viral hepatitis C



OVERVIEW

Definition

Viral hepatitis C, or simply hepatitis C, is a liver disease caused by the hepatitis C virus (HCV).

Types

Depending on the duration of the disease, it can be categorized into acute viral hepatitis C and chronic viral hepatitis C.

Incidence

Viral hepatitis C is endemic worldwide. China belongs to the low endemic area of viral hepatitis C. It is estimated that there are about 10 million cases of HCV infection.

Etiology

Causes of disease

Sources of Infection

The infectious agents of viral hepatitis C are people infected with viral hepatitis C, including those who have viral hepatitis C and those with asymptomatic HCV infection.

People suffering from chronic viral hepatitis C and asymptomatic infected people are easily overlooked due to mild or asymptomatic symptoms and need to be protected.

Routes of transmission

Transmission through blood

Sexual transmission: HCV RNA can be detected in the semen or vaginal secretions of HCV-infected people, and there is a risk of sexual transmission, especially in AIDS patients, who are at higher risk of HCV infection.

Mother-to-child transmission: HCV-positive mothers are at risk of transmitting HCV to their newborns.

Other routes: There are still 15% to 30% of sporadic hepatitis C with unknown routes of transmission.

Reminder: HCV is generally not spread by the following routes: these include ritual kissing, hugging, sneezing, coughing, food, sharing utensils and cups of water, and contact without skin breaks and blood exposure.

Susceptible People

Any group of people can be infected with HCV.

The following groups are at high risk and have an elevated risk of infection.

Pathogenesis

The mechanism of HCV infection is not fully understood. It consists of two main mechanisms: immunization and direct viral damage, and may be influenced by a variety of factors, including the virus and the host.

Immune response: After HCV infects liver cells, the immune system will produce an immune response, which is manifested as an inflammatory reaction in liver tissue.

Direct stem cell damage: HCV products within the liver cells may also directly injure the liver cells.

Symptoms

The incubation period for viral hepatitis C ranges from 2 to 26 weeks, with an average of 50 days. The incubation period after blood transfusion is 7 to 33 days, with an average of 19 days.

Main Symptoms

Acute viral hepatitis C has a slow onset and may include symptoms such as lack of appetite, nausea, and vomiting to a lesser extent, and in a few cases, fever, as well as jaundice with yellowing of the skin and the whites of the eyes (sclera), and deepening of the color of the urine.

Chronic viral hepatitis C symptoms are less pronounced and may also present with uncharacteristic symptoms such as fatigue and jaundice. Symptoms usually develop slowly and may be detected during a blood donation or physical examination.

Other symptoms

HCV infection can also cause symptoms outside of the liver, such as joint pain, purpura, and hematuria. Upon examination, diseases such as cryoglobulinemia, glomerulonephritis, and dry syndrome may be detected.

Viral hepatitis C in children: it usually develops slowly and may last for months to years without manifestations of hepatitis.

Complications

Cirrhosis: abdominal discomfort, weakness, poor appetite, dyspepsia, malnutrition, jaundice, etc.

Liver failure: weakness, fatigue, weight loss; extreme loss of appetite, anorexia, epigastric stuffiness and discomfort; yellowing and progressive deepening of the sclera (white of the eyes) and skin; skin purpura or petechiae, spontaneous bleeding of the gums, nosebleed; fever, etc.

Hypersplenism: pallor, easy fatigue; susceptibility to infectious diseases, easy fever; subcutaneous petechiae and ecchymosis, bleeding gums, nosebleed, etc.

Gastrointestinal bleeding: abdominal pain, blood in stool or black stool. In severe cases, there may be vomiting of blood, etc.

Hepatic encephalopathy: Abnormalities in brain function, such as personality changes, decreased intelligence, and behavioral disorders, often occur. Motor and reflex abnormalities, such as muscle clonus and hyperreflexia, may also occur.

Portal hypertension: abdominal pain, black stools; abdominal wall veins may show a greenish sea serpent-like shape; fever, left upper abdomen may have tenderness; abdominal wall, lower limbs or generalized depressed edema; loss of appetite, low urine output.

Hepatorenal syndrome: jaundice, oliguria, anuria, azotemia, dilutional hyponatremia; loss of appetite, abdominal distension, nausea and other manifestations may occur.

Acute Kidney Injury: oliguria, with the decrease of renal function can affect other systems, including loss of appetite, nausea and vomiting, abdominal distension and diarrhea, respiratory distress, impaired consciousness, agitation.

Consultation

Department of Medicine

Gastroenterology

When symptoms such as fever, jaundice, malaise, nausea, vomiting, loss of appetite, abdominal distension and pain in the right upper abdomen occur, it is recommended to consult a doctor promptly.

Department of Infectious Diseases

If you have been diagnosed, or have a history of close contact with a diagnosed patient, or have the above symptoms after receiving a blood/blood product transfusion, you may consult the Department of Infectious Diseases.

Emergency Department

In the event of an emergency such as vomiting blood, drowsiness, or unconsciousness, it is recommended to visit the Emergency Department immediately.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of documents, common problems

Tips for seeking medical treatment

During the visit, abdominal ultrasound, chest CT, abdominal CT and other tests are often needed, so avoid wearing clothing made of metal, and inform the doctor if you are pregnant or planning to become pregnant.

Preparation Checklist

In particular, you should pay attention to the time of onset of symptoms and special manifestations.

Is there fever? What is the highest temperature?

Is there fatigue?

Is there jaundice, such as yellowing of the skin, sclera, urine, etc.?

Is there a palpable right upper abdominal mass? Is it accompanied by pain?

How long have these symptoms been present?

Have you received any blood transfusions or blood products?

Have you received an organ transplant, hemodialysis, or eyebrow tattoo?

Have you been in close contact with anyone with Hepatitis C?

Test results in the last six months that can be carried to the doctor’s office

Laboratory tests: blood test, liver function

Imaging tests: abdominal ultrasound

Medication in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office

Antipyretics: ibuprofen, acetaminophen

Antiviral drugs: sofosbuvir, gecalcivir, etc.

Diagnosis

Diagnosis is based on

Medical history

May have experience with blood transfusions, tattoos, sharing personal hygiene items such as razors with others.

History of blood transfusion.

History of close contact with HCV-infected individuals with broken skin or mucous membranes.

Clinical manifestations

There may be no obvious symptoms or there may be a lack of appetite, nausea, vomiting, malaise, fever, and jaundice.

Laboratory Tests

Confirmation of the diagnosis relies mainly on HCV antibody testing, viral nucleic acid testing.

Blood biochemistry and other tests are also needed to understand the extent and cause of liver damage.

If the HCV test is positive, further genotyping is needed to guide treatment.

Blood biochemistry tests require fasting to draw venous blood, so usually need to fast after dinner the day before the test, do not drink water, do strenuous exercise before the test.

Indicators include alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum albumin, and plasminogen activity.

Blood is drawn to check for HCV antibodies; a positive result indicates that there has been an HCV infection, but it is not certain that there is a current infection and further testing for HCV RNA is needed.

A negative result rules out viral hepatitis C and is therefore often used for rapid initial screening.

HCV RNA testing confirms the presence of a current infection and is an important test for a definitive diagnosis.

Positive results can be available 1 to 3 weeks after infection.

It includes genotyping and drug resistance-related genetic testing.

Current antiviral therapy drugs are effective against all genotypes, and testing for viral genotypes is required if treatment with genotype-specific antiviral drugs is used.

Imaging

The most commonly used test for liver examination is abdominal ultrasound.

The advantages are that it is simple to perform, easy to examine, non-invasive and intuitive; the disadvantages are that it is easily limited by equipment, body position, operator’s skill and experience.

Abdominal ultrasound can determine the size and shape of the liver and spleen, the condition of important blood vessels in the liver, and whether there are any occupying lesions.

Precautions: Adjust the body position according to the doctor’s instructions during the examination.

CT is a radiologic examination that can observe the shape of the liver and find out whether there is cirrhosis or space-occupying lesions.

If space-occupying lesions are found, it is possible to roughly determine whether they are benign or malignant.

Precautions: For CT scanning of the abdomen, fast for at least 4 hours before the examination, and drink water, milk or beverages.

Magnetic Resonance Imaging (MRI) is non-radioactive and is able to show changes in liver tissue structure more clearly.

With the help of contrast, dynamic and enhanced scanning, it can effectively distinguish whether the occupying lesion is benign or malignant.

Cautions

Transient elastography

Based on ultrasonography, transient elastography is a non-invasive test that is convenient, fast and can be repeated many times.

The results can distinguish mild liver fibrosis, progressive liver fibrosis or early cirrhosis more accurately.

If combined with the relevant indicators of blood test, the accuracy of liver fibrosis diagnosis can be improved.

Differential Diagnosis

Viral hepatitis C needs to be differentiated from other causes of hepatitis, such as other viral hepatitis, drug-induced hepatitis, alcoholic liver disease, and autoimmune liver disease. Those who present with jaundice also need to be differentiated from other causes of jaundice.

Other causes of hepatitis

Similarities: Both may present with lack of appetite, nausea, vomiting, jaundice, etc. Laboratory tests may reveal abnormal liver function.

Differences: HCV serology and nucleic acid test results can be used as the basis for diagnosis and differentiation.

Other causes of jaundice

Similarities: Both may present with jaundice, and laboratory tests may reveal abnormal bilirubin levels.

Differences: Specific differences are listed below.

Viral Hepatitis C may be experienced definitively or through blood transfusions, exposure to blood products, etc., while other jaundices may be due to medications, infections, cholecystitis, cholelithiasis, pancreatic head cancer, liver cancer, etc.

Viral hepatitis C presents less frequently with jaundice and may present with symptoms such as lack of appetite, malaise, and nausea, while other jaundices may present with symptoms of the primary disease. Hepatitis C virus serologic testing can clarify the presence or absence of HCV infection.

Treatment

Hepatitis C viral hepatitis is treated with medication in combination with general therapy. Since it is prone to chronicity, antiviral treatment is effective in controlling the disease. In severe cases, artificial liver support system and liver transplantation may be used depending on the situation.

General treatment

When symptoms such as fever, fatigue and jaundice are severe, bed rest and reduced activity are recommended.

Pay attention to the changes of jaundice, fatigue and other symptoms, and monitor liver function and coagulation function regularly.

Medication

Antiviral therapy

Treatment goal: to remove HCV, to obtain cure, to remove or reduce HCV-related liver damage, to stop disease progression, and to improve the quality of life.

Indications for treatment: All HCV RNA-positive patients should receive antiviral treatment without contraindications.

Precautions for medication

It is one of the options for the treatment of HCV, with better therapeutic effects in some patients, but with more adverse reactions and a longer course of treatment.

It is suitable for patients with hepatitis C who have relapsed or have poor efficacy after primary treatment or treatment with polyethylene glycol interferon combined with ribavirin.

Packages of sofosbuvir, dalatasvir, ledipavir, and asurevir are available. There are also combination preparations such as Brace Sofosbuvir Vipatasvir, Gecarevir Perentavir, Ledipavir Sofosbuvir, Elbasvir Gravir, etc.

Different drugs have different combination regimens, and the applicable population is affected by genotype and should be individualized.

Medication for special populations

Antiviral therapy is given under close observation to avoid liver failure or hepatocellular carcinoma.

Interferon combined with ribavirin regimen is available, or a combination of direct-acting antiviral drugs without interferon is also available.

Interferon is prohibited, and leedipavir sofosbuvir or sofosbuvir velpatasvir is chosen according to genotype, and the medication is aimed at improving liver function and survival.

Liver transplantation is performed when available.

Evaluation is required prior to medication, and the decision should be made after fully weighing the advantages, disadvantages, and risks.

Direct-acting antiviral drug regimens without interferon and ribavirin are preferred, such as ledipavir sofosbuvir and sofosbuvir vipatasvir.

In cases of co-infection with HBV, care is taken to monitor HBV DNA along with anti-HCV therapy.

Nucleoside (acid) analogs can be used for anti-HBV treatment if HBV DNA is significantly active.

In the case of co-infection with HIV, attention should be paid to the interaction between anti-HCV drugs and anti-retroviral drugs.

Infants delivered by HCV-infected individuals should be tested for HCV RNA at 1 to 2 months of age for early diagnosis. anti-HCV testing after 18 months of age excludes the effects of maternal antibodies.

Antiviral therapy is currently approved for children older than 2 years of age, with stricter indications than for adults, and treatment should be initiated only when there is significant liver fibrosis.

A regimen of interferon combined with ribavirin is used, with dose adjustments as prescribed.

Oral anti-HCV medications may be used for those over 12 years of age or weighing more than 35 kg.

Note that the medication may interfere with growth and development in children, with frequent or worsening adverse effects.

Artificial liver support system

Artificial liver support system therapy is an important treatment when liver failure occurs.

Artificial liver support system simulates part of the function of the liver outside of the body with the help of devices, etc., and temporarily replaces the liver to perform detoxification and other functions.

Artificial liver support systems vary in complexity and can perform different liver functions, and some systems can replace more liver systems. Some systems can replace more liver systems, reducing the burden on the liver and allowing liver cells to “rest”.

Liver transplantation

Viral hepatitis C does not usually require surgery. If chronic viral hepatitis C progresses to liver failure, liver transplantation may be needed.

There is still a risk of re-infection after liver transplantation, which requires long-term monitoring and treatment.

Prognosis

Cure

Acute viral hepatitis C tends to become chronic or viral carrier, with a chronicity rate of 55% to 85%. With the use of direct antiviral drugs, complete cure of viral hepatitis C has been possible.

Hazards

HCV is contagious and can be spread to others.

HCV infection develops relatively slowly. 20 years after infection, the incidence of cirrhosis is 5% to 15% in the general population and 2% to 4% in children and young women.

Thirty years after infection, the incidence of hepatocellular carcinoma is 1% to 3%, mainly in those with progressive liver fibrosis or cirrhosis. Once cirrhosis develops, the annual incidence of hepatocellular carcinoma rises to 2% to 4%.

When infected with HCV, age over 40, diabetes, alcoholism, and co-infections such as hepatitis B virus or human immunodeficiency virus can accelerate the progression of the disease.

Cirrhosis and hepatocellular carcinoma are the major life-threatening causes of chronicity. Those who develop cirrhosis have a 10-year survival rate of 80%; in the case of decompensation (inability of liver reserve function to meet needs), the 10-year survival rate is 25%. The risk of death in the 1st year after diagnosis of hepatocellular carcinoma is 33%.

HCV antibodies are non-protective, and after recovery from HCV infection, a person may be re-infected despite being antibody positive.

Daily

Daily Management

Dietary management

Regular, small and frequent meals, no overeating, eight minutes of fullness, and maintain appropriate body weight.

As the liver function is impaired, avoid oily food to reduce the burden on the liver. Do not eat high salt and high fat food, such as fatty meat, deep-fried, barbecued and pickled food.

Prioritize low-fat foods, such as low-fat milk or yogurt (1~2 cups a day), beans, egg whites (no more than 3 whole eggs a week), skinless chicken or fish and shrimp (one poker box size a day).

Substitute vegetable oils for animal oils, such as peanut oil, olive oil, corn oil and soybean oil.

Do not limit your staple food to refined white rice and noodles, but add various types of coarse grains, mixed beans and potatoes in moderation.

Eat less high-sugar foods, such as sugar, candies, sweet drinks, pastries, concentrated fruit juices, jams and honey.

Eat more vegetables, especially green leafy vegetables; eat about 1 fist-sized piece of fruit a day.

Stop drinking alcohol to prevent further damage to the liver.

Take vitamin supplements as prescribed by your doctor.

Do not ingest moldy foods, substandard drinking water, etc.

Alcohol may damage the liver, so it must be abstained from.

Life management

Take medication as prescribed by your doctor. Since the liver is impaired and much of the drug metabolism needs to pass through the liver, do not change medication or alter the dosage of medication without authorization.

Do not share personal items such as razors and nail clippers with others.

Clothes contaminated with blood should be washed separately.

When itching occurs, do not scratch the skin to prevent bleeding and infection.

You can wash your skin with water, do not rub your skin hard or use irritating cleansers.

When you have fatigue or fever, it is best to rest in bed and wait for your body to recover gradually before getting out of bed.

Keep a regular routine and avoid staying up late and being tired. You can choose to walk, tai chi and other low-intensity exercise, the time is not too long, do not feel fatigue can be.

Avoid sexual behavior until the infectiousness disappears, or insist on using condoms. Chronic patients, in particular, need to take protective measures to prevent transmission.

Chronic viral hepatitis C treatment cycle is long, need to maintain optimism and adhere to the treatment, do not give up.

Follow-up

Patients who return to the clinic should follow the doctor’s instructions for regular follow-up and continue with the relevant examinations.

The examination items include routine blood test, HCV load, biochemistry, liver and spleen ultrasound, liver hardness, liver fibrosis and alpha-fetoprotein.

If there is cirrhosis, it is recommended to review the abdominal ultrasound and serum alpha-fetoprotein every 6 months; and review the gastroscopy once a year to find out whether there is any occurrence of esophagogastric fundus varices.

For those with progressive liver fibrosis and cirrhosis, abdominal ultrasound and serum alpha-fetoprotein are recommended every 6 months. Gastroscopy should be repeated periodically for esophagogastric fundal varices.

Prevention

Prevention in special populations

Prevent blood-borne infections.

Prevent transmission by sexual contact

Avoid mother-to-child transmission: If a pregnant woman is HCV RNA positive, she should truthfully inform her doctor and minimize invasive operations such as amniocentesis.

After the diagnosis of viral hepatitis C is confirmed, you need to pay attention to the following aspects to prevent transmission to others.