Hepatitis C: Clinical sciences

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Introduction0:00–0:33

Hepatitis C virus or HCV. For short is a bloodborne viral infection that's typically transmitted through contaminated blood or sexual contact.
Once inside the body, hepatitis C virus circulates through the blood, eventually reaching the liver where it infects hepatocytes.
Acute hepatitis C infections are usually asymptomatic. But if the virus sticks around long enough in the body, acute infection can progress to chronic infection which can lead to the development of cirrhosis and even hepatocellular carcinoma.

Unstable patient0:33–1:41

Now, if you suspect hepatitis C infection first perform an ABCD E assessment to determine if your patient is unstable or stable, if unstable.
Your patient may present with alarming signs and symptoms such as altered mental status, asterixis, upper gi hemorrhage and ascites in this case, immediately stabilize their airway, breathing and circulation.
Next, obtain IV access and put your patient on continuous vital sign monitoring including BP, heart rate and pulse oximetry.
Here's a clinical pearl to keep in mind, these findings can be seen in individuals with fulminant hepatitis, often referred to as acute liver failure, which is most often caused by viral hepatitis or acetaminophen overdose.
Hepatic encephalopathy is a key feature while lab findings suggestive of fulminant hepatitis include elevated transaminases like AST and alt, as well as elevated PTI nr and serum bilirubin.
It's important to recognize these patients on time and once stable, refer them to a liver transplant center for further management.

Stable patient1:41–2:36

Ok. Let's go back to the ABCD E assessment and take a look at stable individuals.
If the patient is stable, obtain a focused history and physical examination history typically reveals symptoms such as fatigue, anorexia, low grade fever, as well as nausea and vomiting.
Additionally, your patient might report right, upper quadrant abdominal pain and difficulty sleeping. Finally, history might be positive for IV substance use needle stick injury, sexual intercourse without protection or receiving a non sterile tattoo.
On the other hand, physical exam typically reveals jaundice and abdominal tenderness while sometimes you might notice inflammatory skin changes like psoriasis or urticaria as well as signs consistent with thrombocytopenia such as pete.

Labs2:36–3:07

Your next step is to order labs such as CBCC, MP, PTI, NR and PTT, which might reveal thrombocytopenia as well as elevated or normal AST and a LT bilirubin, PTI Nr and PTT.
These lab findings in combination with your patient's signs and symptoms should lead you to suspect hepatitis C infection.
Keep in mind that many patients with HCV are asymptomatic. So they may come to clinical attention on routine lab evaluation.

Positive HCV antibody test3:07–5:16

Once you suspect hepatitis C infection, you should order an HCV antibody test to determine whether or not your patient has HCV antibodies.
Let's take a look at a positive HCV antibody test first, in this case, obtain an HCV RNA test to assess the viral load. Or in other words, how much of the HCV is in the patient's blood?
As a side note, many labs will reflexively send the HCV RNA test if the HCV antibody is positive. So if the HCV RNA test does not detect viral load, assess for risk factors such as a history of HCV exposure in the last six months or history of immunocompromised status.
Now, here's a clinical pearl to keep in mind. Patients that are HCV antibody positive with undetectable HCV RNA levels may have three possible clinical scenarios.
Firstly, they might have been infected but clear the infection spontaneously. Secondly, they may have had an HCV infection that was already treated with antiviral medication.
And thirdly, the patient's antibody test may be a false positive. In this case, if your suspicion is high based on clinical presentation, you should repeat HCV antibody test and order HCV RNA test within six months to rule out or confirm the diagnosis.
So back to assessing risk factors, no known exposure to the virus and no history of immunocompromised state mean that you should consider alternative diagnoses.
However, if your patient reports HCV exposure or is immunocompromised, then you should repeat the HCV RNA test six months after the initial testing.
If the HCV RNA test has not detected viral load after six months, you should consider alternative diagnoses. On the other hand, if the HCV RNA test detects viral load, you can confirm the diagnosis of acute or chronic hepatitis C.
All right, now that we are done with HCV antibody positive, but HCV RNA negative individuals, let's go back to the initial HCV RNA test that you ordered.

Negative HCV antibody test5:16–6:29

Once you've detected positive HCV antibodies. If the initial HCV RNA test detects a viral load, you can also confirm the diagnosis of acute or chronic hepatitis C.
So now that we've reviewed what to do when the initial antibody testing is positive. Let's switch our focus to a CV antibody negative individuals.
If antibody testing is negative, an HCV RNA test will not reflexively be sent in most cases. This is because no further testing is needed.
However, sometimes there can be a false negative HCV antibody test. This can happen if there hasn't been enough time for a patient to develop antibodies or if an impaired immune system can't produce antibodies.
So if the initial HCV antibody test is negative, you should also assess for HCV exposure in the past six months or immunocompromised status.
If your patient has had no exposure to hepatitis C in the last six months and is not immunocompromised, then no further testing is required and you should consider an alternative diagnosis on the flip side.
If your patient has either had an HCV exposure or is immunocompromised, then you should order an HCV RNA test. If the test is negative and viral load is not detected.

Treatment6:29–8:00

There's no hepatitis C infection. So you should consider an alternate diagnosis.
However, if the HCV RNA test detects viral load, your patient has acute or chronic hepatitis C. Ok.
Now that we've confirmed the diagnosis of hepatitis C, let's turn our attention to management in general. The same treatment is used for both acute and chronic HCV.
As long as the patient is not pregnant or has no history of liver cancer, liver transplant cirrhosis or past treatment for HCV.
First, if you haven't already make sure that you obtain a pretreatment HCV RNA for viral load level. This will help you to determine baseline viremia and to monitor response to medical therapy.
Also screen your patient for viral coinfections like hepatitis B and HIV. Next, start an antiviral therapy with a combination of glecaprevir and pibrentasvir or sofosbuvir and velpatasvir after 12 weeks, recheck HCV RNA to confirm resolution also called sustained viral response or SVR additionally encourage lifestyle modifications such as avoiding alcohol and avoid hepatotoxic medications like acetaminophen and make sure your patient is up to date on hepatitis A and B vaccines as coinfection with these viruses can worsen HCV infection.

Review8:00–10:36

Lastly remember that hepatitis C can lead to serious complications like cirrhosis and cancer which are major killers and huge threats to quality of life.
For this reason. Be sure to routinely check labs such as CBCC MP and I NR.
And if your patient develops cirrhosis don't forget to check liver ultrasound as well as alpha fetoprotein or a FP levels every six months.
Since high levels are highly suggestive of hepatocellular carcinoma. All right.
As a quick recap. If you suspect hepatitis C first do an ABCD E assessment to determine if your patient is stable or unstable.
If unstable, your patient will typically present with alarming signs and symptoms such as altered mental status, asterixis, upper gi bleeds and ascites In this case, stabilize the airway breathing and circulation, obtain IV access and put your patient on continuous vital sign monitoring.
On the other hand, if your patient is stable, first order an HCV antibody test, if positive order an HCV RNA test to assess the viral load, a detectable viral load confirms the diagnosis of hepatitis C infection.
On the other hand, if the viral load is undetectable, assess for immunocompromised status or HCV exposure within the past six months, lack of risk factors should make you consider alternative diagnoses.
While patients with these risk factors require another HCV RNA test in six months. If viral load is still undetectable, consider an alternative diagnosis.
But if it's detectable on repeat HCV RNA test, you just confirm the diagnosis of acute or chronic hepatitis C infection.
Now, if the HCV antibody test is negative, assess for immunocompromised status or HCV exposure. If the patient lacks risk factors, you should consider an alternative diagnosis.
But if there is a known history of risk factors, again, obtain the HCV RNA test. If there is no viral load detected, you should consider an alternative diagnosis on the flip side, detected viral load confirms the diagnosis of acute or chronic hepatitis C infection.
Finally, the management for HCV infection includes screening for coinfections, therapy with antiviral medications, lifestyle modifications, hepatitis A and B vaccinations and monitoring of liver function as well as CBC.