 Frequently
Asked Questions
Click here for a glossary
of terms to help you understand the
words used here and by your doctor.
- What is hepatitis?
- Why should I be concerned
about having viral hepatitis?
- What should I know about
hepatitis A.
- What should I know about
hepatitis B?
- What should I know about
hepatitis C?
- I did IV drugs a few times
with friends many years ago, but I never got sick. Wouldn't
I know if I had been infected?
- Is hepatitis curable?
- My doctor recommends I have
a liver biopsy. What is it?
- What do the biopsy results
mean?
- What is hepatitis?
The term "Hepatitis" is a general term and refers to an
inflammation of the liver. The inflammation may be caused
by alcohol, drugs (such as acetaminophen), or infection
with a virus. Hepatitis is often classified as "acute hepatitis" or "chronic
hepatitis". Acute merely means that the illness is short-term
(less than six months duration). Chronic hepatitis means
that the illness has existed longer than six months. The
word "acute" does not refer to the severity of the illness
- only to the amount of time a person has been infected.
In the United States the viruses most often associated
with hepatitis are the hepatitis A, B and C viruses. Other
hepatitis viruses exist (such as hepatitis D, E, and G),
but are very rare in the U.S. Each of these viruses is
transmitted in a different way.
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- Why should I be concerned
about having viral hepatitis?
The inflammation caused by hepatitis can damage your liver
and even cause liver failure. This is serious because your
liver is essential for life and damage to it can lead to
severe illness or even death A person can have hepatitis
and not know it. It is important to know if you are infected
with hepatitis because certain behaviors- such as drinking
alcohol- can quicken or increase the damage from hepatitis.
Also, if you are infected it is possible to pass the infection
to others. Simple measures can prevent transmission to
others. These measures are outlined below and in the Prevention/
Vaccination section of this website.
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- What should I know
about hepatitis A.
Hepatitis A virus (HAV) is contracted by putting something
in the mouth that has been contaminated with the stool
of a person with hepatitis A. This type of disease transmission
is called "fecal-oral" transmission. While this
sounds unlikely, it is relatively common. HAV infections
can occur from situations such as eating raw shellfish
from waters where inadequately treated sewage is discharged,
unwashed produce, or foods prepared by infected food handlers
with improper handwashing facilities or procedures. HAV
can also be spread through improper handwashing after diapering
children, cleaning bedpans, or improperly treated sewage.
The most frequent symptoms of HAV are fatigue, nausea vomiting,
fever/chills, jaundice, dark urine, light-colored stools,
and abdominal pain. Since many illness include these symptoms,
sometimes people do not recognize the illness as HAV. HAV
may make you very ill initially, but most cases last only
a few days and clear up on their own. By itself, it is
rarely life threatening. In many parts of the world HAV
is so common that most of the population has had it by
age five. Your doctor can check for antibodies to hepatitis
A with a blood test. If you have had hepatitis A, you are
immune to repeat infection. If you have another viral hepatitis,
such as hepatitis C, contracting hepatitis A can cause
acute illness. Fatal illness has been reported. Since hepatitis
A can be avoided through vaccination, vaccination is wise
for those with other forms of hepatitis. If you travel
to areas where HAV is common, you should be vaccinated
before your trip. More about prevention and vaccination
can be found in the Prevention/ Vaccination section of
this website.
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- What should I know
about hepatitis B?
Hepatitis B (HBV) is contracted through exposure to infected
body fluids. Infection is possible through unprotected
sex and contact with the blood during childbirth, accidents,
use of non-sterile tattoo epuipment, drug injection, and
medicinal needles, and (prior to routine screening of the
blood supply) from transfusions and other blood products.
In the US we now routinely screen the blood supply, test
most pregnant women, and vaccinate and protect healthcare
workers so infection usually occurs from unprotected sex
and sharing of drug paraphernalia. Infection can occur
from sharing not just needles, but also syringes, water,
cotton, and "cookers". In much of the world unsterile medical
equipment and mother to child transmission is still common.
About 30% of persons with HBV have no signs or symptoms.
If HBV symptoms do occur they include jaundice, fatigue,
abdominal pain, loss of appetite, nausea, vomiting, and
joint pain. Signs and symptoms are less common in children
than adults. Once infected, some people recover on their
own but some become chronically infected- often called
HBV "carriers". Carriers, even if they seem healthy, can
transmit the HBV virus to others. Whether a person recovers
or becomes a carrier depends in part on when they were
infected. Most adults (about 90%) will fight off infection
on their own, but infants and children are more likely
to develop chronic infection and become carriers. Left
untreated, chronic HBV can progress to end-stage liver
disease (ESLD) or even liver cancer which without liver
transplantation leads to death. The supply of donated livers
is inadequate and transplantation comes with many risks.
It is best to treat HBV before ESLD occurs. For information
about treatment of HBV, please see the "Treatment" section
of this website. HBV can be prevented by eliminating exposure
to infected body fluids: practice safe sex, wear gloves
and use bleach solutions when dealing with blood spills,
and do not share needles or other drug paraphernalia. Vaccination
against HBV is available and currently recommended for
all infants and children in the US. Adults at high risk
for exposure to infected fluids (healthcare workers, emergency
response personnel, IV drug users, and men who have sex
with men) are encouraged to be vaccinated as well. Worldwide
efforts to eliminate HBV through vaccination are underway
but there is a long way to go, as routine vaccination of
infants is not universal. In the US, most community health
departments offer free or low-cost immunizations. Our section
on Prevention/Vaccination can provide more details about
prevention of HBV. If you have more questions about hepatitis
B, we recommend you visit the website of the Hepatitis
B Foundation- www.hepb.org.
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- What should I know
about hepatitis C?
Hepatitis C virus (HCV) was isolated and named in 1989.
Prior to 1989 patients with symptoms of hepatitis that
were not hepatitis A or B were diagnosed as non-A, non-B
(NANB) hepatitis. We now know that many of these NANB infections
were caused by HCV. Most people (80%) infected with HCV
have no signs or symptoms. When symptoms do occur they
may include jaundice, fatigue, dark urine, abdominal pain,
loss of appetite, and nausea. Some people (15- 30%) go
on to recover on their own but most will become chronically
infected. HCV usually progresses very slowly. People are
often shocked when told that they have a blood test positive
for the hepatitis C antibody. Hepatitis C is transmitted
through exposure to infected body fluids. It is less likely
to be sexually transmitted or transmitted from mother to
baby than HBV. Many people are thought to have been infected
from transfusions of blood or blood products in the years
before HCV was identified and a test was available. Today
the US blood supply is screened for HCV and is very safe.
IV drug use and other blood exposures are now the leading
cause of HCV infection. Just one episode of injecting drugs
can transmit HCV. Some people with HCV report having used
injection drugs just once many years ago. Intranasal cocaine
use (snorting) and body piercing or tattooing by commercial
vendors is unlikely to cause infection. However "jailhouse
tattoos" and "street tattoos" carry a higher risk of infection
since HCV is more common in prison than the general population,
needles are not sterilized, and needles and ink are often
used on many people. Long term consequences of chronic
HCV infection are cirrhosis and end stage liver disease
(ESLD). While most people will not develop cirrhosis, some
people with cirrhosis (about 20%of cirrhosis) will go on
to develop ESLD. Symptoms of ESLD may not show up until
life-threatening complications develop, when liver transplantation
is the only option. It is therefore important to be tested
for HCV. If you experimented with IV drugs, even once,
you are at risk for having HCV and should be tested. If
you received a blood transfusion or other blood products
before 1992 or have been exposed to potentially infected
blood you should be tested for HCV. The initial blood test
looks for antibodies that indicate exposure to the virus.
To find out if you are chronically infected or recovered
from HCV on your own you need a follow up test for the
virus itself. People who have been exposed to HCV but recovered
will have a positive initial test (antibodies) but a negative
second test (no virus). If you are still infected, both
tests will be positive. Treatment for HCV is becoming more
and more effective. A person with HCV should see a qualified
gastroenterolgist or hepatologist. The doctor may request
a liver biopsy. See the questions below about liver biopsy
for more information. For more information about hepatitis
treatment, please see the section of this website labeled "Treatment".
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- I did IV drugs a
few times with friends many years ago, but I never
got sick. Wouldn't I know if I had been infected?
Sometimes people do become "sick" but most people never
know they've been infected by hepatitis B or C. This is
particularly true of HCV. That's why testing or "screening" for
hepatitis should be based on risk factors, not your belief
that you have or have not been sick.
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- Is hepatitis curable?
Hepatitis A is self-limiting, meaning a person gets infected
and his or her body fights off the infection. Previous
infection protects against future infection. Prolonged
illness or death generally occurs only in rare situations.
Hepatitis B is quite complicated. Once infected, even
if a person "fights off" the infection, there is probably
always a possibility of "relapse". Treatment can reduce
the degree of your infectiousness (ability to infect
others) and your risk of developing hepatocellular carcinoma
(liver cancer). Seek out good medical care and see your
doctor regularly. Immunize your children, household contacts
and sex partners! Contact previous sex partners if there
is a chance you could have infected them, so they can
protect themselves and their loved ones. Hepatitis C
(HCV) is now considered curable through treatment. Unfortunately,
not everyone who receives treatment responds in the most
desirable way. Sustained viral response (no detectable
virus in your blood) is the goal and if you remain virus
free for a year, you probably have been "cured". The
experts now consider someone to be cured if they have
no detectable virus in their blood five years following
the end of treatment. If it's not there, it can't come
back. That's a cure. The best way to achieve sustained
viral response is to adhere to your prescribed treatment
regime. As treatments continue to improve, the number
of HCV patients who are cured will increase.
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- My doctor recommends
I have a liver biopsy. What is it?
The purpose of a liver biopsy is to examine a sample of
liver tissue. Your doctor can tell a lot about your health
and the condition of your liver through blood tests, ultrasounds
and CAT scans, but nothing can compare to the information
gained from looking at the liver cells directly. The information
gained can help in making critical treatment decisions.
Many people are afraid of the procedure, but it is usually
not as bad as people fear. Your doctor will discuss the
method he or she will use to perform the biopsy. The methods
are usually, a "percutaneous" (through the skin)
needle biopsy or a "trans-jugular" (through the
jugular vein). There are advantages and disadvantages to
both methods. The percutaneous (through the skin) method
is simple, quick, less costly, and yields a more generous
tissue sample for the pathologist. Although the procedure
may sound scary, it is quick and usually not painful. Your
upper abdomen on your right side will be cleaned and "prepped" with
sterile cloths and your doctor will feel for the correct
space between your ribs to insert the biopsy needle (in
some cases the biopsy spot may be marked using an ultrasound
probe). He or she will instruct you to take a deep breath
and blow it all out and hold very still. The needle will
then be inserted and removed very quickly. Then it's over!
The anxiety is usually worse than the procedure! You may
be asked to stay in bed propped on your side to hold pressure
against the biopsy site for a few hours to reduce the small
chance that you might experience internal bleeding. You
will then be discharged to home. Another doctor, a pathologist,
will examine the liver cells under a microscope and discuss
them with your doctor, who will speak to you about the
findings. Complications from this procedure are very rare.
The transjugular method is entirely different. With this
method a radiologist will drape you and clean your neck
with betadine (an antiseptic liquid) before inserting a
long flexible wire through the skin of your neck and into
the jugular vein. Using fluoroscopy (like a x-ray "movie")
he or she will thread the wire through the blood vessels
and into a vein in the liver. The tip of the wire will
then be pushed through the wall of the vein and into the
liver tissue to obtain a sample. This sample will be withdrawn
with the wire, a dressing will be placed on the insertion
site on your neck, and you will be discharged. Transjugular
biopsies are usually reserved for people who cannot have
percutaneous biopsies, for example people who have an increased
risk of internal bleeding from cirrhosis, when your platelet
count can be low, but sometimes gastroenterologists who
do not perform percutaneous biopsies will send all of their
patients for transjugular biopsies. With a transjugular
approach there is no risk of bleeding except at the insertion
site on the neck, a minor risk. When the wire pushes through
the wall of the vein, it is already in the blood vessel.
This method is more expensive and yields a much smaller
sample of liver tissue, but is used because it allows people
with advanced disease or bleeding problems to be receive
a biopsy. The information gained from a biopsy cannot be
overstated. It is critical. Don't let fear defeat you in
your quest for information and control over your hepatitis.
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- What
do the biopsy results mean?
A specially trained doctor, a pathologist, will examine
the liver tissue obtained during your biopsy. Pathologists
look for many things when they examine liver biopsies.
First they put small bits of the liver tissue onto glass
slides and stain the slides with a couple of different
stains. Different stains are used to look for different
things. An "H and E" stain is used to look for inflammation.
A "trichrome" stain is used to look for fibrosis (scarring).
Other stains look for iron or different components of the
liver tissue. If you have hepatitis B, a stain will probably
be used to look for the number of cells infected with the
virus. This is not possible with hepatitis C. Inflammation
The liver is a homogenous organ, that is, similar throughout.
It is interwoven with tiny veins, arteries, and bile ducts
that thread throughout the organ. It may help you to imagine
the liver as a large fine-celled sponge. There are areas
where these vessels are located, and areas where there
are lots of liver cells, called hepatocytes. In the liver
the areas where the tiny arteries and bile ducts are located
are called portal areas and the areas filled with liver
cells are called lobular areas. The portal areas can be
imagined as "plumbing connections" where tiny arteries
feed the liver cells and tiny veins and bile ducts drain
blood and bile away from the lobular area. There are millions
and millions of portal areas in your liver. In hepatitis
C, the portal areas are usually inflamed first, while in
hepatitis B the features are very different. Inflammation
can vary in different portal areas so it is important that
the pathologist has enough liver tissue to look at about
10 portal areas to have a good idea of the extent of damage.
The pathologist will score the inflammation in your tissue
by examining portal areas and lobular areas closely for
inflammation, that is the presence of clusters of white
blood cells (remember that white cells are one of the body's
defenses against infection. Your body is trying to fight
off the virus.) He or she will see how far the inflammation
extends from the portal area out into the lobule (this
type of inflammation is called either piecemeal activity
or interface hepatitis). The pathologist will add all the
elements, including the number of portal areas affected,
the extent of the inflammation in the affected portal areas,
the amount of piecemeal activity and come up with both
a numerical score and a description. Typically, the description
is most helpful, and inflammation is described as absent,
mild, moderate, or severe. As you might expect, the more
toward severe the inflammation is, the more urgent the
need for treatment and the more strongly your doctor will
recommend it. Fibrosis Fibrosis is another word for scarring.
The worse the fibrosis, the worse the scarring. In hepatitis
C the portal areas are generally affected most, and fibrosis
begins there. Early damage will be described as "portal
fibrosis", then "fibrous portal expansion" as the inflammation
causes scar tissue to extend outward. As fibrosis extends
it can meet with fibrosis from an another portal area.
This is called "bridging fibrosis". The next step is "extensive
bridging fibrosis" as more portal areas become extensively
scarred. The next step is "nodule formation" which indicates
that these bridges surround the lobules. Think of the sponge
with the walls of the cells being the fibrotic tissue.
The liver is three-dimensional, and what is a circle of
fibrosis on a slide is really a sphere or ball of fibrosis
surrounding a lobule of liver tissue. When most of the
liver tissue becomes lobular it is "cirrhotic".
Sometimes the liver tissue will be described as "fragmented",
meaning that the bits of liver tissue have separated into
fragments when they were prepared on the slides. This is
common in cirrhosis, where the fragments are usually nodules.
Pathologists try to "stage" their biopsies based on the
fibrosis. The higher the number, the more the scarring.
The most common scoring system in the USA is the Ishak
system, where a score of 0 represents no fibrosis, and
6 is established cirrhosis. Scores of 1 and 2 indicate
degrees of portal fibrosis, stages 3 and 4 indicate bridging
fibrosis. A score of 5 indicates nodular formation and
incomplete cirrhosis. A score of 6 indicates established
cirrhosis. In Europe, a different scoring system with 4
levels is used (1 is for all portal fibrosis, 2 is some
bridging fibrosis, 3 is extensive bridging fibrosis, and
4 includes nodularity all the way to established cirrhosis).
When you receive biopsy results be certain you know which
scoring system was used. Ask, for instance, "stage 2 of
how many stages?" Stage 4 in the Metavir system is significantly
different from stage 4 under the Ishak system. This is
your biopsy, your liver, your body. Make sure you understand
the results you receive. Steatosis Steatosis is fat. There
can be a number of reasons to have steatosis in the liver,
and patches of fat appear on the biopsy slide as empty "bubbles" where
bits of fat used to be. Fat in the liver appears for a
number of reasons, including obesity, but it a very common
finding in hepatitis C infection. Having small amounts
of steatosis or "patchy steatosis" is typical
in HCV. It doesn't interfere in the functioning of the
liver and should not worry you. Large amounts of steatosis
can interfere with your liver functioning and your doctor
should discuss it with you.
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