NewYork-Presbyterian. The University Hospital of Columbia and Cornell.

Digestive Diseases

Hepatitis C

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About Hepatitis C

Viral hepatitis is caused by one of five known viruses, hepatitis A, B, C, D, and E. Hepatitis C is a serious disease caused by the hepatitis C virus (HCV), which affects the liver and accounts for most cases of viral hepatitis in the US. Approximately 4.1 million Americans, or 1.6% of the population in this country are infected with HCV, and of these, about 3.2 million are chronically infected.

HCV accounts for approximately 15% of cases of acute viral hepatitis, 60-70% of cases of chronic viral hepatitis, and nearly 50% of cases of cirrhosis, end-stage liver disease, and liver cancer. Men, alcoholics, patients with cirrhosis, individuals over age 40, and those with HCV for 20-40 years have a higher risk of HCV-related liver cancer.

New infections have declined from about 240,000 per year in the 1980s to approximately 19,000 annually in 2006.

Infection with HCV causes lifelong, chronic infection in about 75%-85%, cirrhosis (scarring and dysfunction of the liver) in about 20% after about 10-20 years, liver cancer, and can also cause liver failure and death. Infection with HCV is the most common indication for liver transplant. There is currently no vaccine for HCV.

Symptoms of Hepatitis C

Many individuals chronically infected with HCV do not have any symptoms, and may have normal blood tests. Others may feel like they have the flu, with fever, fatigue, nausea, lack of appetite, or mild upper-right abdominal pain or discomfort, or diarrhea, and may have elevated liver enzymes as indicated in their blood tests. Others may only have mild symptoms, and moderate elevations of liver enzymes.

Individuals with more advanced disease may have jaundice (yellowish tint to skin and/or eyes), light-colored stools, or darker urine. If HCV infection is advanced and cirrhosis is present, patients usually experience fatigue, weakness, itching, dark urine, fluid buildup in the legs (edema) or abdomen (ascites), nausea, and little appetite. Advanced HCV infection may involve organs and systems other than the liver, and may cause complications such as skin rashes, kidney disease, neuropathy, and joint and muscle aches.

Patients with acute hepatitis may have symptoms of jaundice, nausea and fatigue, elevations in one liver enzyme, and tests may show the presence of HCV antibodies. However, diagnosis of acute HCV may be difficult because HCV antibodies, while definitive for infection status, may not be present when the patient has acute, symptomatic HCV infection, but only appear only 2-8 weeks after symptoms had manifested. If our physicians suspect acute HCV infection, she or he will recommend a PCR test for HCV RNA, or an antibody test a month after symptoms begin.

Risk Factors for Hepatitis C

HCV is most often spread via the blood of an infected individual. Most cases of HCV are due to intravenous drug use (sharing needles with a person infected with the virus), receiving blood clotting factors produced before 1987, or receiving a blood transfusion or organ donation before 1992, the year blood donations and transplanted organs began to be screened for HCV.

Others at lower risk for the virus include patients on long-term kidney hemodialysis, healthcare workers exposed to accidental needle sticks, and babies born to HCV-infected mothers (the risk for transmission is about 4%). Other, lesser risk factors include having sex with, or sharing razors or toothbrushes with an infected individual, and getting a tattoo from infected equipment. Having sex with a partner with a sexually transmitted disease or multiple partners increases the risk of contracting HCV if one partner is infected with the virus. Sporadic transmission – cases in which the source of the infection is not known, accounts for about 10% of acute HCV and 30% of chronic cases of this infection.

In contrast to HCV cases in the US, HCV in the developing world is usually spread via medical procedures, including non-sterile vaccinations and blood transfusions performed with reused medical equipment.

There are six known variations, or genotypes of HCV and about 50 subtypes of HCV. Physicians test patients for each genotype to determine what type of antiviral drug therapy is likely to be most effective. Most patients in the US are genotype 1a or 1b, and genotype 2 and 3 account for 10-20% of patients.

Diagnosis of Hepatitis C

Our liver specialists will perform a physical examination to determine whether the liver or spleen is enlarged or if tenderness is present. A number of blood tests will determine if someone is infected with HCV. They may include:

• an enzyme immunoassay, or EIA antibody test
• a recombinant immunoblot assay, or RIBA if the EIA is positive
• a PCR test to detect the presence of viral RNA, and second test to determine the amount, or titer of the virus in the blood
• a blood test to check platelet and white blood cell counts
• liver biopsy – some patients may also have a liver biopsy, which a physician performs using an ultrasound-guided thin needle placed in the abdomen. The physician extracts a very small piece of the liver via the needle, which our pathologists check to determine if the liver is damaged, and if so, to what extent.

In addition, physicians may perform a computed tomography (CT or CAT) scan, ultrasound, or magnetic resonance imaging (MRI) to determine if liver damage is present.

Treatment for Hepatitis C

Combination drug therapy with the antiviral drug, ribavirin, and pegylated interferon (a type of interferon treated to remain in the body longer) is the approved treatment for HCV. Patients with genotype 2 and 3 will usually have 24 weeks of combination therapy, and those with genotype 1 – the most common type – usually receive 48 weeks of treatment.

Side-effects of interferon treatment include flu-like symptoms, such as chills, fever, headache, rapid heartbeat, and muscle and joint pain when first treated. Subsequent side-effects may include fatigue, cognitive problems, depression, irritability, and low blood count. More severe side-effects are rare, and include hearing loss, lung problems, suicidal thoughts, seizures, worsening of liver disease, and acute kidney or heart failure. About 40% of patients will require a reduction in interferon dose because of severe side-effects, and about 15% stop treatment.

Side-effects of combination treatment include severe anemia and kidney failure.

Our physicians monitor patients with HCV regularly with blood tests and sometimes, liver biopsy. Patients with hepatitis C should not drink any alcohol – even modest amounts – eat a healthy diet, exercise moderately, and get sufficient rest. They should also not take any over-the-counter medicines or herbal remedies without consulting their physician, as they may be toxic to the liver.

Research for Hepatitis C

Patients with viral hepatitis, and in particular, hepatitis B and C, benefit from research carried out by members of the NewYork-Presbyterian team. We are home to the Center for the Study of Hepatitis C, a collaborative research and treatment partnership comprised of physicians and researchers from Weill Cornell Medical College, Rockefeller University, and NewYork-Presbyterian Hospital. The Center has a serum and tissue repository, and a database with blood and liver samples of over 1,500 patients.

The Center for the Study of Hepatitis C also works closely with our Hospital's Center for Special Studies, which treats about 5,000 HIV-infected patients, and with the Methadone Clinic, which sees about 400 patients. Many of these patients are also infected with hepatitis.

Additionally, NewYork-Presbyterian has one of the nation's most extensive clinical trials programs. Our physicians have led and participated in several of the key clinical trials that have advanced the treatment and management of hepatitis C, including those trials that have defined the current standard of treatment of ribavirin and pegylated interferon.