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Hepatitis C, Chronic

By Anna E. Rutherford, MD, MPH, Assistant Professor of Medicine;Clinical Director of Hepatology, Harvard Medical School;Brigham and Women’s Hospital

Chronic hepatitis C is inflammation of the liver that is caused by the hepatitis C virus and that has lasted more than 6 months.

  • Hepatitis C often causes no symptoms until after it has badly damaged the liver.

  • Doctors diagnose chronic hepatitis C based on blood tests.

  • If chronic hepatitis C has caused cirrhosis, screening for liver cancer is done every 6 months.

  • Chronic hepatitis C is treated with antiviral drugs.

Acute hepatitis C becomes chronic in about 75% of affected people.

An estimated 2.7 to 3.9 million people in the United States have chronic hepatitis C. Worldwide, 71 million people are estimated to have chronic hepatitis C.

Chronic hepatitis C, if untreated, causes cirrhosis in about 20 to 30% of people. However, cirrhosis may take decades to develop. The risk of liver cancer is increased usually only if cirrhosis is present.

There are different types (genotypes 1 through 6) of hepatitis C virus, which are sometimes treated with different drugs.

Symptoms

Many people with chronic hepatitis C have no symptoms. Some have a feeling of being generally ill (malaise), loss of appetite, fatigue, and vague abdominal discomfort.

Often, the first specific symptoms are those of chronic liver disease or cirrhosis. These symptoms can include

  • An enlarged spleen

  • Small spiderlike blood vessels visible in the skin (called spider angiomas)

  • Redness of the palms

  • Accumulation of fluid within the abdomen (ascites)

  • Abnormally high blood pressure in the veins that bring blood from the intestine to the liver (portal hypertension)

  • Deterioration of brain function due to malfunction of the liver (hepatic encephalopathy)

  • Jaundice (yellowing of the skin and whites of the eyes)

Portal hypertension develops because the large amount of scar tissue in the liver interferes with blood flowing through the liver. As a result, blood backs up in the veins that bring blood to the liver (portal veins), and pressure in these veins increases.

Brain function deteriorates because the badly damaged liver cannot remove toxic substances from the blood as it normally does. These substances then build up in the blood and reach the brain. Normally, the liver removes them from the blood, breaks them down, then excretes them as harmless by-products into the bile (the greenish yellow fluid that aids in digestion) or blood (see Functions of the Liver). Treatment of hepatic encephalopathy can prevent the deterioration of brain function from becoming permanent.

Screening

Certain people should talk to their doctor about being tested for hepatitis C, whether they have symptoms suggesting hepatitis or not.

People who have the following characteristics should be screened for hepatitis C:

  • Were born between 1945 and 1965, regardless of country of birth

  • Are currently using or have ever injected illicit drugs, even if only one time or only in the distant past

  • Have inhaled illicit drugs

  • Were treated with injections (given by vein or injected into a muscle) for a blood clotting problem before 1987

  • Were given a blood transfusion or organ transplant before July 1992

  • Are currently or have ever been treated with long-term hemodialysis

  • Have abnormal liver test results or chronic liver disease

  • Work in health care or public safety and were exposed to blood through a needlestick or other injury by a sharp object

  • Have HIV infection

  • Have ever been imprisoned

  • Are children born to women with hepatitis C

Such testing is important because symptoms may not develop until the infection has extensively damaged the liver, years after people are first infected.

Diagnosis

  • Blood tests

Doctors may suspect chronic hepatitis C when

  • People have typical symptoms.

  • Blood tests (done for other reasons) detect abnormally high liver enzymes.

  • People have been previously diagnosed with acute hepatitis C.

Testing for chronic hepatitis C usually begins with blood tests to determine how well the liver is functioning and whether it is damaged (liver function tests). Liver function tests involve measuring the levels of liver enzymes and other substances produced by the liver. These tests may help establish or exclude the diagnosis of hepatitis, identify the cause, and determine the severity of liver damage.

Blood tests are also done to help doctors identify which hepatitis virus is causing the infection.

Blood tests are done determine whether the person is infected with hepatitis C virus. These tests measure the following:

  • Antibodies produced by the person's immune system in response to the hepatitis C virus

  • Genetic material of the hepatitis C virus (called hepatitis C virus RNA)

If chronic hepatitis C is confirmed, doctors also check for HIV infection and hepatitis B because these infections are often spread in the same ways—through contact with bodily fluids, such as blood or semen.

After hepatitis C is diagnosed, tests may be done to determine how badly the liver is damaged and to check for other causes of liver disease. Tests may include

  • Specialized imaging tests, such as ultrasound elastography and magnetic resonance elastography

  • Blood tests to measure substances (called markers) that indicate whether and how much fibrosis is present

Screening for liver cancer

If people have chronic hepatitis C, screening for liver cancer is done every 6 months. It may include the following:

  • Ultrasonography

  • Sometimes measurement of levels of alpha-fetoprotein

Levels of alpha-fetoprotein—a protein normally produced by immature liver cells in fetuses—usually increase when liver cancer is present.

Treatment

  • Antiviral drugs

Chronic hepatitis C is treated with antiviral drugs called direct-acting antivirals. Usually, several drugs are used together.

For chronic hepatitis C, treatment is indicated if both of the following are present:

  • Liver enzyme levels are elevated.

  • Biopsy shows that inflammation is progressing and scar tissue is continuing to develop.

Treatment varies based on the type of hepatitis C virus causing the infection. New antiviral drugs to treat hepatitis C are being developed, and thus recommended treatments are rapidly changing.

Many antiviral drugs are available to treat hepatitis C. They include sofosbuvir, daclatasvir, paritaprevir, ritonavir, ombitasvir, dasabuvir, telaprevir, boceprevir, simeprevir, elbasvir, grazoprevir, velpatasvir, glecaprevir, pibrentasvir, and ribavirin (all taken by mouth).

Treatment can last from 8 to 24 weeks. Treating hepatitis C can eliminate the virus from the body and thus stop inflammation and prevent scarring, which can lead to cirrhosis.

Ribavirin, telaprevir, boceprevir, and simeprevir can cause birth defects. Both men and women who have to take these drugs should use birth control during treatment and for 6 months after treatment ends.

If chronic hepatitis C infection has severely damaged the liver, liver transplantation may be done. After liver transplantation, people with hepatitis C are often treated with antiviral drugs, which improve their chance of being cured.

After treatment is completed, doctors do blood tests to determine how much of the virus's genetic material is present. If none is detected 12 weeks and 24 weeks after treatment is completed, depending on the drug regimen used, people are probably cured.

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Drugs Mentioned In This Article

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  • VICTRELIS
  • NORVIR
  • VIRAZOLE