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Hepatitis C

What is Hepatitis C? 

Hepatitis C (HCV) is a viral infection that affects your liver. The virus is carried in blood and it can be spread by contact with infected blood. Once infected, it can cause short-lived symptoms (acute). Around 30% of those first infected will clear Hepatitis C from their body by their immune system within six months. Those who do not clear the virus will have chronic hepatitis C.

 

What are the symptoms of HCV infection? 

Most people with an acute HCV infection will not have any symptoms when they first infected. However, you may have vague symptoms such as:

  • Joint pain
  • Feeling tired
  • Muscle ache
  • Nausea
  • Loss of appetite
  • Jaundice (Yellowing of the eyes)

Most people with chronic HCV remain well for many years and do not have symptoms. However, HCV can cause liver inflammation and if left untreated, the persistently inflamed liver may lead to liver scarring and hardening called “cirrhosis”. If cirrhosis worsens over time, symptoms will develop including:

  • Yellowing of the skin or whites of the eyes called jaundice.
  • Swelling in the legs.
  • Accumulation of fluid in the belly or lungs causing abdominal distension and shortness of breath.
  • Vomiting blood.

How could I have caught HCV Infection? 

HCV is passed from person to person through blood-to-blood contact. This can happen through:

  • Sharing needles when injecting intravenous drugs.
  • Blood transfusion before screening was introduced in 1991.
  • Body piercing, tattoos or acupuncture where infected equipment is not been sterilized properly.
  • Sharing toothbrushes, razors or other things that could have infected blood on them.
  • Unprotected oral, vaginal or anal sexual intercourse where blood is present.

It is rare but sometimes may get infected through:

  • Dialysis or surgical procedures.
  • Mother to child contact during delivery (<5%).
  • Practising high-risk sexual activities with an infected long-term sexual partner.
  • Breastfeeding where the mother with HCV has cracked or bleeding nipples.

How does HCV affect my liver?

The infection causes cells in your liver to become inflamed. If the virus remains active, the inflammation gradually causes scar tissue to form in your liver. The scarred tissue is stiffer than normal liver tissue and is called fibrosis.

The rate at which fibrosis occurs can vary between individuals. The process may be faster if you:

  • are male
  • are over age of 40
  • are obese
  • are diabetic
  • drink alcohol
  • have another virus (co-infection) such as HIV or Hepatitis B
  • smoke

Over time, your healthy liver cells may be replaced with increasing amounts of scar tissue and the liver will become cirrhotic (hardening), loses shape and does not function well.

When liver cirrhosis is severe, complications will occur including:

  1. Jaundice, which causes yellowing of the whites of your eyes and your skin. Your urine will become dark tea-coloured.
  2. Higher risk of developing liver cancer (hepatocellular carcinoma).
  3. Accumulation of fluid/water that causes your ankles/legs and abdomen to swell up (ascites).
  4. Accumulation of toxic waste in your blood that causes confusion (encephalopathy) which is made worse if you are constipated/dehydrated or if you have an infection.
  5. Increasing liver pressure which can lead to swelling of blood vessels in your gullet called “oesophagal/gastric varices”. The swollen blood vessels may burst and cause bleeding. If you vomit blood, this is a medical emergency and you should seek help immediately from your nearest hospital.

Gradually and eventually the damage causes your liver to stop working. This is known as a liver failure. The only treatment for liver failure is to have a transplant.

How is HCV diagnosed and assessed?

It can be detected by testing your blood using an HCV antibody test. If it is positive, it means you have are likely to have been infected with the virus. However, the test does not tell you if the virus is active or not. To detect whether you have an active HCV infection, you will need a further blood test called HCV-RNA test.

Essential blood tests performed at the specialist hepatitis clinic:

Name of test What does it tell you?
Viral load, HCV RNA quantitation The number of viral RNA particles in your blood, which indicates how active the infection is. The test is valuable for monitoring your response to treatment.
Viral genotype Which type of HCV virus you have. There are six types of HCV. These are known as genotypes. They are usually specific to a geographical area. The type of viral genotype can affect your response to treatment and how long you need to take it. The liver specialist will discuss this with you.
Hepatitis B surface antigen and HIV screening Positive tests show that you have additional viruses which may indicate that scarring of your liver may happen at a faster rate.
Liver function tests Measures several markers that can tell how well your liver is working, in addition to how inflamed or damaged it is.
Blood clotting studies Your liver helps to make substances that cause blood to clot (clotting factors). When your liver function is compromised, the production of clotting factors can be affected. This test tells how well your liver is carrying out this function of making clotting factors.
Kidney function When liver damage gets worse, your kidney and electrolytes in the blood may also be affected.
Full blood counts Looking at your blood level of red cells, white cells and platelets. A low red cell level may indicate you are bleeding from body e.g bleeding from varices. You may experience vomiting blood or passing black stool. This may make you feel easy lethargy, giddiness and shortness of breath. A high number of white cell counts may indicate an infection while a low number of platelet may indicate that your liver has severe scarring.

If you have chronic Hepatitis C, doctors will also want to know whether you have cirrhosis (liver scarring). Methods to check for cirrhosis include:

  1. Blood tests – Using the results of certain blood tests, we can work out a fibrosis score, which can be used as an indirect indicator of how much liver scarring you have.
  2. Liver imaging – Ultrasound or CT/MRI scan which look at the morphology of the liver as well as other complication from the liver scarring e.g. fluid accumulation in the abdomen, enlarged spleen or a liver tumour.
  3. Fibroscan – This machine is attached with a monitor and a sensor probe to measure the stiffness of your liver. The greater the liver tissue stiffness score, the greater the degree of scarring. It is non-invasive, painless and has no side effects.
  4. Liver biopsy remains the most accurate test to determine whether your liver has turned to scar. However, it is an invasive test and has possible small risks/complications including bleeding from the site, pain and infection. For this test, a doctor will give you a local anaesthetic and then insert a fine hollow needle through your skin and into your liver. A small sample of liver tissue will be obtained for examination to see how bad the damaged or scarring of your liver is.

 

What are the available treatment options for HCV?

HCV infection is potentially curable. Effective anti-viral therapy is available but the cost may be an issue. If you have financial difficulty, a doctor will refer you to the medical social workers (MSW) for financial assistance.

Generally, there are 2 treatment options:

  1. The first option consists of weekly injections of pegylated interferon (PegIFN) and daily oral ribavirin tablets. You will be prescribed according to your genotype and the stage of your disease. The liver specialist will ensure you are ready and have all the necessary information before starting treatment.

You may need the treatment for 6 months to one year. The treatment may cause side effects. The side effects from pegIFN include:

  • Fever
  • Headaches
  • Fatigue
  • Difficult sleeping, low mood, depression
  • Muscle aches, joint pains
  • Thyroid gland problems
  • Skin problems
  • Being more susceptible to catching other infections.

Ribavirin can cause anaemia (low red cell counts) and is toxic to an unborn child. For this reason, anyone starting on this drug is advised not to become pregnant during treatment or at least 6 months after completing treatment.

You will be closely and regularly monitored in the clinic while you are on these combination treatments.

  1. The second treatment options are an oral antiviral treatment (direct-acting agents, DAA) in pill form. You will have to take a combination of 2 or more medicines depending on which type of virus and how serious your liver scarring is. Treatment usually lasts 3 to 6 months. These drugs are relatively new. They are highly efficacious and relatively much fewer side effects if compared to PegIFN. However, they are far more expensive and may not be affordable for every patient with HCV.

Will I need a liver transplant?

If you have cirrhosis with serious complications mentioned before, liver transplantation will be discussed as a treatment options if there is no contraindication. Liver transplantation does not cure the HCV infection and the virus will in time affect the new liver. Anti-viral treatment may be considered before or after the liver transplantation depending on how serious your cirrhosis is. A liver tranplant does offer you a chance to improve your health and quality of life.

How can I avoid giving HCV to others?
Unlike Hepatitis B, there is no vaccine available to prevent against Hepatitis C. The following precautions will help prevent transmission of hepatitis C virus to others:

  • Do not share your toothbrush, razors, hair clippers, nail clippers or scissors.
  • Use a condom during sexual activities.
  • Keep cuts covered.

What simple measures can I take to protect my liver?
If you have Hepatitis C virus infection, try to:

  • Avoid drinking alcohol.
  • Abstain from drug overdose/abuse
  • Keep your body weight within your recommended Body Mass Index (BMI).
  • Get Hepatitis A, B, influenza and pneumococcal vaccinations.
  • Avoid traditional Chinese medicine (TCM) and over–the-counter drugs which may potentially harm your liver.
  • Have regular follow-up and monitoring with your liver specialist.
  • Stop smoking
  • Adopt a healthy lifestyle and dietary habit.

By Dr. Wong Guan Wee, March 2017

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