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2.9.0 What Are the Different Clinical Indications?



2.9.0 What are the different clinical indications of HCV?

The most often reported clinical symptoms are: fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting and, sometimes, jaundice (CDC).

Often doctors incorrectly assume that hepatitis C is a liver disease and that the only “real” symptoms of hepatitis C are related to liver disease and liver dysfunction.

The virus itself has been found in the nervous system, the lymphatic system, the muscles and the heart where it causes direct inflammation. Many physicians, unfortunately, do not take this other activity and the stress it subjects us to into account. Rather than relying on the latest tests and literature to help form a diagnosis, they often mistakenly assume that hepatitis C is only a liver disease, and that, unless the patient has obvious cirrhosis, the complaints are psychosomatic
Just as HIV often causes death by AIDS-related pneumonia, even though HIV is not a lung disease, hepatitis C often causes death through liver failure or liver cancer, but it is not a liver disease. Hepatitis C is a virus that lives in and attacks many other organs of the body. It is also an active virus which engages the immune system to the point of exhaustion. The high viral activity is called viremia.

When your body is under attack from a hepatitis C viral flare-up, the immune system mounts a defense which produces symptoms much like that of having the flu. The primary symptoms are aches, tiredness, fogginess and maybe a slight fever. These symptoms are the result of the immune system’s response to the hepatitis C virus.

For a list of common reported symptoms of hepatitis C see the survey above. (2.2.2)

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2.9.1 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.

For some reason many physicians continue to assume that if the enzyme levels are low or near normal, that there is no cause for worry or need for treatment. However, the studies which show that THERE IS NO NECESSARY CORRELATION BETWEEN ENZYME LEVELS IN THE BLOOD AND THE EXTENT OF LIVER DAMAGE are too numerous to mention. Several individuals had to insist on a liver biopsy, only to find out that despite the low enzymes, they had grade 2 and grade 3 liver damage. One is dead, another is Joan King. You may post her at jking.hepcbc@gmail.com  and she will tell you her story.

HEP C AND ALT’S - WHAT IS NORMAL?

Alan Franciscus

Twenty to thirty percent of people with HCV have persistently normal alanine aminotransferase (ALT) levels. It is currently recommended that HCV+ individuals with normal ALT levels should not be treated with antiviral medications and followed simply by measuring their ALT levels. However, emerging data suggests that it may not be this simple. What does this mean for the patient that has persistently normal ALT counts? Should they be biopsied and treated? This is a ‘hot’ area of research and some recent findings are changing the way the medical profession views this group of HCV+ patients.

We know that most HCV+ individuals with persistently normal ALT levels have a less serious disease progression and milder disease. The National Institutes of Health (NIH) and European consensus conferences recommended no liver biopsy or antiviral therapy in patients with persistently normal ALT levels outside of clinical trials due to the assumed mild disease progression and low response rates to current antiviral therapy. Some medical professionals dismiss this group as healthy ‘carriers’ and offer minimal medical follow-up. However, some of these patients with normal ALT’s do not fit so neatly into this category and researchers are finding that a small percentage of these patients may have moderate to severe liver damage.

Alanine aminotransferease (ALT’s – formally called SGPT) is produced in the liver in response to liver injury or cell death. This injury is not specific to HCV inflammation, but can come from a variety of agents such as alcohol, medications and other substances that can produce liver injury. This is usually, but not always, the first indication that someone may be infected with HCV. Normal values: 0-48 IU/L

It should be noted that many experts believe the normal ALT range value for women should be lower than the range value for men. In fact, women populate a large part of this ‘normal group’. The lower ALT levels in women might be explained by the production of estrogen which is believed to lower ALT levels.

Biopsy

In a recent study by Edmund J Bini and others (AASLD abstract #485) 43 patients with persistently normal ALT levels and 96 with abnormal ALT levels were followed. Normal levels were defined by 3 normal ALT readings taken at least 1 month apart. The researchers found that the abnormal ALT levels group had significantly more advanced liver disease than patients with normal ALT’s. However, 28% of the patients with normal ALT’s had advanced liver disease, which led the researchers to recommend that all patients with normal ALT’s undergo a liver biopsy for disease staging.

In a different study by Luis Balart, MD and others, over 300 patients with persistently normal ALT levels defined as 3 normal ALT levels readings taken 6 weeks apart for a period of 6 months were studied. It was found that most of these patients had mild liver disease, but a small percentage had more advanced disease, and some patients were found to have cirrhosis. Based on his study, Dr. Balart recommended that other factors should be considered when evaluating these patients and a biopsy should be considered.

Treatment

This is a much more complex issue. In a recent study conducted by Dr. Mitchell L. Shiffman and colleagues, it was found that response to interferon monotherapy was similar in both normal (58 patients) and abnormal (37 patients) ALT level groups. The researchers concluded that persons with persistently normal ALTs should undergo a liver biopsy and considered for treatment if the liver is damaged. These findings have been collaborated by previous studies.

However, some evidence suggests that antiviral treatment for a small segment of this group could be counterproductive. Some patients do not respond to treatment, but develop elevated ALT levels that continue to be elevated after treatment is stopped. The big question is if antiviral treatment for this subset of patients make the disease worse. This is a very important, controversial issue. This area of research is expanding and deserves more attention. It is hoped that a patient with normal ALT values will at the very least be offered additional liver function tests and a liver biopsy if necessary to establish if severe disease is present and given the option for antiviral treatment.

Common tests used to measure liver function:

Liver function tests include a variety of tests to help gauge the health of the liver. Measuring ALT’s does not give a complete picture of liver health. A list of the more common liver function tests follow with the normal values listed. It is important to remember that ‘normal values’ vary from lab-to-lab and can be influenced by the way the blood samples are handled. Treatment decisions should never be made based on one test and always consult with a medical professional to accurately interpret test results.

Albumin is a blood protein produced by the liver. It is responsible for keeping fluids and salts within blood vessels. If the liver does not produce enough albumin, water retention in the form of swelling occurs usually in the feet and ankles. Normal values: 3.2-5.0g

Alkaline Phosphatase (AP) is an enzyme mainly found in the liver and is responsible for phosphorus metabolism, which delivers energy to the cell. Elevated levels of AP along with elevated GGT indicate that something is wrong in the liver. Normal values: 35-115 IU/L

Aspartate Aminotransferase (AST – formerly called SGOT) is a liver enzyme used for amino acid metabolism. Elevated levels indicate liver injury. Tests for this enzyme and ALT are the most frequently used blood tests to watch changes in liver inflammation. Normal values: 0-42 IU/L

Bilirubin is a waste product produced by the liver. A healthy liver will convert these bile salts into water-soluble substances that are excreted by the body. When the liver is damaged it is unable to convert these bile salts into a water-soluble substances leading into a buildup of toxic yellowish liquid which produces jaundice (yellowing of the skin). This is seen in some acute cases of hepatitis C and in end stage liver disease. Normal values: 0-1.3mg

Gamma-Glutamyltranspepidase (GGT) is a liver enzyme used in metabolizing glutamate (an amino acid). High levels of GGT may indicate blockage and damage to bile ducts. Normal values: 30-60 IU/L

Platelets are blood cells that help the blood to clot. Low platelet counts indicate liver damage. Platelets counts are also followed closely during interferon therapy. Normal values: 130-400 thousand/MCL
(HCV Advocate – http://www.hcvadvocate.org )

This information is provided by the Hepatitis C Support Project. Reprint permission is granted and
encouraged with credit to the Hepatitis C Support Project.
[Note: Normal values may vary from one lab to another.

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2.9.1a Elevated alpha-fetoprotein levels

It is fairly common for alpha-fetoprotein markers to be elevated in patients with hepatitis C. Alpha-fetoprotein is a marker for tumors, but unless your numbers are extremely high, (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. In fact a recent study cautions that in anti-HCV positive patients, AFP level is not a good single reference for diagnosis of HCC. Anti-HCV positive patients should be routinely screened for HCC by image studies along with serum AFP level. (Hepatogastroenterology 1999 Nov-Dec;46(30):3208-11)

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2.8.0 How Does HCV Affect Children?

Hepatitis C FAQ

2.9.2 Jaundice





 

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