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Hepatitis C

Hepatitis C is a blood-borne virus that predominantly infects the cells of the liver. This can cause inflammation of and sometimes significant damage to the liver and affect its ability to perform its many, varied and essential functions.

 

Although it has always been regarded as a liver disease (hepatitis means inflammation of the liver), recent research has shown that hepatitis C affects a number of other areas of the body including the digestive system, the lymphatic system, the immune system and the brain.

Transmission

Viruses gain access to the human body by all possible entry routes. They are inhaled in droplets, swallowed in food and fluids, passed through saliva, passed from mother to child, through faeces, via sexual contact and through blood to blood contact.

The immune system deals swiftly with most viruses. Each mechanism of the immune system may be involved in resisting a viral attack including white blood cells that engulf the viral particles and lymphocytes that produce antibodies against the virus or attack virally infected cells. This leads to recovery from most viral infections within a few days to weeks. Furthermore the immune system is often sufficiently sensitized by the infection to make a second illness from the same virus rare. However, if the virus is able to dodge or outwit the immune system the infection can become chronic. In some cases the response of the immune system can cause as many problems as the virus. This is called an immunopathic response. It is a major issue with HCV.

Blood and blood products

In the UK since September 1991 all blood and blood products are screened for blood borne viruses. People in receipt of blood from transfusions or blood products (including clotting agents for haemophiliacs) may have been exposed to hepatitis C prior to 1991.

If you have had an accident or operation in the UK prior to 1991 that may have required you to have a transfusion of blood or blood products you may have been exposed to tainted blood. It is worth noting that you may not always be aware that you were given blood, especially if you were very ill. If you have received blood this will be recorded in your medical records.

The Global Database on Blood Safety indicates that 80% of the world’s population does not have access to reliable and safe blood. It is estimated that 43% of the blood collected in developing countries is not tested for HIV, Hepatitis B, Hepatitis C or Syphilis and globally 5-10% of infections are caused by unsafe blood and blood products (World Health Organisation).

Drug use

Between 30-80% of IV drug-users are reckoned to be infected with hepatitis C and because you put the potentially infected material directly into your blood stream, sharing injecting equipment is one of the most high risk behaviours.

If you have been an injecting drug user and shared any injecting paraphernalia - needle, syringe, spoon, filter water, even once, even if it was a long time ago, then you are at significant risk of having contracted the virus.

Sharing snorting equipment e.g. rolled bank notes or straws potentially poses a risk of transmission. This is because the lining of the nose is very thin and fed with a rich supply of blood. Cocaine for example is very corrosive to the mucous membranes of the nose. As a result traces of blood perhaps even too small for the eye to see, but still containing enough virus can lurk on banknotes and straws. While there have been no documented cases, in theory the risk is significant. The risk is much lower than sharing IV equipment as it is not such an efficient method of transmission.

Hairdressers/Barbers

The hepatitis C virus can be present in small traces of blood, often invisible to the naked eye. Equipment used by hairdressers and barbers including scissors, clippers and razors may have been exposed to infected blood and if not sterilised or cleaned between customers pose a risk of transmission. The likelihood of this happening is very difficult to estimate as it will depend on a number of variables. If you got cut at a barbers or hairdresser, particularly abroad in high prevalence countries, then you may be at some risk. However, blood does flow out of the body when you get cut which may lessen the chances of infection.

Haemodialysis

Haemodialysis for those with kidney failure is a known transmission route for hepatitis C. Haemodialysis involves the removal of waste products from the blood. This is done by passing a person’s blood through an artificial kidney machine, and re-introducing the filtered blood back into the body. The risk of infection is increased in those who undergo long-term dialysis and has been estimated at between 10%-20%.

Household transmission i.e. sharing razors and toothbrushes

Because razors, nail scissors, nail clippers, toothbrushes and possibly even towels may carry traces of blood, sharing them with an infected person may present a risk of acquiring hepatitis C. If the implement is tainted with infected blood and you sustain an injury from it, then the virus could be introduced into your bloodstream. Similarly, traces of blood which could contain virus can be present on toothbrushes and if shared by a person with bleeding gums or a mouth injury transmission is possible. The risk is hard to assess.

Medical and dental procedures

Invasive surgical and dental procedures pose a risk of exposure to the virus, especially in less developed countries. In developed countries healthcare workers are required to use new or sterilised equipment and observe universal control procedures that safeguard both patients and themselves; this does not, however, exclude all risks. In many developing countries these precautions may not be observed. If you have ever had a dental or medical procedure performed abroad, you may have been exposed to risk of infection.

A similar distinction also exists regarding infected doctors carrying out invasive procedures (particularly those where doctors are using sharp instruments but cannot see his or her own hands). This is not permitted in developed countries but this only guards against those whose infections are known. Many developing countries may have less stringent regulations.

Needlestick injury

Needle stick injuries are an occupational hazard of many health care workers, including nurses, anaesthetists, dentists and laboratory technicians. If you know the needle or implement has been exposed to the blood of someone who has hepatitis C the risk is thought to be around 3.3% which is a 1 in 30 risk.

Piercing

Piercing is a potential source of risk unless all equipment is new or sterilised (sterilisation must be done ultrasonically in an autoclave) only new jewellery, preferably from a sealed package, is used. This equally applies to self-piercing. Most body piercing parlours in the UK operate to high standards. However, the situation differs across the country because regulation is carried out by local authorities in some cases, (most of London) by licensing and in other cases using byelaws. These can vary from area to area but the DoH have produced a model set of byelaws(click here) that set out the standards that you ought to expect from a piercing shop. You are unlikely to find these standards in developing countries.

There is also a risk in sharing jewellery that goes through the skin with other people.

Sexual intercourse

The risk of sexual transmission of hepatitis C is considered very low. The risk is higher for some sexual activities, especially where there is potential exposure to blood. This includes vaginal sex during menstruation or anal sex, with the associated risk of anal tears. Sex toys such as vibrators or dildos used during these activities are a potential risk. Oral sex, in the absence of blood is considered to be a low risk activity. In addition, the presence of some sexually transmitted infections may increase the risk. Unprotected sex, even once, with someone who is HIV-positive as well as hepatitis C-positive is a significant risk. The risk of hepatitis C transmission is much higher in the presence of HIV as well. Click here to read the results of a 10 year study into sexual transmission.

Steroids

Sharing any injecting equipment poses a risk of hepatitis C transmission; this includes equipment used to inject steroids to enhance fitness and physique.

Tattoos

The risks of tattooing are predominantly associated with re-used and unsterilised needles, although the virus has been found in tattooing ink also. The hygiene standards of tattoo parlours in the UK are uneven. Regulation is carried out by local authorities in some cases, (most of London) by licensing and in other cases using byelaws. These can vary from area to area but the DoH have produced a model set of byelaws (click here) that set out the standards that you ought to expect from a tattooing parlour. You are unlikely to find these standards in developing countries.

Tattooing with re-used equipment in high risk countries is a significant risk.

Vaccinations

Vaccination programmes in the developed world are considered to pose a very low risk of hepatitis C transmission. However, in the developing world, evidence exists that the same needles are sometimes used to vaccination numerous individuals, especially school children. The high incidence of hepatitis C in Egypt is largely attributed to mass public immunisation programmes.

General

Preventing the transmission of hepatitis C is largely common sense. It basically involves being aware of anything that has come into contact with your blood:

  • Anything that has cut you
  • Anything that you drip blood on or has soaked up your blood
  • Anything that you have inserted through your skin into your body
  • Making sure that it is properly cleaned or properly disposed of before it comes into contact with anyone else

In general you need to be aware that if you are infected with hepatitis C a tiny drop of your blood could infect someone else if it gets into their body. So it's obviously better to take precautions and this section examines ways to be really safe. However, it is far from clear that all these precautions are strictly necessary but it's important to be careful rather than paranoid about the risk of infecting others.

Any professionals that you work with should be aware of universal precautions, this ensures that everyone in all settings are treated the same.

This would include:

  • Phlebotomists (nurses who take your blood)
  • Tattooists
  • Body/ear piercers
  • Acupuncturists
  • Dentists

Prevention

Sexual transmission

The risk of sexual transmission is very low in the absence of any other complicating factors - see research paper below. Even so the best way to be absolutely certain that you do not transmit hepatitis C is to use barrier contraception such as a condom or femidom (female condom).

The complicating factors that may increase the risk of transmission are:

  1. The presence of blood from menstruation or anal sex, particularly fisting (the lining of the anus is thin and prone to tears).
  2. The presence of ulcers or sores on your genitalia i.e. from a sexually transmitted infection such as gonorrhoea, herpes, genital warts.
  3. If either partner is co-infected with HIV the risk of sexual transmission of both viruses appears to increase.

It is important to bear in mind that condoms can break and you may want to consider using a heavy duty variety, particularly if there is a higher risk of transmission. It is never advised to use two condoms for added protection.  When latex rubs against latex the heat generated makes the condom weaker and it is more likely to rip. 
To read the results of a trial on sexual transmission of hepatitis C click here

Mother to baby

The risk of transmission from mother to child is thought to be approximately 5%. The risk is higher in women who are co-infected with HIV. If you are pregnant or planning to have a child and are hepatitis C positive, it is important to discuss this with your consultant. Whether there is anything you can do to lessen the transmission risk is uncertain. There is some evidence that mothers with lower viral loads are less likely to transmit infection. It is not believed that caesarean delivery makes any difference. On the other hand breastfeeding if your nipples are bleeding is also believed to pose a risk.

Injecting drugs

If you are intravenously injecting drugs and share any equipment that could come into contact with blood hepatitis C is possible. This obviously applies to the needle and syringe you use but also applies to water, filters and spoons even if you are using a new needle. Any needle that has been used before could still have invisible drops of blood attached to it. When this is placed in a spoon the blood can dissolve again ino the water and be deposited on the spoon or the filter ready for someone else to draw it up.

The best way to avoid transmitting the disease is to use new syringes, new needles, a clean spoon, sterile water and a new filter. If for some reason you are sharing spoon, water or filter and do not have access to a new syringe and needle the next best thing is to thoroughly clean the ones you have. Unfortunately hot water by itself will not kill hepatitis C and is not an efficient way of sterilising. Try as a minimum to use bleach (1 part bleach 10 parts water), drawing it in and flushing it out several times but remember then to do the same thing with hot water to flush out the bleach.

Anyone who gets pricked by a discarded needles could become infected it is important to dispose of used needles carefully and safely. The best place is a proper sharps bin, which you can get from your local needle exchange and some chemists. The next best thing is to recap the needle and put it in a sealed hard plastic container.

Snorting drugs i.e. cocaine

If you share a rolled up note or straw for snorting drugs you risk exposing yourself and others to hepatitis C. This is especially true if your nose is bleeding. Cocaine in particular is very alkaline and corrosive to the thin membranes in the nose. If even tiny drops of  blood too small to see, get onto the straw or note and someone else then uses it, it is quite possible for them to make blood to blood contact through their own nasal membranes.

Household transmission

Accidents happen at home. People cut themselves, get nose bleeds and so on. If you have hepatitis C and you have an accident that causes bleeding it is important to be aware of what your blood has come into contact with. If it is an implement that has cut you, clean it thoroughly with bleach and rinse off the bleach with equal thoroughness. Then clean any surface that your blood may have dripped onto again with bleach. If you have used anything to staunch the flow such as tissues or sticking plasters ideally dispose of them in a sealed plastic bag. This applies to used sanitary towels and tampons also. If it is not disposable then wash it at the highest possible temperature and if possible add bleach.

Medical and dental procedures

Hospitals and dental practices are strictly regulated to prevent blood borne virus transmission and in theory it should not be necessary to inform them that you have hepatitis. In practice however, this may not always be the case so it is responsible to tell them though they are likely to ask you anyway. However, they should not treat you any differently once they know because this suggests that their normal practice is inadequate.

Acupuncture

It is responsible to tell your acupuncturist if you have hepatitis C because awareness of infection control varies widely from one practitioner to another.

Personal hygiene articles

Razors, hair and nail clippers, scissors and toothbrushes will, at times, come into contact with blood. Even tiny traces of dried blood may be sufficient to cause infection so it's best not to share any of these articles, and ideally to keep them separately so that no one will borrow them.
For example, toothbrushes can easily carry droplets of dried blood if your gums bleed during brushing and so are best not put in a shared mug where they can easily come into contact with other people's brushes. Razor blades are particularly vulnerable to accumulating specks of dried blood so it's important at least to make sure if someone borrows your razor to use a new blade.

Body piercing, tattoos, electrolysis

If you have hepatitis C and want to get a tattoo, piercing or have electrolysis, then the responsible thing to do is to inform the person carrying out the procedure. They should be taking adequate precautions anyway to prevent the transmission of blood borne diseases.
The precautions they should be taking are:

  1. Using new sterile needles each time
  2. Properly sterilising re-usable equipment
  3. Using new jewellery
  4. Using new ink for each person and cleaning the containers between customers

If you are going to pierce or tattoo at home, it is best to use new equipment for each person and dispose of everything with care. For example to dispose of a piercing needle safely, put a cork over the point and place it ideally in a sharps bin or otherwise in a thick plastic container with a top or lid and put in the rubbish.

Testing (reasons to get tested)

Certainty

If you are worried that you may have been exposed to hepatitis C, uncertainty can be a lot more stressful than knowing you do have it. If you have been unwell, taking a test will either eliminate hepatitis C as a possible cause or, if you receive a positive result, it can explain your symptoms and knowing why you feel the way you do can be a big relief. And of course once you do know, you have a range of options for addressing the disease.

Taking responsibility for your own health

Although hepatitis C is a serious health issue, treatment is now available and in a significant number of cases, can clear the virus and can also slow down disease progression. Hepatitis C is a progressive illness therefore the sooner you know you have the disease, the sooner you can take action to help yourself, and the more success you can have in alleviating symptoms, slowing progression and even clearing the virus.

Once you have received a diagnosis you will be referred to a specialist experienced in hepatitis C. Not only will this mean that your condition will be monitored closely and treatment options considered, but it will also enable you to ask important questions. You will gain further information that will enable you to make choices about how you can best manage your condition. You can also manage any symptoms physical or mental that you may be experiencing.

Simple lifestyle changes such as reducing your alcohol intake, cutting down on smoking and improving your diet can make a significant difference to your health. See caring for yourself

Knowing about your condition will enable you to take more control over your life in general; this is very important for your psychological health. You may feel more able to make plans for both the short and long term future.

Protecting others

If your test result is positive, you can take appropriate measures to ensure that you do not transmit the virus to others. See transmission prevention.

Things to consider before testing

Getting the timing right

Before you make your decision, consider whether this is the right time for you to take the test: are you prepared, have you considered the implications of your result? This is not to dissuade you from taking the test, but to encourage planning for it. If you do have hepatitis C, postponing taking a test for a short period of time whilst you prepare yourself is unlikely to make a great deal of difference.

Having a pre-test consultation with a professional

The point of having a pre-test consultation is to explore the implications of a positive or negative test result. It is advisable to only go ahead with a test after you have considered these implications and you feel confident that you are prepared. If you are at all unsure, require further information or you feel you need to discuss it with someone else, then make arrangements to return at a later date.

Access to a pre-test discussion will vary according to where you are tested. For example all sexual health clinics and most drug agencies will provide a pre-test discussion with those who request a hepatitis C antibody test. Some GPs will provide the service, although this will largely depend on the resources they have. Whether you receive a pre-test discussion may also depend on the circumstances that have led to considering a test. For example if your doctor is undertaking a series of investigative tests to determine the cause of symptoms you have presented with, then it is likely that a hepatitis C test may be undertaken alongside a series of other tests and pre-test discussion may not be considered.

Emotional impact

You may want to prepare yourself for the impact of a positive diagnosis. The result may cause very strong emotions that can be hard to handle on your own. You may, for example, experience a lot of anger about how you contracted it or remorse about certain actions.

A positive diagnosis is, without doubt, a life-changing experience. Not only may it confirm your worst fears, but it may also place a huge question mark over your future. For example, am I going to die? How ill am I going to get? Will I be able to have children? Will I be able to continue work? Who will care for me? Who will love me? Being faced with these uncertainties on your own can be a tall order. Do you think you could cope without support? If you think you will need supporting, do you have someone to be there for you?

Putting support in place

You may find it easier to arrange to have someone available to talk to after you receive your result. This could be a professional, a family member or a close friend. It is possible you will find the actual impact of a positive diagnosis more distressing than you had imagined, so it is good to have some support arranged in advance just in case.

Impact on your partner

As it is possible, although extremely rare, that hepatitis C can be sexually transmitted, you may need to consider the possibility that a positive diagnosis could mean your partner may also be positive. Another thing to consider is that your partner may be negative and if you receive a positive result in theory there is a small risk you may be able to pass the virus on to them and so you may want to open up the question of how this may affect your relationship.

Financial impact

How will the result affect your access to a mortgage or insurance? If your test result is positive and you apply for a mortgage or insurance, you may be asked about your hepatitis C status. You are required by law to give an honest answer: if you lie and your deception is discovered, your insurance will be invalidated and any claims refused. To address this consideration you may decide to postpone your test until after organising any insurance or mortgage.

If either your mortgage broker or insurance provider wishes to obtain a medical report about you from your doctor, they are required to gain your permission prior to contacting them. However, be very careful: sometimes you sign papers that merely contain quotes or estimates, but they may also include small print that states you are giving them permission to obtain your medical records. Read all the small print very carefully before signing anything. You are entitled to see any requested medical reports prior to them being dispatched. If you wish to see the report you should make any request clear to your doctor.

To conclude

Prior to taking a test you should consider whether you are prepared for the changes it may make to your life. Perhaps you could make some preliminary arrangements or put some plans into place before going for a test. But remember, delaying or postponing testing should be about giving you time to prepare for it. The only definite way to know whether you have hepatitis C is by taking the test and on the whole this is a positive step to take.

Asking for a test

Some GPs are reluctant to undertake, or make a referral for hepatitis C testing. This may be for a number of reasons. They may consider that other tests should be performed prior to a hepatitis C test or they may, with the information they have on you and your health, not perceive that you have been exposed to any risk of a hepatitis C infection. They may actually not know much about hepatitis C. However, if you are at all concerned that you may have been exposed to hepatitis C or have symptoms that may be attributed to hepatitis C and you feel a hepatitis C antibody test is necessary, do not be swayed. Explain your concerns and, if necessary, ask for a second opinion. If you are experiencing real resistance from your GP and deem it necessary to make a complaint or change your GP, you can exercise your right to do so. See Dealing with doctors.

Alternatively, if you are generally happy with the care your GP is providing you but you are unable to obtain a hepatitis C antibody test via them, you could consider approaching your local Sexual Health Centre or GUM Clinic at your local hospital.

Some GUM or Sexual Health clinics may also be unwilling to test for hepatitis C as it is not strictly speaking a sexually transmitted disease. It may help if they think that you could have been exposed to HIV at the same time.

If you have already received a negative antibody test result in the past and you are concerned about a subsequent exposure you are entitled to a further test. You do not have to return to the same testing site; neither do you have to reveal that you have previously been tested. All information you provide should be treated with respect and confidence.

Getting tested-the process

The process of getting a diagnosis involves 2 blood tests.

  1. A hepatitis C antibody test is the first test undertaken. This is to determine whether you have ever been exposed to the hepatitis C virus by testing for the presence of antibodies to the virus generated by your immune system.

    If you receive a negative hepatitis C antibody test but you have experienced symptoms or have been recently exposed to hepatitis C then you are likely to be advised to receive a second test. It is important to remember that what is called a 'window period' exists when your immune system may not have had time to produce antibodies. This can be up to 6 months from the time you may have been exposed to the virus.

    You may not have produced antibodies following exposure to hepatitis C. This can be the case if your immune system is not functioning properly, for example if you have HIV or have had a kidney transplant. Those with compromised immune systems should always test for the virus itself with a PCR test.

    So if you have the test within this window period of six months and the result is negative, it does not necessarily mean that you don't have the virus.

    If you receive a positive hepatitis C antibody test, this does not necessarily mean you are currently infected. Up to 20% of people clear the virus from their bodies yet they still have hepatitis C antibodies. There is a chance that you may have been infected with hepatitis C in the past but you are no longer infected.

  2. The PCR test determines whether you are currently infected by detecting active hepatitis C virus replication in the blood.

    A positive PCR result means your immune system did not clear the infection during the acute phase of infection and has progressed to the chronic phase.

    The PCR test will usually be undertaken by the hepatology unit of your local hospital, although some GPs, GUM and Sexual Health Clinics will perform this test as well. Regardless of where your blood test is initiated all blood samples will be sent to a laboratory for analysis; this is usually at your local hospital. Test results are usually returned within two weeks, sometimes sooner.

Functions of the liver

It would be difficult to overestimate the importance of the liver to the healthy functioning of the human body. It is a truly remarkable organ. The liver acts as a processing plant, a battery, a filter, a warehouse and distribution centre all in one. Without it we would not survive.

The number and range of tasks and functions it carries out is staggering:

  • It transforms the food we eat into energy to build cells and tissues in our body.
  • It detoxifies all the poisonous chemicals that enter our bodies such as alcohol, drugs and pollutants.
  • It stores vitamins, fat, sugars, and minerals and sends them out around the body as and when they are needed.
  • It makes a digestive juice called bile so that fats can properly be broken down and absorbed by the body.
  • It produces hormones that regulate sexual desire and function.
  • It is engaged in so many activities that the energy that it creates carrying them out warms the blood that passes through it and helps maintain the body’s temperature.

The immune system, digestive tract, kidney, brain and cardio-vascular system all depend on a healthy and well-functioning liver. This is why liver diseases such as hepatitis C can have such varied symptoms, as all the body’s major systems and organs can potentially be affected by a diseased liver.

It is because of this that it is so important to understand both how the liver works and how to look after it.

Location of the liver

The liver is located under the ribs on the right hand side of the body. It lies just below the lungs under the top of the diaphragm to which it is attached. The diaphragm is the muscle beneath the lungs that regulates our breathing. The liver is partly protected by the rib cage and is packed in so tightly that it can leave a slight impression on the top of the liver.

The liver is the largest organ in the body. It is shaped like a wedge, weighing between 1.2 and 1.5kg and is about 5 inches across and about 7 inches along its diagonal. It is divided into two main lobes, the right and the left. Fibrous ligaments separate the two lobes on the underside. The right lobe is the larger of the two and has two smaller lobes itself. All the lobes of the liver perform the same functions. The whole liver is encased in a protective fibro-elastic sheath called Glissons capsule.

The liver is attached to the gallbladder (via the cystic duct). Together they make up the hepatobiliary system. Bile is a greenish digestive juice which is manufactured inside liver cells. It then passes to the gallbladder for storage until it is needed. When food enters the intestine, bile is secreted into the intestine, via the common bile duct. The pancreas also secretes fluid containing digestive enzymes into the gut as well as producing the hormones insulin and glucagon which are released into the blood stream to control blood sugar levels. Insulin prevents blood-sugar levels from rising too high, while glucagon quickly raises levels when they are too low.

The Hepatobiliary System

The liver is attached to the gall bladder. The liver secretes bile (a digestive fluid) into the hepatic ducts. Bile flows into the gall bladder to be stored and then drains into the duodenum during digestion. The liver, gallbladder and hepatic ducts are collectively known as the Hepatobiliary System. The pancreas also secretes digestive juices into the duodenum and is sometimes considered a subsidiary part of the hepatobiliary system.

The Portal Venous System & Hepatic Artery

The liver has two blood supplies.

  • 25% of the blood it receives comes as oxygen-rich blood direct from the lungs through the Hepatic Artery.
  • 75% comes through the Portal Venous System. Blood laden with the products of digestion travels from the intestines and joins up with blood from the spleen and the pancreas in the Portal Vein before entering the liver. After the blood has travelled through the liver it returns to the heart via the vein called the Vena Cava.

The Liver's Blood Supplies

The liver is reddish brown in colour because it is saturated in blood. A gallon of blood passes through the livers complicated network of arteries, veins and capillaries every two and half minutes.

The liver, unlike any other organ in the body, has two blood supplies. The largest amount of blood (about 75%) comes through the portal vein system. This is a network of blood vessels that transports blood through the intestine, stomach, the spleen and the pancreas draining into the portal vein and then into the liver. All the products of digestion from nutrients to toxins pass into the liver through this route. The Spleen releases iron broken down from destruction of red blood cells for use by the liver.

The second blood supply to the liver is via the hepatic artery which delivers highly oxygenated blood from the lungs. Once blood has been de-oxygenated and processed by the liver it is transported through the liver to the central hepatic vein and then out of the liver to the heart.

The portal vein and hepatic artery enter the liver through a fissure called the Porta Hepatis and then both divide into branches to the right and left lobes of the liver.

Inside the Liver

Hepatocytes

The primary and most common cells of the liver (making up 90 per cent of the livers cells) are called hepatocytes. These are highly sophisticated cells that carry out most of the many functions of the liver. Hepatocytes are all identical. The multiple tasks that the liver performs are not split up or shared out between them. They are all capable of carrying out the same functions.

Hepatocytes are split up into groups or batches to form lobules. These are the functional units of the liver. There are up to a million lobules in the liver.

Each lobule is organised around a central vein. Plates or strips of liver cells or hepatocytes radiate out from this central vein like spokes from a wheel. On the outside of each lobule are branches of both the portal vein and the hepatic artery supplying each lobule.

Small blood channels called sinusoids run from these branches of the portal vein and hepatic artery through the lobules. Every cell in the lobule is bathed in this blood flow. There are over one billion sinusoids in the liver. The consequence of this stacked system is that blood runs very slowly through the sinusoids. This allows time for the liver cells to both take in what they need from the bloodstream and to export other products.

The sinusoids are lined by tissue made up of endothelial cells. Other cells in the sinusoids include Kupffer cells, Pitt Cells and Hepatic Stellate or fat cells.

Kupffer cells remove aged and damaged red blood cells and attack and neutralise bacteria and viruses. Pit cells are a type of immune cell called natural killer cells . Under certain cicumstances Hepatic Stellate cells can produce collagen fibres leading to scarring or fibrosis

Biliary system

Running parallel to the sinusoids through the lobules are small channels called bile canaliculi. The bile produced by hepatocytes flows into these canaliculi and then moves to the outside of the lobule to branches of the bile duct which drain into progressively larger ducts until it reaches the right and left hepatic ducts. These are the final channels out of the liver from each lobe of the liver. They join up outside the liver in the common hepatic duct. This drains into the gallbladder where bile is stored until it is needed for fat digestion.

Lymph

The liver also manufactures lymph which regulates the fluid balance within the body. Lymph is a colourless fluid that flows through a network of channels through the body called the lymphatic system. Approximately half of the lymph made in the body is formed in the liver. Fluid from the tissues of the liver flows into an area between the sinusoids and the hepatocytes called the Space of Disse where lymph is formed. It then flows through small lymphatic channels out into the bodys main lymphatic system.

How the liver is held together

The sinusoids, lymph vessels and the bile ducts are all contained in and supported by connective tissue that branches and extends throughout the liver. This tissue provides the scaffolding around and through which all these various channels and ducts are threaded. It also separates each lobule from its neighbours.

Treatment

Choosing treatments

There is a huge range of things you can do about your hepatitis C. Those that loosely involve making lifestyle changes are covered in Caring For Yourself in the Wellness section and also worth looking at is the section on Mental and Emotional Attitude. This section looks at conventional (pegylated interferon and ribavirin) treatment.

Choosing between them is unlikely to be easy, particularly as there is so little hard evidence for the effectiveness of alternative therapies. The reason there is evidence for conventional treatment is that medicine requires a licence from the Government and this can only be obtained on the basis of evidence on effectiveness and safety collected from controlled trials.

The fact that there is no evidence, of course, does not mean that something does not work. There have been definite cases of people clearing hepatitis C while taking alternative therapies, notably chinese medicine, western herbs and supplements. However, the numbers have not been great and it is not certain that the results were entirely due to those treatments (people frequently try several alternative remedies at the same time, for example). Added to the lack of evidence, it appears that what works for some people does not work for others, and this also applies to conventional (pegylated interferon and ribavirin) treatment.

One approach is firstly to decide exactly what your priority is. Clearing the virus now is not necessarily the most important goal for everyone.

Some may want to

  • Be free from any of the effects of Hepatitis C
  • Address particular symptoms
  • Just keep the virus in check
  • Improve their overall quality of life

Once you have decided that, you then have to decide what you are prepared to pay for that, in terms of time, money, discomfort and risk.

If your priority is above all to clear the virus now, then there is no question that conventional treatment offers the best chance of doing so. You may dispute the figures from the drug company sponsored trials, but what you cannot dispute is that large numbers of people, particularly with genotypes 2 or 3, now have no detectable trace of the virus in their systems following treatment. There may be a price to pay for this and you can read a full discussion of the pros and cons in Considering treatment.

If your priority is not to clear the virus right now or you cannot afford the time, discomfort or risk (the treatment is free on the NHS in the UK), then there are many alternatives available. You can read about these alternatives and also about diet, herbs and lots more in the Wellness section.

Interferons & Ribavirin

  • Interferons
  • Pegylated interferon
  • Ribavirin

Interferons

Interferons are a group of naturally occurring proteins that form an essential part of the immune system. Interferons operate in two primary ways, firstly they directly hinder the replication process of the virus and secondly they enhance the immune response. They hinder the replication process by binding to receptors that are present on nearly all cell types and preventing a virus from entering the cell and replicating within it. They enhance the immune response by stimulating activity of immune cells and rendering virus-infected cells more susceptible to the responses of the immune system. The three types of interferon are referred to by Greek letters - alpha, beta and gamma.

In its naturally occurring form alpha interferon is produced by the body to fight infections, notably flu, and is responsible for many of the symptoms associated with flu, such as headaches, fever, shivering (it is often the case that it is the bodys reaction rather than a disease itself that makes you feel ill). As a treatment for hepatitis C, it is synthetically produced in a laboratory and administered by injection under the skin in doses considerably higher than occur naturally. So it is hardly surprising that some of the usual side effects of taking interferon are flu-like symptoms.

Peglated Interferon

Laboratory-produced standard interferon is broken down relatively fast by the body. As a result, its effectiveness decreases, allowing the hepatitis C virus to multiply in between injections. Pegylation is a process whereby a large molecule chain is attached to the interferon to slow the rate at which it is broken down. This molecule chain is made up of essentially inactive chemicals and does not change the basic nature of the interferon but it allows consistent levels of the drug to circulate in the body and consequently maintain a consistent attack on the virus. It also means that, whereas standard interferon needs to be taken 3 times a week, pegylated interferon only has to be injected once a week.

2 drug companies manufacture pegylated interferon. Roche Products Ltd make Pegasys (interferon alpha 2A) and Schering-Plough Ltd make ViraferonPeg/PegIntron (interferon alpha 2B). They are similar, although not identical. More details can be found on their websites -see links list top right of page - but before checking them out, you should be aware of 2 things:

  • WARNING 1: These websites are intended for a US audience only. In the UK, it is against the law for pharmaceutical companies to promote their products to the general public
  • WARNING 2: However they look; these two sites are basically promoting the use of the companies products.

Side effects

  • Side effects that may require dose reduction or an end to treatment:
  • Other side effects

Interferon and ribavirin are strong drugs and they have potential side effects. Not everyone experiences side effects but it is rare to have none at all. You should expect to get at least a few of them, particularly at the beginning. The list below sets them out and rates them as common, less common and rare. Some of these symptoms you may already have as a result of your hepatitis C. If you already have them, the table below refers to the likelihood that they will get worse.

The list is really the same for interferon (pegylated or standard) with or without ribavirin, since it is interferon that is the main cause. The exception to this is anaemia, which is a side effect of ribavirin only. Because anaemia lowers the amount of oxygen carried around the body, particularly to the muscles, it tends to increase the fatigue that interferon causes.

Side effects that may require dose reduction or an and to treament:

Severe anaemia (lowered levels of haemoglobin) rare
Severe neutropenia (lowered levels of neutrophils, which are part of the immune system) rare
Thrombocytopenia (lowered levels of platelets, which help blood to clot) rare
Diabetes rare

OTHER SIDE EFFECTS

Flu like symptoms, including

Fatigue common
Headaches common
Fever (in the 48 hours following an interferon injection) less common
Shaking less common
Muscular and joint aches less common
Dizziness rare

Sight problems, including

Retinal problems rare
Blurred vision rare
Anaemia common
Thyroid disease rare

Digestion/stomach symptoms, including

Nausea less common
Decreased appetite less common
Diarrhoea rare
Vomiting rare

Mental symptoms, including

Depression common
Insomnia less common
Irritability/intolerance less common
Concentration difficulties rare

Respiratory symptoms, including

Coughing rare
Difficulty breathing rare

Skin problems, including

Hair loss common
Pruritis (itching) less common
Rash rare
Dry skin rare

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Roweena Russell, E: roweena@hiwecanhelp.com , T: 079 57 57 6305
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