It is still an uphill struggle to find a doctor who is experienced in diagnosing and treating hepatitis C. Hepatologists specialize in diseases of the liver, and would be your best choice in physicians, followed by a gastroenterologist (a digestive disease specialist) or an infectious disease specialist. If there is a hepatitis support group nearby, they would be an excellent source of advice in identifying local doctors who may be familiar with hepatitis, or you can contact the American Liver Foundation (ALF) for a list of doctors near you. The best way to identify local support groups is to contact one of the national organizations. If there are no hepatitis knowledgeable doctors in your area and you wish to find an out-of-town specialist, you may read about such specialists from time to time in the newsletter of one of the national organizations.

If your own doctor is sympathetic but not knowledgeable, you might gather together some medical articles on hepatitis and hepatitis treatments and encourage your doctor to study them.

WHAT IS THE DIFFERENCE BETWEEN A GASTROENTEROLOGIST AND A HEPATOLOGIST?
A hepatologist specializes in treating liver disease. A gastroenterologist does guts, essentially. I recommend finding a hepatologist, as they are more likely to be on top of the latest information concerning treatment of hepatitis C.

HOW IS IT DIAGNOSED?
While the newer HCV antibody tests are better; false positive results still occur, and further testing should be used to confirm the antibody test. Abnormal liver function tests (LFTs) suggest chronic disease, but there is no correlation between the level of the liver function tests and how severe the disease is. A liver biopsy is the best way to identify liver inflammation or early cirrhosis.

Before 1990 doctors could diagnose HCV only by ruling out other possibilities (thus the old name for HCV "non-A, non-B hepatitis). Hepatitis C antibodies may not develop for two to six months after infection, so only two-thirds of patients who go to the doctor with possible hepatitis C infection can be diagnosed with blood tests. Diagnosis may have to exclude other possible causes such as HAV, HBV, cytomegalovirus, Epstein-Barre virus infection, as well as nonviral liver problems such as fatty liver, or alcohol or drug-related diseases.

Follow-up blood tests are very important in order to determine if the disease has become chronic. The blood tests for antibodies are usually repeated three and six months after the original illness.

Diagnosis is most commonly made after detecting an antibody to a portion of HCV in the blood. This indicates that the person was exposed to the virus and that their immune system made an antibody. The test can show false positive reactions and therefore confirmation is necessary by finding evidence that the Hepatitis C virus is actually in the blood using the polymerase chain reaction (PCR), an extremely sensitive test for viral RNA.

ANTIBODY TESTS
Antibody tests indicate whether the body has been exposed to the virus and has produced antibodies to fight it. They do not determine whether or not someone still has the virus, or how long they've been infected.

WHAT IS A PCR?
Polymerase Chain Reaction (PCR) . HCV PCR tests are a newly developed test that came onto the market in late 1994. HCV PCR tests look for the presence of the virus. Information gained from the HCV PCR can be useful in interpreting unclear antibody test results. The HCV PCR cannot tell how long someone has been infected.

Basically, your blood sample is broken up and certain parts are "fed" to E.coli bacteria, which grow real fast. When there are enough of them, they are put into the "bacteria-matic". Then that stuff is separated, and the remains are x-rayed, producing that pretty sheet of stripes that you see in cops and robbers shows and the OJ trial.

There are two sets, one side is the control, which is a known HCV, the other side is you. If they match you have the virus.

There are 3 major tests for HCV.

1. The ELISA test detects antibody to the virus.
2. The RIBA test is the confirmatory test for HCV.
3. The Quantitative HCV PCR test, which measures the amount of virus circulating in a person's blood stream.

IS IT POSSIBLE THE TEST COULD BE WRONG?
Antibody tests are usually positive or negative, but sometimes they come back unclear. Tests that come back positive are redone to confirm they are right. Unclear results are repeated and if still unclear, different types of blood tests are done. If you get a positive test result and have no risk background (for example, blood transfusions or injecting drug use) it's a good idea to check with your doctor to make sure that the blood laboratory double checked the result by using confirmatory tests.

BIOPSY
If viral hepatitis infection occurs, it may resolve on its own or become chronic. However, patients with chronic hepatitis often do not experience symptoms. On the other hand, others complain of excessive fatigue, weakness, and a reduced capacity for exercise.

Since liver damage may occur even in asymptomatic cases (no patient complaints), it is important to perform a biopsy and determine whether there is ongoing liver damage. As chronic hepatitis progresses, damage to liver cells may impair liver function. The biopsy of the damaged liver indicates the degree of cellular necrosis (death of liver cells), inflammation (cellular infiltration and swelling), and scarring (scar tissue beginning to replace functioning liver cells). - "Understanding Chronic Hepatitis" - Schering - 10/92 INH-001/17098403

WHAT IS A LIVER BIOPSY?
Liver biopsy is a diagnostic procedure used to obtain a small amount of liver tissue, which can be examined under a microscope to help identify the cause or stage of liver disease.

The most common way a liver sample is obtained is by inserting a needle into the liver for a fraction of a second. This can be done in the hospital with a local anesthetic, and the patient may be sent home within 3-6 hours if there are no complications.

The physician determines the best site, depth, and angle of the needle puncture by physical examination or ultrasound. The skin and area under the skin is anesthetized, and a needle is passed quickly into and out of the liver. Approximately half of individuals have no pain afterwards, while another half will experience brief localized pain that may spread to the right shoulder.

Patients are monitored for several hours after a biopsy to make sure serious bleeding has not occurred. Some patients occasionally have a sudden drop in blood pressure after a biopsy that is caused by a "vagal" reflex and not by blood loss; this is caused by sudden irritation of the peritoneal membrane. The characteristics that distinguish this from a bleeding event are: 1) slow pulse rather than rapid, 2) sweating, and 3) nausea.

WHAT ARE THE DANGERS OF LIVER BIOPSY?
The risk of a liver biopsy is minimal. The primary risk is bleeding from the site of needle entry into the liver, although this occurs in less than 1% of patients. Other possible complications include the puncture of other organs, such as the kidney, lung or colon. Biopsy, by mistake, of the gallbladder rather than the liver may be associated with leakage of bile into the abdominal cavity, causing peritonitis. Fortunately, the risk of death from liver biopsy is extremely low, ranging from 0.1% to 0.01%.

A biopsy should not be done if: 1) you have taken aspirin in the last 5-7 days, 2) the hemoglobin is below 9-10 grams/dl, 3) the platelets are below 50,000-60,000, or 4) the prothrombin time INR is above 1.4. Those with bleeding disorders such as hemophilia which can be temporarily corrected with transfused clotting factors can be biopsied safely.

WILL IT HURT?
Most doctors will not do percutaneous needle liver biopsies under anesthesia. This is because the liver is directly under the diaphram and moves as you breathe. When the needle is inserted through the skin and body wall, the liver must not be moving or else there is danger of a laceration. To keep the liver from moving, the patient has to stop breathing momentarily. Doctors prefer to have you alert and following directions, but if you are very anxious you may want to ask for a sedative to help you relax.

The injections of the local anesthetic and the actual puncture of the liver capsule itself can be a little painful for some people, but it only takes a second and is over very quickly. Other people feel no pain at all, and don't even realize it's over with until the doctor tells them they're finished.

Occasionally there will be a small to moderate amount of pain afterwards. If you find that you are uncomfortable, your doctor will generally prescribe a light painkiller immediately after the biopsy. The pain may be well away from the biopsy site, possibly in the pit of your stomach or typically in the right shoulder. The liver itself has no pain-sensing nerve fibers, but a small amount of blood in the abdominal cavity or up under the diaphram can be irritating and painful. Very occasionally, small adhesions (scar tissue) may form at or near the biopsy site, and can cause a chronic pain that persists near the liver area after the biopsy.

CHRONIC PERSISTANT OR CHRONIC ACTIVE -WHAT'S THE DIFFERENCE?
Hepatitis C is considered to be "chronic" if it has persisted for longer than 6 months. The term "Chronic Persistent" used to be used to define hepatitis which persisted for longer than 6 months, but which was not currently causing active damage to the liver. The term "Chronic Active" was used to define hepatitis which persisted for longer than 6 months, and which was actively destroying the liver. The differentiation between "persistant" and "active" is not commonly used any more, with the assumption being that if the virus exists, it is causing damage whether it is moving quickly or not.

About 85 percent of HCV-infected individuals fail to clear the virus by 6 months and develop chronic hepatitis with persistent, although sometimes intermittent viremia. This capacity to produce chronic hepatitis is one of the most striking features of HCV infection. The majority of patients with chronic infection have abnormalities in ALT levels that can fluctuate widely. About one-third of HCV patients with chronic infection have persistently normal serum ALT levels. Antibodies to HCV or circulating viral RNA can be demonstrated in virtually all patients with chronic HCV hepatitis.

Chronic HCV is typically an insidious process, progressing, if at all, at a slow rate without symptoms or physical signs int eh majority of patients during the first two decades after infection. A small proportion of patients with chronic HCV hepatitis - perhaps less than 20 percent - develop nonspecific symptoms, including mild intermittent fatigue and malaise. Symptoms first appear in many patients with chronic HCV hepatitis at the time of development of advanced liver disease.

Although patients wtih HCV infection and normal ALT levels have been referred to as "healthy" HCV carriers, liver biopsies can show histological evidence of chronic hepatitis in many of these patients. - National Institutes of Health Consensus Statement on Hepatitis C 1997

WHAT ARE THE MAIN SYMPTOMS OF HEPATITIS C?
Acute hepatitis C is almost indistinguishable from acute hepatitis B infection. Patients with acute hepatitis C are frequently asymptomatic (meaning that they have no symptoms), even when liver tests are abnormal. - "Hepatitis C & E: how much of a threat?" Special Issue: Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9, p105(8)

Soon after contracting the infection many people have a flu-like illness with fatigue, fever, muscular aches and pain, nausea and vomiting. About 10% of patients become jaundiced (their skin turns yellow). Generally these symptoms resolve and the patient has no symptoms of liver disease for many years. Symptoms may occur from two weeks to six months after exposure but usually within two months.

What are the symptoms of chronic infection and cirrhosis? The symptoms of chronic infection range from no symptoms at all, to gradually progressive fatigue and lack of energy, to complete debility. The effects of the virus vary widely between individuals.

The symptoms of cirrhosis include progressive fatigue, jaundice (yellow skin), icterus (yellow eyes), dark urine (the color of cola), abdominal swelling, muscle wasting, itching, disorientation and confusion, loss of appetite, and easy bruisability.

FATIGUE
The main symptom of most people with hepatitis C is chronic fatigue, ranging from simply getting tired easily to extreme, debilitating fatigue.

UPPER RIGHT QUADRANT (URQ) PAIN (SIDE PAIN)
Even though the liver itself contains no nerve endings, and does not feel pain, many people with HCV experience a pain on the upper right side of their body, just beneath the ribs. This is thought by some to be "referred pain" from the swelling of the liver capsule due to the disease process. This pain may also be referred to the right shoulder or to the back between the shoulder blades.

LOSS OF LIBIDO
Many hepatitis C patients find that they are no longer interested in sex. This tends to be especially true for those undergoing interferon treatment. This is not necessarily directly related to the hepatitis, but is most likely due to the stress, discomfort and exhaustion caused by the struggle with a chronic illness.

RED PALMS
Red palms can occur in any chronic liver disease and are not specifically caused by the virus. The cause for the redness is unknown, but it's speculated that it may involve upset hormone metabolism or microcirculatory changes.

NAUSEA
A few of the more popular nausea aids are chewing candied ginger, putting a (small) drop of peppermint oil on the end of your tongue, eating small frequent meals, dry crackers and weak tea, and popsicles.

BRAIN FOG
This is the mental fuzziness and forgetfulness that some people experience. It's not the same as encephalopathy, and seems to occur in all stages of the illness. Some people have found taking CoEnzyme Q10, also known as CoQ10, to be helpful (2 30mg capsules per day). Another listmember recommends taking Gingko Biloba.

ITCHING
The build-up of bilirubin in the skin may cause itching. Itching can be treated with antihistamines, or cholestyramine (which binds bile in the intestines). Actigall and Questran are two drugs reported to help with this problem.

VISION PROBLEMS
Some hepatitis patients complain of blurring vision, and dry eyes. This can be especially true while undergoing interferon treatment.

DIZZINESS
Some people have found that wearing "Sea Bands" helps with their dizziness. Sea Bands are elastic bands that can be bought, usually in sporting goods stores, which press against pressure points in the wrist. They were designed for use in seasickness.

DRY MOUTH
There are two products (mouthwash and toothpaste) by the name of Biotene, which are designed to help with the problem of a dry mouth and gum problems as a result of medication use. Several listmembers have reported great relief by using these products.

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?
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.

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, eadaches, 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 Sjogren'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

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 the urine) 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.

LICHEN PLANUS
Occasionally, people with chronic hepatitis C develop a skin condition called lichen planus. It is a grouping of small, itchy, irregular, flat-topped reddened bumps. The bumps often have a network of very fine gray lines on their tops. The bumps show up most often on the wrists, shins, lower back, or genitals. Lichen planus also frequently occurs in the mouth, where it looks like a white, net-like plaque. It sometimes shows up as mouth ulcers and can be treated with a steroid mouth rinse called Dexamethasone Elixir or Nystatin tablets.

CYCLES AND FLAREUPS
Hepatitis flareups tend to occur in cycles, where for a while you may feel pretty good, then bad (maybe days to weeks for each period), then good again. It can be frustrating to obtain some relief, but then not know whether you have recovered or if you are merely between cycles.

Some people claim that they begin to feel better in the Spring, then start to feel worse again in August/September, with a low point usually around November/December.

SHOULD I BE VACCINATED AGAINST OTHER TYPES OF HEPATITIS?
Patients with chronic hepatitis C who are at risk for hepatitis B should be offered vaccination during their first contact with healthcare professionals, according to a report from Great Britain's University of Cambridge. ( "Prospective Study of Hepatitis B Vaccination in Patients with Chronic Hepatitis C," British Medical Journal, May 25, 1996;312:1336-1337 ).

Chronic hepatitis C (HCV) infection is estimated to occur in between 70- and 92 percent of intravenous drug users. These IV drug users are also at risk for parenterally or sexually transmitted hepatitis B. Coinfection with hepatitis B virus (HBV) may accelerate underlying liver damage due to hepatitis C.

HCV AND WOMEN'S CONCERNS
Women can be affected by hepatitis C in a different way from men. This is possibly due to hormonal effects and liver damage.

MENSTRUATION
The hormonal effects of HCV can involve menstrual irregularities, particularly if you are experiencing significant hepatitis C symptoms. It is important that your general health is checked as well as your hepatitis C monitored. Tampons and sanitary napkins should be secured in plastic bags before going into the trash.

BIRTH CONTROL
If you are experiencing significant hepatitis symptoms, using the estrogen-based contraceptive pill may be inadvisable. In these cases, the progesterone-only pill or Depo-Provera may be preferable.

HORMONE REPLACEMENT THERAPY
If you have severe hepatitis symptoms you may need to discuss with your doctor whether hormones should be used for menopausal symptoms. If this is the case, external vaginal creams and skin patches are probably better than pills.

Dysfunctional uterine bleeding and premature menopause, and most any other sort of hormonal aberration is pretty common with chronic liver disease. The liver processes these hormones, and they tend to not get processed properly when the liver is damaged.

While on interferon therapy, many woman find that they come down with one yeast infection after another, due to the immunosuppression.

Waste paper products (napkins and tampons) which have been exposed to blood should be securely wrapped and disposed of in a safe manner. A 10% bleach (soak for 30 minutes) should be used on all contaminated surfaces, and in the laundry for clothing and linens which have been exposed to blood.

Sexual intercourse during your period is *not* safe.

PREGNANCY AND BREASTFEEDING
A substantial proportion of pregnant women with hepatitis C virus infection have circulating HCV RNA, even when they are asymptomatic, according to a report from Italy. Researcher A. Floreani and colleagues noted, however, that these women do not have an increased risk of obstetric complications and that pregnancy does not appear to induce symptomatic liver disease. - "Obstetrics (HCV); Circulating HCV RNA Does Not Increase Pregnancy Complications", Hepatitis Weekly, June 24, 1996

If a baby is born to an HCV+ mother and its blood was tested at birth for hepatitis C antibodies, the test would come back positive. This is because the baby has some of its mother's antibodies. These antibodies clear naturally over time. A test at 12 months usually confirms a toddler has the virus.

BREASTFEEDING
The hepatitis C virus has not been found in samples of breastmilk taken from HCV+ women. Transmission risk via breastmilk is therefore very unlikely. There are many advantages to breastfeeding. Breastfeeding mothers should check their nipples before each feed and avoid breastfeeding if they are cracked or bleeding.

Circulating HCV RNA does not increase pregnancy complications. A substantial proportion of pregnant women with hepatitis C virus infection have circulating HCV RNA, even when they are asymptomatic, however, these women do not have an increased risk of obstetric complications and that pregnancy does not appear to induce symptomatic liver disease. "There is no risk to the outcome of pregnancy in an anti-HCV positive pregnant mother. The majority of pregnant women have normal transaminase levels during the course of pregnancy, although a substantial proportion have circulating HCV RNA. Pregnancy does not induce a deterioration of liver disease, and HCV infection does not increase the risk of obstetric complications." - "HCV Infection in Pregnancy," British Journal of Obstetrics and Gynecology, 1996;103:325- 329

HOW DOES HCV AFFECT CHILDREN?
Children with chronic hepatitis cannot be treated simply like miniature adults. Specific issues and questions need to be addressed when dealing with the pediatric age group.

Pediatric patients are less likely than adults to have symptoms of infection with hepatitis C, leaving the viruses undetected and possibly unknowingly spread. According to information available on the natural history of HCV, the percentage of children who become chronic and the long-term outcomes are similar to the percentage of adults. Children who are chronic carriers of HCV have normal growth patterns.

Liver biopsy appears to be less valuable in children than adults. Chronic hepatitis rarely progresses to cirrhosis in children. In 16 HCV children followed for up to 14 years, encephalopathy (mental confusion), ascites (swollen stomach), or bleeding did not develop. The lack of cirrhosis in children with HCV is consistent that a time period of 10 to 20 years or more is required for cirrhosis to occur. Hepatocellular carcinoma occurs very rarely in the pediatric group.

Few studies exist examining interferon use in children with chronic HCV, however a recent study in Hepatology suggests that interferon therapy may be beneficial The rates of initial and long-lasting response were higher in the study than those observed in adults treated with standard schedules. Possible explanations include the shorter time of infection in children, and that most have a mild form of liver disease. The results of this study are encouraging, according to the researchers, but more investigation needs to be conducted.

Many questions still remain about chronic hepatitis C in children. Further studies need to be done to determine the disease's course and progress as well as the role of interferon treatment.

WHAT ARE THE DIFFERENT CLINICAL INDICATIONS OF HCV?

ELEVATED LIVER ENZYMES
There are two general categories of "liver enzymes." The first group includes the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST), sometimes referred to as the SGPT and SGOT. These are enzymes that are indicators of liver cell damage. The other frequently used liver enzymes are the alkaline phosphatase and gamma-glutamyltranspeptidase (GGT and GGTP) that indicate obstruction to the biliary system, either within the liver or in the larger bile channels outside the liver.

The ALT and AST are enzymes that are located in liver cells and leak out and make their way into the general circulation when liver cells are injured. The ALT is thought to be a more specific indicator of liver inflammation, since the AST may be elevated in diseases of other organs such as heart disease or muscle disease. ALT and AST are often used to monitor the course of chronic hepatitis and the response to treatments, such as prednisone and interferon. The alkaline phosphatase and the GGT are elevated in a large number of disorders that affect the drainage of bile, such as a gallstone or tumor blocking the common bile duct, or alcoholic liver disease or drug-induced hepatitis, blocking the flow of bile in smaller bile channels within the liver. The alkaline phosphatase is also found in other organs, such as bone, placenta, and intestine. For this reason, the GGT is utilized as a supplementary test to be sure that the elevation of alkaline phosphatase is indeed coming from the liver or the biliary tract. In contrast to the alkaline phosphatase, the GGT tends not to be elevated in diseases of bone, placenta, or intestine. Mild or moderate elevation of GGT in the presence of a normal alkaline phosphatase

is difficult to interpret and often caused by changes in the liver cell enzymes induced by alcohol or medications, but without causing injury to the liver.

ELEVATED ALFHA-PHETOPROTEIN LEVELS
It is fairly common for alfa-phetoprotein markers to be elevated in patients with hepatitis C. Alfaphetoprotein is a marker for tumors, but unless your numbers are extremely high (for example, in the hundreds), there is no need for alarm. Your doctor will probably want to perform further studies, such as an ultrasound or CT scan, just to be on the safe side

JAUNDICE
Jaundice (yellow skin) may appear as a symptom occasionally, but is most common during an acute attack. Jaundice is caused by the buildup of bile pigment that is passed by the liver into the intestines. This same bile buildup can also cause intense itching.

HEPATOMEGALY, SPLENOMEGALY
Some people experience a swelling of the liver (hepatomegaly) or the spleen (splenomegaly) as a result of hepatitis.

SPIDER NEVI
Spider nevi are small capillaries that are seen on the surface of your skin. Branches form (grow) from the one capillary and it can either look like a small red spider or a splat (kind of like a squashed spider). They are also referred to as spider angiomas. If you have less than 10 that can be considered normal, more than that and it's an indication of chronic liver disease. They can be found only above the waist, usually on the chest, upper arms, shoulders, face, neck and upper back.

ASCITES
Occurring in cirrhosis, the accumulation of fluid in the abdominal cavity, or ascites, is related to portal hypertension, significant reduction in serum albumin, and renal retention of sodium. The volume of abdominal ascites in adults with cirrhosis may reach levels as great as 10 to 12 liters (10.6 to 12.7 quarts). Ascitic fluid may accumulate in the scrotum and in the chest cavity, where its presence, combined with the upward pressure on the diaphragm from the abdominal fluid, may severely affect breathing. Appetite also is often reduced by the abdominal distention.

Ascites are treated by the removal of enough fluid directly from the abdomen by needle puncture to ease discomfort and breathing. Patients are placed on diets low in salt, and they are given diuretic drugs to increase the output of water by the kidneys. If these measures do not control massive ascites, ascites can be drained internally into the general venous blood system by running a plastic tube from the abdominal cavity, under the skin of the chest, into the right internal jugular vein of the neck (peritoneovenous shunt of LeVeen).

PORTAL HYPERTENSION / VARICES
Sometimes occurring in cirrhosis, portal hypertension is the increased pressure in the portal vein and its tributaries resulting from blockages to the blood flow into the liver. It is usually caused by the scarring processes of cirrhosis. The increased pressure causes varices, or dilations of the veins leading into the portal vein. When varices are located in superficial tissues, they may rupture and bleed profusely. Two such locations are the lower esophagus and the perianal region.

Esophageal varices are likely to bleed most heavily, and this bleeding is frequently associated with the onset of hepatic encephalopathy or coma. Because of their location at the lower end of the esophagus or the upper portion of the stomach, bleeding from varices is often difficult to control. If variceal bleeding persists, surgical formation of a shunt, or artificial passageway, from the portal vein to an abdominal vein may be done.

HEPATIC ENCEPHALOPATHY
Hepatic encephalopathy refers to the changes in the brain that occur in patients with advanced acute or chronic liver disease. If liver cells are damaged, certain substances that are normally cleansed from the blood by the healthy liver are not removed (mainly ammonia, or possibly certain fatty acids). A patient with chronic hepatic encephalopathy may develop progressive loss of memory, disorientation, untidiness, and muscular tremors, leading to a form of chronic dementia. The ingestion of protein invariably aggravates these symptoms.

The treatment of hepatic encephalopathy involves, first, the removal of all drugs that require detoxification in the liver and, second, the reduction of the intake of protein. Restricting the amount of protein in the diet will generally lower the levels of amino acids and ammonia in the bloodstream and brain. Most physicians advise their patients with this condition to eat only about 40 grams of protein a day, and will prescribe lactulose or neomycin to lower amino acid production. Non-meat proteins, such as those found in vegetables and milk, are also recommended. Certain amino acids are used in treatment, since they are considered less likely to cause mental impairment. A dietary supplement rich in these amino acids is used at many liver treatment centers.

CIRRHOSIS
When chronic diseases cause the liver to become permanently injured and scarred, the condition is called cirrhosis. The scar tissue that forms in cirrhosis harms the structure of the liver, blocking the flow of blood through the organ. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also slowed is production of proteins and other substances made by the liver.

People with liver cirrhosis may develop many problems beyond the liver. When the liver is scarred, the blood cannot easily get through the liver, and backs up under higher than normal pressure (portal hypertension). This often causes ascites, which is yellow fluid that leaks out of the bloodstream into the abdominal cavity.

If the ascites becomes tense, it can cause an umbilical hernia (a protruding belly button). The backed-up blood also often creates varices, in which the pressure causes the blood vessels around the esophagus to burst causing significant blood loss. Varices can be treated with beta blockers, or can be obliterated using endoscopically-placed rubber bands or injections of liquid that cause the varices to scar. If endoscopy fails to stop bleeding, a TIPS (transjugular intrahepatic portosystemic shunt) can be created by inserting a short metal mesh tube through a neck vein into the liver and connecting the portal vein in the liver to a regular vein in the liver. Another alternative is to surgically redirect some of the blood flow around the liver.

People with cirrhosis sometimes may develop jaundice (a yellowing of the whites of the eyes or the skin) due to an accumulation of bilirubin in the blood. If the bilirubin is excreted in the urine, the urine may turn dark.

People with cirrhosis are also at risk for hepatic encephalopathy, which is fatigue or confusion caused by ammonia and other products of protein digestion which are inadequately cleared from the bloodstream by the liver.

People with cirrhosis often bruise easily because the liver manufactures reduced amounts of clotting factors. Additionally, platelets may be lower than normal in the circulation if the spleen is enlarged. A spleen enlarged from portal hypertension may hold onto too many platelets.

Chronic HCV infection leads to cirrhosis in at least 20 percent of patients within 2 decades of the onset of infection. Cirrhosis and end-stage liver disease may occasionally develop rapidly, especially among patients with concomittant alcohol use. - National Institutes of Health Consensus Statement on Hepatitis C 1997

FULMINANT HEPATITIS
In very rare cases hepatitis symptoms develop quickly and become very severe. This less common form of hepatitis is called fulminant hepatitis or fast-progressing hepatitis, and it requires prompt medical attention. It can be fatal in up to 70 to 80 percent of cases. The kidneys may fail, and the liver shrinks as cells are killed. The person may fall into a coma and die. Fulminant liver failure following HCV infection has been reported but is a rare occurrance.

DOES HCV INCREASE THE LIKELIHOOD OF CANCER?
Chronic infection by HCV is associated with an increased risk of liver cancer. The prevailing concept is that hepatocellular carcinoma (HCC) occurs against a background of inflammation and regeneration associated with chronic hepatitis over the course of approximately 3 or more decades. Most cases of HCV-related HCC occur in the presence of cirrhosis. The risk for a person with chronic HCV hepatitis developing HCC appears to be 1-5 percent after 20 years, with striking variations in rates in different geographic areas of the world. Once cirrhosis is established, the rate of development of HCC is 1-4 percent per year. - National Institutes of Health Consensus Statement on Hepatitis C 1997

Chronic infection with hepatitis C virus (HCV) is regarded as a risk factor for hepatocellular cancer, mostly in patients with liver cirrhosis. We looked for HCV genomes in the livers of patients with hepatocellular cancer who did not have cirrhosis to see whether HCV was directly oncogenic. Cancerous and non-cancerous liver tissue, and serum samples from 19 patients negative for hepatitis B surface antigen were analysed by polymerase chain reaction for the presence of HCV genome, HCV replication, HCV genotyping, and HBV genome. 13 of 19 patients were HCV RNA-positive in cancerous and non-cancerous liver tissue; 8 of 17 tested were anti-HCV positive. Among the 13 HCV RNA-positive patients, 11 had genotype 1b and 2 had genotype 2a. 7 of 13 serum samples were HCV RNA positive. 7 of 19 patients were HBV DNA positive in cancerous and non-cancerous liver tissue, 5 of them anti-HBc positive. 4 patients were both HCV RNA and HBV DNA positive and 3 were both HCV RNA and HBV DNA negative. The results provide evidence for the association of HCV, mostly genotype 1b, with hepatocellular cancer without the intermediate step of cirrhosis. - "HCV-associated liver cancer without cirrhosis", De Mitri MS; Poussin K; Baccarini P; Pontisso P; D'Errico A; Simon N; Grigioni W; Alberti A; Beaugrand M; Pisi E; et al, Department of Internal Medicine, University of Bologna, Italy, Lancet 345: 413-5 (1995 )

Previously, we reported the high prevalence of hepatitis C virus (HCV) infection in patients with oral cancer or oral lichen planus in Kyushu, Japan. We now report a 61-year-old man with chronic hepatitis C and no oral lesions who developed oral cancer 6 months after interferon therapy (interferon alpha, 6 million units (MU) daily for 2 weeks and then 3 times a week for 14 weeks). This case emphasizes the need for periodic oral cavity examinations of hepatitis C patients and contributed to the investigation of oral cancer and HCV. - "Oral cancer and hepatitis C virus (HCV): can HCV alone cause oral cancer?--a case report." Kurume Medical Journal, 1996 Vol 1, Issue 43, pp 97-100

It is thought that treatment with interferon reduces the risk of later developing liver cancer. "The low incidence of hepatocellular carcinoma in patients treated with interferon suggests that interferon may prevent the development of hepatocellular carcinoma." - "Risk Factors and the Effect of Interferon Therapy in the Development of Hepatocellular Carcinoma," Journal of Gastroenterology and Hepatology 1997 Feb;12(2):149-155

An association between chronic hepatitis C infection and non-Hodgkin's lymphoma has been reported. " HCV Infection and Extrahepatic Malignancies," Journal of Clinical Gastroenterology 1997 Mar;24(2):87-89

HOW MANY OF US ARE THERE?
Hepatitis C accounts for 20% of community-acquired hepatitis in the US. Approximately 200 case of hepatitis C are reported in New York State each year. -- "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA

Each year, 150,000 new cases of hepatitis C infection occur in the United States. -- " Hepatitis C & E: how much of a threat?" Special Issue: Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9, p105(8)

The (US) Center for Disease Control and Prevention, estimates that at least 17 1/2 million people (in the US) are living with chronic hepatitis C infections and as many as 150,000 Americans are newly infected with hepatitis C each year.

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