Diagnosis of Hepatitis C

A proper evaluation of HCV requires collecting all information that is needed to make recommendations with respect to treatment of the virus and complications of the disease. It provides important clues for the outcome of the disease (prognosis).

This may require a variety of diagnostic tools after initial history taking and physical examination.

  1. Cause(s) confirmation by history and specific testing
    • HCV alone, or HCV + other causes such as co-existing HBV, alcohol, fat or iron overload
    • Viral load (the amount of virus in the blood)
    • Genotype (strain of the virus)
    • Co-existing HIV (risk factors often identical!)
  2. Severity
    • Clinical symptoms (fatigue, fluid retention, gastrointestinal bleeding, mental confusion etc.)
    • Blood tests: bilirubin, transaminases, albumen, INR, Hemoglobin, white blood cells, platelets, (see also: liver tests explained)
    • Imaging: US, CT, MRI (likely cirrhosis, spleen enlargement, abnormal circulation in abdomen, fluid overload (ascites))
    • Histological findings or equivalents (What looks liver tissue like?)
    • Liver biopsy (the classical assessment)
    • Fibrosis markers in blood
    • Elasticity assessment (scar formation) with Fibroscan (widely in Europe, not yet approved by FDA)
    • Alternative scar assessment with MRI, US etc.
    • Presence of varices (abnormal vessels in wall of esophagus or stomach causing bleeding: often needs endoscopy)
  3. Other patient characteristics
    • Other disease such as kidney failure, heart disease
    • Psychiatric disease
    • Ongoing addiction problems

This information enables a physician to provide an opinion and make recommendations with respect to

How is the information used in making treatment recommendations?

This is best illustrated by discussing a few patients.

Example 1: Janice
Janice is a 27-year old customer service clerk at a car dealership. She felt fatigued and saw her PCP. He found her to have abnormal liver tests and subsequently diagnosed her with hepatitis C infection: She had HCV antibodies in her blood (anti-HCV) and virus was detected in her blood by PCR testing. She was very upset, and frustrated that she had to wait 8 weeks to be seen by a liver specialist (a gastroenterologist with a focus on liver disease and also called hepatologist) because "the harm needed to be stopped promptly". Various friends had told her that HCV was incurable and she would die if a liver transplant was not done at some stage. Also, she felt uncomfortable, putting her partner at risk: Should they rather have protected intercourse with condoms? Could they conceive?

The liver specialist saw her and obtained further history:

The liver specialist did further testing (blood work including HIV testing, ultrasound) and now was able to provide information and recommendations that should help to alleviate concerns:

Follow-up: After hearing all this, Janice deferred treatment. Her hepatologist received a birth announcement of Xavier some 11-months later with the comment: "Thanks for your encouragement: We would now like a second child ". A healthy second child was born a year later.

Two years later she reappeared for an appointment. After some discussion ("I wanted to know what my liver looks like now") she underwent a liver biopsy. It showed mild inflammation and pretty mild scarring. She wanted "to be done with the virus". She was treated after extensive information and education. It was a pretty rough year. Close monitoring and support by nurse practitioner and the psychiatry team with use of anti-depressants led to permanent eradication of the virus. A year after therapy she was declared cured and only suggested to have in a few years once more HCVRNA testing done to reconfirm cure.

Her fatigue was quite a bit less after reassurances during her first visit and would come and go over time. She had her children tested and they had no virus, as expected.

Example 2: Keith
Keith is a 44 years old male, working in home construction and also doing plumbing work. He is divorced but maintains great relationships with his former wife and 2 teenage kids. He had noted swelling of his legs that got worse over time and particularly bad by the end of the day. His friends noted that he really did not look that good lately. He had lost some 15 lbs of weight with no specific effort. He went to see his PCP who send him after limited testing right away to a liver specialist.

Further history:

Physical examination:

Blood tests:

Imaging: MRI of abdomen

Impression of liver specialist
Very advanced liver disease ("decompensated cirrhosis") due to a combination of chronic HCV infection with excessive alcohol use. Joint/skin complaints caused by abnormal proteins (cryoglobulins).

Right now no possibility to treat with antivirals (very risky because of ascites). Impotence likely secondary to liver disease + alcohol (impaired testosterone production, testicular atrophy, more female hormone)

With him and family was discussed:

Follow-up: Three weeks later he had another office visit. He had lost some 20 lbs of weight. This is likely loss of his excessive fluid retention. His kids had motivated him to stop and he had been successful without any specific counseling. He had still swollen legs and some abdominal fluid. Spironolactone was increased to 100 mg, and furosemide 40 mg was added. An endoscopy showed varices that were treated with rubber band ligation and therapy was initiated with nadolol to reduce pressure with a fu band ligation scheduled.

Four weeks afterwards he had lost a further 13 lbs and felt a lot better. Energy and appetite had improved.

Two months later an ultrasound conformed complete disappearance of fluid in his belly and legs had minimal fluid only. His protein in the blood (albumin) had increased to near normal values and his Hgb had increased. His varices were completely eradicated. His joints continued to hurt him intermittently. A few weeks in the South had been a major relieve, being back in the North had worsened his complaints.

Comments: Although HCV is a major contributor, this patient came really under attention due to the combined effects of alcohol and NSAIDS superimposed on the likely already HCV damaged liver. It may take 4-8 months but stopping alcohol can dramatically improve symptoms and chances.

Completely stopping NSAIDS is key in controlling fluid retention.

We now could consider to carefully try to eradicate the HCV virus, but with such advanced disease, it is tricky. If he is lucky, he tolerates therapy and the cryoglobulins may disappear and relieving him from the skin and joint problems. He needs future control for the development of new varicose veins. He remains at high risk for developing liver cell cancer (HCC) and he may deteriorate and need a liver transplant. His chances of becoming a candidate are much better now that he is off alcohol for a prolonged period. In addition he has started a weight loss program to lose real weight instead of excessive fluid overload.