatigue, anxiety, and depression - these can negatively impact on the person's quality of life.
  • Cirrhosis
  • Hepatocellular carcinoma
  • Decompensated liver disease - oesophageal varices, ascites, bleeding problems, hepatic encephalopathy, and death
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