Hepatitis C Symptoms
Most people who contract hepatitis C (hep C) have no symptoms. However, those that do have symptoms may experience:
- loss of appetite,
- muscle and joint pains.
- abdominal pain,
Hepatitis C infection is an infection of the liver caused by the hepatitis C virus (also referred to as HCV). It is difficult for the human immune system to eliminate hepatitis C from the body, and infection with hepatitis C usually becomes chronic. Over decades, chronic infection with hepatitis C damages the liver and can cause liver failure. In the U.S., the CDC has estimated that approximately 29,718 new cases occurred in 2013. When the virus first enters the body there usually are no symptoms, so this number is an estimate. Up to 85% of newly-infected people fail to eliminate the virus and become chronically infected. In the U.S., more than three million people are chronically infected with hepatitis C. Infection is most commonly detected among people who are 40 to 60 years of age, reflecting the high rates of infection in the 1970s and 1980s. There are 8,000 to 10,000 deaths each year in the U.S. related to hepatitis C infection. Hepatitis C infection is the leading cause of liver transplantation in the U.S. and is a risk factor for liver cancer.
Most people who contract hepatitis C (hep C) have no symptoms. However, those that do have symptoms may experience:
Hepatitis means inflammation of the liver. Hepatitis C is one of several viruses that can cause hepatitis. It is unrelated to the other common hepatitis viruses (for example, hepatitis A or hepatitis B). Hepatitis C is a member of the Flaviviridae family of viruses. Other members of this family of viruses include those that cause yellow fever and dengue fever.
There are at least six different genotypes (strains) of the virus which have different genetic profiles (genotypes 1 to 6). In the U. S., genotype 1 is the most common strain of hepatitis C. Even within a single genotype there may be some variations (genotype 1a and 1b, for example). Genotyping is used to guide treatment because some viral genotypes respond better to some therapies than to others.
Like human immunodeficiency virus (HIV), hepatitis C multiplies very fast and attains very high levels in the body. The genes that make the surface proteins of the virus also mutate (change) quickly, and thousands of genetic variations of the virus ("quasi-species") are produced daily. It is impossible for the body to keep up with making effective antibodies against all of the quasi-species circulating at one time. It has not been possible yet to develop an effective vaccine since the vaccine must protect against all genotypes.
Hepatitis C infection in the liver triggers the immune system, which leads to inflammation. Very few people experience typical hepatitis symptoms such as dark urine or clay colored stools in acute or early infection. Chronic hepatitis C usually causes no symptoms until very late in the disease, and hepatitis C has been referred to by sufferers as the "sleeping dragon." Over several years or decades, chronic inflammation may cause death of liver cells and scarring ("fibrosis"). Extensive scarring in the liver is called cirrhosis. This progressively impairs vital functions of the liver. Cirrhotic livers are more prone to liver cancer (hepatoma). Drinking alcohol speeds up liver damage with hepatitis C. Concurrent HIV infection also accelerates progression to cirrhosis.
About 75% of people have no symptoms when they first get hepatitis C infection. The remaining 25% may have
Very few people experience hepatitis symptoms or signs such as dark urine, yellow eyes, or clay colored stools in acute or early infection. Over time, people with chronic infection may develop signs of liver inflammation. This is often the first suggestion that the infection may be present. Infected individuals may become easily fatigued or complain of nonspecific symptoms.
As cirrhosis develops, symptoms and signs increase and may include:
Because hepatitis C is transmitted by exposure to blood, there is no specific period of contagiousness. If a person develops chronic hepatitis C, their blood carries the virus and is contagious to others for their entire life, unless the person is cured of their hepatitis C.
This is hard to say for certain what the incubation period for hepatitis C is because most people who are infected with hepatitis C do not have symptoms early in the course of the infection. Those who develop symptoms early after getting infected (6 to 10 weeks) experience mild gastrointestinal symptoms that may not prompt a visit to the doctor.
This is hard to say for certain because most people who are infected with hepatitis C do not have symptoms early in the course of the infection. Those who develop symptoms early after getting infected (6 to 10 weeks) experience mild gastrointestinal symptoms that may not prompt a visit to the doctor.
Most of the signs and symptoms of hepatitis C infection relate to the liver. Less often, hepatitis C infection can affect organs other than the liver.
Hepatitis C infection can cause the body to produce abnormal antibodies called cryoglobulins. Cryoglobulins cause inflammation of arteries (vasculitis). This may damage skin, joints, and kidneys. Patients with cryoglobulinemia (cryoglobulins in the blood) may have
In addition, infected individuals with cryoglobulinemia may develop Raynaud's phenomenon in which the fingers and toes turn color (white, then purple, then red), and become painful at cold temperatures.
The U.S Preventive Health Services task force recommends that all adults born between 1945 and 1965 be tested once routinely for hepatitis C, regardless of whether risk factors for hepatitis C are present. One-time testing also is recommended for:
People who may have been exposed to hepatitis C in the previous 6 months should be tested for viral RNA load rather than hepatitis C antibody because antibody may not be present early in hepatitis C infection.
In general, yearly screening may be appropriate for people with ongoing risk factors such as repeated sexually transmitted diseases (STDs) or many sex partners, ongoing IV drug use, or long-term sex partners of people with hepatitis C. Whether or not to test these people is determined on a case-by-case decision.
Hepatitis C is treated by either a gastroenterologist, a hepatologist (a gastroenterologist with additional training in liver disease), or an infectious disease specialist. Surgeons who specialize in surgery of the liver, including liver transplantation, are part of the medical team and should see patients with advanced disease (liver failure or cirrhosis) early, before the patient needs a liver transplant. They may be able to identify issues that need to be addressed before surgery can be considered. Other persons that can be helpful in managing patients include dieticians to consult on nutritional issues and pharmacists to assist with management of drugs.
There are several blood tests for the diagnosis of hepatitis C infection. Blood can be tested for antibody to hepatitis C. It takes up to six months for antibodies to develop after the initial infection with hepatitis C, so screening for antibodies may miss a few newly-infected individuals. Having antibodies is not an absolute indication of active, multiplying hepatitis C virus, but if the antibody test is positive (antibody is present), the statistical probability of active infection is greater than 99%.
Several tests are available to measure the amount of hepatitis C virus in a person's blood (the viral load). The hepatitis C virus's RNA can be identified by a type of test called polymerase chain reaction (PCR) that detects circulating virus in the blood as early as 2-3 weeks after infection, so it can be used to detect suspected acute infection with hepatitis C early infection. It also is used to determine whether active hepatitis is present in someone who has antibodies to hepatitis C, and to follow the viral load during treatment.
Blood tests are also performed to identify the genotypes of HCV. Genotypes respond differently to different treatment, so this information is important in selection of the most appropriate treatment regimen.
Estimation of liver fibrosis using blood tests also is quite reliable in diagnosing clinically significant scarring; these include FIB-4, FibroSure, Fibrotest, and Aspartate Aminotransferase-to-Platelet ratio index (APRI).
The next step is to determine the level of liver scarring that has occurred. Liver biopsy allows examination of a small sample of liver tissue under a microscope, however, liver biopsy is an invasive test, and has significant risks of bleeding. It also might miss abnormal areas in early disease.
Non-invasive tests have largely replaced liver biopsy except in special situations. Liver stiffness indicates that advanced liver scarring or cirrhosis may be present. Transient elastography may be used to measure this stiffness by ultrasound or magnetic resonance imaging (MRI).
Pre-treatment evaluation for hepatitis C also should include:
Interferons and pegylated interferons such as Peg-Intron A, Pegasys, Roferon, and Infergen, were mainstays of treatment for years and produced sustained viral response (SVR, or cure) of up to 50%-80%. These drugs were injected, had many adverse effects, required frequent monitoring, and were often combined with oral ribavirin, which caused anemia. Treatment durations ranged up to 48 weeks.
Direct-acting agents (DAA) are antiviral drugs that act directly on hepatitis C multiplication.
The treatment of hepatitis C is best discussed with a doctor or specialist familiar with current and developing options as this field is changing, and even major guidelines may become outdated quickly.
The latest treatment guidelines by the American Association for the Study of Liver Disease (AASLD) and Infectious Disease Society of America (IDSA) recommends use of DAAs as first-line treatment for hepatitis C infection. The choice of DAA varies by specific virus genotype, and the presence or absence of cirrhosis. In the U.S., specific insurance providers also might influence the choice due to the high cost of DAAs. Patients are encouraged to discuss options with their health-care professional.
Treatment is recommended in all patients with chronic hepatitis C unless they have a short life expectancy that is not related to liver disease. Severe life-threatening liver disease may require liver transplantation. Newer therapies with DAAs have allowed more and more patients to be treated.
The ultimate goals of antiviral therapy are to
When people first get hepatitis C, the infection is said to be acute. Most people with acute hepatitis C do not have symptoms so they are not recognized as being infected. However, some have low-grade fever, fatigue or other symptoms that lead to an early diagnosis. Others who become infected and have a known exposure to an infected source, such as a needle-stick injury, are monitored closely.
Treatment decisions should be made on a case-by-case basis. Response to treatment is higher in acute hepatitis infection than chronic infection. However, many experts prefer to hold off treatment for 8-12 weeks to see whether the patient naturally eliminates the virus without treatment. Approaches to treatment is evolving. Patients with acute hepatitis C infection should discuss treatment options with a health-care professional who is experienced in treating the disease. There is no established treatment regimen at this time.
If the hepatitis C RNA remains undetectable at the end of the treatment and follow-up period, this is called a sustained virologic response (SVR) and is considered a cure. Over 90% of people treated with DAAs are cured. These people have significantly reduced liver inflammation, and liver scarring may even be reversed.
Few people with hepatitis C are at risk for problems if they are treated, however there are some factors that affect treatment regimens, such as concurrent HIV medications and kidney dysfunction. Some drugs are not safe for people with cirrhosis. Individuals who are unable to comply with the treatment schedule for psychological reasons or ongoing drug or alcohol abuse may not be good candidates for treatment because the drugs are very costly and require adherence to the pill regimen and regular follow-up visits. There are some important drug interactions with some of the medications that should be considered by the health-care professional.
Compared to these drugs, the side effects of DAAs are far fewer and more tolerable. These side effects usually do not require discontinuation of therapy and are self-limiting after completion of therapy.
Hepatitis C is the leading reason for 40% to 45% of liver transplants in the U.S. Hepatitis C usually recurs after transplantation and infects the new liver. Approximately 25% of these patients with recurrent hepatitis will develop cirrhosis within five years of transplantation. Despite this, the five-year survival rate for patients with hepatitis C is similar to that of patients who are transplanted for other types of liver disease.
Most transplant centers delay therapy until recurrent hepatitis C in the transplanted liver is confirmed. Oral, highly effective, direct-acting antivirals have shown encouraging results in patients who have undergone liver transplantation for hepatitis C infection and have recurrent hepatitis C. The choice of therapy needs to be individualized and is rapidly evolving.
Once patients successfully complete treatment, the viral load after treatment determines if there is an SVR or cure. If cure is achieved (undetectable viral load after treatment), no further additional testing is recommended unless the patient has cirrhosis. Those who are not cured will need continued monitoring for progression of liver disease and its complications.
While cure eliminates worsening of fibrosis by hepatitis C, complications may still affect those with cirrhosis. These individuals still need regular screening for liver cancer as well as monitoring for esophageal varices that may bleed.
Over several years or decades, chronic inflammation may cause death of liver cells and cirrhosis (scaring, fibrosis). When the liver becomes cirrhotic, it becomes stiff, and it cannot perform its normal functions of clearing waste products from the blood. As fibrosis worsens, symptoms of liver failure begin to appear. This is called "decompensated cirrhosis" or "end-stage liver disease." Symptoms of end-stage liver disease include:
The liver and spleen have an important function of clearing bacteria from the blood stream. Cirrhosis affects many areas of immune function, including attraction of white blood cells to bacteria, reduced killing of bacteria, reduced production of proteins involved in immune defenses, and decreased life span of white blood cells involved in immune defenses. This may be referred to as having cirrhosis-associated immune dysfunction syndrome or CAIDS.
Transmission of hepatitis C can be prevented in several ways.
Prevention programs aim at needle sharing among drug addicts. Needle exchange programs and education have reduced transmission of hepatitis C infection. However IV drug users are a difficult to reach population, and rates of hepatitis C remain high among them. Among healthcare workers, safe needle-usage techniques have been developed to reduce accidental needle-sticks. Newer needle systems prevent manual recapping of needles after use of syringes, which is a frequent cause of accidental needle-sticks There is no clear way to prevent transmission of hepatitis C from mother to fetus at this time. People with multiple sexual partners should use barrier precautions such as condoms to limit the risk of hepatitis C and other sexually transmitted diseases, including HIV. If one partner is infected, monogamous couples may want to consider the low risk of transmission of hepatitis C infection when deciding whether to use condoms during sex. Some couples may decide to use them and some may not. Screening of the blood supply has almost eliminated the risk of transmission of hepatitis C infection through transfusion. People with hepatitis C infection should not share razors or toothbrushes with others because of the possibility that these items may be contaminated with blood. People who want to get a body piercing(s) or tattoo(s) are encouraged to do so only at licensed piercing and tattoo shops (facilities), and verify that the body piercing or tattoo shop uses infection-control practices.
It is critical that physicians and clinics follow manufacturers and regulatory agency directions for sterilizing/cleaning instruments and that disposable instruments be discarded properly. There is no need to use special isolation procedures when dealing with hepatitis C infected patients.
In general, among patients with untreated hepatitis C:
Drinking alcohol and acquiring other hepatitis viruses are risk factors for worse liver disease. People with chronic hepatitis C should avoid drinking alcohol and should be screened for antibodies to hepatitis A and B. If they do not have antibodies, they should be vaccinated against these other hepatitis viruses.
People with hepatitis C should be educated about preventing HIV infection. Infection with both HIV and hepatitis C speeds up and worsens liver damage caused by the hepatitis C. Hepatitis C also can affect the HIV infection and how it is treated. About 25% of people with HIV infection are co-infected (also infected) with hepatitis C, and up to 90% of IV drug users with HIV are co-infected with hepatitis C. Screening for hepatitis viruses is important in all people infected with HIV, just as screening for HIV is important in people who have hepatitis C.
Liver cancer (hepatocellular carcinoma, or hepatoma) is associated with cirrhosis from chronic hepatitis C. Some experts recommend screening patients with hepatitis C infection and cirrhosis for liver cancer periodically.
As our knowledge of hepatitis C increases, more and more patients are being diagnosed with chronic infection. Current research includes diagnosis, natural history, treatment, and vaccine development, and the field is constantly changing.
"HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C." American Association for the Study of Liver Diseases. Updated Feb 24, 2016.
"Hepatitis C FAQs for Health Professional." Centers for Disease Control and Prevention. Updated Mar 11, 2016.
"HIV/AIDS and Viral Hepatitis." Centers for Disease Control and Prevention. Updated Jun 09, 2015.
"Hepatitis C." Updated Jul 2015.
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In addition, each person's blood is either Rh-positive or Rh-negative. It is important to know what to expect before, during, and after a blood transfusion, and the risk factors or complications of a blood transfusion.