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Hepatitis C

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Overview

The hepatitis C (HCV) virus is an RNA virus spread through exposure to infected blood or bodily fluids, and through vertical transmission from mother to child. It may lead to a self-limiting disease but can result in chronic hepatitis C which can predispose to liver cirrhosis and hepatocellular cancer.

The incubation period of HCV is around 6-9 weeks. There is no vaccine for hepatitis C.

Epidemiology

  • Hepatitis C may be undiagnosed as it can remain asymptomatic for many years after infection
  • Hepatitis C is found worldwide but its prevalence is not evenly distributed

Risk Factors

  • Close contact with people infected with HCV
  • Injecting intravenous drugs
  • High-risk sexual behaviours (e.g. unprotected sex with multiple partners)
  • Family history
  • Infants born to mothers with HCV

Presentation

Many patients are asymptomatic until liver cirrhosis, failure, or hepatocellular carcinoma develops. Features seen may include:

  • Flu-like prodrome: fever, chills, malaise, joint pain
  • Nausea and vomiting
  • Right upper quadrant pain
  • Jaundice
  • Tender hepatomegaly
  • Palmar erythema
  • Spider naevi
  • Ascites
  • Asterixis

Differential Diagnoses

Acute hepatitis A

  • Although there is no significant difference in presentation, hepatitis A is transmitted via the faecal-oral route. An example risk factor can be eating and drinking in unhygienic places

Acute hepatitis E

  • Although there is no significant difference in presentation, hepatitis E is transmitted via the faecal-oral route. An example risk factor can be eating and drinking in unhygienic places
  • Hepatitis E classically affects pregnant people

Investigations

  • Liver function tests:
    • In acute hepatitis C:
      • Bilirubin – increased (usually >85 µmol/L)
      • ALT, AST – increased (usually 500 – 10,000 IU/L) and ALT > AST
      • ALP – may be raised to up to 2 times the upper limit of normal
    • In chronic hepatitis C, AST and/or ALT may be slightly elevated or normal
  • Hepatitis C RNA testing:
    • If positive, send a repeat test for confirmation of infection
    • If negative, send a repeat test after 6 months. If still negative, then the person has cleared the infection but is not immune to reinfection.

Management

Overview

  • 1st-line: refer to gastroenterology/hepatology and notify Public Health England
  • Antivirals are given depending on the HCV genotype which is tested before treatment.

Monitoring

  • Patients are followed up by specialists and regularly have liver function tests and HCV RNA testing to assess their response to treatment.

Patient Advice

  • Patients should avoid drinking alcohol as this can increase the risk of cirrhosis and hepatocellular carcinoma
  • Patients should take steps to minimise transmission to other people:
    • Avoid sharing items that may be contaminated with blood (e.g. toothbrushes and razors)
    • Avoid unprotected sexual intercourse including oro-anal or oro-genital sex until they have become non-infectious or their partner has been immunised
    • Avoid sharing needles
    • Avoid donating blood, semen, or organs

Complications

  • Acute hepatitis C can lead to fulminant hepatitis (<1%)
  • Chronic hepatitis can develop in around 50-85% of patients

Prognosis

  • The prognosis varies significantly and depends on the severity of liver fibrosis

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