Approach to the Patient with Chronic Hepatitis C Infection
June 15, 2002
Approach to the Patient with Chronic Hepatitis C Infection
Abstract & Commentary
Synopsis: Primary care physicians should identify patients with chronic hepatitis C infection, advise them regarding transmission risks, and should assist in treatment decisions.
Source: Herrine SK. Ann Intern Med. 2002;136:747-757.
Hepatitis C virus (HCV) is one of the most important causes of chronic liver disease in the United States, accounting for 15% of acute viral hepatitis, 60-70% of chronic hepatitis, and up to 50% of cirrhosis and liver cancer. Almost 4 million Americans, or 1.8% of the US population, have antibody to HCV (anti-HCV), indicating ongoing or previous infection with the virus. Hepatitis C causes an estimated 8000-10,000 deaths annually in the United States. Hepatitis C is asymptomatic in up to 75% of those infected, and progresses to cirrhosis in 15-20% of cases. Abnormal ALT levels should lead to tests for hepatitis B and C infections. Testing might involve HCV enzyme immunoassay, confirmed by recombinant immunoblot assay or HCV RNA by PCR or HCV confirmation by branched chain DNA testing. Since up to 30% of patients with replicating hepatitis C have persistently normal ALT levels, one must also consider screening those with definite or potential risk factors (transfusions, IV drug use, nasal cocaine use, hemodialysis patients, tattoo and religious scarification recipients, and those exposed sexually or children of infected mothers). Although 15-40% of acutely exposed patients will have spontaneous resolution of infection, chronic infection develops in the remainder. Five percent of chronic infections lead to hepatocellular carcinoma. Alcohol use is a negative prognostic factor in infected individuals. All patients with chronic HCV infections healthy enough to have antiviral therapy should be referred to a gastroenterologist or hepatologist familiar with interferon-based treatment regimens. Liver biopsies are often done in infected patients to establish stage and prognosis. Hepatitis A vaccination should be considered in all HCV-infected patients since hepatitis A may have a grim prognosis in this setting. Current treatment for hepatitis C includes parenteral interferon and oral ribavirin. Treatment is associated with significant morbidity and a high cost, but more than 50% of adequately treated patients demonstrate sustained virologic response.
Comment by Malcolm Robinson MD, FACP, FACG
It is critically important for hepatitis C to be identified prior to the development of irreversible complications, and this responsibility clearly falls most directly on the primary care physician. The subtle or nonexistent symptomatology of hepatitis C-infected patients complicates such identification. For the same reason, the successful referral of appropriate patients for treatment can be very difficult even if the patients are diagnosed. In addition to the wealth of information in this article, a useful web site from NIDDK regarding hepatitis C management can be found at: www.niddk.nih.gov/health/digest/pubs/chrnhepc/chrnhepc.htm.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.
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