Hepatitis C: Presentation, Diagnosis, Prevention

Since many patients with hepatitis C are asymptomatic, presentation may be incidental or fortuituos. Some patients may progress to the point of cirrhosis or even decompensated liver disease without any antecedent symptoms. Some patients may present with a wide variety of symptoms, not all necessarily due to hepatitis C. Some of the ways in which patients present are:

  • abnormal Ast or Alt on routine screening:
    – insurance exams
    – prenatal clinic
    – assessment for various symptoms, e.g. abdominal pain
  • positive anti hepatitis C on screening:
    – Blood donor clinics
    – Red Cross Lookback Program
  • contacts of positive case:
    – partner: but sexual transmission has a lifetime risk of about 3% and most partners have contracted hep C by sharing needles
    – children of positive mothers (Hepatitis Knowledge Network Vol.1 No. 2)
  • screening of high risk persons:
    – previous blood transfusion or blood products (prior to 1990)
    – previous or present IVDU
    – multiple sexual partners (particularly if other STD’s present)
    – previous body piercing, tattoos
    – snorting of cocaine with common straw
  • fatigue:
    – a small number of persons present with fatigue (subsequent newsletter)
  • evidence of liver disease:
    – spider angiomata
    – palmar erythema
  • decompensated liver disease:
    – cirrhosis
    – portal hypertension with varices and ascites
  • autoimmune diseases accentuated by hep C:
    Although this means of presentation is not common, some presenting conditions are: – arthritis
    – lichen planus
    – diabetes
    – thrombocytopoenia

Diagnosis

Although the diagnosis of chronic hepatitis C can be made by checking for the antibodies and determining the presence of the HCV RNA, patients must be thoroughly assessed relative to their liver disease and other complications. A good progressive approach is as follows:

  • a medical history of risk factors and symptoms
  • a history of liver disease:
    – jaundice, pale stools, dark urine
    – bleeding (nose bleeds, bleeding gums), bruising
    – pruritus
    – abdominal swelling, peripheral oedema
  • examination for signs of liver disease:
    – spider angiomata
    – jaundice
    – gynecomastia, loss of body hair
    – hepatomegaly
    – testicular atrophy
    – nail changes
  • examination for signs of portal hypertension:
    – splenomegaly
    – varices
    – abdominal and chest wall veins
    – ascites with or without peripheral oedema
  • hematological tests indicating liver disease:
    – thrombocytopoenia (and possibly neutropoenia)
    – prolonged INR or prothrombin time
    – macrocytic anemia, often with target cells biochemical tests of liver disease: – Ast, Alt over one and a half times normal for three months (alkaline phosphatase and gamma GT are cholestatic enzymes not hepatocellular enzymes)
    – decreased albumin
    – elevated bilirubin
    – polyclonal increase in gamma globulins serological tests for hepatitis C:
    – antibody poistive (anti hepatitis C by ELISA then by RIBA)
    – HCV RNA (usually by PCR, qualitative adequate)
    rule out other causes of liver disease: (subsequent newsletter)
    pathological confirmation by liver biopsy: (subsequent newsletter)

Prevention:

Treatment is important, prevention is vital. Hepatitis C is spread predominantly by blood to blood and other ways are infrequent. Logical means of prevention are:

  • personal health measures:
    – avoid sharing toothbrushes, razors, etc.
    – avoid unprotected sex during menstrual period (Hepatitis Knowledge Network Vol.1 No. 2)
    – clean all blood contamination with bleach
    – cover open sores and burns with a bandage
  • ¬†general health measures:
    – do not share needles or rigs
    – do not share straws to snort cocaine
    – avoid unprotected, promiscuous sex
    – only use tattoo parlours which use disposable needles
    – do not share body piercing needles

Alcohol:

Consumption of alcohol makes hepatitis C more active and progress more rapidly. Thus, all patients with chronic hepatitis C should be advised to minimize, if not eliminate, alcohol use.

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