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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