Hepatitis C: clinical features, causes, diagnosis, treatment

Hepatitis C is a liver disease. It arises from a virus that can only live in the human body. The disease is also called a “gentle killer”, because it has the ability to disguise itself as other ailments and at the same time poses a danger to life. All people should know about the clinic, diagnosis and treatment of hepatitis C, because no one is safe from infection.

The discovery of hepatitis C and the study of the pathogen

Experts began to think about the existence of hepatitis "neither A nor B" back in the 70s of the last century. However, it was not possible to confirm the guesses. Virological methods at that time did not allow to identify the pathogen, although the search for the etiological agent was carried out. Only a few years later, the attempts were successful. A step forward in the study of hepatitis C has been made thanks to new molecular biological methods.

The study of the causative agent of the disease is associated with the names of people such as M. Houghton and Q. Choo. The first researcher in a group of scientists in 1988 sequenced the HCV gene, a small RNA-containing virus. A year later, the second scientist, along with his colleagues, successfully performed the cloning of HCV RNA. Immunoreactive oligopeptides were obtained. They formed the basis of diagnostic products designed to detect antibodies to the virus.

Further study of the pathogen and the causes of hepatitis C allowed specialists to identify 6 genetically different groups (genotypes) of the virus: 1a, 1b, 2a, 2b, 3a and 4. More than 100 subtypes of the pathogen were also found. Regarding genotypes, it is worth noting that researchers have identified some features in geographical distribution. For example, in European countries, genotype 1b is most often recorded, in North America - 1a, in Russia - 1b.

World Health Organization on Hepatitis

The World Health Organization reports that the hepatitis C clinic is known worldwide. Everywhere this disease is registered. According to statistical information, globally, approximately 130-150 million people are infected with hepatitis C. The most affected regions of our planet are West and North Africa, East and Central Asia. The highest prevalence of the disease in these places is explained by the use of unsafe methods for various medical procedures, injections. It is also worth noting that currently the number of people with hepatitis C virus is actually increasing despite the fact that there are effective treatments.

According to WHO, hepatitis C, as well as other viral hepatitis, is a very serious threat to public health on an international scale. Previously, these diseases were not given due attention. Today, any measures need to be taken to reduce the number of infected people and save lives.

In 2016, the World Health Organization launched the global health sector strategy for viral hepatitis. This document presents the goals that are planned to be achieved by 2030:

• reduce the incidence by 90% (the number of new cases of hepatitis C virus infection);
• reduce mortality by 65%;
• achieve blood safety (check 100% of donated blood using tests of guaranteed quality);
• improve the diagnosis of viral hepatitis;
• improve the quality of treatment.

Etiology and epidemiology

The hepatitis C clinic is the result of the existence of HCV in the human body. This is a small spherical virus. Its dimensions in diameter are 50 nm. The genus of the pathogen is Hepacivirus, and the family is Flaviviridae. The structure of the viral particle includes a single-stranded linear RNA, nucleocapsid and protein-lipid membrane. A characteristic feature of the pathogen genome is its mutational variation associated with the replacement of individual nucleotides. The constant updating of the antigenic structure leads to the simultaneous existence of multiple variants of the virus. This explains the fact of the long and sometimes even lifelong survival of HCV. The human immune system simply does not have time to respond to antigenic variants of the pathogen.

Sources of hepatitis C virus are people who have an acute or chronic stage of the disease. How is hepatitis C transmitted from humans? The least important are the natural pathways of the pathogen. Extremely low is the likelihood of infection during sexual intercourse, at home, at the birth of a child from an infected woman.

Answering the question of how hepatitis C is transmitted from humans, it is worth noting that the parietal transmission mechanism plays the largest role. Infection often occurs at the time of medical and non-medical manipulations. The first group includes invasive medical and diagnostic procedures, surgical interventions, blood transfusions and its components. Among the non-medical manipulations that have the risk of contracting the hepatitis C virus include piercing, tattooing, injecting drug addiction. By the way, today drug addicts are one of the most epidemiologically significant and numerous risk groups for HCV infection. According to the World Health Organization, somewhere in 67% of people with injecting drug dependence are sick with hepatitis C.

Hepatitis C Clinic

After the virus enters the body, the incubation period begins. In duration, it can be from 2 to 26 weeks (on average - from 6 to 8 weeks). The course of hepatitis C includes 2 stages - acute (OGS) and chronic (CHC). The acute stage in a large number of patients proceeds without any suspicious symptoms. Only in 10–20% of cases does the hepatitis C clinic manifest itself. It has the following features:

1. After the incubation period, the prodromal period begins. The first signs of hepatitis C in women and men are malaise, weakness. Dyspeptic syndrome is observed, which is characterized by signs such as nausea, loss of appetite.
2. The prodromal period is replaced by a peak period. Some people develop mild jaundice (this symptom of hepatitis C in a woman is clearly visible in the photo), but most often this change is not observed. The anicteric variant of the course remains unrecognized due to the absence of complaints in sick people. Sometimes it proceeds under the guise of other diseases of the digestive system. In this case, a characteristic difference between the anicteric variant of hepatitis C from other ailments is excruciating itching on the trunk and legs without the appearance of rashes on the skin.

In 20–25% of people, the acute hepatitis C clinic disappears and the disease cures. In 75–80% of cases, the disease goes into a chronic stage. It includes 2 phases - latent and reactivation. The latent phase begins first. No signs of hepatitis C are observed at this time. In its duration, the latent phase can be from 10 to 20 years. During this period, infected people feel healthy. Some of them only complain of minor severity, localized in the right hypochondrium. However, no one attaches special importance to this symptom, because it usually occurs during physical exertion and a violation of the diet.

An increase in the replicative activity of the virus is characteristic of the HCV reactivation phase. During this period, a clinic of chronic hepatitis C occurs - certain symptoms of the disease. They include asthenovegetative syndrome. It combines a number of suspicious signs. Here is a list of them:

• fast fatiguability;
• weakness;
• disability;
• excessive sweating;
• headache;
• sleep disturbance;
• emotional instability.

The clinic of chronic hepatitis C in the reactivation phase also includes dyspeptic syndrome. Sick people complain of a loss of appetite, a sensation of a bitter taste in the mouth, nausea, heaviness and pain in the right hypochondrium and epigastric region. In the later stages of the disease, itching is observed. Some infected people experience extrahepatic symptoms of chronic viral hepatitis: gastritis, pancreatitis, skeletal muscle damage, kidney damage, etc.

The periods of the natural course of CHC and the consequences

In 2001, T. Poynard et al. isolated in the natural course of chronic hepatitis C period 4:

1. The first 10 years since the pathogen entered the human body. The rate of disease progression at this time is minimal. The exception is people who are infected over the age of 50.
2. The next 15 years (approximate period). This period is characterized by a slow and constant progression of the disease.
3. The next 10 years. The rate of development of the disease is increasing.
4. The last 5 year period. For him, a characteristic high activity of the pathological process. This period leads to the terminal stage of the disease.

In 25–50% of cases, the end of chronic hepatitis C is cirrhosis. This is a serious disease in which the parenchymal tissue is irreversibly replaced by fibrous tissue. HCV cirrhosis can be continuously progressive and slowly progressing with periods of prolonged remission.

In the initial stage of a compensated disease, people may notice a feeling of heaviness and pain in the upper abdomen, flatulence, weight loss, decreased performance, asthenia (increased fatigue). In approximately 20% of patients, the initial stage of cirrhosis occurs latently. The disease is usually discovered by specialists accidentally during an examination for any other diagnosis or during a routine examination.

With the progression of the pathological process in the clinic of viral hepatitis C complicated by cirrhosis, asthenic and dyspeptic syndromes become more pronounced. There are nosebleeds, bleeding gums. For the expanded decompensated stage of liver cirrhosis, the following symptoms are characteristic:

• large belly with thin legs and arms ("spider figure");
• portal hypertension (increased pressure in the portal vein system caused by impaired blood flow in the inferior vena cava, hepatic veins, portal vessels);
• jaundice;
• pronounced manifestations of hemorrhagic syndrome, etc.

Upon transition to the terminal stage, hepatic cell failure, portal hypertension, and hepatic encephalopathy increase. Patients develop hepatorenal and hemorrhagic syndromes, ascites, a bacterial infection joins.

About 5-7% of people with chronic viral hepatitis C develop hepatocarcinoma, a malignant liver disease. The main risk factors for cancer are liver cirrhosis, concomitant HBV infection, alcohol abuse, male gender, age over 55 years. The most common clinical signs of this disease include hepatomegaly (an increase in liver size), a palpable tumor, pain in the upper abdomen. Later, jaundice, expansion of the superficial veins of the abdomen, ascites are added to the clinical picture.

Diagnosis of the disease

In the diagnosis of hepatitis C are used:

1. Molecular biological laboratory methods. Using them, specialists identify viral RNA, measure the viral load, determine the genetic characteristics of the patient and the virus.
2. Immunochemical laboratory methods. They are designed to detect hepatitis C markers - virus antigens and antibodies to them.

A significant role in the diagnosis of viral hepatitis is played by ultrasound of the abdominal organs. This method allows you to detect changes that cannot be detected during a physical examination. Thanks to ultrasound, doctors receive information:

• about an increase (decrease) in the liver;
• the condition of the edge of this organ;
• change in echogenicity of the parenchyma;
• expansion of the splenic and portal veins, etc.

The most important method for the diagnosis of chronic viral hepatitis is a morphological study of liver biopsy specimens. According to the results, one can learn about histological changes that occurred even before the appearance of clinical symptoms and functional impairment (the degree of activity of the pathological process, the severity of fibrosis are determined, other causes of liver damage are excluded). Specialists obtain material for research by percutaneous puncture biopsy. It is important to carry it out correctly in accordance with standard technology. The optimal length of the biopsy specimen is 2.5 cm. With a decrease in its length from 3 to 1 cm and a diameter from 1.4 to 1 mm, the risk of obtaining a false conclusion about the degree of histological activity increases to 70%.

A liver biopsy may not be performed in all cases, because this study has contraindications. For this reason, non-invasive methods for assessing liver fibrosis are currently being introduced into the diagnosis. For example, the usefulness of elastometry has been proven. This research is carried out on the FibroScan device. It allows you to judge the change in the elastic properties of the liver by reflected vibrational pulses, which are subjected to computer analysis. Non-invasiveness is not the only advantage of elastometry. The positive aspects of this method include:

• convenience and speed of use (about 5 minutes are spent on the examination of the patient);
• a larger estimated volume of liver tissue compared with a biopsy (approximately 100-200 times more);
• the possibility of examining children.

Treatment of acute hepatitis C

In acute viral hepatitis C, treatment is not prescribed immediately. Therapy is postponed for 8-12 weeks after the onset of the disease. This delay is done for the reason that the human immune system can cope with the virus on its own. If this period passes, and HCV RNA continues to be detected in the blood, then antiviral treatment is started (no later than 12 weeks).

In the presence of an acute hepatitis C clinic, standard interferon-type drugs are used. Monotherapy is quite effective (80–90%). For those who do not know what interferon is, it is an immunostimulating protein produced in the body in response to the penetration of a viral infection. The doctor, when prescribing treatment to the patient, may prefer PegIFN. This is a special type of prolonged-release interferon. The advantage of PegIFN is that for effective treatment, a lower frequency of administration is required (compared to standard interferons).

The optimal duration of therapy for acute hepatitis C is 24 weeks. Standard interferons can be used for 24 weeks at 3 million IU every other day or for the first 4 weeks at 5 million IU every day, and for the remaining 20 weeks - 5 million IU every other day. For the use of prolonged-acting interferons, the following are established:

• for PegIFGα2a - 180 mcg once a week;
• for PegIFGα2b - 1.5 mcg / kg once a week;
• for CEPEG-IFNα2b - 1.5 μg / kg 1 time per week.

During interferon therapy, the viral hepatitis C clinic may be supplemented with side effects from the use of drugs. Often manifested flu-like syndrome. In patients, body temperature rises, malaise, sweating, headache occur, appetite worsens, aches in joints and muscles begin to be felt. Usually, all these symptoms are observed only at the very beginning of treatment. More rarely, during the period of immunotherapy, mental disorders, dyspeptic syndrome, dermatological reactions are recorded.

To combat side effects, doctors prescribe additional drugs. For example, with the flu-like syndrome, the use of paracetamol or other non-steroidal anti-inflammatory drugs is indicated. In 10-15% of cases, the doctor considers the question of reducing the dose of interferon, and in some cases, drug withdrawal may be required.

Treatment for chronic hepatitis C

The goal of drug treatment for chronic hepatitis C is to improve the quality of life and increase the life expectancy of people with this disease. Therapy is prescribed when detecting virus RNA in the blood serum and histological signs of liver damage. Before starting antiviral treatment, patients must be referred by doctors to a number of examinations. This is necessary in order to exclude concomitant diseases and ensure maximum safety and effectiveness of further therapy.

For the treatment of chronic hepatitis C, several treatment regimens are provided. You can find them in the table below.

Additional nuances

All those people who have manifest forms of viral hepatitis are subject to hospitalization. Patients undergo treatment in infectious hospitals. In chronic viral hepatitis (CVH), the indication for hospitalization in the infectious or hepatological department is a clinical-biochemical exacerbation or decompensation at the stage of liver cirrhosis. In the presence of a latent form of the disease, treatment is carried out on an outpatient basis.

Hepatitis C therapy does not only include medication. The patient is advised to consider several recommendations:

1. It is important to observe the protective regime - rest more, avoid overloads. In severe cases of the disease (acute form, exacerbation of chronic hepatitis, decompensated liver cirrhosis), bed rest is needed. In a horizontal position, blood supply to the liver improves, and reparative processes in this organ are quickly completed.
2. An important element of treatment is the control of stool, fluid balance. Constipation is unacceptable, because they provoke intestinal auto-toxicity. In order to get rid of this delicate problem, laxatives of plant origin, food sorbitol, and lactulose help. Regarding the control of fluid balance, it is worth noting that drinking should be plentiful (2-3 liters per day).
3. When treating, it is important to eat right, make up your diet from foods that do not negatively affect the digestive system, do not disrupt metabolism, and do not damage hepatocytes.
4. It is necessary to protect the liver from additional loads. Experts advise against taking medications without prescription and the presence of indications. Also, patients are strongly advised to avoid drinking alcohol at any dose. Ethanol inhibits the immune system, affects the liver. With alcohol abuse, fibrosis develops faster, the risk of developing cirrhosis increases significantly.

Preventative measures

It is impossible to prevent hepatitis C vaccination, since there is no vaccine that can protect against HCV. However, preventive measures have been developed. They are recommended to be observed by medical personnel, because sometimes, due to their negligence, infection of healthy people occurs. Professionals should:

• pay attention to hand hygiene (wash hands thoroughly, perform surgical treatment of hands, use gloves);
• properly carry out medical injections, operations, diagnostic invasive procedures, strictly observe universal safety measures;
• test donated blood for hepatitis B, C, syphilis, HIV.

The World Health Organization states that harm reduction measures should be taken for injecting drug users. Access to sterile injecting equipment and effective treatments for addiction is required.

Preventive measures include condom use during sexual intercourse. The probability of transmission of hepatitis C virus in this way is extremely small, but still not worth the risk. Yes, and it is important to remember that condoms protect against a huge list of sexually transmitted infections.

All of the above measures are the primary prevention of hepatitis C. There is also secondary prevention, which is provided for people infected with HVC. The World Health Organization recommends them:

• seek advice from specialists in treatment and medical care;
• get immunized with vaccines that protect against the development of other viral hepatitis (A and B);
• undergo regular examinations with the aim of early detection of chronic liver disease.

The clinic, diagnosis and treatment of hepatitis C can be called an urgent topic. This disease is a very serious problem. It did not cover a specific country, but the whole world. World Hepatitis Day is held annually on July 28th. On this day, activities are being carried out in all corners of the planet to deepen understanding of this problem. Information is being intensely implemented. By the way, it is very important. Knowledge helps people to prevent the occurrence of a disease or to properly deal with an ailment that has arisen.