Hepatitis C is the most common liver disease currently seen in clinical practice. The incubation period, from the time of exposure to the virus until the onset of the disease, is one to six months. Early symptoms include poor appetite, lack of interest in food, nausea, aching muscles and joints, and light fever. Some people experience only mild symptoms such as tiredness, periodical pressure below the right ribs caused by the enlarging liver, and aching muscles and joints. Only 1 in 10 patients with acute Hepatitis has symptoms. The remaining nine have no symptoms whatsoever. In 8 out of 10 patients, the infection becomes chronic.

Many patients remain asymptomatic until decompensation occurs. Lack of symptoms and minor liver enzyme elevations are typical of HCV infection and cannot be taken as evidence of lack of progression. HCV RNA testing confirms the diagnosis. Liver biopsy helps assess disease activity and stage the severity of fibrosis and is recommended for most patients with hepatitis C. Once this information is obtained, a rational program for treatment and monitoring can be planned. Patients with newly discovered hepatitis C infection require thorough education about the disease's natural history, transmission, interaction with alcohol, and treatment. In many cases, referral to a gastroenterologist or hepatologist may be the appropriate way to ensure necessary instruction and availability of the latest treatment options.

Symptoms commonly reported by persons with hepatitis C include:

Flu-like illness

Indigestion - gastrointestinal reflux disorder

Irritable Bowel syndrome

Muscle and joint pain

Myalgia is muscle pain or aching

Night sweats

Depression, mood swings

Fatigue - mild to severe

Abdominal bloating

Diarrhea

Headaches

Numbness in extremities

Mental confusion / 'brain fog

Itchy skin

Dizziness & peripheral vision problems

Liver pain

Cognitive dysfunction

Shortness of Breath

Loss of appetite

Visual Changes

Chest Pains

Chills Fever

Facial Puffiness

Female Problems (irregular menses, severe PMS)

Palpitations

Yellowing of the Skin Jaundice

Loss of Libido

Spider Nevi

Swelling of the lymph nodes

Other less common symptoms include pain or discomfort in the abdomen on the right side, itching, nausea, appetite/weight loss, mental fuzziness.

Hepatitis C virus is one of many causes of swelling of the liver (hepatitis). The liver plays a crucial role in cleaning the blood and metabolizing different substances we ingest. When the liver isn't working correctly, "poisons" build up in the blood. In addition, the liver makes bile, and if it isn't released correctly, it builds up in the body causing a yellowing of the skin and eyes (called jaundice and icterus, respectively). People first infected with HCV commonly get mild flu-like symptoms with aches, fever, and chills.

Symptoms are most common in patients who have developed cirrhosis.

As the liver disease progresses, complications of cirrhosis and liver failure may occur, including jaundice, ascites (accumulation of fluid in the abdomen), variceal bleeding (bleeding from collateral vessels in the the esophagus, stomach or intestines secondary to impedence of blood flow through the liver), leg edema and encephalopathy (mental confusion due to the accumulation of toxic metabolic products that cannot be cleared by the liver).

Please see our section on Cirrhosis for photos of complications and symptoms.

Joint pain can also be caused by a condition known as cryoglobulinemia. About 1/3 of people with hepatitis C have this problem, which is caused by antibodies attaching themselves to the hepatitis C virus. If you are having joint and muscle pain, let your doctor know. He or she may want to test you for cryoglobulinemia because it can also cause problems with blood vessels.

SIGNS AND SYMPTOMS THAT MAY BE ASSOCIATED WITH HEPATITIS C
(Tina M. St. John, MD )

http://www.hepcchallenge.org/manual/signs_symptoms_final.htm

INTRODUCTION: Hepatitis C affects different people in different ways. Your personal experience with hepatitis C will be as unique as you are. This chapter reviews the most common signs and symptoms experienced by people with chronic hepatitis C. At first glance, the mere length of the chapter may appear overwhelming, but keep in mind, this is just a list of possibilities. If you have any of the signs or symptoms described in this chapter, it is important that you do not assume they are a result of having hepatitis C. Your health care provider can determine if they are associated with your hepatitis C. Very few people experience all of these signs and symptoms. Many of them will come and go on their own. For troublesome and/or persistent problems, there are things you and your health care provider can do to either make them go away, or make them easier to live with.

You may be wondering what the difference is between a sign and a symptom. A sign is an abnormality that is detected by your health care provider during an examination. A symptom is something you, as a person with hepatitis C, experience as a result of the disease. Signs and symptoms are discussed together because sometimes a sign is also a symptom. Fever is a good example of something that is both a sign and a symptom. Your health care provider can take your temperature and find out that you have a fever, so it is a sign. But if you have a fever, you can tell you have a fever because your skin is warm, so fever is also a symptom.

There are three sections following this introduction. The first section briefly explains how the hepatitis C virus causes disease. The second section reviews possible signs and symptoms that people with hepatitis C who do not have cirrhosis may experience. The last section reviews additional signs and symptoms that people with hepatitis C who have cirrhosis may experience.

HOW THE HEPATITIS C VIRUS CAUSES DISEASE: According to current understanding, the hepatitis C virus (HCV) causes disease in two general ways. The first is by infecting cells. Once inside the cell, the virus directly damages or kills the cell. This mechanism is called cytopathic damage. The second way the hepatitis C virus causes damage is by provoking an immune response. The immune system is your body's way of protecting itself from invading agents such as viruses and bacteria. An overactive or misdirected immune response can damage infected cells and the normal surrounding tissue. This mechanism is called immunopathic damage.

When HCV was first discovered, experts thought the virus infected only liver cells. However, more recent research has revealed that HCV also infects parts of the immune system, specifically the lymphatic system and peripheral blood mononuclear cells. Experts now understand that hepatitis C is not just a liver disease but is a systemic disease, meaning it can affect nearly any organ of the body. As you read through the list of possible signs and symptoms associated with hepatitis C infection, you may find some of the symptoms you have been experiencing that you thought were caused by something else may actually be caused by hepatitis C. This is important because knowing why you are having a symptom is often the first step in alleviating the symptom, or making it less troublesome.

SIGNS AND SYMPTOMS OF HEPATITIS C WITHOUT CIRRHOSIS:

The possible signs and symptoms of hepatitis C without cirrhosis involve every organ system of the body. Although some of these symptoms can be quite uncomfortable, most of them do not indicate that your liver disease is getting worse. New symptoms should always be discussed with your health care provider so you can work together to keep your life with hepatitis C as active, productive, and enjoyable as possible.

Arthralgia: Arthralgia is pain in the joints. Frequent sites of joint pain are the hips, knees, fingers, and spine, although any joint can be a source of pain. Arthralgia associated with hepatitis C can be migratory, meaning it moves around. You may have pain in your hip one day and in your knee the next. This symptom usually comes and goes, and is rarely present all the time. If you experience joint pain, it is important to talk with your health care provider before taking anything to treat the pain because some over-the-counter pain medicines (such as acetaminophen) are potentially harmful to the liver.

Fever, Chills, and Night Sweats: Many people with HCV periodically experience fevers. The fevers are usually low, typically less than 101 degrees Fahrenheit. As the fever comes down, you may experience chills and sweating. You may have fevers only at night. If this happens, you may wake up with your bedclothes and/or your sheets wet with sweat. This experience is called night sweats.

Fatigue: Fatigue is feeling tired, and nearly all people with hepatitis C experience fatigue at one time or another. The fatigue may be mild and relieved by naps or going to bed earlier. However, the fatigue can be severe at times, feeling like near exhaustion even after a full night of sleep. Fatigue experienced by people with hepatitis C may also be accompanied by increased feelings of anger, hostility, and depression.1 These feelings may persist even after the fatigue has passed.

Fatigue and sleep disturbances

Fatigue can be described as a sense of excessive tiredness and lack of energy. Many people with hepatitis C will experience fatigue at some stage. Fatigue can impact on work, family relations and other activities. It can cause you to be withdrawn, moody, cranky and irritable, have outbursts of anger and a lack of energy or feelings of physical weakness. A good night’s rest will not always help you overcome fatigue. Fatigue may also be linked to other factors, such as depression.

Problems with sleeping vary widely for people who have hepatitis C and can include difficulty falling asleep, waking up a lot or sleeping excessive amounts. Sleep disturbances are common among the general population and it is often difficult to work out what impact hepatitis C is having on a person’s sleeping patterns. Sleep problems have an impact on a person’s quality of life and can exacerbate other symptoms of hepatitis C, especially fatigue.

General lifestyle practices can impact on fatigue and sleeping patterns:

eat a well-balanced diet.
drink alcohol in moderation or not at all and stop or reduce smoking.
do regular moderate exercise.

Making adjustments to your day-to-day life may support you to manage fatigue. Have realistic expectations of yourself and what you are able to do. Don’t beat yourself up over feeling tired and lethargic:

plan the day’s activities around times that tiredness and fatigue normally appear. When energy is higher complete extra tasks (e.g. cook food in batches and freeze to eat later);
sit down to iron clothes or shower, so you don’t have to support yourself;
use equipment that helps you conserve energy. For example, use a washing trolley instead of carrying the washing to the line;
pace yourself during the day and allow yourself regular breaks; and
take short naps during the day. However, be aware that excessive sleep can cause people to feel more tired and may cause sleep difficulties at night.

Practices that may help manage sleeping difficulties include:

set specific sleep times to try to regulate your body clock;
allow enough time for eight hours sleep each day. Eight hours sleep is generally enough for an adult, although individual needs will vary;
establish a bedtime routine that you do most nights before bed. This may involve washing your face, having a warm drink and reading a book or magazine;
avoid exercising just before sleeping;
minimise caffeine intake (such as in coffee and cola drinks) in the afternoon, particularly if sleep is difficult;
jasmine tea, camomile tea, lavender scent and warm milk may help to relax people and assist with sleep; and
occasional use of sleeping sedatives may provide some relief. Consult your doctor before using sleeping sedatives.

Fluid Retention: Fluid retention occurs when your body holds on to more water than it needs. The extra water leaks into the tissues. If you have fluid retention, you may notice swelling of your feet, ankles, fingers, and/or face. People with fluid retention often have frequent urination, especially at night.

Flu-like Syndrome: People with hepatitis C can experience periodic flu-like syndromes. These episodes usually last a few days, rarely more than a week. The most common symptoms are fever, chills, headache, fatigue, and muscle aches.

Lymphadenopathy: Lymphadenopathy is swelling of the lymph nodes. Lymph nodes are normally about the size of a pea or a kidney bean. Because HCV infects the lymphatic system, it frequently causes the lymph nodes to swell. The lymph nodes of the armpits, groin, and neck are relatively close to the skin surface, and are usually examined to see if you have lymphadenopathy. If you have lymphadenopathy, it may or may not be painful when you press on the swollen lymph nodes.

Myalgia: Myalgia is muscle pain or aching. People with hepatitis C may experience myalgia. Usually, if you have this symptom, you will experience it as a generalized feeling. However, some people report having pain in only one area of the body. This symptom tends to come and go, and is rarely present all the time. If you experience muscle aches or pain, it is important to talk with your health care provider before taking anything to treat the pain because some over-the-counter pain medicines are potentially harmful to the liver.

People with hepatitis C may experience muscle and joint pain. Common sites of joint pain are the hips, knees, fingers, and spine, although any joint can be a source of pain. Pain associated with hepatitis C can move around and come and go. Aches and pains in the muscles are usually experienced as a generalised feeling. However, some people report having pain in only one area of the body.

It is generally considered acceptable to take anti-inflammatory medication for muscle and joint pain (following the instructions on the packet). However, you should first consult your doctor about the use of anti-inflammatory drugs.

Some people find mild physical activity can help manage muscle and joint pain. Mild physical activity increases blood flow to joints and muscles and can reduce stiffness. Heat packs on the sore area, warm baths and massage may also provide temporary relief.

Some people find benefit in complementary and alternative therapies, such as herbal products or massage. It is best to be advised by a qualified complementary/alternative professional about any therapies or products that could be useful. If you pursue complementary and alternative therapies it is important that you tell your liver specialist and GP of any therapies that you have recently used, are using, or plan to use.

Pruritus: Pruritus is the medical word for itching. People with hepatitis C sometimes have pruritus. Often, it is limited to the palms of the hands and/or the soles of the feet. However, some people have generalized pruritus, meaning they itch all over.

Sleep Disturbances:Insomnia is difficulty sleeping, and it may be part of your experience with hepatitis C. Insomnia can occur in different forms. You may have trouble falling asleep, or you may wake up often during the night. Some people report having unusually vivid, intense, and/or frightening dreams. Such dreams can contribute to insomnia.

Spider Nevi: Spider nevi are small, red, spider shaped spots on the skin. They are usually less than ½ inch around. They are most commonly seen on the face and chest, but can occur anywhere on the skin. Spider nevi are painless and do not itch.

Weakness: People with hepatitis C sometimes experience a sense of weakness. This symptom can vary from mild to severe, and tends to come and go.

Abdominal and Digestive System Signs and Symptoms

Abdominal Pain: You may experience episodes of abdominal pain if you have hepatitis C. Pain on the right side just below the ribs is likely to be from the liver. People usually report this pain as being short, sharp, or stabbing. More constant, cramping pain closer to the middle of chest, but under the ribs, can be due to gall bladder problems that may accompany hepatitis C. You may experience pain elsewhere in the abdomen. If you experience any new pain in the abdomen, it is important for you to tell your health care provider right away so the source of the pain can be determined.

Appetite Changes and Weight Loss: People with hepatitis C frequently experience changes in their appetites. You may find you no longer want the foods you once enjoyed. Many people find they are particularly put off by fatty foods and alcohol. For some, foods that are at room temperature or cold are more appealing than hot foods. The distaste for alcohol is actually good for you because alcohol increases the damage done to the liver by HCV. People with hepatitis C should not drink any alcohol including beer, wine, wine coolers, and mixed drinks. If changes in your appetite are causing you to lose weight, you need to discuss this with your health care provider because good nutrition is particularly important for people with hepatitis C.

Bloating: Bloating is usually described by people with hepatitis C as a feeling of fullness in the abdomen. You may notice your clothes seem tight around your waist. This bloating may or may not be accompanied by weight gain.

Diarrhea and Irritable Bowel Syndrome: Diarrhea can be experienced as unusually loose stools or an increase in the frequency of bowel movements, with or without a change in the consistency of the stool. If the diarrhea is accompanied by cramping abdominal pain and persists, it is often termed irritable bowel syndrome.

Indigestion and Heartburn: Indigestion is usually experienced as an uncomfortable feeling of fullness in the stomach. It is often accompanied by queasiness and burping of a mixture of gas and stomach contents. When this occurs, you may notice a burning in your throat and/or a sour taste in your mouth. Heartburn is experienced as pain or burning in the chest under the breastbone. It, too, may be accompanied by burping of gas and stomach contents. Both indigestion and heartburn can be brought on by and last longer after a fatty meal.

Jaundice: Jaundice is a yellowish discoloration of the skin and/or the whites of the eyes. It is caused by a yellow substance in the blood called bilirubin. The liver normally breaks down bilirubin. If the liver is not working normally, bilirubin can build up in the blood and begin to stain the skin. If the liver starts to work more normally, jaundice will fade or go away.

: Nausea is the feeling that you may vomit. Hepatitis C may cause episodes of nausea. Although it is usually not accompanied by vomiting, it can be a very uncomfortable and debilitating symptom. If you are having nausea, talk with your health care provider because there are many ways to treat this symptom.

Cognitive, Mood, and Nervous System Signs and Symptoms

Cognitive Changes: Your cognitive ability refers to your ability to think clearly and to concentrate. Some people with hepatitis C notice they have changes in their cognitive ability. This can take several different forms. You may find you cannot concentrate for long periods of time, or you may notice your thought processes seem slower than usual. You may have a hard time coming up with words you want to say, or you may just feel mentally tired. These cognitive changes are sometimes called ‘brain fog.’ Like other symptoms of hepatitis C, these cognitive changes often come and go.

Depression: Hepatitis C does not directly cause depression, but concerns about the disease and changes it may cause in your life can lead to depression. Some of the symptoms of depression include:

• sleeping more or less than usual
• eating more or less than usual
• hopelessness
• helplessness
• irritability
• lack of interest in your usual activities, and
• feelings of sadness and/or despair most of the time

If you have one or more of these symptoms, you may have depression and should discuss what you are feeling with you health care provider. Depression can seriously interfere with your quality of life, and can make it difficult for you to do what you need to do to take care of yourself. Depression is nothing to be ashamed of, and it can be treated. If you have any of the symptoms of depression, talk to your health care provider right away.

Dizziness: Some people experience dizziness as feeling as if they are going to faint. Others experience dizziness as disorientation, or feeling as if the world is spinning around them. Both of these can be symptoms of hepatitis C. If you are experiencing dizziness, talk with your health care provider because this can be not only troublesome for you, but also dangerous.

Headaches: Headaches can be symptoms of hepatitis C. For some people, the headaches are mild, but for others, the headaches are severe. If you are having headaches, talk to your health care provider before taking any medicines for your headaches because some over-the-counter pain medicines can be harmful to your liver.

Mood Swings: Hepatitis C can sometimes cause mood swings. Some people find this symptom is worse during the winter months.

Numbness or Tingling: A significant number of people with hepatitis C have numbness or tingling in their extremities. Your extremities are those parts of your body that extend from the main part of your body, that is, your arms and legs, fingers and toes. Most people with numbness or tingling feel it in their fingers and toes, but it may extend into the arms and legs. Numbness is a decreased sense of feeling. In its most severe form, the affected areas have no sense of feeling. Tingling can sometimes be painful. People describe painful tingling as feeling like being stuck with pins. This symptom tends to come and go.

Visual Changes: There are a number of visual changes that can accompany hepatitis C infection. You may find you are not seeing as clearly as you once did. Peripheral vision, that is, the ability to see things that are at the sides of your view, can also be diminished. Some people report seeing small specks called ‘floaters’ moving across their view. This can occur when the eyes are open or closed. Another symptom you may experience is dryness of the eyes, or feeling as if there is something scratchy in your eyes. All of these symptoms can come and go.

Blood Sugar Abnormalities

: Hepatitis C can cause blood sugar abnormalities, either high or low. High blood sugar causes symptoms such as extreme thirst, frequent urination, fatigue, and weight loss. Low blood sugar causes light-headedness or dizziness, nausea, and weakness. The symptoms of low blood sugar are worst when you have not eaten anything for several hours, and are relieved by eating or drinking something. If you are having any of the symptoms of either high or low blood sugar, tell your health care provider right away.

Chest Pain: Hepatitis C can cause chest pain. However, chest pain can also be a symptom of serious heart or lung disease. If you have chest pain, you must contact your health care provider immediately so he or she can find out the source of your pain.

Menstrual and Menopausal Changes: Women with hepatitis C may have menstrual changes such as irregular periods, spotting, or increased premenstrual symptoms. Menopausal women may experience an increase in menopausal symptoms such as hot flashes and mood swings.

Palpitations: A heart palpitation is involuntarily becoming aware of your heart beating. Palpitations occur in different forms. You may feel your heart is beating harder or faster than usual, or that it is beating irregularly. If you have palpitations, you need to tell your health care provider immediately so he or she can make sure you are not having a problem with your heart.

Sexual Changes: Some people with hepatitis C have a decreased interest in sexual activity. Decreased sexual response and lack of intensity of sexual response have also been reported. Sexual changes can be an upsetting symptom of hepatitis C. If you are experiencing sexual changes, talk with your health care provider, and your spouse or partner. There are things that you, your health care provider, and your partner can do to help you have a satisfying sex life.

Symptoms of Acute Viral Hepatitis

General Symptoms. Symptoms of acute viral hepatitis may begin suddenly or develop gradually. They may be so mild that patients mistake the disease for the flu. Nearly all patients experience some fatigue and often have mild fever. Gastrointestinal problems are very common, including nausea and vomiting and a general feeling of discomfort in the abdomen or a sharper pain that may occur in the upper right area if the abdomen. This pain tends to increase during jerking movements, such as climbing stairs or riding on a bumpy road. GI problems can lead to loss of appetite, weight loss, and dehydration. After about two weeks, dark urine and jaundicea yellowish color in the skin and whites of the eyes -- develops in some, but not all, patients. Children tend not to develop jaundice. About half of all hepatitis patients have light colored stools, muscle pain, drowsiness, irritability, and itching -- usually mild. Diarrhea and joint aches occur in about a quarter of patients. The liver may be tender and enlarged and most people have mild anemia. In about 10% of patients, the spleen is enlarged.

Symptoms of Fulminant Hepatitis. In very rare cases, within two months of onset, a very serious condition known as fulminant hepatitis develops. Symptoms may include a large swollen abdomen (known as ascites) and a peculiar hand-flapping tremor (called asterixis). These symptoms may be followed by stomach and intestinal bleeding and mental confusion, stupor, or coma caused by brain injury (encephalopathy).

Symptoms Typical of Acute Hepatitis A. Symptoms of hepatitis A are usually mild, especially in children. They generally appear between two and six weeks after exposure to the virus. Adult patients are more likely to have fever, jaundice, and itching that can last one to several months.

Symptoms Typical of Acute Hepatitis B. Hepatitis B symptoms appear long after the initial infectionusually four to 24 weeks. Many patients may not even experience symptoms, or they may be mild and flu-like. About 10% to 20% of patients have a fever and rash. Nausea is not common. Hepatitis B patients may experience general aching in the joints, but sometimes the pain can resemble arthritis, affecting specific joints and accompanied by redness and swelling.

Symptoms Typical of Acute Hepatitis C. If they appear at all, symptoms develop about a month or two after a person is infected with hepatitis C. These are usually milder than those of hepatitis B. About 75% of patients show no signs of jaundice, and many do not experience any symptoms.

Symptoms of Chronic Hepatitis

Symptoms of Chronic Hepatitis B and C. Both hepatitis B and C can progress to chronic hepatitis usually with no early acute symptoms. Symptoms of progressive chronic viral hepatitis may be very subtle and no more than a mild persistence of acute symptoms for six or more months. In fact, chronic hepatitis C can be present for as long as 20 years without presenting any obvious problems. In some patients, itchy skin may be the first symptom. Some patients develop pain in small joints in the body (such as the hand) that may be nearly indistinguishable from symptoms of rheumatoid arthritis, fibromyalgia, or carpal tunnel syndrome. In other patients, chronic hepatitis B or C can lead to long term disability or liver failure before they experience any symptoms at all.

Symptoms of Chronic Autoimmune Hepatitis. The symptoms of chronic autoimmune hepatitis range from minimal to severe, including fatigue, jaundice, fever, and weight loss. The liver and spleen are often enlarged. In addition, patients with this condition may experience skin disorders, including palmar erythema (red palms) and spider angioma (a blood-red spot, the size of a pinhead, from which tiny blood vessels radiate like spider legs). Itching is not common, however. The abdomen or legs may be swollen due to the accumulation of fluid.

Well-Connected Board of Editors

Harvey Simon, M.D., Editor-in-Chief
Massachusetts Institute of Technology; Physician, Massachusetts General Hospital

Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, M.D., Ph.D., Metabolism
Harvard Medical School; Associate Physician, Massachusetts General Hospital

Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Irene Kuter, M.D., D. Phil., Oncology
Harvard Medical School; Assistant Physician, Massachusetts General Hospital

Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

Carol Peckham, Editorial Director

Cynthia Chevins, Publisher

Hepatitis C & women

Women with hepatitis C have a number of specialized needs related to their reproductive and sexual health.

Women need accurate information to assist them to make informed decisions about their health care needs.¹ The impact of hepatitis C on the reproductive and sexual health of women is not well understood and warrants further research.

Menstruation

Menstrual fluid contains blood and other body fluids. As hepatitis C is transmitted by blood-to blood contact, there is in theory the possibility of transmitting hepatitis C through contact during menstruation. However, the risk of heterosexual or female-to-female sexual transmission is extremely low and there is no evidence that sex during menstruation increases risk of sexual transmission. In theory, having sex while menstruating can increase the risk of transmitting hepatitis C if your sexual partner has any open cuts, wounds or abrasions. Using dental dams for oral sex, and condoms with male partners will reduce the risk of blood to blood contact.

Following standard precautions for infection control will lower the risk of transmitting hepatitis C through menstruation. This includes disposing of used tampons and sanitary pads in hygienic disposal units or in leak proof plastic bags in the general rubbish.

Most women’s periods do not change because they have hepatitis C, although some find they miss a period or have shorter periods. It is important to understand that any change in your menstrual cycle may not be related to having hepatitis C. Any change in a woman’s menstrual cycle should be discussed with a doctor, as it may or may not be related to hepatitis C.

Birth control

The oral contraceptive pill is fine for the vast majority of women with hepatitis C however if you have severe liver disease, you may not be able to tolerate the oestrogen hormones that are in the oral contraceptive pill or in hormone replacement therapy (HRT). This is because the liver may have problems breaking down these hormones. Please consult your doctor for further information on the use of the oral contraceptive pill or HRT.

Women with hepatitis C with severe liver damage, or who are experiencing significant symptoms, should discuss the use of the contraceptive pill with their doctor.

There are other forms of contraception that can be explored. This includes hormone injections or implants and barrier methods such as the diaphragm.

It is important that all these options are explored with a trusted doctor to find what is best for your situation.

Menopause

Just as oestrogen hormones in the oral contraceptive pill can cause problems for women with hepatitis C, hormone replacement therapy (HRT) may also not be well tolerated.

The hormonal changes that women with hepatitis C experience as part of menopause are not all associated with the virus—seek the advice of a doctor or an endocrinologist (a hormone specialist) for any problems experienced with menopause and HRT.

Pregnancy

Hepatitis C does not reduce the likelihood of a woman becoming pregnant.
The risk of hepatitis C transmission from mother to child is low, about 6%. Hepatitis C is more likely to be transmitted during birth than while the baby is inside the mother.

Women with low levels of the virus in their blood are unlikely to transmit hepatitis C to their baby. Women with high levels of the virus, those with serious liver damage or those in the acute phase of infection, have a higher risk of transmitting hepatitis C to their baby.

A baby born to a mother with hepatitis C will inherit the mother’s antibodies and test antibody positive until the child is about 15–18 months of age. In most cases, the child’s hepatitis C antibodies naturally disappear after 18 months. Therefore, testing a baby for hepatitis C is not recommended until the baby is older than 2 years. In saying this though, infection can be detected by PCR testing as early as 2–3 weeks. So, if parents are concerned they can ask for this to be done after 4–6 weeks, with follow-up testing if negative. For more information on antibody and PCR testing visit the Know your tests page.

Pregnancy is also not considered to cause deterioration of liver disease in women who have hepatitis C.

Women with hepatitis C on treatment (pegylated interferon and ribavirin) are required to use two forms of contraception (one for each partner) to ensure they do not become pregnant during their treatment, and for six months following the end of treatment. This is because pegylated interferon and especially ribavirin can cause birth defects.

Breastfeeding

There are no confirmed reports of hepatitis C transmission from mother-to-baby by breast milk. Current scientific opinion remains that there is no significant evidence of HCV transmission through breast-feeding. Scientists have found traces of the virus in breast milk and colostrum (the breast fluid produced by the mother in the first few days of breastfeeding) but not enough to transmit hepatitis C. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists currently recommends that breastfeeding should not be discouraged, as no cases of hepatitis C transmission have been documented by this route.

Damage to the breast such as cracked nipples could pose a possible risk to the baby if blood-to-blood contact occurs through small tears or scratches in or around the baby’s mouth. It is recommended that women with hepatitis C who are breastfeeding should express and discard their breast milk while their nipples are cracked. Treat cracked nipples so they do not bleed and seek help from a breastfeeding counsellor or nurse lactation consultant to discuss ways of preventing cracked nipples.

Breast milk supplies a balanced food supply for the baby, as well as protecting the baby from many illnesses especially in the first weeks, however, the final decision whether to breastfeed is entirely up to the mother.

References

¹Gifford, S. M., O’Brien, M. L., Bammer, G., Banwell, C. & Stoove, M. (2003). Australian women’s experiences of living with hepatitis C virus: Results from a cross-sectional survey. Journal of Gastroenterology and Hepatology, 18, 841–850.

SIGNS AND SYMPTOMS OF HEPATITIS C WITH CIRRHOSIS

Approximately 20-40% of people with chronic hepatitis C go on to develop liver cirrhosis over a period of 10-40 years. Because blood cannot flow well through a cirrhotic liver, blood backs up in the vessels leading to the liver. This back up of blood leads to an increase in pressure in those blood vessels, a condition known as portal hypertension . Many of the signs and symptoms of cirrhosis are related to portal hypertension.

The liver has many functions, so there are a number of things that can go wrong when the liver is not functioning normally. The liver not functioning normally causes the other signs and symptoms of hepatitis C with cirrhosis.

Ascites: Portal hypertension associated with cirrhosis can cause fluid to leak from the blood vessels leading to the liver. This fluid builds up in the abdomen and is called ascites. Ascites causes the abdomen to become distended or enlarged.

Bleeding Problems: The liver produces many of the substances needed for normal blood clotting. A cirrhotic liver may not produce enough of these substances for normal clotting. If you have a cirrhotic liver and begin bleeding for any reason, it may be difficult to get the bleeding stopped.

Bone Pain: Cirrhosis can lead to a deficiency in vitamin D. This can cause softening of the bones and bone pain. This pain is most often felt in the legs, hips, and spine.

Bruising: Cirrhosis can lead to a deficiency in vitamin K. This can lead to easy bruising. If you are experiencing easy bruising, tell your health care provider because this symptom can often be reversed with appropriate treatment.

Caput Medusae: Caput medusae refers to enlarged, visible veins that start at the navel and spread out and up over the abdomen. They are caused by portal hypertension.

Gastroesophageal Varices: Gastroesophageal varices are another complication of portal hypertension. These varices are enlarged, fragile veins found where the esophagus (the tube that takes food from your mouth to your stomach) meets the stomach. These veins can burst and bleed. If you have cirrhosis and begin to vomit blood, you must call an ambulance and get to an emergency room as soon as possible to get the bleeding stopped.

Glossitis: Glossitis is a sore tongue. If you have glossitis, your tongue will be redder than usual and will be sensitive to salty and sour foods, and carbonated beverages.

Hemorrhoids: Hemorrhoids are enlarged, fragile veins found around the anus (the opening through which your bowel movements pass). Hemorrhoids can be a complication of portal hypertension. If you have hemorrhoids, they may bleed occasionally. If the bleeding persists, or is frequent, be sure to discuss it with your health care provider.

Hepatic Encephalopathy: Hepatic encephalopathy is one of the most serious complications of cirrhosis. It can occur in an acute form that develops over a period of days to weeks, or it can occur in a chronic form that develops over a period of months to years. There are a number of different symptoms that can indicate hepatic encephalopathy, but all of them indicate abnormalities of the nervous system. Early symptoms include euphoria (feeling unusually happy for no apparent reason) or depression, confusion, slurred speech, or abnormal sleeping patterns. If these symptoms are not treated, they will progress to severe confusion, incoherent speech, tremors, and rigidity. It is urgent for these symptoms to be treated or you could fall into a coma. With the acute form of hepatic encephalopathy, treatment will usually reverse all of the symptoms. However, with the chronic form, some of the symptoms may not be reversible.

Melanosis: Melanosis is a gradual darkening of those areas of skin that are exposed to the sun. The skin tends to get darker over time.

Night Blindness: Cirrhosis can lead to a deficiency in vitamin A. This can lead to episodes of night blindness. If this occurs, be certain to talk about it with your health care provider because this symptom is often reversible.

Shortness of Breath: Shortness of breath can develop as a complication of portal hypertension. Some people experience this symptom only at night; others experience it during the day as well. If you are having shortness of breath, discuss it with your health care provider who can help you with this problem.

Steatorrhea: Steatorrhea is the passing of fat in your bowel movements. The presence of fat in the stool makes the stool smell particularly bad, and causes it to float in the toilet bowl. Steatorrhea is usually accompanied by an increased amount of stool and intestinal gas.

Xanthelasma: Xanthelasmas are small deposits of fat just under the surface of the skin around your eyes. They appear as small, raised, yellowish bumps on the skin.

Xanthoma: Xanthomas are small deposits of fat just under the surface of the skin over your joints and/or tendons. They appear as small, raised, yellowish nodules.

SUMMARY: The experience of living with hepatitis C is quite different from one person to another. It is also variable for each person over time. There will probably be days when you feel great. There may be other times when you feel overwhelmed by different signs or symptoms associated with hepatitis C. And there will likely be still other times when you feel somewhere in between these two states. Below are a few things you may find helpful to keep in mind about your signs and symptoms as you learn to live with hepatitis C.

Discuss your signs and symptoms with your health care provider. There are many ways to treat the signs and symptoms associated with hepatitis C, so there is no need to suffer in silence.

Always tell your health care providers if you start to experience a new sign or symptom. Doing this will help them in their efforts to help you feel your best.

Keep all of your health care providers informed about what treatments, medicines, and supplements you are using to manage your hepatitis C. Sometimes, different treatments interact with one another in ways that cause side effects that you may experience as new signs or symptoms.

Do not panic if you start to experience new signs or symptoms. Although many of the signs and symptoms associated with hepatitis C can be troubling to you, they do not necessarily mean your liver disease is getting worse.

Frequently Asked Questions about Hepatitis C and Fatigue

Most people infected with chronic hepatitis C virus (HCV) have few symptoms or physical signs of the virus in the first two decades after infection. However, about 20 percent of those with HCV develop vague symptoms, including mild intermittent fatigue and malaise. Fatigue, which may lead to a significant decrease in quality of life, may be the first and only sign that the liver is being affected by the virus. Following are answers to some frequently asked questions about hepatitis C and fatigue.

Q. Why is fatigue associated with hepatitis C?

A. Much of the fatigue a person with HCV experiences is due to an activated immune system attempting to eliminate the virus. Despite the effective creation of antibodies against it, the hepatitis C virus can undergo frequent mutation, allowing it to avoid being eliminated from the body in 85 percent of those who contract it. In an ongoing effort to rid the body of the virus, the immune system continues to create weapons against the virus including antibodies, interleukins, and white blood cells. At times, the immune response leads to the production of immune complexes, collections of antibodies that course through the body. Immune complexes may deposit in the joints, the blood vessels in the skin, or in the kidney, leading to arthritis, rashes or glomerulonephritis (a form of kidney disease). These conditions are referred to as "extra-hepatic manifestations" of hepatitis. An immune system activated to fight a virus like HCV might also begin developing antibodies against other tissues in the body, including the thyroid. The resulting autoimmune illness, such as autoimmune thyroiditis, can result in still more symptoms of fatigue.

Q. What underlying conditions might an HCV-infected patient have that could contribute to his or her fatigue?

A. Fatigue in HCV-infected individuals is most likely due to the virus' presence. However, a number of conditions that are readily diagnosed and treated may add to the level of fatigue. Iron deficiency anemia and hypothyroidism are both common among women and can certainly contribute to loss of energy. Depression is also common and often manifests itself as excessive sleepiness and fatigue. In fact, being diagnosed with a chronic condition can actually worsen an individual's depression.

Q. How should conditions associated with HCV be treated?

A. In general, these conditions may be treated independently of the hepatitis. Those that are clearly related to HCV may respond to treatment with approved therapy for HCV. All medications ingested by a patient with HCV should be reviewed by his or her physician because many drugs are metabolized by the liver, which may already be compromised by the virus. Some medications, particularly some antidepressants, can lead to fatigue if serum levels are too high. Therefore, in some cases, drug dosages may need to be reduced.

Q. What changes can a person make to ease the impact of the fatigue on his or her life?

A. Most doctors recommend HCV patients eat a well-balanced diet, drink alcohol only in moderation and stop smoking. With these changes, energy levels may improve. In addition, coping with fatigue means balancing activity and rest. Some suggestions include taking short naps between activities and crafting a schedule that balances strenuous activities with ones that are less strenuous. For those with exhausting jobs, devising a flexible work schedule or telecommuting from home may be good options.

Headaches

Some people with hepatitis also complain about headaches. These headaches may go away completely after a while, but then come back. Sometimes they are mild, but at other times they are severe. They are not like migraine headaches. You can treat the headaches with over-the-counter medication. (Again, check with your doctor about what to use.) Also, take time to relax and drink plenty of fluids. Staying rested and drinking lots of fluids may prevent headaches.

Nausea and loss of appetite

Sometimes people with hepatitis have nausea and loss of appetite. You should try to eat, even if you don't feel like it. It may help to eat many small meals rather than 3 large ones. But some patients find it is easier to eat a larger meal in the morning. Dry crackers, weak tea, ginger ale, and ice pops may be easier for you to eat than other foods. If the nausea lasts, or if you are vomiting, let your doctor know. He or she may be able to prescribe a medication to relieve the problem.

Stress and depression

Having an illness can be very stressful and sometimes downright depressing. Some of your coworkers and friends may believe false information, particularly about how the disease is spread, and this may change their attitudes toward you. You may also feel somewhat isolated because your friends and family don't understand how you feel. You might feel tired all the time, or that you don't have enough energy, or that no matter how much you sleep, you just don't feel like getting out of bed. By 9 AM, you feel as if you've put in an entire workday. But you can get help to cope with these feelings.

Hepatitis and Depression

A diminished interest in recreational or pleasure activities or other activities that used to be enjoyable; a diminished ability to think or concentrate—indecisiveness; trouble sleeping or, alternatively, sleeping all the time; a significant weight loss or weight gain when not when not trying to lose or gain weight; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; recurrent thoughts of death or thinking about suicide; and taken together, these characteristic may cause significant distress or impairment in social, occupational, or other important areas of functioning. *These are all symptoms reported by people who suffer from hepatitis.* *They are also the clinical diagnostic criteria for Major Depression.* Many with hepatitis have said they were mistakenly diagnosed with depression when they were trying to find out what was wrong with their bodies (the “it’s all in your mind” diagnosis). There have also been those who thought they were depressed and in the process of being evaluated for medication for depression were diagnosed with hepatitis. It is however possible, and even probable, to have both: a diagnosis of Viral Hepatitis *and* a diagnosis of Clinical Depression. It can become sort of a self perpetuating downward spiral. That is, low energy, chronic fatigue, consistently not feeling well, along with the decrease in functioning that comes with these symptoms, all from hepatitis; combined with the impact of having a potentially fatal disease, are all very depressing things. An increase in depression leads to even lower energy, more decrease in functioning and even the possibility of making physical symptoms worse. Depression alone can be a serious debilitating disease. Combined with hepatitis it can be devastating. So how can you tell and what can you do? First, if you experience five or more of the symptoms above, talk to your doctor about depression. You might also want to consider seeing a therapist. Depressed or not, someone to talk to about the feelings that you experience around having hepatitis can really be a help in sorting things out sometimes. Your medical doctor or your therapist may refer you to a psychiatrist to prescribe one of the anti-depressant medications. Many of these have been shown to be very effective in treating depression. As with all medications, it is always good to be an informed consumer.

Cerebral affect of the hepatitis C virus

Evidence for a cerebral affect of the hepatitis C virus Choline/creatine ratios are elevated in regions of the brain of patients with hepatitis C, according to research published in the latest issue of the Lancet. A team from London, England, investigated whether hepatitis C virus (HCV) affects cerebral function. Patients with HCV infection frequently complain of symptoms akin to the chronic fatigue syndrome. They also score worse on health-related quality of life indices than matched controls. The researchers used proton magnetic-resonance spectroscopy (1H MRS) to measure cerebral choline/creatine ratios in subjects. "This suggests that a biological process underlies the extrahepatic symptoms in chronic HCV infection. " Daniel Forton. This was performed in 30 patients with histologically-defined mild chronic HCV infection, 29 age-matched and sex-matched healthy controls, and in 12 patients with chronic hepatitis B. They found that the choline/creatine ratios were significantly higher in the white matter and basal ganglia of the HCV group, compared with both the hepatitis B group and healthy volunteers. This elevation was found to be unrelated to hepatic encephalopathy or a history of intravenous drug abuse. Daniel M Forton, of Imperial College School of Medicine, St Mary's Hospital, London, concluded on behalf of the group, "The elevation in choline/creatine ratios suggests that a biological process underlies the extrahepatic symptoms in chronic HCV infection. "These findings have implications for the direction of future research and ultimately for patient treatment." Lancet 2001; 358: 38-9 10 July 2001

Q. What is the most common symptom of hepatitis?
A. Fatigue (severe tiredness) is the most common symptom of hepatitis.
Q. What is a good and simple exercise?
A. Walking is a good exercise that can be done regularly by almost anyone.

Q. What potentially serious condition can cause joint pain in hepatitis patients?
A. A condition known as cryoglobulinemia is sometimes the cause of joint pain in hepatitis patients. You need to talk to your doctor if you think you have this condition.

Q. What is the most important step in dealing with symptoms?
A. Your attitude, and how you take control of your life through it, can make the biggest difference in how you feel, despite this disease.

http://pages.prodigy.com/hepc/hepc2.htm

HEPATITIS/LIVER PAIN?

The liver has no nerves, but the liver is surrounded by a capsule (a bit like a sausage skin). The capsule has nerves in it which are sensitive to stretching and to inflammation and thus some people can occasionally experience pain if the liver becomes enlarged or inflamed. However, there are other causes for pain in that area. The brain is not very good at distinguishing pain from different organs. Liver pain is comparatively rare and usually the pain is actually from the large bowel (colon) as it squeezes bowel contents around (it acts like a wriggling worm and is always active) - thus most of the activity that the brain receives is from the colon which can "tie itself in figurative knots" sometimes with trapped wind and increased contractions. There are other organs that also lie in close proximity to the liver and could be responsible for discomfort including the gall bladder and the pancreas and the bile ducts. However for the most part the issues are often with the colon, but the liver, even in people without liver disease, can be uncomfortable if the colon is hyperactive.

Many Hepatitis C patients feel a variety of abdominal pains and discomfort, but unfortunately too often these pains are dismissed as having nothing to do with chronic liver disease. This is because abdominal organs are not responsive to many things what would normally elicit severe pain. The pain fibers in the large interior organs, such as the liver , are usually sensitive only to stretching or increased wall tensions, which is what happens as the liver becomes inflamed. About 20 percent of patients complain of pain over the liver area, in the right upper side of the abdomen just beneath the ribs. Some experts suspects this could be Referred pain caused by inflammation and swelling of the covering of the liver. This pain also may occur in the right shoulder or to the back between the shoulder blades.

Pain that is caused by sensory nerves in the liver may cause a pain that is hard to describe- Dull cramping or aching, appearing anywhere from the midline to the lover abdominal area. It may be accompanied by nausea and vomiting , swearing , pale skin and restlessness during sleep. Patients often move about in bed, occasionally finding relief with a change in position.

Moreover, bacterial or viral infection of any organ in the abdominal are including the liver may cause abdominal pain.

Pain or discomfort of the liver

People with hepatitis C may experience episodes of abdominal pain. Pain or soreness on the right side just below the ribs could be from the liver.

Before attempting to treat pain or discomfort of the liver it is important to discuss symptoms and pain management with your doctor. For some people reducing alcohol consumption to below the levels recommended for the general community or abstaining from alcohol altogether, may bring relief. Using a heat pack over the liver, particularly at night, may also relieve liver pain or discomfort.

Pain relief medication, both over-the-counter and on prescription, is generally considered acceptable for temporarily treating liver pain—but there are exceptions. The use of pain medication in people with chronic hepatitis C should first be discussed with your doctor.

People who have undergone treatment and are PCR negative six months after treatment ceases should find a noticeable decrease in their symptom. For others, there is usually a decrease in the discomfort after completing treatment.

VISCERAL PAIN

Visceral pain may be referred to a remote area of the body, where it is perceived as cutaneous pain (sensation of pain in the skin) in an area supplied by the same spinal cord level as the affected abdominal organ. Referred pain is usually well localized and appears when noxious visceral stimuli become more intense. Thus, swelling of the liver capsule by a hematoma (swollen blood vessels) after liver biopsy is first perceived in the abdomen but may be referred to the right shoulder.

Sensory Pain

Pain resulting from stimulation of sensory afferent nerves innervating abdominal organs. The pain is often difficult to describe (usually as cramping or aching), dull in nature, and poorly localized to the midline from the upper (epigastrium) to the lower abdominal area. The pain may be accompanied by nausea, vomiting, sweating, pallor, and restlessness.

PARIETAL PERITONEAL PAIN

When the parietal peritoneum (abdominal membrane that encloses that body cavity) becomes involved as a result of abdominal pathology (disease process), nerves supplying the area are stimulated and generally produce pain that is more intense and more precisely localized than is visceral pain. The classic example is the localized pain of acute appendicitis. Parietal pain is often aggravated by movement; hence the patient's desire to lie completely still.

PSYCHOGENIC PAIN

This is obviously abdominal pain that is perceived but without any local cause. Unfortunately, this may be a pain mechanism that some physicians choose to attribute to some chronic hepatitis patients' episodes of pain. However, as cited above, physicians should take the time to explain and concede that there are valid causes for different types and intensities of abdominal pain that arise from our internal organs due to inflammation and toxic conditions.

FURTHERMORE.....

When the hollow structures of the gallbladder and biliary tract dilate due to the disease process, pain is experienced in the upper abdomen or right upper abdomen. Pain may also be referred to the back between the shoulder blades. Pain from the pancreas is also felt in the upper abdomen and is often referred to the middle of the back. In a manner analagous to the liver, gallbladder, and biliary tract on the right, lesions in the tail of the pancreas that involve the diaphragm, may result in referred pain to the left shoulder. Bacterial or viral infection of any intraabdominal organ may cause abdominal pain. Interference with venous or arterial blood flow can affect the abdominal organs. Clinically this may present as severe abdominal pain and shock.

Dangerous Over The Counter Drugs

By Peggy Peck, MedPage Today Staff Writer
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco
http://www.medpagetoday.com
May 22, 2006
MedPage Today Action Points

* Explain to interested patients that a number of over-the-counter and prescription drugs contain acetaminophen, which may put acute hepatitis patients at risk of acetaminophen toxicity at lower doses than previously recognized.

* This study was published as an abstract and presented in a poster at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.

Review
LOS ANGELES, May 22 - Over-the-counter flu remedies such as Nyquil or Theraflu are often used for relief of the flu-like symptoms of acute hepatitis, a choice that may trigger acute liver failure because those agents contain acetaminophen.

Serum samples from 72 patients with fulminant hepatitis detected evidence of acetaminophen toxicity in 12.5% of patients, said William M. Lee M.D., of the University of Texas Southwester Medical Center in Dallas, who reported the findings at Digestive Disease Week sessions here today.

Dr. Lee and colleagues used a high-pressure liquid chromatography with electrochemical detection to assess acetaminophen levels. They studied 10 patients with liver failure due to confirmed acetaminophen overdose as a positive control group.

The average serum concentration of acetaminophen adducts was 0.45 nmol/mL versus 5.58 nmol/mL in the control group. Nonetheless, Dr. Lee said the evidence of acetaminophen adducts was "a second insult to the liver cells on top of hepatitis."

Importantly, the toxicity occurred when the patients used the over-the-counter flu medicines at therapeutic doses. "None reported doses that would exceed 4 g/day," he said. That is lower than previously reported toxic doses, he said.

Acetaminophen toxicity occurs in a dose-related fashion. Seven or eight grams consumed over the course of three to four days can be fatal, Dr. Lee said.

An online check of ingredients in cold and flu products found acetaminophen listed as an ingredient in 26 OTC remedies, including Coricidin D, Triaminic, NyQuil, DayQuil, and Dristan as well as Midol and Pamprin.

In this series, 67% of patients who had detectable acetaminophen-protein adducts in their blood died within three weeks of hospital admission versus 27% of patients who had no evidence of acetaminophen use (P=0.017).

Liver toxicity is a well known side-effect of acetaminophen, he said, noting that acetaminophen overdose is a leading cause of liver failure and liver transplants "I am surprised it is still on the market," Dr. Lee said.

He later qualified that statement saying that but the drug is so popular, and is sold under so many different brands-the most popular being Tylenol-that he doubts it would ever be removed from the market.

That said, he noted that people with liver disease are frequently unaware that they are using acetaminophen-containing compounds, which could put them at risk for liver failure.

"Vicodin and Percocet are the two most popular prescription compounds containing acetaminophen and these are often prescribed for pain relief in people with liver disease," he said. "Unbundling of both of these drugs, which might be done at some point, would be significant in terms of reducing accidental acetaminophen overdose."

He said that in 2002 a FDA advisory committee recommended that labels of over-the-counter cold and flu medicines be changed so that the front label would list acetaminophen as an ingredient. "But that was in 2002 and the FDA has yet to act on that recommendation."

John M. Vierling, M.D., president of the American Society for the Study of Liver Diseases, a professor of medicine at Baylor in Houston, said the hallmarks of acetaminophen toxicity are "a change in mental state and alteration in clotting ability."

Dr. Vierling called acetaminophen an "excellent drug" but added that Dr. Lee's study suggests the need to advise patients with chronic liver disease to avoid not only Tylenol and other acetaminophen products but also to be cautious when selecting cold and flu medicines.

The patients were included in the National Institutes of Health Acute Liver Failure Study (1999-2004), a national registry of acute liver failure cases. Dr. Lee said there are roughly 2,000 cases of acute liver failure annually and about 500 of those are fatal.

Primary source: Digestive Disease Week
Source reference:
Lee, WM et al "Acetaminophen as a co-factor in acute liver failure due to viral hepatitis determined by measurement of acetaminophen-protein adducts" Abstract S1002.

IT'S NOT ALL IN YOUR HEAD!

Some doctors (but thankfully fewer than there used to be) insist on believing that HCV usually has no symptoms, and dismiss the patient's complaints as being "all in their head". Some HCV+ patients have been treated for depression for many years before their actual diagnosis of HCV was uncovered.

Much is still unknown about the hepatitis C virus, and many physicians have not had much experience treating it. Many doctors are not yet familiar with the research which legitimizes the various symptoms which go along with this virus.

Emerging illnesses such as HCV typically go through a period of many years before they are accepted by the medical community, and during that interim time patients who have these new, unproven symptoms are all too often dismissed as being "psychiatric cases". This has been the experience with HCV as well.

WHAT IS THE EVOLUTION OF THE DISEASE?

Three out of four people infected with hepatitis C - not 50%, as once thought - will remain infected for life. Up to half of those people will develop cirrhosis, scarring of the liver, and up to 10,000 will die this year, say doctors and disease trackers meeting in San Diego. The latest findings are sobering because about 1.4% of the U.S. population is infected with the virus

- "Hepatitis C Chronic 75% of the Time", USA Today, 05-15-1995

- At least 50-80% of people infected with HCV will develop chronic hepatitis; ultimately, 20-30% of those will progress to cirrhosis. Another 20-30% may develop chronic HCV infection without abnormal elevations of liver enzymes in the blood. - "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA

WHAT OTHER MEDICAL PROBLEMS CAN BE RELATED TO HCV?

Chronic hepatitis C infection occasionally causes problems for parts of the body beyond the liver. The organs most often affected include the blood vessels, skin, joints, kidneys, and thyroid gland. If chronic hepatitis C infection causes liver cirrhosis (severe scarring of the liver rarely caused by hepatitis C), many problems may arise from the cirrhosis, per se.

Potential problems from cirrhosis include fluid accumulation in the abdomen, bleeding into the stomach, jaundice, confusion, poor blood clotting, and susceptibility to infection.

---

Hepatitis has so many symptoms that it's easy to ascribe all new anomalies to this disease. But HCV patients are not exempt from getting other illnesses also, therefore it is important to regularly monitor your health and to consult with your doctor about the changes as they progress.

CRYOGLOBULINEMIA

One-third to one-half of people with chronic hepatitis C infection have cryoglobulinemia (antibodies in the bloodstream attached to the hepatitis C RNA that happen to solidify when cold). Hepatitis C is recognized as the most common cause of mixed cryoglobulinemia. Most of the people with cryoglobulinemia from hepatitis C have had their hepatitis for a long time or have cirrhosis. People with higher concentrations of hepatitis C RNA in their blood do not seem to have a higher risk of having cryoglobulinemia. Usually the cryoglobulins are in low concentration and cause no symptoms. About twenty-percent of people with hepatitis C and cryoglobulinemia have symptoms.

Symptoms most often associated with cryoglobulinemia include mild fatigue, joint pains, or itching. Occasionally, people with cryoglobulinemia develop vasculitis (inflammation of the blood vessels) which can cause purpura (purple skin lesions), Raynaud's phenomenon (the hands turn white, then blue, and then red from constriction and subsequent dilation of the blood vessels), or numbness
in the hands and feet. The presence of cryoglobulinemia does not effect people's response to interferon. In fact, some people with vasculitis have improvement in the vasculitis as their liver tests improve on interferon.

THYROID AND AUTOIMMUNE PROBLEMS

Chronic hepatitis C infection is also associated with many autoimmune diseases (where the body develops antibodies which attack parts of itself). For example, about one-tenth of people with chronic hepatitis C infection (more often in women and older people) have antibodies to the thyroid gland, one-half of whom may develop hypothyroidism (an underactive thyroid gland).

Additionally, interferon therapy causes hypothyroidism or hyperthyroidism (an overactive thyroid gland) in about one-tenth of those treated. People with hypothyroidism may suffer from fatigue poor memory, weakness, constipation, weight gain, muscle cramps, intolerance to cold, hoarse voice, coarse skin, and brittle hair. People with hyperthyroidism may suffer from anxiety, insomnia, weakness, diarrhea, weight loss, intolerance to heat, velvet-like skin, and brittle nails. Hypothyroidism can be treated with thyroid hormone pills. Hyperthyroidism can be treated with pills that block thyroid hormone synthesis. If the thyroid gland dysfunction is from interferon treatment and is caught early, the thyroid gland will return to normal once interferon is stopped.

From NATAP http://www.natap.org/

Thyroid disease - Thyroid disorders are common in patients with chronic HCV, particularly women [57,58]. One of the largest studies included 630 consecutive patients with HCV (without cirrhosis) who were compared with 389 subjects from an iodine-deficient area, another control group of 268 persons from an area of iodine sufficiency, and 86 patients with chronic hepatitis B [58]. Mean TSH levels were significantly higher and free T3 and T4 levels significantly lower in patients with HCV than in all other groups. Patients with HCV were more likely than controls to have hypothyroidism (13 versus 3 to 5 percent ), anti-thyroglobulin antibodies (17 versus 9 to 10 percent), and anti-thyroidperoxidase antibodies (21 versus 10 to 13 percent). Another report suggested that thyroid abnormalities were seen predominantly in women [57]. (See "Pathogenesis of Hashimoto's thyroiditis (chronic autoimmune thyroiditis)").

Overall, antithyroid antibodies are present in 5 to 17 percent of patients with HCV infection, and thyroid disease, primarily hypothyroidism, occurs in 2 to 13 percent of patients [57,58]. The highest prevalence of both thyroid antibodies and thyroid disease is found in older women. However, whether or not the prevalence is higher than in age- and sex-matched controls is controversial [59,60].

A separate issue is the development of thyroid disease in patients with HCV infection who are treated with interferon alfa. Approximately 1 to 5 percent of such patients develop painless thyroiditis. Other thyroid abnormalities can also occur, including Graves' disease and permanent hypothyroidism, or increased serum antithyroid antibody concentrations without thyroid dysfunction [59-62]. The changes in thyroid function usually appear after three months of therapy, but can occur as long as interferon alfa is given.

The risk of any form of thyroid disease is greater in those patients who have increased serum antithyroid antibody concentrations before the initiation of therapy, a finding which suggests that interferon alfa in some way exacerbates underlying thyroid autoimmune disease. (See "Principles of interferon therapy in liver disease and the induction of autoimmunity", section on Thyroid disease). The presence of antithyroid peroxidase antibodies appears to be the most significant risk factor for the development of thyroid dysfunction during interferon therapy [62]. Other risk factors may include female gender, older age, and the presence of other autoantibodies [60]. Women with chronic hepatitis C and high antithyroid peroxidase antibody titers are at particular risk.

Thyroid dysfunction may resolve following the discontinuation of interferon treatment.

In summary, all patients receiving interferon alfa should be monitored for thyroid disease, particularly women and patients with preexisting antithyroid antibodies. Interferon therapy usually can be continued while hypothyroidism is being treated. On the other hand, we have usually stopped interferon in patients who develop clinically apparent hyperthyroidism.

MUSCULOSKELETAL

- Hepatitis C-associated osteosclerosis is a rare disorder characterized by a marked increase in bone mass during adult life. While most cases have been reported in patients with a history of intravenous drug abuse, it has also been seen with hepatitis C after blood transfusion [85]. Periosteal, endosteal and trabecular bone thickening occurs throughout the skeleton with the exception of the cranium. During active disease, forearm and leg pain are common, bone remodeling (turnover) is high, and bone mineral density is two- to three-fold higher than age-matched norms. The increased remodeling may respond to bisphosphonates or calcitonin, but spontaneous remission has also been described. Abnormalities in insulin-like growth factors (IGF-1 and IGF-II) or their binding proteins may contribute to the increase in bone formation in this disorder [86].

Arthritis is noted in 2 to 20 percent of HCV patients. The arthritis is an evanescent rheumatoid-like picture in two-thirds of the cases and an oligoarthritis in the rest. (See "Specific viruses that cause arthritis").

RHEUMATOID ARTHRITIS-LIKE SYMPTOMS

Hepatitis C infection can present with rheumatic manifestations indistinguishable from rheumatoid arthritis. The predominant clinical findings include palmar tenosynovitis: small joint synovitis, and carpal tunnel syndrome. Risk factors such as transfusions and IV drug abuse or a history of hepatitis or jaundice should be included in the history of present illness of any patient with acute
or chronic polyarthritis or unexplained positive RF. In such patients, gammaglutamyl aminotransferase, serologic studies for hepatitis C, and other tests appropriate for chronic liver disease should be performed. - " Journal of Rheumatology, June 1996;23(6):979-983.

FIBROMYALGIA

Fibromyalgia is the name for a condition that typically includes widespread muscle pain, fatigue and abnormal sleep patterns. Until a few years ago, doctors called the condition fibrositis or muscular rheumatism and believed that for the most part, the condition was "all in the patient's head". Today, fibromyalgia is recognized by medical organizations as a genuine and serious problem.

The symptoms of fibromyalgia typically include pain in many muscles, and around ligaments and tendons, persistent fatigue, waking up feeling tired even after a full night's sleep, headaches, bouts of constipation and diarrhea, abdominal pain, painful menstrual periods, sensitivity to cold, numbness or tingling, and difficulty exercising.

Symptoms vary widely among patients and tend to wax and wane over time. An illness, injury, cold weather or emotional stress may trigger a fibromyalgia episode or make ongoing symptoms worse.

A study at the Oregon Health Sciences University and Portland Adventist Hospital suggests hepatitis C may trigger fibromyalgia ("Fibromyalgia: A prominent feature in patients with musculoskeletal problems in chronic hepatitis C, A report of 12 patients," by A. Barkhuizen,
G.S. Schoepflin, and R.M. Bennett, Journal of Clinical Rheumatology, Vol. 2, No. 4, August 1996) .

This study is the first to show a link between the two illnesses.It was determined that the between the hepatitis C virus and fibromyalgia followed three distinct patterns:In nine patients, fibromyalgia developed as a long-term complication of the hepatitis, arising on average 13.4 years after the virus was acquired.In two patients, fibromyalgia arose simultaneously with the hepatitis C infection.In one patient, pre-existing fibromyalgia was significantly worsened by the hepatitis C.
It is unknown why the hepatitis C virus and fibromyalgia may be linked, but the authors suggest that hepatitis C causes chronic activation of the immune system that leads to muscle aching, fatigue, mental changes, sleep abnormalities, and alterations of the neuroendocrine system.The patients with both hepatitis C and fibromyalgia could be distinguished from most other patients with fibromyalgia alone because they had symptoms unusual to fibromyalgia. These symptoms included synovitis (inflammation of the membrane around a joint, bursa, or tendon) and vasculitis (inflammation of a blood or lymph vessel). In addition, laboratory findings pointed to a disease process other than fibromyalgia.

DERMATOLOGICAL MANIFESTATIONS

The main dermatologic disorders in HCV infection include (1) vasculitis (mainly cryoglobulin-associated vasculitis, the cause of which is HCV in most cases, and, possibly, some cases of polyarteritis nodosa); (2) sporadic porphyria cutanea tarda; (3) cutaneous and/or mucosal lichen planus; and (4) salivary gland lesions, characterized by lymphocytic capillaritis, sometimes associated with lymphocytic sialadenitis resembling that of Sjoegren's syndrome.

Hepatitis C virus is the cause of, or is associated with, various dermatologic disorders. In patients with such disorders, HCV infection must be sought routinely because antiviral therapy may be beneficial in some of them. - Arch Dermatol. 1995; 131:1185-1193

Necrolytic acral erythema -

Necrolytic acral erythema is a pruritic, psoriasis-like skin disease characterized by a sharply marginated, erythematous to hyperpigmented plaques with variable scale and erosion on the lower extremities. In a series of 30 patients who presented with the disorder, all were found to have antibodies to HCV [81]. Biopsy specimens showed psoriaform changes, keratinocyte necrosis and papillomatosis. Improvement was observed in a patient who had been treated for HCV with interferon alfa (and subsequent relapse nine months after discontinuation). Topical and systemic corticosteroids had a variable benefit. Other reports have confirmed improvement

PORPHYRIA CUTANEA TARDA (PCT)

Porphyrins are a group of compounds that are mainly synthesized in the bone marrow. They play an important role in many chemical reactions in the body, e.g. with proteins to build hemoglobin. They are later converted to bile pigments mainly in the liver. Porphyrinuria increase of porphyrins in theurine) may be caused by chronic liver diseases. Hepatitis C is a major cause of porphyria throughout the world and may cause many symptoms, including excess blood iron - important in conjunction with an interferon therapy (since elevated blood iron seems to reduce the effect of interferon).

Porphyria cutanea tarda is a rare deficiency of a liver enzyme essential for cellular metabolism. The enzyme deficiency may cause sun exposed skin to blister, ulcerate, turn dark, or bruise. Hair may increase on the forehead, cheeks, or forearms, and the urine may turn pink or brown. It now appears that hepatitis C is the most common trigger of porphyria in people who are predisposed. Topical sunscreens do not prevent the skin lesions. Avoidance of alcohol and removal of iron by repeated phlebotomy (blood removal) or taking medication that binds to iron sometimes helps. Chloroquine (an anti-malaria drug), which removes a toxic by-product of the enzyme deficiency, may help, as well.

Autoimmune idiopathic thrombocytopenic purpura

- Anti-HCV antibodies occur