An estimated 3 percent of the world's people carry a virus that silently attacks their livers. Most people infected with the hepatitis C virus (HCV) have no symptoms at all. In fact, most people don't know they have the disease until liver damage shows up, decades later, during routine medical tests.
Hepatitis C is one of six identified hepatitis viruses — the others are A, B, D, E and G. All cause the liver to become inflamed, which interferes with its ability to function. Hepatitis C is generally considered to be among the most serious of these viruses.
Over time, hepatitis C infection can lead to liver cancer, liver failure or cirrhosis — irreversible and potentially fatal scarring of the liver. Unlike HIV, the virus that causes AIDS, the hepatitis C virus usually isn't transmitted through sexual contact. Instead, its primary mode of transmission is contaminated blood — through needles shared by drug users or through blood transfusions.
Although vaccines exist for hepatitis A and B, no vaccine for hepatitis C has been developed. Researchers hope to find a medication that will inhibit the growth of the virus and prevent long-term complications, such as cirrhosis and cancer, from developing.
Signs and symptoms
Normally, hepatitis C infection produces no signs or symptoms during its earliest stages. When it does, they're generally mild and flu-like and may include:
- Slight fatigue
- Nausea or poor appetite
- Muscle and joint pains
- Tenderness in the area of your liver
Even if you develop chronic hepatitis from the hepatitis C virus, you may have few, if any, symptoms. In many cases, symptoms may not appear for decades. Sometimes, though, you may experience one or more of the following:
- Lack of appetite
- Nausea and vomiting
- Persistent or recurring yellowing of your skin and eyes (jaundice)
- Low-grade fever
Hepatitis C can cause damage to your liver, even if you don't have symptoms. You're also able to pass the virus to others without having any symptoms yourself. That's why it's important to be tested if you think you've been exposed to hepatitis C or you engage in behavior that puts you at risk.
In general, you contract hepatitis C by coming in contact with blood contaminated with the virus. Most people with hepatitis C became infected through blood transfusions received before 1992, the year improved blood-screening tests became available.
You can also contract the virus by injecting drugs with contaminated needles and, less commonly, from contaminated needles used in tattooing and body piercing. Needle exchange programs, which increase the availability of sterile needles, are helping to reduce the risk of hepatitis C, HIV and other blood-borne diseases.
A small percentage of babies born to mothers with hepatitis C acquire the infection during childbirth. Mother-to-infant transmission rates are higher among women infected with both hepatitis C and HIV. Talk with your doctor about these risks before becoming pregnant.
In rare cases, hepatitis C may be transmitted sexually. And in many people infected with hepatitis C, no risk factor can be identified.
Effective blood-screening procedures have greatly reduced the chances of HCV infection from transfusions. But if you received a blood transfusion before 1992, you're at risk of hepatitis C.
You are also at risk if you:
- Have used illicit intravenous (IV) or intranasal drugs, such as cocaine
- Received an organ transplant before 1992
- Are a health care worker who has been exposed to infected blood
- Received clotting factor concentrates before 1987 or have the clotting disease hemophilia and received blood before 1992
- Are receiving hemodialysis for kidney failure
When to seek medical advice
See your doctor if you think you may have been exposed to the hepatitis C virus, if you notice your skin or eyes turning yellow or if you have any other symptoms of hepatitis. Don't let your concern about what others may think keep you from getting medical care.
If you received a blood transfusion before 1992 from a donor who later tested positive for the hepatitis C virus, you may have received a letter from your hospital or blood bank recommending that you be screened.
If you're being treated for hepatitis, see your doctor right away if you develop any of the following signs and symptoms:
- Increased drowsiness, confusion or irritability
- Vomiting, diarrhea or abdominal pain
- Increased jaundice
- Skin rash
- Loss of appetite
Screening and diagnosis
A blood test can determine whether you have hepatitis C. If test results indicate that you have HCV, your doctor may measure the quantity of the virus in your blood (viral load) and evaluate the genetic makeup of the virus (genotype). There are six known HCV genotypes. Knowing which genotype you have will help your doctor determine the best course of treatment for you and how likely you are to respond to treatment.
Your doctor may also recommend a liver biopsy, a procedure in which a small sample of liver tissue is removed for microscopic analysis. Before the biopsy, you'll receive a local anesthetic to decrease the pain. Your doctor then inserts a thin needle into your liver to remove the tissue sample. Liver biopsy is unlikely to have any complications, although you may have some pain or bleeding afterward. Rarely, significant bleeding can occur.
Although a biopsy isn't necessary to confirm a diagnosis of hepatitis C, it can help determine the severity of the disease and guide treatment decisions. It may also help rule out other causes for your liver problem, such as alcoholic or drug-induced hepatitis, autoimmune hepatitis or excess iron (hereditary hemochromatosis).
A small number of people infected with hepatitis C fight off the virus on their own without any permanent damage. For the rest, the disease settles in and slowly attacks the liver, although even then, the course of the disease can vary greatly from person to person.
Most people infected with HCV develop chronic hepatitis. Some people infected with hepatitis C develop cirrhosis, usually within two decades after infection. Of those who develop cirrhosis, about one-third progress to liver failure within 10 years. In addition, between 1 percent and 5 percent of people with HCV eventually develop liver cancer.
Rarely, HCV infection can be associated with skin and kidney problems. The hepatitis C virus is linked to an increased risk of porphyries catenae trade, a condition that may cause a blistering rash, and to cryoglobulinemia, which can cause a purplish rash (purport) on your lower extremities and may lead to kidney damage.
A normal liver (left) shows no signs of scarring. In cirrhosis (right), scar tissue replaces normal liver tissue.
A diagnosis of HCV doesn't necessarily mean you need treatment. The National Institutes of Health recommends treatment for HCV if you have:
- A positive test result indicating hepatitis C virus circulating in your bloodstream
- A biopsy that indicates significant liver damage
- Elevated levels of a liver enzyme called alanine aminotransferase (ALT) in your blood
Even so, doctors continue to debate who needs treatment. If you have only slight liver abnormalities, your doctor may decide against medical treatment because your long-term risk of developing a serious disease is slight, and the side effects of treatment can be severe.
On the other hand, because there's no foolproof way to know whether you'll develop liver disease later on, your doctor may recommend fighting the virus. Improved treatment methods and a higher success rate in fighting hepatitis sometimes tip the argument in favor of more aggressive approaches.
The standard of care for hepatitis C treatment is weekly injections of a drug called pegylated interferon alfa combined with twice-daily oral doses of ribavirin (Rebetol) — a broad-spectrum antiviral agent. Two pegylated interferon medications are available, peginterferon alfa-2b (Peg-Intron) and peginterferon alfa-2a (Pegasys).
The goal of HCV treatment is to clear the virus from your bloodstream. Combined pegylated interferon and ribavirin clear HCV infection in up to half of people with genotype 1 — the most common genotype found in the U.S. — and in up to 80 percent of those with genotypes 2 and 3.
If you have genotype 1 HCV, your doctor may recommend a course of relatively high-dose medications for 48 weeks. If you have genotype 2 or genotype 3, a 24-week course of medications at a lower dose may be adequate.
If one course of combined pegylated interferon and ribavirin doesn't clear HCV from your bloodstream, your doctor may recommend a second course of combination therapy. If your viral load declined during the first round of medications, a second round may clear the virus completely. Even if there was no change in your viral load during the first course of treatment, a second course may help reduce the damage HCV does to your liver.
Side effects of medications
Side effects from interferon include severe flu-like symptoms, irritability, depression, concentration and memory problems and insomnia. Ribavirin can cause a low red blood cell count (anemia), gout and birth defects. Both drugs can cause skin irritation and extreme fatigue.
A small number of people taking combined pegylated interferon and ribavirin may experience psychosis or suicidal behavior. For this reason, treatment with interferon isn't recommended if you have a history of uncontrolled major depression. You're also not a good candidate for this treatment if you have untreated thyroid disease, low blood cell counts or autoimmune disease, or if you drink alcohol or use drugs and are unwilling to stop or seek help with stopping.
Side effects from combined pegylated interferon and ribavirin are generally most severe during the first weeks of treatment, and may be improved with pain relief medications and antidepressants. However, some people taking interferon need their dosage reduced because of severe side effects, and others must stop treatment altogether.
The best treatment for people with end-stage liver disease is liver transplantation. However, the number of people awaiting transplants far exceeds the number of donated organs. But several new developments in transplantation may make it possible for more people to receive the organs they desperately need.
These developments include the donation of liver segments from living relatives, splitting one donated liver between two recipients, new organ allocation policies and, especially, new approaches to liver transplants for people with HCV.
Until recently, HCV-infected livers were routinely discarded. But studies show that people already infected with HCV who receive livers from HCV-positive donors can do as well as if they had received a liver not infected with the virus. This may mean that many more livers will become available for people with hepatitis C.
Liver transplantation does not cure HCV. The majority of people with hepatitis C who receive liver transplants experience a recurrence of the virus. Those with HCV who receive liver transplants also are at greater risk of developing cirrhosis within five years than are people with HCV who don't receive a transplant. Treatment with HCV-fighting medications may help prevent a recurrence of infection or treat recurrent illness that develops after a liver transplant.
Because no effective vaccine for hepatitis C exists, the only way to protect yourself is to avoid becoming infected. That means taking the following precautions:
- Avoid risky sexual behavior. Don't engage in unprotected sex with multiple partners or with one partner whose health status is uncertain.
- Avoid illegal drug use. Don't share needles or other drug paraphernalia. Contaminated drug paraphernalia is responsible for more than half of all new hepatitis C cases. Avoid nasal use of cocaine.
- Avoid body piercing and tattooing. If you do undergo piercing or tattooing, be absolutely certain the equipment is sterile.
If you receive a diagnosis of hepatitis C, your doctor will likely recommend certain lifestyle changes. These measures will help keep you healthy longer and protect the health of others as well:
- Eliminate alcohol consumption. Alcohol speeds the progression of liver disease.
- Avoid medications that may cause liver damage. Your doctor can advise you about these medications, which may include over-the-counter (OTC) medications such as acetaminophen (Tylenol, others) as well as prescription drugs.
- Maintain a healthy lifestyle. Be sure you exercise regularly, get plenty of rest and eat a healthy diet that emphasizes fresh fruits, vegetables and whole grains.
- Help prevent others from coming in contact with your blood. Cover any wounds you may have and don't share razors or toothbrushes. Don't donate blood, body organs or semen, and advise health care workers that you have the virus.
Complementary and alternative medicine
In Europe, the herb milk thistle (Silybum marianum) has been used for centuries to treat jaundice and other liver disorders. Today, scientific studies have confirmed that the chief constituent of milk thistle, silymarin, may aid in healing and rebuilding the liver. Silymarin seems to stimulate the production of antioxidant enzymes that help the liver neutralize toxins. It also seems to increase the production of new liver cells and may even improve the severe scarring of cirrhosis.
These benefits have not been proved in people with hepatitis C, however. Furthermore, although milk thistle may help the liver, it will not cure hepatitis C nor will it prevent the disease from recurring.
Milk thistle is available in capsule or alcohol-free extracts. Check with your doctor before trying this or any other herb to make sure it won't interact with other medications you're taking.