You know how important your liver is to the well being of your body. It removes toxins, helps in digestion, stores vitamins, changes food into energy, aids your immune system, regulates fat and so much more. So when the liver becomes inflamed by hepatitis, there is cause for concern.
There are many types of viral hepatitis. A, B, and C are all caused by viruses. Symptoms include swelling and tenderness. Sometimes the damage can be permanent. Causes include alcohol, drugs, chemicals and viral infections. If the inflammation continues at least six months or longer it is called chronic hepatitis. Thanks to research in the field of viral hepatitis, tremendous advances have been made. But, identification of the specific viruses is key in determining the effective treatment. Many options are available and should be evaluated by one of our Charleston Gastroenterology Center specialists.
Causes, incidence, and risk factors
Hepatitis can be caused by:
- Immune cells in the body attacking the liver and causing autoimmune hepatitis. Infections from viruses (such as hepatitis A, B, or C), bacteria, or parasites
- Liver damage from alcohol, poisonous mushrooms, or other poisons. Medications, such as an overdose of acetaminophen, which can be deadly
Hepatitis may start and get better quickly (acute hepatitis), or cause long-term disease (chronic hepatitis). In some instances, it may lead to liver damage, liver failure, or even liver cancer.
How severe hepatitis is depends on many factors, including the cause of the liver damage and any illnesses you have. Hepatitis A, for example, is usually short-term and does not lead to chronic liver problems.
The symptoms of hepatitis include:
- Abdominal pain or distention
- Breast development in males
- Dark urine and pale or clay-colored stools
- Fever, usually low-grade
- General itching
- Jaundice (yellowing of the skin or eyes)
- Loss of appetite
- Nausea and vomiting
- Weight loss
Many people with hepatitis B or C do not have symptoms when they are first infected. They can still develop liver failure later. If you have any risk factors for either type of hepatitis, you should be tested regularly.
Signs and tests
A physical examination may show:
- Enlarged and tender liver
- Fluid in the abdomen (ascites) that can become infected
- Yellowing of the skin
Your doctor may order laboratory tests to diagnose and monitor the hepatitis, including:
- Abdominal ultrasound
- Autoimmune blood markers
- Hepatitis virus serologies
- Liver function tests
- Liver biopsy to check for liver damage
- Paracentesis if fluid is in your abdomen
Your doctor will discuss possible treatments with you, depending on the cause of your liver disease. Your doctor may recommend a high-calorie diet if you are losing weight.
- Liver cancer
- Liver failure
- Permanent liver damage, called cirrhosis
Other complications include:
- Esophageal varices that can bleed
- Spontaneous bacterial peritonitis (fluid in the abdomen that becomes infected)
Seek immediate care if you:
- Have symptoms from too much acetaminophen or other medicines — you may need to have your stomach pumped
- Vomit blood
- Have bloody or tarry stools
- Are confused or delirious
Call your doctor if:
- You have any symptoms of hepatitis or believe that you have been exposed to hepatitis A, B, or C.
- You cannot keep food down due to excessive vomiting. You may need to receive nutrition through a vein (intravenously).
- You feel sick and have travelled to Asia, Africa, South America, or Central America.
Hepatitis C FAQ ( Continued )
Are there different types of HCV?Yes. There are generally accepted to be 6 genotypes of HCV (1, 2, 3, 4, 5, and 6). Some genotypes have subtypes (e.g. 1a, 1b, 2a, 2b). The different genotypes differ slightly in medicines are used to treat them and how easy they are to cure. Genotype 1 is the most common genotype in the US (70%). Genotype 2 and 3 are the next most common. Genotype 3 is slightly harder to cure with new medications and appears to cause a higher risk of cirrhosis and fatty liver disease.
Who is at risk for HCV? Who should be tested?
Patients with a history of blood transfusion before 1992 or the use of intravenous drugs or an unregulated tattoo should all be tested. To simplify things for patients and doctors the Center for Disease Control and the US Preventative Health Task Force recommend testing everyone born between 1945 and 1965. Patients with HIV should also be tested. (www.cdc.gov, US Preventative Task Force)
What about sexual transmission?
Sexual transmission between a man and a woman with monogamous, vaginal intercourse is exceedingly rare with only 1 infection per 125,000 encounters. Other than not sharing a tooth brush or razor, we recommend no special precautions when living with an HCV infected patient. Any other precautions are unreasonable and do nothing more than make the patient feel socially isolated. (Terrault, N. Hepatology. 2013 Mar;57(3):881-9)
Unfortunately, sexual transmission between 2 men, especially when one or both have HIV is not rare. Barrier protection (e.g. condoms) is recommended in this case.
What if I am pregnant or planning to get pregnant?
Fortunately HCV virus is only spread to the unborn child 4% of the time. Unfortunately there is currently no way to reduce that number to 0%. Experts do not discourage breast feeding. Treatment for HCV is not recommended for pregnant women or infants currently. Future medications may ensure that no children born with HCV develop or die from advanced liver disease.
How does the virus behave? How do you know if you have it?
3.6 million Americans are infected with HCV. Unfortunately 50% of patients with HCV don’t know they are infected (Holmberg S, N Engl J Med 2013; 368: 1859). Most patients who come into contact with the virus via needle (tattoo, hypodermic) or blood transfusion will become chronically infected, meaning their blood will have detectable virus (HCV RNA) at all times. Interestingly, 25% of patients will clear the virus from their blood without the aid of medications. These patients will then carry the HCV antibody (Ab) for life, but not suffer any liver disease. Often the so called “liver function tests” (LFT’s) will be abnormally elevated, including AST, ALT, and GGT. Bilirubin and Alkaline phosphatase do not elevate until late in the course of disease.
25% to 40% of patients with chronic HCV will suffer daily damage and repair of their liver which after 20 to 40 years will lead to severe scarring and eventual dysfunction of the liver call cirrhosis. Patients can have no symptoms at all while the cirrhosis is forming and only become aware of infection once they are very ill. Signs of decompensated cirrhosis are jaundice, ascites, hepatic encephalopathy, and muscle wasting. Even small amounts of alcohol make cirrhosis much more common in HCV and should be avoided. Liver cancer, which is very rare in general, is quite common in patients with cirrhosis and they should be checked frequently via ultrasound or other imaging to detect small tumors.
Is HCV curable?
HCV is curable. The definition of cure is to have no detectable virus in the blood 12 weeks (3 months) after medication for HCV has been stopped. We also recommend checking at 24 weeks, 48 weeks and 72 weeks after therapy is stopped. In cured patients, the HCV antibody will always be positive but the HCV RNA will no longer be detectable, liver inflammation disappears, liver scarring can partially or completely reverse, cirrhosis risk decreases, need for liver transplant declines, liver cancer risk can be reduced 70%, and the patient cannot pass the infection to anyone else—A cure! In the past, 1 out a 100 patients would have virus in their blood long after they had previously been thought to be cured, leading some to say the virus could not necessarily be cured. In hindsight these cases may represent reinfection with new HCV after additional risky behavior, not re-emergence of the previous HCV infection from a hidden place in the body.
How is HCV cured?
Currently, most HCV patients can be cured with medications taken by mouth for 90 days to 180 days. The side effects of these medications are minimal and require only occasional blood lab monitoring. The most common side effects are mild headache, mild nausea, and loose stools. All of these side effects are managed rather easily with over the counter or prescription medications. The rate of cure is approximately 90% (9 out 10) in scientific trials. Regimens and cure rates may vary somewhat based on type of HCV (1, 2, 3, 4, 5, and 6), presence of cirrhosis, or previously failed attempts at treatment with interferon.
How is this different from previous treatments for HCV?
Previously the cure of HCV required 3, 6 or 12 months of injectable interferon. Interferon is associated with fatigue anemia, low white blood cells and fever in almost all patients. Some patients cannot tolerate the drug at all physically. Other patients must quit due to severe psychological complications, like depression or anxiety. The newly available oral medications have none of these problems. Almost no patients voluntarily quit the newer oral medications in scientific studies.
Is curing HCV worth the trouble?
Yes. For patients with scarred livers, the benefit is obvious: Less death from liver failure and liver cancer (Annals of Internal Medicine 2013; 158(1): 329-337). However, curing HCV has been proven to be associated with decreased risk of dying from any cause! This suggests that cured patients die less often than uncured patients regardless of severity of liver disease (van der Meer AJ, et al. JAMA. 2012;308:2584-2593) This may be because active HCV disease has been linked to kidney failure, diabetes, lymphoma and fatigue. What kinds of doctors treat HCV? Hepatologists (liver specialists), Gastroenterologists, and Infectious Disease specialists treat HCV. Primary care doctors may treat HCV in the future, but that depends on the individual physician and the insurance company (i.e. some insurance companies will require a specialist to prescribe the medications).
What should I expect if I see a physician to treat my HCV?
You can expect a thorough history of risk factors like blood transfusion and needle stick to determine how long you have had the disease. Blood labs, and ultrasound and physical exam will be ordered to determine what genotype of HCV you have and if you have advanced scarring of the liver. Occasionally a liver biopsy is need to determine how scarred the liver is; however, liver biopsies are becoming increasing less useful in decision making. Biopsies are not definitely required to begin newer HCV medications. A second clinic visit is usually needed to discuss all of the results gathered and recommend a treatment plan. All alcohol must be stopped during treatment because it can prevent the medications from curing the HCV.
Will I be able to afford HCV treatment?
Yes. This is a common question resulting from the publicity over the price of newer HCV treatment regimens. Almost never does a patient take their HCV prescription to a pharmacy, pay on the spot and walk away with HCV medication. Due to the expense and complexity of the medications, most insurance companies require a prior authorization request and the use of a specialty pharmacy. Your physician will write your prescription and forward the order to a specialty pharmacy along with some basic clinical information.
The pharmacy will then contact the pharmacy benefits office of your insurance company and obtain permission to fill the prescription. With most plans the Co-pay for the meds is affordable once approved. Often the drug companies that make the medicines will cover all or part of the monthly co-pay. This helps a lot. Especially since most patients will only be on the medication 3 to 6 months, not for life as with other diseases!
Completely uninsured patients can often get the medications free of charge directly from the manufacturer.