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,
Most people who contract hepatitis C (hep C) have no symptoms. However, those that do have symptoms may experience:
Hepatitis C virus infection is an infection of the liver caused by the hepatitis C virus (also referred to as HCV or hep C). 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 41,200 new cases of hepatitis C occurred in 2016. When the virus first enters the body there usually are no symptoms, so this number is an estimate. About 75%-85% of newly infected people become chronically infected. In the U.S., more than 2 million people are estimated to be 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. HCV infection is the leading cause of liver transplantation in the U.S. and is a risk factor for liver cancer. In 2016, 18,153 death certificates listed HCV as a contributing cause of death; this is believed to be an underestimate.
About 10%-20% of those who develop chronic HCV will develop cirrhosis within 20-30 years. Progression to cirrhosis may be accelerated by age over 50, male gender, alcohol consumption, nonalcoholic fatty liver disease (NASH), co-infection with hepatitis B or HIV, and immune suppressing drugs. HCV infection is the leading cause of liver transplantation due to liver failure in the U.S.
Hepatitis means inflammation of the liver. Hepatitis C is one of several viruses that can cause viral 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 anti-HCV antibodies against all of the quasi-species circulating at one time. It has not been possible yet to develop an effective vaccine because the vaccine must protect against all genotypes.
Hepatitis C infection in the liver triggers the immune system, which leads to inflammation. About 20%-30% of those acutely infected will experience typical hepatitis symptoms such as abdominal pain, jaundice, dark urine or clay-colored stools. However, 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. Drinking alcohol speeds up liver damage with hepatitis C. Concurrent HIV infection, as well as acute hepatitis A or B infection, will also accelerate progression to cirrhosis.
About 70%-80% of people have no symptoms when they first get HCV infection. The remaining 20%-30% may have
Early symptoms of hepatitis C may include dark urine, yellow eyes, or clay-colored stools though this is unusual. Over time, people with chronic HCV infection may develop signs of liver inflammation that suggests that the infection may be present. Infected individuals may become easily fatigued or complain of nonspecific symptoms. The later symptoms and signs of cirrhosis are often absent until inflammation is fairly advanced. As cirrhosis progresses, symptoms and signs increase and may include:
Because hepatitis C is transmitted by exposure to blood, there is no specific period of contagiousness. People who develop chronic hepatitis C carry the virus in their blood and, therefore, are contagious to others for their entire life, unless they are 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 (2 to 12 weeks on average, but may be longer) 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 anti-HCV antibody, because antibody may not be present for up to 12 weeks or longer after infection, although HCV RNA may be detectable in blood as soon as 2-3 weeks after 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.
There is a 4%-7% risk of transmitting HCV from mother to infant with each pregnancy. Currently, there is no CDC recommendation for routine hepatitis C screening during pregnancy, and there is no currently recommended medicine to prevent transmission from mother to infant (prophylaxis). However, CDC is monitoring research findings and may make recommendations in the future as evidence arises.
While data is still limited, a recent study of over 1,000 cases in the United Kingdom found that 11% of infants had been infected at birth, and that these infants were likely to develop cirrhosis in their early 30s. The case for screening for HCV during pregnancy includes the potential to safely treat mothers during pregnancy with direct-acting antiviral agents (DAAs) to treat the mother before cirrhosis develops, prevent infant transmission, and prevent transmission to others. Children born to HCV-infected mothers may also be offered treatment at an early age to prevent cirrhosis, as well as transmission to others. Coordination of care between multiple specialists will be important to accomplish these goals.
Children of HCV-infected mothers may be screened for hepatitis C as early as 1-2 months of age using hepatitis C viral load or PCR testing (See Blood tests for hepatitis C). Antibodies to hepatitis C passed from the mother to child will be present for up to 18 months, so children should be tested for HCV antibody no earlier than this.
Hepatitis C is treated by either a gastroenterologist, a hepatologist (a gastroenterologist with additional training in liver disease), or an infectious disease specialist. The treatment team may include more than one specialist, depending on the extent of liver damage.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 who can be helpful in managing patients include dietitians 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 (anti-HCV antibody). It takes about 8-12 weeks on average, and up to 6 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, for example, Roferon-A and Infergen, and pegylated interferons such as Peg-IntronT, Pegasys, were mainstays of treatment for years. Interferons produced sustained viral response (SVR, or cure) of up to 15%. Later, peglatedll forms produced SVR of 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 anti-viral agents (DAAs) are antiviral drugs that act directly on hepatitis C multiplication.
Hepatitis C treatment 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. Although the individual, public health, and cost benefits of treating all patients with hepatitis C is clear, the most difficult barrier to treating all people with HCV is the very high cost of the drug regimens. 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
A side goal is preventing co-infections with other hepatitis viruses, such as A and B, which can cause more liver disease than HCV alone. These can be prevented by vaccines and treatment.
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 needlestick 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 are 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.
About 5% of people who are treated for HCV infection are not cured by some of the older regimens. These people may still have options for cure with the newer regimens.
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.
People with past hepatitis B or who have chronic active hepatitis B should not be treated for HCV without treating for HBV as well. As highly effective treatment for HCV has emerged, reports of serious hepatitis B have come to light. Similar to HCV, hepatitis B usually does not clear from the liver after acute infection, even though it is far less likely to cause chronic active hepatitis than hepatitis C infection. It remains dormant in most people, but it can reactivate with changes in the immune system. It is not clear why eliminating the HCV can allow the HBV infection to flare up. Hepatitis B screening is an important part of the hepatitis C evaluation. Those who have laboratory evidence of active or past infection with HBV should be monitored while receiving HCV treatment.
Compared to interferons and ribavirin 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.
Patients with hepatitis B co-infection should be monitored for symptoms of reactivation of hepatitis, which are the same as the symptoms of acute hepatitis. The treating doctor may perform blood screening for this as well.
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.
Because hepatitis B co-infection may reactivate or worsen even after treatment for HCV, monitoring for hepatitis symptoms may be needed after the end of therapy.
At this time there are no effective home or over-the-counter treatments for hepatitis C.
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 health care workers, safe needle-usage techniques have been developed to reduce accidental needlesticks. Newer needle systems prevent manual recapping of needles after use of syringes, which is a frequent cause of accidental needlesticks
There is no clear way to prevent hepatitis C transmission 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 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 is very active and includes diagnosis, natural history, treatment, and vaccine development. Thus the field is constantly changing, with new guidelines added frequently.
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 risks, side effecs, or complications of blood transfusions.
Symptoms include yellowing of the skin (jaundice), itching, and fatigue.
The prognosis is good for some people with cirrhosis of the liver, and the survival can be up to 12 years; however the life expectancy is about 6 months to 2 years for people with severe cirrhosis with major complications.