What to know about late-stage hepatitis C
Hepatitis C occurs when the hepatitis C virus, also known as HCV, infects the cells in the liver. A person may contract HCV by coming into contact with the blood or bodily fluids of someone with the virus.
This article discusses the stages of liver disease and the outlook for people who have hepatitis C in the later stages.
Stages of hepatitis C
The terms "acute" and "chronic" refer to the length of time that a person has had the hepatitis C virus.
Acute hepatitis C
Acute hepatitis C presents in the first 6 months after exposure to the hepatitis C virus. There is a 20 to 50 percent chance that the infection will clear on its own within this time.
Chronic hepatitis C
Hepatitis C has a high risk of becoming chronic.
In people with chronic hepatitis C, the infection lasts for longer than 6 months. Hepatitis C becomes chronic in as many as 75 to 85 percent of cases.
Chronic hepatitis C can remain undetected for a prolonged period.
For this reason, many people will not know that they have the infection until a doctor detects it during a routine blood screening.
Progression of liver disease in hepatitis C
As chronic hepatitis C progresses, its effects on the liver include:
Inflammation of the liver is characteristic of early hepatitis C. The virus attacks and kills liver cells, triggering the body's immune system to release inflammatory markers.
These inflammatory markers cause the liver to produce fiber-like proteins that can repair liver damage. A buildup of these proteins can result in a type of scarring called fibrosis.
In fibrosis, the continued buildup of scar tissue prevents blood from reaching some parts of the liver. Without access to the oxygen and nutrients that the blood supplies, the liver cells begin to die, which leads to an ongoing cycle of cell death and scarring.
In the early stages of fibrosis, scar tissue may begin to accumulate around the portal vein, which runs through the liver. This is called portal fibrosis.
As yet more scar tissue builds up, it begins to form thick, fibrous bands called septa.
Advanced fibrosis of the liver can lead to a more severe form of scarring known as cirrhosis. In people with this type of liver damage, scar tissue is so widespread that it impairs the liver's ability to function and regenerate.
An estimated 10 to 20 percent of people with HCV will develop cirrhosis over 20 to 30 years.
The 4 stages of liver fibrosis
A liver biopsy can help determine the severity of liver scarring.
A doctor can determine how severe a person's liver scarring is by carrying out a liver biopsy.
A higher score indicates a more significant disease progression. Healthcare professionals use the METAVIR scoring system to assess the progression of liver fibrosis.
The system assigns a grade to the level of inflammation and the stage of fibrosis.
The METAVIR stages of inflammation are as follows:
The METAVIR stages of fibrosis are as follows:
|F1||Portal fibrosis without septa|
|F2||Portal fibrosis with few septa|
|F3||Numerous septa without cirrhosis|
Stages of cirrhosis
Cirrhosis develops in two stages, beginning with compensated cirrhosis and leading to decompensated cirrhosis, or end-stage liver disease.
Compensated cirrhosis involves liver damage, but the liver still has enough healthy cells to perform its vital functions.
People often remain free of symptoms at this stage, but they may show signs of portal hypertension, which is high blood pressure within the portal vein. This happens when widespread scarring impairs blood flow through the liver.
Decompensated cirrhosis refers to liver scarring that is so widespread that the functioning parts of the organ are no longer able to compensate for the parts that are damaged.
According to the Hepatitis C Trust in the United Kingdom, around 18 percent of people with compensated liver failure will progress to decompensated liver failure within 5 years. This rate rises to 30 percent after 10 years.
As the liver loses its ability to carry out vital functions, the following complications can occur:
- Portal hypertension, which is high blood pressure within the portal vein that can cause blood to bypass the liver completely. As a result, the liver is unable to filter harmful toxins from the blood, and this can lead to further complications, such as variceal bleeding.
- Variceal bleeding is a type of internal bleeding in which the blood vessels within the food pipe or stomach expand and burst. This happens when portal hypertension causes the blood to reroute through veins that are too small. The condition can be life-threatening.
- Edema, which is an accumulation of fluid within the tissues and cavities of the body. This fluid buildup occurs when the liver stops producing enough albumin, which is a substance that affects how much fluid is in cells. In most cases, this fluid builds up in the stomach, which is a condition known as ascites.
- Hepatic encephalopathy, which refers to brain changes that result from exposure to toxins that the liver has been unable to filter from the blood. Symptoms can be mild to severe.
A doctor may recommend an abdominal ultrasound to determine the best treatment plan.
A doctor may conduct the following tests to assess the best course of treatment for an individual with hepatitis C:
- virus tests to find out the specific strain of HCV
- blood tests to assess liver function
- an abdominal ultrasound to look for liver scarring
- an assessment of the stage of fibrosis
- tests to rule out other infections, such as hepatitis B and HIV
The treatment options depend on the severity of liver disease that the tests reveal.
Hepatitis C with compensating cirrhosis
Oral antiviral medications, which remove the virus from a person's blood, are the primary treatment for hepatitis C. The aim is to make the virus undetectable in the blood, which shows that the medication is working. Doctors refer to this as a virologic response.
If this response lasts for 12 weeks or more after finishing treatment, the person has achieved a sustained virologic response (SVR). Around 99 percent of people who have an SVR remain virus-free for the rest of their lives.
Although antiviral treatment is generally more successful when liver fibrosis has a METAVIR score of F2 or below, people with stage F3 or even stage F4 fibrosis can reach SVR.
After achieving an SVR, the hepatitis C infection will not cause further liver damage. However, people with advanced fibrosis or cirrhosis may continue to experience complications as a result of the existing liver damage.
Hepatitis C with decompensating cirrhosis
Until recently, doctors considered a liver transplant to be the only effective treatment for decompensating cirrhosis.
However, a recent small-scale study found that a course of direct-acting antiviral (DAA) medication may improve some people's liver function enough to take them off the waiting list for a liver transplant. People with liver disease that was less severe had a higher likelihood of removal from the list.
However, recent Canadian guidelines warn that certain antiviral drugs may potentially be dangerous for people with severe decompensating cirrhosis. This is because the liver is less able to filter out toxic waste, meaning that the antiviral drugs could accumulate to toxic levels. Doctors must weigh up the benefits against the risks.
When a person is waiting for a liver transplant, a doctor will assess whether or not to pause antiviral treatment.
Hepatitis C is a viral infection that can cause severe liver damage, including cirrhosis and fibrosis. The treatment of chronic hepatitis C will depend on the stage of liver disease and cirrhosis.
In its earlier stages, doctors can sometimes cure hepatitis C with antiviral medications. In some cases, a person with late-stage hepatitis C may need a liver transplant.
Advances in modern medicine mean that the outlook for hepatitis C is improving.