Hepatitis C: symptoms

Hepatitis C is an inflammation of the liver caused by a virus (Hepacivirus, HCV) that, penetrating inside the liver cells, causes the immune system to recognize them as something foreign to the body and induce cell death, called liver necrosis. The dead cells are gradually replaced by scar tissue, giving rise to the process of liver fibrosis that determines the progressive loss of liver function.

As a result of infection, about 60-70 percent of individuals become chronic carriers of the virus. Iron overload, fatty liver disease (“fatty liver”, i.e. accumulation of triglycerides in liver cells), obesity and diabetes may contribute to a more rapid progression of liver disease.

Once scar tissue replaces much of the healthy component of the liver, hepatitis evolves into cirrhosis of the liver, with severe impairment of its activities, up to the risk of liver cancer. There may also be extra-hepatic manifestations, such as mixed cryoglobulinemia (inflammation of small blood vessels) and thyroid disease.

The characteristics of the virus

Hepacivirus was identified in 1989, but its existence had already been discovered in the 70s, since it determined a form of hepatitis different from the already known hepatitis A and B (caused by the HAV and HBV viruses) and therefore called non-A, non-B. Subsequently, seven viral variants of HCV were identified, characterized by specific genotypes, differently distributed in the world and with different response to antiviral therapies: the definition of the genotype is therefore fundamental to establish the type and duration of therapy.

How widespread is hepatitis C

«Hepatitis C affects about 1-2% of the world population, which corresponds to about 150 million infected individuals“, explains Stefano Fagiuoli, director of the Gastroenterology, Hepatology and Transplantology Unit of the Papa Giovanni XXIII Hospital, Bergamo.

“Some estimates – continues the expert – indicate that there would be about one million subjects infected with the HCV virus in Italy; However, the real value is difficult to quantify due to the lack of valid epidemiological data. The only verified data reports that the patients formally followed and registered by specialized health care centers are about 300,000, of which 75,000 have already been treated; while it is not possible to quantify undiagnosed cases”.

«Every year almost 1,000 new cases of HCV infection occur in our country. The objective of eliminating hepatitis C can only be achieved by combining the treatment of all known cases with the identification, as far as possible, of cases of “submerged” infection.’

Italy is the European country with the highest number of people positive for the hepatitis C virus and the southern regions are the most affected (Campania, Puglia and Calabria). In recent decades, the incidence has significantly decreased in Western countries, due to greater safety in blood transfusions and improved health conditions.

Routes of transmission of the virus

In Europe, intravenous drug use, with syringes contaminated with infected blood, has become the main risk factor for HCV transmission.

However, the disease can also be contracted through:

– the execution of tattoos and body piercings in unhygienically protected environments or with non-sterilized instruments

– transmission of the infection perinatally to your child

– transfusion of unscreened blood

– cuts/punctures with infected needles/instruments in hospital settings

– the sharing of devices for taking inhalable drugs and contaminated toothbrushes or bath brushes (high eventuality for example in prisons, where information and prevention campaigns of the disease have been launched) in the presence of minimal lesions of the skin or mucous membranes.

Finally, although hepatitis C is not easily transmitted sexually, unprotected intercourse and intercourse with multiple partners increases the risk.

Symptoms

The acute phase of hepatitis C virus infection is almost always asymptomatic, so much so that the disease is called a “silent killer” because it does not immediately undermine health, at least in appearance.As soon as the infection is contracted, the patient may experience fever, fatigue, loss of appetite, stomach pain, dark urine, jaundice, nausea and vomiting, muscle and joint pain, lack of concentration, anxiety and depression. But they are usually transient symptoms and for many years the disease does not give signs of itself.

Chronic hepatitis, which occurs in more than 70% of patients, can manifest itself with alteration of the normal value of transaminases and with the onset of liver fibrosis.

Complications

Chronic hepatitis C can involve:

– the formation of varicose veins in the esophagus and stomach, which, when broken, cause bleeding;

– enlargement of the spleen, resulting in anemia, drop in white blood cells and platelets;

– jaundice (accumulation of bile pigment in the subcutaneous);

– ascites (accumulation of fluid in the abdomen);

– the reduction of urinary function, with concomitant increase in creatinine and azotemia.

– hepatic encephalopathy (accumulation in the brain through the blood of toxic substances that the liver can no longer dispose of), which causes brain malfunction up to a confused state and coma.

In addition, hepatitis C is the leading cause of cirrhosis, liver cancers, liver transplants and deaths in patients also infected with the HIV virus. In fact, 20 percent of HCV-positive people are co-infected with HIV. The two infections are associated in particular in drug addicts.

Diagnosis

Routine blood tests are not always able to identify HCV infection: if you believe you are exposed to the risk of the virus, consult your doctor.

The specific diagnostic tests are:

Test	Purpose
Alanine amino transferase (ALT) and aspartate transaminase (AST) tests	The increase in these two specific enzymes (also known as GPT and GOT) signals the presence of the virus in the blood.
Elisa (Enzyme Linked Immunosorbent Assay) and Risa (Recombinant Immunoblot Assay) tests	They measure the levels of specific antibodies produced by the body in response to the attack of the virus
Test PCR (Polymerase Chain Reaction)	Detects the genetic material of the virus in biological samples, once the presence of antibodies in the blood has been determined
Restriction Fragment Lenght Polymorphism (RFLP) Test	Determine virus genotypes

Once diagnosed, a liver biopsy can be performed, to determine the degree of inflammation of the liver, the possible presence of fibrosis and the stage of the disease. To determine the severity of fibrosis, liver elastography (a non-invasive measurement system of the “stiffness” of liver tissue) is used by fibroscan. The examinations remain essential for monitoring the progress of the disease and treatment.

How hepatitis C is treated

The goals of therapies are to inactivate the virus, stop the progression of the disease and prevent liver cancer. The type and duration of treatment depends on several factors: the genotype of the virus, the stage of fibrosis, body mass index (BMI), etc.

For decades, treatment has been based on so-called “dual therapy”, a combination of interferon and ribavirin. Scientific research on new molecules has allowed the development of first-generation direct-acting antivirals (DAAs). In addition, a “triple therapy” (pegylated interferon, ribavirin and a protease inhibitor, IP) has been made available for patients with genotype 1 hepatitis C, which allows the eradication of the virus through an innovative mechanism of action.

Recently, the development of the second generation of direct-acting antivirals has further improved the available therapeutic options allowing the successful treatment of genotypes other than 1, in many cases with a shorter treatment duration and an excellent safety profile.

Available medications

The first of the innovative direct-acting antiviral medicines (DAAs) has been available since December 2014, but for years it has been reimbursable by the National Health System only for some patients, selected on the basis of a series of priority criteria established by Aifa (Italian Medicines Agency). “Since 21 March 2017, with the determination No. 500, AIFA has however extended access to care to all patients for whom the therapy is indicated and appropriate, removing any previous limitation“, explains Stefano Fagiuoli.

“This is an epochal turning point,” comments Ivan Gardini, president of the EpaC onlus association. “The conditions are created to definitively fight a disease that causes about 10,000 deaths a year in our country. A result that places us among the top ten nations in the world to guarantee unlimited access to anti-hepatitis C care”.

The personalization of therapy

Further therapeutic options and combinations, even more effective and with a better tolerability and safety profile, are already available or will be soon, allowing an ever greater personalization of care according to the characteristics of the patient.

Massimo Galli, full professor of Infectious Diseases, University of Milan, explains: “It is not just a question of genotype, the specific therapeutic needs that characterize the different populations of patients with hepatitis C constitute a real “mare magnum”. Different degrees of fibrosis, cirrhosis, HCV-HIV co-infection, comorbidities of different entities (diabetes, caridovascular diseases, kidney damage), previous treatment failures: there are many conditions that can further complicate the clinical picture of a patient with HCV and require particular caution in the definition of therapy».

Nutrition

in case of HCV infection, the only recommendation on the food plan is the complete abstention from spirits (wine, beer, spirits): alcohol accelerates the development of liver fibrosis and viral replication. Before starting treatment, it is advisable for those who are overweight to undergo a diet, for a better response to antiviral therapy.

Is there a vaccine for hepatitis C?

There is no vaccine for hepatitis C because the virus is fast and aggressive and when it replicates it changes continuously, managing to evade the body’s immune system. However, hepatitis C patients are advised to be vaccinated against hepatitis A and type B, in order to avoid the overlapping of infections that would accelerate liver impairment.