Gastroenterology & Hepatology
Question 10 of 73
A 28 year old man is brought to the Emergency Department after being found unresponsive in a nearby playpark. On examination you note evidence of intravenous drug use. On checking the patient's records you find he was found to be positive for hepatitis C on a previous admission. Regarding hepatitis C, which of the following statements is CORRECT?
Answer:
Hepatitis C is a notifiable disease. Acute HCV infection refers to the presence of HCV immediately following incubation to within 6 months of acquiring the infection. Most people (more than 60%) are asymptomatic. Chronic HCV infection follows acute infection in 55–85% of people, and refers to the continued presence of HCV 6 months or more after acquiring infection. Chronic HCV infection rarely resolves spontaneously and can lead to complications, such as liver cirrhosis and hepatocellular carcinoma. The hepatitis C virus (HCV) is transmitted by contact with infected blood or blood-derived products. Direct-acting antivirals (DAAs) are now considered first-line treatment. DAAs target different stages in the HCV lifecycle and are successful for over 90% of people with HCV infection.Hepatitis C
Gastroenterology & Hepatology / Sexual Health
Last Updated: 12th February 2021
Hepatitis C infection is a slow, progressive disease of the liver caused by infection with the hepatitis C virus (HCV).
- Acute HCV infection refers to the presence of HCV immediately following incubation to within 6 months of acquiring the infection. Most people (more than 60%) are asymptomatic.
- Chronic HCV infection follows acute infection in 55–85% of people, and refers to the continued presence of HCV 6 months or more after acquiring infection. Chronic HCV infection rarely resolves spontaneously and can lead to complications, such as liver cirrhosis and hepatocellular carcinoma.
Transmission
The hepatitis C virus (HCV) is transmitted by contact with infected blood or blood-derived products.
- Parenteral spread accounts for the majority of cases of HCV in the UK.
- Sharing of needles or other injecting paraphernalia in people who inject drugs (PWID) is the most common route of parenteral transmission.
- Transfusion of infected blood or blood products (before 1991 and 1986, respectively, when screening of blood donors for HCV infection or heat treatment for inactivation of viruses were introduced).
- Re-use or inadequate sterilisation of medical equipment.
- Needlestick or other sharps injuries.
- Exposure to infected blood, for example through sharing personal items that may have blood on them (such as razors or toothbrushes), body modification (tattooing and body piercing), or through occupational and other means.
- In developing countries, where sterile medical supplies are short or non-existent, routine injections and medical/dental procedures may confer a high cumulative lifetime risk of acquiring HCV.
- Sexual transmission of HCV occurs infrequently in monogamous, heterosexual relationships. The risk is increased in people with multiple partners or those at risk for sexually transmitted infections (STIs), in HIV-positive people (particularly in men who have sex with men), and with risky sexual practices (for example anal sex).
- Vertical transmission of HCV from mother to baby generally occurs at a low rate.
Clinical features
Clinical features may include:
- Non-specific fatigue, myalgia, anxiety, depression, poor memory or concentration (may be indicative of chronic hepatitis C infection).
- Nausea and vomiting.
- Right upper quadrant abdominal pain.
- Jaundice (with dark urine and/or pale stools if cholestasis).
- Signs of chronic liver disease (in advanced chronic hepatitis C).
Note that only 25–35% of people experience symptoms in the early stages of infection, and infection occurs after an incubation period. Therefore, a person may not connect their present symptoms to the time of risk exposure.
HCV infection is diagnosed with an antibody test (which indicates if a person has ever been infected with HCV) and HCV ribonucleic acid (RNA) test (to check if HCV infection is active and for genotype analysis).
Management
- Referral
- If acute hepatitis C virus (HCV) infection is suspected (hepatitis C antibody positive with clinical features of acute hepatitis and/or a likely recent source of transmission is identified), arrange a same-day assessment or seek immediate specialist advice.
- If chronic HCV infection is suspected (hepatitis C antibody positive and ribonucleic acid positive with no clinical features of acute hepatitis), arrange an urgent referral.
- Advice
- Measures to reduce the risk of disease progression, such as stopping smoking
- Measures to prevent the spread of the infection, such as not sharing razors, toothbrushes, toiletries, or other items that may be contaminated with blood e.g. drug paraphernalia
- The risk of sexual transmission, which is greater in people co-infected with HIV and with risky sexual practices (for example anal sex)
- Partner notification and contact tracing
- Sources of additional information and support
- Notify the local Health Protection Team of suspected cases of acute viral hepatitis by completing a notification form immediately.
- Specialist management
- Acute infection
- Around 15–45% of people with acute hepatitis C virus (HCV) infection spontaneously clear the virus within 6 months of infection without any treatment.
- If needed, treatment should be started promptly. There is clear evidence that treatment given during the acute phase is more likely to clear infection and reduces the risk of chronic HCV infection and progression of liver disease than treatment in the chronic phase. Treatment should be the same as for chronic infection.
- Chronic infection
- All people with chronic HCV infection should be considered for antiviral therapy, which is always initiated by a specialist. The goal of treatment is to eradicate the virus, achieve a sustained virological response (SVR), and prevent disease progression. SVR (undetectable HCV RNA in the blood 12 weeks after treatment completion) is considered equivalent to a cure.
- The treatment regimen and duration will depend on the HCV genotype, viral load, severity of liver disease, prior HCV treatment history, the presence of comorbidities, and the person's ability to tolerate treatment. Direct-acting antivirals (DAAs) are now considered first-line treatment. DAAs target different stages in the HCV lifecycle and are successful for over 90% of people with HCV infection.
- Acute infection
Complications
- Acute hepatitis C virus (HCV) infection may rarely lead to fulminant hepatitis (less than 1% of all people).
- Chronic HCV infection can lead to liver cirrhosis, liver failure, and hepatocellular carcinoma (HCC), if untreated.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
