This article, written by the association SOS Hepatitis aims to advise you in the follow-up of your hepatitis C.
How do I know if my body has eliminated the virus?
Prior to becoming chronically infected with the hepatitis C virus, an exposed individual will experience an acute phase of the infection, which may be asymptomatic. In about 1 in 5 people exposed to the virus1, their immune system is able to clear the virus and no further intervention is required. While the virus is cleared, the antibodies produced by the body remain in the body.
After a positive test, we must therefore check whether the virus is still present in the blood: we search either the genome (RNA) of the virus, using a technique known as “genomic amplification” (PCR), or the antigen of the virus (HCV Ag), thanks to another technique. If the search for the virus is negative twice or more than three months apart, it means that your body has got rid of the virus: you are cured.1 If this research is positive, the virus is still present. A complete assessment and an adapted medical follow-up are essential.
What are the usual examinations?
Determination of the genotype of the virus. There are six main genotypes of HCV: they are different strains of the same virus. The most common is genotype 1 (1A and 1B), followed by genotype 3, 4 and 2.1 This examination, performed once during the initial assessment, as well as your stage of fibrosis and your specificities (co-infection HIV / HCV, overweight, diabetes, kidney problems, addictions, treatments in progress …), allows your specialist to determine the duration of the possible treatment and the molecules Antiviral to Direct Action (AAD) adapted.
The determination of transaminases
Enzymes, called transaminases, are present in liver and muscle cells. There are transaminases ALAT (or SGPT) and ASAT (or SGOT). When liver cells are destroyed, transaminases are released into the bloodstream. Everyone has transaminases in their blood. But beyond a certain standard, it reveals liver damage1. The increase in ALT transaminases may be significant for viral hepatitis C. In contrast, elevated ASAT transaminases often indicate liver intoxication with alcohol or drugs.1
During acute hepatitis, that is to say within four to six weeks after infection, the increase in transaminases is very important: between 10 to more than 50 times the norm. When hepatitis becomes chronic, the elevation of transaminases in the blood can vary from 1 to 5 times the norm. In people with so-called minimal hepatitis C, the transaminase level is usually about twice the norm. This dosage is normal for one person with chronic hepatitis in four. Now, among these people, one in five already has significant lesions of the liver. Even if your transaminase levels are normal, it is always better to consult a specialist and consider additional tests (biological markers of fibrosis and Fibroscan®). In the absence of treatment, the determination of transaminases, carried out from a blood test, remains an essential element of surveillance: we recommend that it be performed every six months.1
Ultrasound of the liver
Ultrasound can measure the volume of the organ (a diseased liver may be smaller or larger than normal), check the condition of the bile ducts and detect abnormalities: cirrhosis, benign tumors (cysts) or malignant (cancers). The ultrasound of the liver is very often normal in case of hepatitis C. An ultrasound is systematically performed before a biopsy. In case of cirrhosis, this examination must be repeated every 3 to 6 months to detect the first signs of a possible cancer.2
Measuring viral load
It indicates the amount of virus present in the blood. This examination is not necessary if treatment is not considered: in fact, in hepatitis C, the viral load does not affect the severity of the disease and the evolution of the liver lesions.1
What are the tests to evaluate my liver?
The biopsy remains the reference exam to know precisely the lesions of the liver and to evaluate the gravity of the hepatitis. However, FibroTest®, FibroMeter®, and FibroScan®, non-invasive exams, currently replace biopsy in most cases.
The biopsy, also called “liver biopsy puncture (PBH)” is to suck with a needle a tiny piece of liver: the diameter of half a vermicelli, it is reconstituted in a few hours. The biopsy is most often performed under local anesthesia. For an intercostal biopsy (the most common), you are lying on your back; the needle, very fine, is slipped between two ribs, on the right flank. The sting lasts a few seconds. After the biopsy, pain can be felt in the liver or the shoulder: painkillers can be used to remove it.3 The intercostal biopsy requires outpatient hospitalization, that is, for the day. If you live alone or away from the hospital, you will be kept overnight for observation.
The biopsy is generally not very painful and causes no complications if one follows the recommendations of use:
- Do not take anticoagulant medication or aspirin ten days before and one week after the biopsy;
- Arrive on an empty stomach (you can however take your usual medicines with a little water, except for aspirin and its derivatives);
- Stay lying down for six hours after the biopsy;
- Do not practice intense physical activity during the three days following the examination;
- Tell your doctor if you feel pain or fatigue in the following days3
Biological markers of fibrosis
By means of a blood sample, several substances present in the blood are analyzed: their combination and their dosage make it possible to estimate the degree of fibrosis. But these results are not 100% accurate, and they can be distorted in certain situations: other pathologies, taking medication3 … There are several processes with different names: FibroTest®, FibroMeter®…
The elasticity of the liver is measured by a wave recorder on the skin above the liver. The exam looks like an ultrasound, it lasts ten minutes and is completely painless. The result makes it possible to evaluate the degree of fibrosis: the harder the liver, the greater the fibrosis. In case of cirrhosis, this examination gives more details about the possible complications. But the results can be skewed in some people with a large fat layer in the stomach, or ascites.3
Generally, the doctors propose to do the two tests (biological markers of fibrosis and FibroScan®) If the results are concordant, this makes it possible to avoid the biopsy. If the results diverge, the doctor will suggest a biopsy. The doctor may also request a biopsy for additional information on the condition of the liver.
What do the results of these exams mean?
The results of liver biopsy or biological markers of fibrosis are translated as a score called Metavir. This score has two values: the letter A expresses the activity of hepatitis (from 0 = no activity, to 3 = very important activity); the letter F indicates the degree of fibrosis, that is, of the liver (from 0 = no lesions, to 4 = cirrhosis). A person whose Metavir score is “A2 F2” has moderate hepatitis and moderately significant liver lesions (fibrosis). A treatment is usually offered.
How often do you need to have an exam?
Generally, it is desirable to assess liver status and degree of fibrosis every year unless your medical situation has changed in the meantime.3 The transaminase assay should be performed two to four times a year, according to the severity of your hepatitis. In the majority of cases, a complete liver assessment is performed every six months.2 In addition to the transaminase assay, it can measure:
The blood count (NFS) and the platelets: for this analysis of the blood cells, one counts in mm3 the red blood cells, the white blood cells and the blood platelets (during a viral infection, the white blood cells decrease).
The prothrombin level (factor of coagulation of blood synthesized by the liver): the fall in the prothrombin (TP) level may mean liver damage.3
Bilirubin: Its increase in blood indicates a disorder of biliary elimination, which may be due to hepatitis or some other cause.1, 3
Alkaline phosphatases (ALP) are enzymes: their increase in the blood can detect biliary failure.1
Gamma-GTs are also enzymes: like transaminases, their increase in the blood can be a sign of liver cell destruction.1
Albumin is a protein produced by the liver: a drop in its concentration in the blood can show liver failure.1
Immunoglobulins are antibodies: gamma-type immunoglobulins (IgG) are more numerous in the blood in cases of chronic hepatitis.1
TSH (thyroid): hepatitis C can cause inflammation of the thyroid gland; the determination of TSH can detect hypo or hyperthyroidism, that is to say a malfunction of the thyroid.1
Alphafoetoproteins (in case of cirrhosis): their increase may suggest the presence of liver cancer, but this is not systematic.1, 2
Other examinations may be performed depending on the case (lipid balance, ferritin, auto -bodies, search for other viruses) “F3” or “F4” cured consult every six months! Whatever your case and your medical situation, even if your transaminases are normal and you do not feel any symptoms make a complete assessment every six months. Too many cured people never or very rarely see a medical specialist to escape the idea of the disease, to forget or simply because they were not told it was useful! However, the follow-up of a severe fibrosis and the prevention are essential to detect a possible cancer.
- Treatment of people infected with hepatitis B or hepatitis C virus. 2014 recommendations report. Edited by. Pr Daniel Dhumeaux and under the aegis of ANRS and AFEF
- Diagnostic Criteria and Initial Assessment of Uncomplicated Cirrhosis – HAS Report – December 2006
- Methods of assessing liver fibrosis in chronic liver diseases – HAS report – December 2006
* FibroMeters are in vitro diagnostic medical devices manufactured by Echosens. These blood-based scores are intended for the diagnosis and the enantiation of hepatic fibrosis in adult patients with chronic liver disease of viral (including HIV co-infection), alcoholic or metabolic origin. This in vitro diagnostic medical device is a regulated health product that carries CE marking under this regulation.
FibroMeter exams must be performed in accordance with the manufacturer’s pre-analytical and analytical recommendations (www.fibrometer.com). The values obtained must be interpreted by a doctor specialized in liver diseases, taking into account the patient’s entire medical file. In France, the FibroMeter Virus is reimbursed by health insurance organizations, in certain situations and under certain conditions: consult the terms and conditions on the ameli.fr website.
For more information, ask your doctor for advice.
** FibroScan® is a class IIa medical device manufactured by Echosens – CE 0459. FibroScan® is intended for the non-invasive measurement of hepatic elasticity (E) and hepatic ultrasonic attenuation (CAPTM) in children. Man. Reviews must be performed only by an operator certified by the manufacturer or their local accredited representative. The values obtained must be interpreted by a doctor specialized in liver diseases, taking into account the patient’s entire medical file. Check the conditions for taking the FibroScan exam with your paying agencies.
This in vitro diagnostic medical device is a regulated health product that carries CE marking under this regulation. For more information, ask your doctor for advice.