What is viral hepatitis?

Viral hepatitis is an inflammation of the liver caused by one of several viruses: hepatitis A, B, C (formerly known as non-A, non-B), D, E and G. Things other than viruses can also cause hepatitis or inflammation of the liver. One such non-viral cause is autoimmune hepatitis.

What is autoimmune chronic active hepatitis?

The body’s own immune system, for unknown reasons, attacks the liver cells often leading to chronic active hepatitis and cirrhosis. Some patients require treatment with corticosteroids, which suppress the overactive immune response. This disease is not infectious although it is called "hepatitis." It is most common in young white women, but can be found in all age groups, as well as men.

Hepatitis A (HAV)

Eating food or drinking water that has been contaminated with human waste - called the fecal-oral route of
infection- transmits Hepatitis A. Infections with the hepatitis A virus are always acute (except in rare
instances) - patients can clear the virus from their bodies within three to four months, without risk of longterm liver damage. A vaccine is available for the prevention of hepatitis A. The Centers for Disease Control and Prevention (CDC) lists household or sexual contact, day care attendance or employment, and recent international travel as the major known risk factors for becoming infected with this virus. Food handlers and those who have used contaminated needles are also at risk. Given that most all infections with HAV are acute, medical treatment is not needed to eliminate the virus. However, doctors may prescribe medicine to treat symptoms of hepatitis, such as headache and nausea, or they may give patients IV fluids to prevent dehydration. Patients can usually recover at home. Avoiding alcohol is the common recommendation, because, as a toxic substance, alcohol greatly weakens an already damaged liver.
Some people with HAV may not have any symptoms, especially children under two years old. In most cases, however, people experience "flu-like" symptoms, including fatigue and nausea with vomiting, and pain in the liver area. Less common symptoms are dark urine, light-colored stools and fever. Hepatitis A is rarely fatal, except in the young and old, or patients with underlying liver disease, or weakened immune systems (such as in cancer or patients on steroids).

Hepatitis B (HBV)

The hepatitis B virus, a serious form of hepatitis, is spread through contact with infected blood. It is more common and much more contagious than HIV (the virus responsible for AIDS). There are about 1.2 million people in the U.S. with hepatitis B. Most adults can fight off an infection without treatment. However, HBV may develop into a chronic form in up to 15% of patients. If chronic HBV is left untreated the risk of developing cirrhosis and liver cancer increases. A vaccine is available for the prevention of hepatitis B. Because HBV is a blood-borne infection, it is spread in many ways. Just the tiniest amount of blood on common, everyday objects, like a toothbrush, razor or manicure instrument can carry enough of the virus to infect someone. Here are the major ways that hepatitis B is spread:

• Hemodialysis patients (using kidney machines)
• Jobs with exposure to blood (especially healthcare workers)
• Unprotected sex with an infected partner
• Tattoos and body piercing
• Sharing straws for inhaling cocaine
• Sharing person care items (such as nail files and nail clippers)
• Sharing needles for IV drug use

Additionally, people traveling to countries where the hepatitis B virus is known to be endemic (common) are at risk. These areas of the world include most developing countries, Asia, Africa, India, and the Middle East. Pregnant women can also pass the virus to their babies. Some people with HBV have no outward signs or symptoms. But others do experience "flu-like" symptoms, such as fatigue, loss of appetite, nausea and vomiting, fever, weakness and mild abdominal pain. Less common symptoms are dark urine and yellowing of the skin and eyes (jaundice). If patients have been infected with HBV for six months ore more, their doctors may feel they need treatment in order to avoid permanent liver damage. In addition to treatment, patients may also receive a vaccination for the prevention of hepatitis A.

Hepatitis C (HCV)

The most serious form of hepatitis, hepatitis C currently affects over four million Americans. About 85% of all infections develop into chronic infections. If left untreated, there is a high chance of cirrhosis, liver failure and liver cancer. Liver failure due to hepatitis C is now the leading cause of liver transplants in the United States.

Hepatitis C is easily spread by blood. There are many ways of being in contact with blood, and this includes blood from cuts, nosebleeds, or even menstrual blood.

The major ways that hepatitis C is spread include:

• Blood transfusion before 1992
• Hemodialysis patients (using a kidney machine)
• Jobs with exposure to blood (especially healthcare workers)
• Tattoos and body piercing
• Sharing straws for inhaling cocaine
• Sharing personal care items with someone who has hepatitis C
• Sharing needles for IV drug use even if on just one occasion
• Unprotected sex with multiple partners
• Infected mothers have approximately 6% chance of passing the virus to their newborns. This risk
increases with a concurrent HIV infection.
• In about 10% of people with HCV the mode of transmission is unknown

What are the symptoms of Hepatitis C?

Most people who have HCV do not know they have the illness and are free of any symptoms. Interestingly,
in many people, the presence of symptoms does not bear any relationship with the extent of the illness. In
other words, someone with very mild HCV can describe many of the symptoms, while another person who
has much more advanced disease may not have any symptoms of HCV. Some of the more common
symptoms include extreme fatigue, itching and joint pain.

How do I know if I have Hepatitis C?

Usually, people with HCV are discovered because the liver enzymes in their blood are above normal limits, and their doctors do more blood tests to find the cause. Others are found through testing positive while donating blood.

Because HCV-infected individuals may be free of symptoms and unaware of any illness, evaluation may be delayed. If you have ANY risk factors, regardless of how you feel, you must be tested. If someone is considered to be potentially at risk, he or she should see a doctor and have their blood tested for HCV.

Hepatitis D

Hepatitis D, or delta virus, enters cells by binding to a piece of hepatitis B virus. It acts like a hitchhiker and infects only people who either are actively infected with hepatitis B or are chronic carriers of hepatitis B. It is rather like a parasite. It also leads to persistent infection and is more common in people who have acquired hepatitis B through intravenous drug use rather than other routes of transmission.

Hepatitis E

Hepatitis E is another viral cause of liver inflammation that is more common in the developing world than in the United States. This hepatitis virus is also transmitted predominantly by ingesting feces tainted with hepatitis E. Most cases consist of an acute hepatitis from which people recover fully. It can run a more aggressive course in pregnant women. Hepatitis E is very rare in the U.S. and is responsible primarily for an acute form of hepatitis in travelers returning from endemic areas such as Africa.

HEPATITIS C DIAGNOSIS & TREATMENT

Blood tests for the presence of HCV

• ELISA (Enzyme Linked Immunosorbent Assay). The ELISA test for hepatitis C searches the
blood sample for certain biochemical sequences that correspond with the presence of antibodies to
HCV. Antibodies do not show viral presence only a past exposure to HCV. There are a fair
amount of false positives and negatives with this test and antibodies usually are not formed for six
months from the time of exposure. This test is inexpensive and is used as the initial screening for
HCV. This test is continually being improved.
• RIBA (Recombinant Immunoblot Assay). The RIBA test was developed for use in hepatitis C
because of the unreliability of ELISA. This test searches for two different sets of patterns that
correspond to HCV antibodies and a test for the presence of a controlled substance. Pathologists
have to visually assess the positivity of the result by comparison to controls. The test is highly
accurate but not 100%. It is more expensive than an ELISA; therefore it is used as a confirmation
tool. This test is continually being improved.
• HCV-RNA BY PCR (Polymerase Chain Reaction). It is the most sensitive test available. This
test assesses the presence or absence of the hepatitis C virus itself in the blood, and other body
tissue. It can detect minute traces of the HCV in any given medium. It works by taking a sample of
the blood and amplifying the nucleic acid associated with the virus many times.
This test does not rely on the forming of antibodies and may be able to detect the virus after only
three days of infection. Being PCR negative does not necessarily mean that HCV has disappeared completely; it may still be at undetectable levels in the blood, and it may still be present in liver cells and in certain white blood cells. Although PCR has these limitations it is probably the most useful single test that can be used to assess HCV.
• B-DNA for HCV. B-DNA tests for the presence of the virus in the blood, but is less sensitive than
the PCR test. It generates an estimate of viral loads above a certain level. PCR can detect as few or
less than 1000 genomes, while b-DNA only picks up levels over 350,000. It is often used as a
quick test to assess infectivity and viral load. A negative b-DNA test does not mean that you don't
have HCV in your blood. Results of these tests may have caused some confusion in some patients.
You can be b-DNA negative and PCR positive.
• Genotype Tests assess which specific genotype of Hepatitis C virus is present. HCV is actually a
remarkably heterogeneous family of viruses, with at least six distinct genotypes and numerous
subtypes. In this country, most patients (approximately 70%) are infected with type 1, which is
unfortunately less responsive to treatment than other genotypes. The usefulness of the test is
related to the bearing of genotype on prognosis and responsiveness to treatment.

Disease severity

Once the diagnosis is made, the severity of liver disease should be evaluated. The commonly used tools are
the ALT levels, liver function tests, abdominal ultrasound and histologic examination of samples obtained in a liver biopsy. The ALT is not a measure of how well the liver is functioning, but more a marker for the presence of inflammation. It correlates poorly with the degree of liver injury and cannot be used as a gauge for the progression of disease.

Liver Tests

Most liver function tests have a low level of sensitivity for the detection of mild to moderate liver disease. The prothrombin time, serum billirubin and albumin lack specificity and typically become abnormal only after irreversible liver damage or cirrhosis has developed.

Ultrasound

Examination of the liver by ultrasound is useful for detecting other liver diseases, but is not helpful in establishing the severity of ongoing infection or for assessing liver function. Ultrasound can't reliably differentiate a normal liver from one with chronic hepatitis, fibrosis or early cirrhosis. It is, however, useful as a screen for hepatoma (liver cancer), other benign liver tumors, and can often detect ascites (the accumulation of fluid within the abdomen) or possibly collateral venous circulation suggesting portal hypertension.

Liver Biopsy

The only accurate clinical method of determining the severity of liver disease is examination of tissue obtained on a liver biopsy. The assessment of the degree of inflammation and fibrosis present is important in establishing prognosis. A biopsy is not necessary to confirm the diagnosis of Hepatitis C, but it can be a great help to both physicians and patients in making treatment decisions.

Currently, Fibroscan has replaced the need for liver biopsy in most cases of hepatitis C.

Treatment

For the past several years, medical therapy for hepatitis C has taken tremendous strides forward. Currently, with the medications that are FDA approved for treating hepatitis C, we can achieve better than a 95% cure rate. Compared to prior treatments, most of which included interferon, these therapies, taken by mouth, are very well tolerated, with few side effects.

The current medications that are FDA approved include the following:

 

Glecaprevir and pibrentasvir (Mavyret)

Ledipasvir and sofosbuvir (Harvoni)

Simeprevir (Olysio)and sofosbuvir (Sovaldi)

Sofosbuvir and velpatasvir(Epclusa)

Sofosbuvir, velpatasvir, and voxilaprevir (Vosevi)

An excellent online source for hepatitis C treatment in various patient populations is available here as a resource.

Side effects

The new FDA approved drugs for hepatitis C, after 2015, have essentially no serious side effects. 5% of the patients report fatigue; 5% report headache.

What to expect from treatment

The goal of therapy to date has been the permanent eradication of the HCV from the liver. Until recently, it hasn't been clear if the absence of virus at six months would imply a long-term response. Additionally, the effect of viral clearance on the progression of liver injury has been unknown. Some of these answers are becoming available from long-term studies:

If the HCV is absent from the serum six months following therapy, it is very likely that it will remain absent in the long run.

Liver histology improves in virtually all patients that clear the virus permanently.

In patients with established cirrhosis that clear HCV, the risk of progressing to liver cancer appears to be significantly reduced.

The search for improved therapies for HCV continues. To date, antioxidants, including vitamin E, and milk thistle have been shown in small studies to reduce ALT levels in some patients, but do not appear to have any antiviral or histologic effect. No other conventional drug or herbal remedy has been proven in treating HCV.

Conclusion

HCV is the most common cause of chronic viral hepatitis in the United States, currently affecting four
million Americans. Left untreated, it may progress to cirrhosis, which in turn can lead to liver failure and
hepatocellular carcinoma (liver cancer). The course of chronic HCV is accelerated by alcohol intake and
can become worse if complicated by infection with Hepatitis A. Although they can have significant side
effects, current treatment regimens with interferon are completed by 90% of those participating and can
result in long term-sustained response.

HEPATITIS C

How can I avoid spreading HCV?

Get tested. The National Institutes of Health (NIH) recommend that people at risk, including spouses and close contacts of infected people, be tested for HCV infections. People with HCV should not donate blood, semen, organs or tissue. They should not share needles, toothbrushes, razors, nail files, tweezers or other instruments that can become tainted with blood. In addition, open wounds should be covered. Sex partners of infected people should be informed about the possible risk of infection. Safe sex practices, including using latex condoms, may be recommended, though this is an area of controversy among health professionals since sexual transmission -- especially between long-term, monogamous partners -- is low.

What about casual contact?

There is no evidence that the HCV virus can be spread through casual contact such as hugging, sharing meals or utensils. There is also no evidence that HCV is transmittable from mother to infant through breast milk.

Can I give my sexual partner Hepatitis C?

Safer sexual practices are strongly encouraged in persons with multiple sexual partners, including the use of latex condoms. In monogamous long-term relationships, transmission is rare. Although HCV-positive individuals and their partners should be informed of the potential for transmission, there are insufficient data to recommend changes to current sexual practice in persons with a steady partner. It is recommended that sexual partners of infected patients should be tested for the antibody to HCV.

Should my family be tested for Hepatitis C?

Ask your doctor. The likelihood is small that hepatitis C will spread to a family member; however, testing may ease a person's mind. Treatment is not generally prescribed for children with hepatitis C. While the children are being tested, screen for Hepatitis B and get everyone immunized if necessary.

How does alcohol affect the liver?

Alcohol is a toxic chemical that is mostly metabolized by the liver. When the liver metabolizes large quantities of alcohol over a period of time, the cells of the liver can change. For example, the cells may swell, scar or die. Cellular changes such as these, can lead to a variety of liver problems, ranging from an enlarged, fatty liver to cirrhosis, accompanied by liver failure. The degree of liver damage generally correlates to the quantity and duration of alcohol consumption. After repeated toxic insults from alcohol, the liver may no longer function properly. It may have a difficult time producing materials the body needs to be healthy, such as blood clotting factors, thus making an individual more susceptible to infections and diseases.

How can a drinker, especially a problem drinker, abstain from alcohol use after learning he or she
has Hepatitis C?

Many people drink alcohol socially or to relieve stress. Mineral water and fruit juices can be substituted for alcoholic beverages at parties and social functions. Stress management techniques that do not involve alcohol can be adapted, such as regular exercise, yoga, or a meditation routine. The transition from social drinking to problem drinking can be very subtle, and sometimes people do not realize they have grown addicted to alcohol until they try to stop drinking and find that difficult. In the United States, approximately 9% of adult males and 4% of females are addicted to alcohol.

How can an HCV-infected person with an alcohol addiction get help?

Tell your physician that you need help to stop drinking. Your physician can provide referrals. Depending on the severity of your drinking problem, you may be advised to enter a detoxification treatment program designed to monitor and assist your withdrawal from alcohol. These programs also evaluate your physical
and mental health, as well as any psychosocial, occupational and family stresses. If for example, depression is diagnosed, an alcohol-free treatment plan can be created to help you manage that condition. There are also many social support programs available, which your physician can tell you about. For example, Alcoholics Anonymous and other national programs are designed to provide social support to people committed to stop drinking.

The entire family can benefit from being educated about alcoholism and adapting healthy, alcohol-free ways to communicate and deal with stress. Social support programs, such as Al-Anon and Alateen, are available to family members and friends of problem drinkers.