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Symptoms of Chronic Hepatitis
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Hepatitis
C is the most common liver disease currently seen in
clinical practice.
The incubation period, from the time of exposure to
the virus until the onset of the disease, is one to
six months. Early symptoms include poor appetite,
lack of interest in food, nausea, aching muscles and
joints, and light fever. Some people experience only
mild symptoms such as tiredness, periodical pressure
below the right ribs caused by the enlarging liver,
and aching muscles and joints. Only 1 in 10 patients
with acute
Hepatitis has symptoms. The remaining nine have no
symptoms whatsoever. In 8 out of 10 patients, the
infection becomes chronic.
Many patients remain
asymptomatic until decompensation occurs. Lack of
symptoms and minor liver enzyme elevations are
typical of HCV infection and cannot be taken as
evidence of lack of progression. HCV RNA testing
confirms the diagnosis. Liver biopsy helps assess
disease activity and stage the severity of fibrosis
and is recommended for most patients with hepatitis
C. Once this information is obtained, a rational
program for treatment and monitoring can be planned.
Patients with newly discovered hepatitis C infection
require thorough education about the disease's
natural history, transmission, interaction with
alcohol, and treatment. In many cases, referral to a
gastroenterologist or hepatologist may be the
appropriate way to ensure necessary instruction and
availability of the latest treatment options.
Symptoms commonly reported by persons with hepatitis
C include:
Other
less common symptoms include pain or discomfort in
the abdomen on the right side, itching, nausea,
appetite/weight loss, mental fuzziness.
Hepatitis C virus is one of many causes of swelling
of the liver (hepatitis). The liver plays a crucial
role in cleaning the blood and metabolizing
different substances we ingest. When the liver
isn't working correctly, "poisons" build up in the
blood. In addition, the liver makes bile, and if it
isn't released correctly, it builds up in the body
causing a yellowing of the skin and eyes (called
jaundice and icterus, respectively). People first
infected with HCV commonly get mild flu-like
symptoms with aches, fever, and chills.
Symptoms are most common in patients
who have developed cirrhosis.
As the liver disease progresses,
complications of cirrhosis and liver failure may
occur, including jaundice, ascites (accumulation of
fluid in the abdomen), variceal bleeding (bleeding
from collateral vessels in the the esophagus,
stomach or intestines secondary to impedence of
blood flow through the liver), leg edema and
encephalopathy (mental confusion due to the
accumulation of toxic metabolic products that cannot
be cleared by the liver).
Please see our section on
Cirrhosis for photos
of complications and symptoms.
Joint
pain can also be caused by a condition known as
cryoglobulinemia. About 1/3 of people with hepatitis
C have this problem, which is caused by antibodies
attaching themselves to the hepatitis C virus. If
you are having joint and muscle pain, let your
doctor know. He or she may want to test you for
cryoglobulinemia because it can also cause problems
with blood vessels.
Symptoms of Acute Viral
Hepatitis
General
Symptoms. Symptoms of acute viral hepatitis may
begin suddenly or develop gradually. They may be so
mild that patients mistake the disease for the flu.
Nearly all patients experience some fatigue and
often have mild fever. Gastrointestinal problems are
very common, including nausea and vomiting and a
general feeling of discomfort in the abdomen or a
sharper pain that may occur in the upper right area
if the abdomen. This pain tends to increase during
jerking movements, such as climbing stairs or riding
on a bumpy road. GI problems can lead to loss of
appetite, weight loss, and dehydration. After about
two weeks, dark urine and jaundicea yellowish color
in the skin and whites of the eyes -- develops in
some, but not all, patients. Children tend not to
develop jaundice. About half of all hepatitis
patients have light colored stools, muscle pain,
drowsiness, irritability, and itching -- usually
mild. Diarrhea and joint aches occur in about a
quarter of patients. The liver may be tender and
enlarged and most people have mild anemia. In about
10% of patients, the spleen is enlarged.
Symptoms of Fulminant Hepatitis.
In very rare cases, within two months of onset, a
very serious condition known as fulminant hepatitis
develops. Symptoms may include a large swollen
abdomen (known as ascites) and a peculiar
hand-flapping tremor (called asterixis). These
symptoms may be followed by stomach and intestinal
bleeding and mental confusion, stupor, or coma
caused by brain injury (encephalopathy).
Symptoms Typical of Acute
Hepatitis A. Symptoms of hepatitis A are usually
mild, especially in children. They generally appear
between two and six weeks after exposure to the
virus. Adult patients are more likely to have fever,
jaundice, and itching that can last one to several
months.
Symptoms Typical of Acute
Hepatitis B. Hepatitis B symptoms appear long after
the initial infectionusually four to 24 weeks. Many
patients may not even experience symptoms, or they
may be mild and flu-like. About 10% to 20% of
patients have a fever and rash. Nausea is not
common. Hepatitis B patients may experience general
aching in the joints, but sometimes the pain can
resemble arthritis, affecting specific joints and
accompanied by redness and swelling.
Symptoms Typical of Acute
Hepatitis C. If they appear at all, symptoms develop
about a month or two after a person is infected with
hepatitis C. These are usually milder than those of
hepatitis B. About 75% of patients show no signs of
jaundice, and many do not experience any symptoms.
Symptoms of Chronic Hepatitis
Symptoms of Chronic Hepatitis B
and C. Both hepatitis B and C can progress to
chronic hepatitis usually with no early acute
symptoms. Symptoms of progressive chronic viral
hepatitis may be very subtle and no more than a mild
persistence of acute symptoms for six or more
months. In fact, chronic hepatitis C can be present
for as long as 20 years without presenting any
obvious problems. In some patients, itchy skin may
be the first symptom. Some patients develop pain in
small joints in the body (such as the hand) that may
be nearly indistinguishable from symptoms of
rheumatoid arthritis, fibromyalgia, or carpal tunnel
syndrome. In other patients, chronic hepatitis B or
C can lead to long term disability or liver failure
before they experience any symptoms at all.
Symptoms of Chronic Autoimmune
Hepatitis. The symptoms of chronic autoimmune
hepatitis range from minimal to severe, including
fatigue, jaundice, fever, and weight loss. The liver
and spleen are often enlarged. In addition, patients
with this condition may experience skin disorders,
including palmar erythema (red palms) and spider
angioma (a blood-red spot, the size of a pinhead,
from which tiny blood vessels radiate like spider
legs). Itching is not common, however. The abdomen
or legs may be swollen due to the accumulation of
fluid.
Well-Connected Board of Editors
Harvey Simon, M.D.,
Editor-in-Chief
Massachusetts Institute of Technology; Physician,
Massachusetts General Hospital
Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts
General Hospital
John E. Godine, M.D., Ph.D.,
Metabolism
Harvard Medical School; Associate Physician,
Massachusetts General Hospital
Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician,
Massachusetts General Hospital; Active Staff,
Children's Hospital
Irene
Kuter, M.D., D. Phil., Oncology
Harvard Medical School; Assistant Physician,
Massachusetts General Hospital
Paul C.
Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting
Surgeon, Massachusetts General Hospital
Theodore
A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief,
Psychiatric Consultation Service, Massachusetts
General Hospital
Carol
Peckham, Editorial Director
Cynthia
Chevins, Publisher
SIGNS AND
SYMPTOMS THAT MAY BE ASSOCIATED WITH HEPATITIS C
(Tina M. St. John, MD )
http://www.hepcchallenge.org/manual/signs_symptoms_final.htm
INTRODUCTION: Hepatitis C affects
different people in different ways. Your
personal experience with hepatitis C will be as
unique as you are. This chapter reviews the most
common signs and symptoms experienced by people
with chronic hepatitis C. At first glance, the
mere length of the chapter may appear
overwhelming, but keep in mind, this is just a
list of possibilities. If you have any of the
signs or symptoms described in this chapter, it
is important that you do not assume they are a
result of having hepatitis C. Your health care
provider can determine if they are associated
with your hepatitis C. Very few people
experience all of these signs and symptoms. Many
of them will come and go on their own. For
troublesome and/or persistent problems, there
are things you and your health care provider can
do to either make them go away, or make them
easier to live with.
You may be wondering
what the difference is between a sign and a
symptom. A sign is an abnormality that is
detected by your health care provider during an
examination. A symptom is something you, as a
person with hepatitis C, experience as a result
of the disease. Signs and symptoms are discussed
together because sometimes a sign is also a
symptom. Fever is a good example of something
that is both a sign and a symptom. Your health
care provider can take your temperature and find
out that you have a fever, so it is a sign. But
if you have a fever, you can tell you have a
fever because your skin is warm, so fever is
also a symptom.
There are three
sections following this introduction. The first
section briefly explains how the hepatitis C
virus causes disease. The second section reviews
possible signs and symptoms that people with
hepatitis C who do not have cirrhosis may
experience. The last section reviews additional
signs and symptoms that people with hepatitis C
who have cirrhosis may experience.
HOW THE HEPATITIS
C VIRUS CAUSES DISEASE: According to current
understanding, the hepatitis C virus (HCV)
causes disease in two general ways. The first is
by infecting cells. Once inside the cell, the
virus directly damages or kills the cell. This
mechanism is called cytopathic damage. The
second way the hepatitis C virus causes damage
is by provoking an immune response. The immune
system is your body's way of protecting itself
from invading agents such as viruses and
bacteria. An overactive or misdirected immune
response can damage infected cells and the
normal surrounding tissue. This mechanism is
called immunopathic damage.
When HCV was first
discovered, experts thought the virus infected
only liver cells. However, more recent research
has revealed that HCV also infects parts of the
immune system, specifically the lymphatic system
and peripheral blood mononuclear cells. Experts
now understand that hepatitis C is not just a
liver disease but is a systemic disease, meaning
it can affect nearly any organ of the body. As
you read through the list of possible signs and
symptoms associated with hepatitis C infection,
you may find some of the symptoms you have been
experiencing that you thought were caused by
something else may actually be caused by
hepatitis C. This is important because knowing
why you are having a symptom is often the first
step in alleviating the symptom, or making it
less troublesome.
SIGNS AND
SYMPTOMS OF HEPATITIS C WITHOUT CIRRHOSIS:
The possible signs and symptoms of hepatitis C
without cirrhosis involve every organ system of
the body. Although some of these symptoms can be
quite uncomfortable, most of them do not
indicate that your liver disease is getting
worse. New symptoms should always be discussed
with your health care provider so you can work
together to keep your life with hepatitis C as
active, productive, and enjoyable as possible.
Arthralgia:
Arthralgia is pain in the joints. Frequent sites
of joint pain are the hips, knees, fingers, and
spine, although any joint can be a source of
pain. Arthralgia associated with hepatitis C can
be migratory, meaning it moves around. You may
have pain in your hip one day and in your knee
the next. This symptom usually comes and goes,
and is rarely present all the time. If you
experience joint pain, it is important to talk
with your health care provider before taking
anything to treat the pain because some
over-the-counter pain medicines (such as
acetaminophen) are potentially harmful to the
liver.
Fever, Chills,
and Night Sweats: Many people with HCV
periodically experience fevers. The fevers are
usually low, typically less than 101 degrees
Fahrenheit. As the fever comes down, you may
experience chills and sweating. You may have
fevers only at night. If this happens, you may
wake up with your bedclothes and/or your sheets
wet with sweat. This experience is called night
sweats.
Fatigue:
Fatigue is feeling tired, and nearly all people
with hepatitis C experience fatigue at one time
or another. The fatigue may be mild and relieved
by naps or going to bed earlier. However, the
fatigue can be severe at times, feeling like
near exhaustion even after a full night of
sleep. Fatigue experienced by people with
hepatitis C may also be accompanied by increased
feelings of anger, hostility, and depression.1
These feelings may persist even after the
fatigue has passed.
Fluid Retention:
Fluid retention occurs when your body holds on
to more water than it needs. The extra water
leaks into the tissues. If you have fluid
retention, you may notice swelling of your feet,
ankles, fingers, and/or face. People with fluid
retention often have frequent urination,
especially at night.
Flu-like
Syndrome: People with hepatitis C can
experience periodic flu-like syndromes. These
episodes usually last a few days, rarely more
than a week. The most common symptoms are fever,
chills, headache, fatigue, and muscle aches.
Lymphadenopathy:
Lymphadenopathy is swelling of the lymph nodes.
Lymph nodes are normally about the size of a pea
or a kidney bean. Because HCV infects the
lymphatic system, it frequently causes the lymph
nodes to swell. The lymph nodes of the armpits,
groin, and neck are relatively close to the skin
surface, and are usually examined to see if you
have lymphadenopathy. If you have
lymphadenopathy, it may or may not be painful
when you press on the swollen lymph nodes.
Myalgia:
Myalgia is muscle pain or aching. People with
hepatitis C may experience myalgia. Usually, if
you have this symptom, you will experience it as
a generalized feeling. However, some people
report having pain in only one area of the body.
This symptom tends to come and go, and is rarely
present all the time. If you experience muscle
aches or pain, it is important to talk with your
health care provider before taking anything to
treat the pain because some over-the-counter
pain medicines are potentially harmful to the
liver.
Pruritus:
Pruritus is the medical word for itching. People
with hepatitis C sometimes have pruritus. Often,
it is limited to the palms of the hands and/or
the soles of the feet. However, some people have
generalized pruritus, meaning they itch all
over.
Sleep
Disturbances:I nsomnia is difficulty
sleeping, and it may be part of your experience
with hepatitis C. Insomnia can occur in
different forms. You may have trouble falling
asleep, or you may wake up often during the
night. Some people report having unusually
vivid, intense, and/or frightening dreams. Such
dreams can contribute to insomnia.
Spider Nevi:
Spider nevi are small, red, spider shaped spots
on the skin. They are usually less than ½ inch
around. They are most commonly seen on the face
and chest, but can occur anywhere on the skin.
Spider nevi are painless and do not itch.
Weakness:
People with hepatitis C sometimes experience a
sense of weakness. This symptom can vary from
mild to severe, and tends to come and go.
Abdominal and
Digestive System Signs and Symptoms
Abdominal Pain:
You may experience episodes of abdominal pain if
you have hepatitis C. Pain on the right side
just below the ribs is likely to be from the
liver. People usually report this pain as being
short, sharp, or stabbing. More constant,
cramping pain closer to the middle of chest, but
under the ribs, can be due to gall bladder
problems that may accompany hepatitis C. You may
experience pain elsewhere in the abdomen. If you
experience any new pain in the abdomen, it is
important for you to tell your health care
provider right away so the source of the pain
can be determined.
Appetite Changes and
Weight Loss: People with hepatitis C frequently
experience changes in their appetites. You may
find you no longer want the foods you once
enjoyed. Many people find they are particularly
put off by fatty foods and alcohol. For some,
foods that are at room temperature or cold are
more appealing than hot foods. The distaste for
alcohol is actually good for you because alcohol
increases the damage done to the liver by HCV.
People with hepatitis C should not drink any
alcohol including beer, wine, wine coolers, and
mixed drinks. If changes in your appetite are
causing you to lose weight, you need to discuss
this with your health care provider because good
nutrition is particularly important for people
with hepatitis C.
Bloating:
Bloating is usually described by people with
hepatitis C as a feeling of fullness in the
abdomen. You may notice your clothes seem tight
around your waist. This bloating may or may not
be accompanied by weight gain.
Diarrhea and
Irritable Bowel Syndrome: Diarrhea can be
experienced as unusually loose stools or an
increase in the frequency of bowel movements,
with or without a change in the consistency of
the stool. If the diarrhea is accompanied by
cramping abdominal pain and persists, it is
often termed irritable bowel syndrome.
Indigestion and
Heartburn: Indigestion is usually experienced as
an uncomfortable feeling of fullness in the
stomach. It is often accompanied by queasiness
and burping of a mixture of gas and stomach
contents. When this occurs, you may notice a
burning in your throat and/or a sour taste in
your mouth. Heartburn is experienced as pain or
burning in the chest under the breastbone. It,
too, may be accompanied by burping of gas and
stomach contents. Both indigestion and heartburn
can be brought on by and last longer after a
fatty meal.
Jaundice:
Jaundice is a yellowish discoloration of the
skin and/or the whites of the eyes. It is caused
by a yellow substance in the blood called
bilirubin. The liver normally breaks down
bilirubin. If the liver is not working normally,
bilirubin can build up in the blood and begin to
stain the skin. If the liver starts to work more
normally, jaundice will fade or go away.
Nausea: Nausea is
the feeling that you may vomit. Hepatitis C may
cause episodes of nausea. Although it is usually
not accompanied by vomiting, it can be a very
uncomfortable and debilitating symptom. If you
are having nausea, talk with your health care
provider because there are many ways to treat
this symptom.
Cognitive, Mood, and
Nervous System Signs and Symptoms
Cognitive Changes:
Your cognitive ability refers to your ability to
think clearly and to concentrate. Some people
with hepatitis C notice they have changes in
their cognitive ability. This can take several
different forms. You may find you cannot
concentrate for long periods of time, or you may
notice your thought processes seem slower than
usual. You may have a hard time coming up with
words you want to say, or you may just feel
mentally tired. These cognitive changes are
sometimes called ‘brain fog.’ Like other
symptoms of hepatitis C, these cognitive changes
often come and go.
Depression:
Hepatitis C does not directly cause depression,
but concerns about the disease and changes it
may cause in your life can lead to depression.
Some of the symptoms of depression include:
• sleeping more or
less than usual
• eating more or less than usual
• hopelessness
• helplessness
• irritability
• lack of interest in your usual activities, and
• feelings of sadness and/or despair most of the
time
If you have one or
more of these symptoms, you may have depression
and should discuss what you are feeling with you
health care provider. Depression can seriously
interfere with your quality of life, and can
make it difficult for you to do what you need to
do to take care of yourself. Depression is
nothing to be ashamed of, and it can be treated.
If you have any of the symptoms of depression,
talk to your health care provider right away.
Dizziness: Some
people experience dizziness as feeling as if
they are going to faint. Others experience
dizziness as disorientation, or feeling as if
the world is spinning around them. Both of these
can be symptoms of hepatitis C. If you are
experiencing dizziness, talk with your health
care provider because this can be not only
troublesome for you, but also dangerous.
Headaches: Headaches
can be symptoms of hepatitis C. For some people,
the headaches are mild, but for others, the
headaches are severe. If you are having
headaches, talk to your health care provider
before taking any medicines for your headaches
because some over-the-counter pain medicines can
be harmful to your liver.
Mood Swings:
Hepatitis C can sometimes cause mood swings.
Some people find this symptom is worse during
the winter months.
Numbness or
Tingling: A significant number of people with
hepatitis C have numbness or tingling in their
extremities. Your extremities are those parts of
your body that extend from the main part of your
body, that is, your arms and legs, fingers and
toes. Most people with numbness or tingling feel
it in their fingers and toes, but it may extend
into the arms and legs. Numbness is a decreased
sense of feeling. In its most severe form, the
affected areas have no sense of feeling.
Tingling can sometimes be painful. People
describe painful tingling as feeling like being
stuck with pins. This symptom tends to come and
go.
Visual Changes:
There are a number of visual changes that can
accompany hepatitis C infection. You may find
you are not seeing as clearly as you once did.
Peripheral vision, that is, the ability to see
things that are at the sides of your view, can
also be diminished. Some people report seeing
small specks called ‘floaters’ moving across
their view. This can occur when the eyes are
open or closed. Another symptom you may
experience is dryness of the eyes, or feeling as
if there is something scratchy in your eyes. All
of these symptoms can come and go.
OTHER SIGNS AND
SYMPTOMS:
Blood Suger Abnormalities: Hepatitis C can cause
blood sugar abnormalities, either high or low.
High blood sugar causes symptoms such as extreme
thirst, frequent urination, fatigue, and weight
loss. Low blood sugar causes light-headedness or
dizziness, nausea, and weakness. The symptoms of
low blood sugar are worst when you have not
eaten anything for several hours, and are
relieved by eating or drinking something. If you
are having any of the symptoms of either high or
low blood sugar, tell your health care provider
right away.
Chest Pain:
Hepatitis C can cause chest pain. However, chest
pain can also be a symptom of serious heart or
lung disease. If you have chest pain, you must
contact your health care provider immediately so
he or she can find out the source of your pain.
Menstrual and
Menopausal Changes: Women with hepatitis C may
have menstrual changes such as irregular
periods, spotting, or increased premenstrual
symptoms. Menopausal women may experience an
increase in menopausal symptoms such as hot
flashes and mood swings.
Palpitations: A
heart palpitation is involuntarily becoming
aware of your heart beating. Palpitations occur
in different forms. You may feel your heart is
beating harder or faster than usual, or that it
is beating irregularly. If you have
palpitations, you need to tell your health care
provider immediately so he or she can make sure
you are not having a problem with your heart.
Sexual Changes: Some
people with hepatitis C have a decreased
interest in sexual activity. Decreased sexual
response and lack of intensity of sexual
response have also been reported. Sexual changes
can be an upsetting symptom of hepatitis C. If
you are experiencing sexual changes, talk with
your health care provider, and your spouse or
partner. There are things that you, your health
care provider, and your partner can do to help
you have a satisfying sex life.
SIGNS AND SYMPTOMS
OF HEPATITIS C WITH CIRRHOSIS
Approximately 20-40%
of people with chronic hepatitis C go on to
develop liver cirrhosis over a period of 10-40
years. Because blood cannot flow well through a
cirrhotic liver, blood backs up in the vessels
leading to the liver. This back up of blood
leads to an increase in pressure in those blood
vessels, a condition known as portal
hypertension . Many of the signs and symptoms of
cirrhosis are related to portal hypertension.
The liver has many
functions, so there are a number of things that
can go wrong when the liver is not functioning
normally. The liver not functioning normally
causes the other signs and symptoms of hepatitis
C with cirrhosis.
Ascites: Portal
hypertension associated with cirrhosis can cause
fluid to leak from the blood vessels leading to
the liver. This fluid builds up in the abdomen
and is called ascites. Ascites causes the
abdomen to become distended or enlarged.
Bleeding Problems:
The liver produces many of the substances needed
for normal blood clotting. A cirrhotic liver may
not produce enough of these substances for
normal clotting. If you have a cirrhotic liver
and begin bleeding for any reason, it may be
difficult to get the bleeding stopped.
Bone Pain: Cirrhosis
can lead to a deficiency in vitamin D. This can
cause softening of the bones and bone pain. This
pain is most often felt in the legs, hips, and
spine.
Bruising: Cirrhosis
can lead to a deficiency in vitamin K. This can
lead to easy bruising. If you are experiencing
easy bruising, tell your health care provider
because this symptom can often be reversed with
appropriate treatment.
Caput Medusae: Caput
medusae refers to enlarged, visible veins that
start at the navel and spread out and up over
the abdomen. They are caused by portal
hypertension.
Gastroesophageal
Varices: Gastroesophageal varices are another
complication of portal hypertension. These
varices are enlarged, fragile veins found where
the esophagus (the tube that takes food from
your mouth to your stomach) meets the stomach.
These veins can burst and bleed. If you have
cirrhosis and begin to vomit blood, you must
call an ambulance and get to an emergency room
as soon as possible to get the bleeding stopped.
Glossitis: Glossitis
is a sore tongue. If you have glossitis, your
tongue will be redder than usual and will be
sensitive to salty and sour foods, and
carbonated beverages.
Hemorrhoids:
Hemorrhoids are enlarged, fragile veins found
around the anus (the opening through which your
bowel movements pass). Hemorrhoids can be a
complication of portal hypertension. If you have
hemorrhoids, they may bleed occasionally. If the
bleeding persists, or is frequent, be sure to
discuss it with your health care provider.
Hepatic
Encephalopathy: Hepatic encephalopathy is one of
the most serious complications of cirrhosis. It
can occur in an acute form that develops over a
period of days to weeks, or it can occur in a
chronic form that develops over a period of
months to years. There are a number of different
symptoms that can indicate hepatic
encephalopathy, but all of them indicate
abnormalities of the nervous system. Early
symptoms include euphoria (feeling unusually
happy for no apparent reason) or depression,
confusion, slurred speech, or abnormal sleeping
patterns. If these symptoms are not treated,
they will progress to severe confusion,
incoherent speech, tremors, and rigidity. It is
urgent for these symptoms to be treated or you
could fall into a coma. With the acute form of
hepatic encephalopathy, treatment will usually
reverse all of the symptoms. However, with the
chronic form, some of the symptoms may not be
reversible.
Melanosis: Melanosis
is a gradual darkening of those areas of skin
that are exposed to the sun. The skin tends to
get darker over time.
Night Blindness:
Cirrhosis can lead to a deficiency in vitamin A.
This can lead to episodes of night blindness. If
this occurs, be certain to talk about it with
your health care provider because this symptom
is often reversible.
Shortness of Breath:
Shortness of breath can develop as a
complication of portal hypertension. Some people
experience this symptom only at night; others
experience it during the day as well. If you are
having shortness of breath, discuss it with your
health care provider who can help you with this
problem.
Steatorrhea:
Steatorrhea is the passing of fat in your bowel
movements. The presence of fat in the stool
makes the stool smell particularly bad, and
causes it to float in the toilet bowl.
Steatorrhea is usually accompanied by an
increased amount of stool and intestinal gas.
Xanthelasma:
Xanthelasmas are small deposits of fat just
under the surface of the skin around your eyes.
They appear as small, raised, yellowish bumps on
the skin.
Xanthoma: Xanthomas
are small deposits of fat just under the surface
of the skin over your joints and/or tendons.
They appear as small, raised, yellowish nodules.
SUMMARY: The
experience of living with hepatitis C is quite
different from one person to another. It is also
variable for each person over time. There will
probably be days when you feel great. There may
be other times when you feel overwhelmed by
different signs or symptoms associated with
hepatitis C. And there will likely be still
other times when you feel somewhere in between
these two states. Below are a few things you may
find helpful to keep in mind about your signs
and symptoms as you learn to live with hepatitis
C.
Discuss your signs
and symptoms with your health care provider.
There are many ways to treat the signs and
symptoms associated with hepatitis C, so there
is no need to suffer in silence.
Always tell your
health care providers if you start to experience
a new sign or symptom. Doing this will help them
in their efforts to help you feel your best.
Keep all of your
health care providers informed about what
treatments, medicines, and supplements you are
using to manage your hepatitis C. Sometimes,
different treatments interact with one another
in ways that cause side effects that you may
experience as new signs or symptoms.
Do not panic if you
start to experience new signs or symptoms.
Although many of the signs and symptoms
associated with hepatitis C can be troubling to
you, they do not necessarily mean your liver
disease is getting worse.
Frequently Asked
Questions about Hepatitis C and Fatigue
Most
people infected with chronic hepatitis C virus (HCV)
have few symptoms or physical signs of the virus in
the first two decades after infection. However,
about 20 percent of those with HCV develop vague
symptoms, including mild intermittent fatigue and
malaise. Fatigue, which may lead to a significant
decrease in quality of life, may be the first and
only sign that the liver is being affected by the
virus. Following are answers to some frequently
asked questions about hepatitis C and fatigue.
Q.
Why is fatigue
associated with hepatitis C?
A.
Much of the fatigue a person with HCV experiences is
due to an activated immune system attempting to
eliminate the virus. Despite the effective creation
of antibodies against it, the hepatitis C virus can
undergo frequent mutation, allowing it to avoid
being eliminated from the body in 85 percent of
those who contract it. In an ongoing effort to rid
the body of the virus, the immune system continues
to create weapons against the virus including
antibodies, interleukins, and white blood cells. At
times, the immune response leads to the production
of immune complexes, collections of antibodies that
course through the body. Immune complexes may
deposit in the joints, the blood vessels in the
skin, or in the kidney, leading to arthritis, rashes
or glomerulonephritis (a form of kidney disease).
These conditions are referred to as "extra-hepatic
manifestations" of hepatitis. An immune system
activated to fight a virus like HCV might also begin
developing antibodies against other tissues in the
body, including the thyroid. The resulting
autoimmune illness, such as autoimmune thyroiditis,
can result in still more symptoms of fatigue.
Q.
What underlying
conditions might an HCV-infected patient have that
could contribute to his or her fatigue?
A.
Fatigue in HCV-infected individuals is most likely
due to the virus' presence. However, a number of
conditions that are readily diagnosed and treated
may add to the level of fatigue. Iron deficiency
anemia and hypothyroidism are both common among
women and can certainly contribute to loss of
energy. Depression is also common and often
manifests itself as excessive sleepiness and
fatigue. In fact, being diagnosed with a chronic
condition can actually worsen an individual's
depression.
Q.
How should conditions
associated with HCV be treated?
A.
In general, these conditions may be treated
independently of the hepatitis. Those that are
clearly related to HCV may respond to treatment with
approved therapy for HCV. All medications ingested
by a patient with HCV should be reviewed by his or
her physician because many drugs are metabolized by
the liver, which may already be compromised by the
virus. Some medications, particularly some
antidepressants, can lead to fatigue if serum levels
are too high. Therefore, in some cases, drug dosages
may need to be reduced.
Q.
What changes can a
person make to ease the impact of the fatigue on his
or her life?
A.
Most doctors recommend HCV patients eat a
well-balanced diet, drink alcohol only in moderation
and stop smoking. With these changes, energy levels
may improve. In addition, coping with fatigue means
balancing activity and rest. Some suggestions
include taking short naps between activities and
crafting a schedule that balances strenuous
activities with ones that are less strenuous. For
those with exhausting jobs, devising a flexible work
schedule or telecommuting from home may be good
options.
Headaches
Some
people with hepatitis also complain about headaches.
These headaches may go away completely after a
while, but then come back. Sometimes they are mild,
but at other times they are severe. They are not
like migraine headaches. You can treat the headaches
with over-the-counter medication. (Again, check with
your doctor about what to use.) Also, take time to
relax and drink plenty of fluids. Staying rested and
drinking lots of fluids may prevent headaches.
Nausea and loss of
appetite
Sometimes
people with hepatitis have nausea and loss of
appetite. You should try to eat, even if you don't
feel like it. It may help to eat many small meals
rather than 3 large ones. But some patients find it
is easier to eat a larger meal in the morning. Dry
crackers, weak tea, ginger ale, and ice pops may be
easier for you to eat than other foods. If the
nausea lasts, or if you are vomiting, let your
doctor know. He or she may be able to prescribe a
medication to relieve the problem.
Stress and depression
Having
an illness can be very stressful and sometimes
downright depressing. Some of your coworkers and
friends may believe false information, particularly
about how the disease is spread, and this may change
their attitudes toward you. You may also feel
somewhat isolated because your friends and family
don't understand how you feel. You might feel tired
all the time, or that you don't have enough energy,
or that no matter how much you sleep, you just don't
feel like getting out of bed. By 9 AM, you feel as
if you've put in an entire workday. But you can get
help to cope with these feelings.
Hepatitis and
Depression
A
diminished interest in recreational or pleasure
activities or other activities that used to be
enjoyable; a diminished ability to think or
concentrate—indecisiveness; trouble sleeping or,
alternatively, sleeping all the time; a significant
weight loss or weight gain when not when not trying
to lose or gain weight; fatigue or loss of energy;
feelings of worthlessness or excessive or
inappropriate guilt; recurrent thoughts of death or
thinking about suicide; and taken together, these
characteristic may cause significant distress or
impairment in social, occupational, or other
important areas of functioning.
*These are all symptoms
reported by people who suffer from hepatitis.*
*They are also the clinical diagnostic criteria for
Major Depression.* Many with hepatitis have said
they were mistakenly diagnosed with depression when
they were trying to find out what was wrong with
their bodies (the “it’s all in your mind”
diagnosis). There have also been those who thought
they were depressed and in the process of being
evaluated for medication for depression were
diagnosed with hepatitis. It is however possible,
and even probable, to have both: a diagnosis of
Viral Hepatitis *and* a diagnosis of Clinical
Depression. It can become sort of a self
perpetuating downward spiral. That is, low energy,
chronic fatigue, consistently not feeling well,
along with the decrease in functioning that comes
with these symptoms, all from hepatitis; combined
with the impact of having a potentially fatal
disease, are all very depressing things. An increase
in depression leads to even lower energy, more
decrease in functioning and even the possibility of
making physical symptoms worse. Depression alone can
be a serious debilitating disease. Combined with
hepatitis it can be devastating. So how can you tell
and what can you do? First, if you experience five
or more of the symptoms above, talk to your doctor
about depression. You might also want to consider
seeing a therapist. Depressed or not, someone to
talk to about the feelings that you experience
around having hepatitis can really be a help in
sorting things out sometimes. Your medical doctor or
your therapist may refer you to a psychiatrist to
prescribe one of the anti-depressant medications.
Many of these have been shown to be very effective
in treating depression. As with all medications, it
is always good to be an informed consumer.
Fog (HCV
Affects Cerebral Function)
______________________________________
Evidence
for a cerebral affect of the hepatitis C virus
Choline/creatine ratios are elevated in regions of
the brain of patients with hepatitis C, according to
research published in the latest issue of the
Lancet. A team from London, England, investigated
whether hepatitis C virus (HCV) affects cerebral
function. Patients with HCV infection frequently
complain of symptoms akin to the chronic fatigue
syndrome. They also score worse on health-related
quality of life indices than matched controls. The
researchers used proton magnetic-resonance
spectroscopy (1H MRS) to measure cerebral choline/creatine
ratios in subjects. "This suggests that a biological
process underlies the extrahepatic symptoms in
chronic HCV infection. " Daniel Forton. This was
performed in 30 patients with histologically-defined
mild chronic HCV infection, 29 age-matched and
sex-matched healthy controls, and in 12 patients
with chronic hepatitis B. They found that the
choline/creatine ratios were significantly higher in
the white matter and basal ganglia of the HCV group,
compared with both the hepatitis B group and healthy
volunteers. This elevation was found to be unrelated
to hepatic encephalopathy or a history of
intravenous drug abuse. Daniel M Forton, of Imperial
College School of Medicine, St Mary's Hospital,
London, concluded on behalf of the group, "The
elevation in choline/creatine ratios suggests that a
biological process underlies the extrahepatic
symptoms in chronic HCV infection. "These findings
have implications for the direction of future
research and ultimately for patient treatment."
Lancet 2001; 358: 38-9 10 July 2001
Q. What is the most common symptom
of hepatitis?
A. Fatigue (severe tiredness) is the most common
symptom of hepatitis.
Q. What is a good and simple
exercise?
A. Walking is a good exercise that can be done
regularly by almost anyone.
Q. What potentially serious
condition can cause joint pain in hepatitis
patients?
A. A condition known as cryoglobulinemia is
sometimes the cause of joint pain in hepatitis
patients. You need to talk to your doctor if you
think you have this condition.
Q. What is the most important step
in dealing with symptoms?
A. Your attitude, and how you take control of your
life through it, can make the biggest difference in
how you feel, despite this disease.
http://pages.prodigy.com/hepc/hepc2.htm
HEPATITIS/LIVER
PAIN?
Many Hepatitis C patients feel a
variety of abdominal pains and discomfort, but
unfortunately too often these pains are dismissed as
having nothing to do with chronic liver disease.
This is because abdominal organs are not responsive
to many things what would normally elicit severe
pain. The pain fibers in the large interior organs,
such as the liver , are usually sensitive only to
stretching or increased wall tensions, which is what
happens as the liver becomes inflamed. About 20
percent of patients complain of pain over the liver
area, in the right upper side of the abdomen just
beneath the ribs. Some experts suspects this could
be Referred pain caused by inflammation and swelling
of the covering of the liver. This pain also may
occur in the right shoulder or to the back between
the shoulder blades.
Pain that is caused by sensory nerves
in the liver may cause a pain that is hard to
describe- Dull cramping or aching, appearing
anywhere from the midline to the lover abdominal
area. It may be accompanied by nausea and vomiting ,
swearing , pale skin and restlessness during sleep.
Patients often move about in bed, occasionally
finding relief with a change in position.
Moreover, bacterial or viral
infection of any organ in the abdominal are
including the liver may cause abdominal pain.
VISCERAL
PAIN
Visceral pain may be referred to a
remote area of the body, where it is perceived as
cutaneous pain (sensation of pain in the skin) in an
area supplied by the same spinal cord level as the
affected abdominal organ. Referred pain is usually
well localized and appears when noxious visceral
stimuli become more intense. Thus, swelling of the
liver capsule by a hematoma (swollen blood vessels)
after liver biopsy is first perceived in the abdomen
but may be referred to the right shoulder.
Sensory Pain
Pain resulting from stimulation of
sensory afferent nerves innervating abdominal
organs. The pain is often difficult to describe
(usually as cramping or aching), dull in nature, and
poorly localized to the midline from the upper (epigastrium)
to the lower abdominal area. The pain may be
accompanied by nausea, vomiting, sweating, pallor,
and restlessness.
PARIETAL
PERITONEAL PAIN
When the parietal peritoneum
(abdominal membrane that encloses that body cavity)
becomes involved as a result of abdominal pathology
(disease process), nerves supplying the area are
stimulated and generally produce pain that is more
intense and more precisely localized than is
visceral pain. The classic example is the localized
pain of acute appendicitis. Parietal pain is often
aggravated by movement; hence the patient's desire
to lie completely still.
PSYCHOGENIC
PAIN
This is obviously abdominal pain that
is perceived but without any local cause.
Unfortunately, this may be a pain mechanism that
some physicians choose to attribute to some chronic
hepatitis patients' episodes of pain. However, as
cited above, physicians should take the time to
explain and concede that there are valid causes for
different types and intensities of abdominal pain
that arise from our internal organs due to
inflammation and toxic conditions.
FURTHERMORE.....
When the hollow structures of the
gallbladder and biliary tract dilate due to the
disease process, pain is experienced in the upper
abdomen or right upper abdomen. Pain may also be
referred to the back between the shoulder blades.
Pain from the pancreas is also felt in the upper
abdomen and is often referred to the middle of the
back. In a manner analagous to the liver,
gallbladder, and biliary tract on the right, lesions
in the tail of the pancreas that involve the
diaphragm, may result in referred pain to the left
shoulder. Bacterial or viral infection of any
intraabdominal organ may cause abdominal pain.
Interference with venous or arterial blood flow can
affect the abdominal organs. Clinically this may
present as severe abdominal pain and shock.
Pain and Liver Disease
In many patients that have been diagnosed with
hepatitis and/or
liver disease, many complain of abdominal pain,
located mostly in
the right upper quadrant, right flank or epigastric
area. Although
less frequent, left upper quadrant and lower
abdominal pain has
also been reported.
Abdominal pain:
The nervous system pathways that convey abdominal
pain messages are
known as the visceral and somatic pathways. Both of
these pathways
are part of the sympathetic nervous system. The
visceral fibers are
sensitive to stretch and spasm but are not affected
by temperature
or sectioning of the nerve. The somatic pathways
innervate the
abdominal cavity wall, parietal peritoneum, and
parts of the
diaphragm. These fibers are sensitive to pressure,
tension,
traction, chemical and bacterial toxins, enzymes,
infiltrative
processes and edema. The central parts of the
diaphragm and biliary
tract have axon fibers that carry messages in
conjunction with the
phrenic nerve and are responsible for complaints of
referred pain
to the shoulder area.
Biliary system pain:
Gallbladder and biliary tract spasms can cause pain
that radiates
to the right shoulder and subscapular area.
Inflammation of the
gallbladder wall can cause localized subcostal pain
and rebound
tenderness.
Intestinal pain:
Most acute or chronic abdominal pain is bowel
related. Right upper
quadrant pain is frequently due to large bowel
distention (hepatic
flexure area) and small bowel ileus producing spasms
and/or cramps.
Pain in the left upper quadrant can also be caused
by distention of
the colon in the splenic flexure area. Lower
abdominal pain would
be more likely caused by bladder or rectal problems.
Liver pain:
Liver pain (right upper quadrant) is due to the
distention of the
liver capsule which has pain receptors. Rapid
increases in liver
size from inflammation (viral hepatitis or alcohol
induced) or a
tumor are the most common causes of liver pain. When
the liver
becomes cirrhotic, specific liver pain is rarely the
cause of right
upper quadrant complaints.
Pancreatic pain:
In viral or alcohol induced liver disease, the
pancreas may become
inflamed, stimulating somatic nerve endings, causing
severe pain
that radiates to lateral quadrants, back and left
shoulder, going
through the back. It is made worse by lying down and
improved when
in the knee chest position or bending forward.
Splenic pain:
Splenomegaly or infarction of the spleen may be
present with liver
disease. Pain complaints will be most likely right
upper quadrant.
Pain in acute or chronic liver disease may be
difficult to manage
due to the excretion of many analgesics by the liver
and/or
kidneys. Reduced dosages, and careful monitoring of
hematological
and neurological function is critical to prevent
accumulation and
toxicity. Acute or chronic hepatic failure may lower
plasma
clearance of opiates such as Morphine, prolong the
terminal
elimination half-life, and increase oral
bioavailability
(Hasselstrom, Eriksson, Persson, Rane, Svensson, and
Sawa, 1990).
Non- opiate analgesics are often contraindicated in
patients with
hepatic or renal dysfunction. Acute pain in the face
of chronic
disease needs prompt investigation, to rule out
ulcer,
gastrointestinal bleeding, thrombosis of the portal
system or
spleen, presence of tumor or development of
inflammation or
infection.
Warnings for all
those who have Hepatitis
|
|
IBUPROFEN WARNING
Dr. Thomas Riley III, the medical director
for the liver transplant program at the
Milton S. Hershey Medical Center at the Penn
State Geinsinger Health System ways that
patients with chronic hepatitis C experience
a 10-fold rise in their enzymes after taking
ibuprofen, suggesting significant liver
injury.
He added that if too much medication is
taken the patient risks speeding up the
process of going from chronic hepatitis to
cirrhosis of the liver.
Dr. Riley has an article in the September
issue of the American Journal of
Gastroenterology.
IBUPROFEN-INDUCED
HEPATOTOXICITY IN PATIENTS WITH CHRONIC
HEPATITIS C
Hepatitis C is a common chronic infection.
Nonsteroidal anti-inflammatory drugs are
commonly ingested both over-the-counter and
by prescription. This case report describes
three cases where ibuprofen use leads to a
marked rise in hepatitic transaminases with
one case repeating on rechallenge. These
cases support the recommendation of
acetaminophen over Nonsteroidal
anti-inflammatory drug use in patients with
chronic hepatitis C.
AUTHOR: Riley TR 3rd, Smith JP, Penn State
Geisinger Health System, The Milton S.
Hershey Medical Center, The Pennsylvania
State University, Department of Medicine,
Hershey 17033-0850, USA SOURCE: Am J
Gastroenterol 1998 Sep; 93(9) 1563-1565
PREVENTIVE CARE IN CHRONIC LIVER DISEASE
J Gen Intern Med 1999 Nov, 14 (11): 699-704
Preventive Care in Chronic Liver Disease
Riley TR, Smith JP
Objective: To identify preventive care
measures that are appropriate for and
specific to patients with chronic liver
disease and to provide recommendations and
information that can be shared with
patients. Measurements: A review of the
literature was undertaken using MEDLINE from
1970 to present. Priority was given to
randomized controlled studies, but case
reports, case-control studies, and reviews
were included. Main Results: Evidence for
the avoidance of alcohol and other toxic
substances, immunizations, and dietary
modifications for chronic liver disease is
summarized. In addition, measures that are
effective in the mitigation of the
complications of cirrhosis are reviewed.
Conclusions: Preventive care can play an
important role in patients with chronic
liver diseases. Based on the existing date,
the preventive strategies of Alcohol
avoidance, Hepatitis vaccination, Avoidance
of NSAIDs (nonsteroidal anti-inflammatory
drugs), iron supplementation when
appropriate, and a low-fat diet are prudent
in patients with chronic liver disease. Once
cirrhosis develops, screening for
hepatocellular cancer with alpha-fetoprotein
testing and ultrasound, and screening for
varices by endoscopy are justified.
IT'S NOT
ALL IN YOUR HEAD!
Some doctors (but
thankfully fewer than there used to be)
insist on believing that HCV usually has no
symptoms, and dismiss the patient's
complaints as being "all in their head".
Some HCV+ patients have been treated for
depression for many years before their
actual diagnosis of HCV was uncovered.
Much is still unknown
about the hepatitis C virus, and many
physicians have not had much experience
treating it. Many doctors are not yet
familiar with the research which legitimizes
the various symptoms which go along with
this virus.
Emerging illnesses such as
HCV typically go through a period of many
years before they are accepted by the
medical community, and during that interim
time patients who have these new, unproven
symptoms are all too often dismissed as
being "psychiatric cases". This has been the
experience with HCV as well.
WHAT IS THE EVOLUTION
OF THE DISEASE?
Three out of four people
infected with hepatitis C - not 50%, as once
thought - will remain infected for life. Up
to half of those people will develop
cirrhosis, scarring of the liver, and up to
10,000 will die this year, say doctors and
disease trackers meeting in San Diego. The
latest findings are sobering because about
1.4% of the U.S. population is infected with
the virus
- "Hepatitis C Chronic 75%
of the Time", USA Today, 05-15-1995
---
At least 50-80% of people
infected with HCV will develop chronic
hepatitis; ultimately, 20-30% of those will
progress to cirrhosis. Another 20-30% may
develop chronic HCV infection without
abnormal elevations of liver enzymes in the
blood. - "Prevention, Diagnosis, and
Management of Viral Hepatitis", AMA
WHAT OTHER MEDICAL
PROBLEMS CAN BE RELATED TO HCV?
Chronic hepatitis C
infection occasionally causes problems for
parts of the body beyond the liver. The
organs most often affected include the blood
vessels, skin, joints, kidneys, and thyroid
gland. If chronic hepatitis C infection
causes liver cirrhosis (severe scarring of
the liver rarely caused by hepatitis C),
many problems may arise from the cirrhosis,
per se.
Potential problems from
cirrhosis include fluid accumulation in the
abdomen, bleeding into the stomach,
jaundice, confusion, poor blood clotting,
and susceptibility to infection.
---
Hepatitis has so many
symptoms that it's easy to ascribe all new
anomalies to this disease. But HCV patients
are not exempt from getting other illnesses
also, therefore it is important to regularly
monitor your health and to consult with your
doctor about the changes as they progress.
CRYOGLOBULINEMIA
One-third to one-half of
people with chronic hepatitis C infection
have cryoglobulinemia (antibodies in the
bloodstream attached to the hepatitis C RNA
that happen to solidify when cold).
Hepatitis C is recognized as the most common
cause of mixed cryoglobulinemia. Most of the
people with cryoglobulinemia from hepatitis
C have had their hepatitis for a long time
or have cirrhosis. People with higher
concentrations of hepatitis C RNA in their
blood do not seem to have a higher risk of
having cryoglobulinemia. Usually the
cryoglobulins are in low concentration and
cause no symptoms. About twenty-percent of
people with hepatitis C and cryoglobulinemia
have symptoms.
Symptoms most often
associated with cryoglobulinemia include
mild fatigue, joint pains, or itching.
Occasionally, people with cryoglobulinemia
develop vasculitis (inflammation of the
blood vessels) which can cause purpura
(purple skin lesions), Raynaud's phenomenon
(the hands turn white, then blue, and then
red from constriction and subsequent
dilation of the blood vessels), or numbness
in the hands and feet. The presence of
cryoglobulinemia does not effect people's
response to interferon. In fact, some people
with vasculitis have improvement in the
vasculitis as their liver tests improve on
interferon.
THYROID AND
AUTOIMMUNE PROBLEMS
Chronic hepatitis C
infection is also associated with many
autoimmune diseases (where the body develops
antibodies which attack parts of itself).
For example, about one-tenth of people with
chronic hepatitis C infection (more often in
women and older people) have antibodies to
the thyroid gland, one-half of whom may
develop hypothyroidism (an underactive
thyroid gland).
Additionally, interferon
therapy causes hypothyroidism or
hyperthyroidism (an overactive thyroid
gland) in about one-tenth of those treated.
People with hypothyroidism may suffer from
fatigue poor memory, weakness, constipation,
weight gain, muscle cramps, intolerance to
cold, hoarse voice, coarse skin, and brittle
hair. People with hyperthyroidism may suffer
from anxiety, insomnia, weakness, diarrhea,
weight loss, intolerance to heat,
velvet-like skin, and brittle nails.
Hypothyroidism can be treated with thyroid
hormone pills. Hyperthyroidism can be
treated with pills that block thyroid
hormone synthesis. If the thyroid gland
dysfunction is from interferon treatment and
is caught early, the thyroid gland will
return to normal once interferon is stopped.
RHEUMATOID
ARTHRITIS-LIKE SYMPTOMS
Hepatitis C infection can
present with rheumatic manifestations
indistinguishable from rheumatoid arthritis.
The predominant clinical findings include
palmar tenosynovitis: small joint synovitis,
and carpal tunnel syndrome. Risk factors
such as transfusions and IV drug abuse or a
history of hepatitis or jaundice should be
included in the history of present illness
of any patient with acute
or chronic polyarthritis or unexplained
positive RF. In such patients, gammaglutamyl
aminotransferase, serologic studies for
hepatitis C, and other tests appropriate for
chronic liver disease should be performed. -
" Journal of Rheumatology, June
1996;23(6):979-983.
FIBROMYALGIA
Fibromyalgia is the name
for a condition that typically includes
widespread muscle pain, fatigue and abnormal
sleep patterns. Until a few years ago,
doctors called the condition fibrositis or
muscular rheumatism and believed that for
the most part, the condition was "all in the
patient's head". Today, fibromyalgia is
recognized by medical organizations as a
genuine and serious problem.
The symptoms of
fibromyalgia typically include pain in many
muscles, and around ligaments and tendons,
persistent fatigue, waking up feeling tired
even after a full night's sleep, headaches,
bouts of constipation and diarrhea,
abdominal pain, painful menstrual periods,
sensitivity to cold, numbness or tingling,
and difficulty exercising.
Symptoms vary widely among
patients and tend to wax and wane over time.
An illness, injury, cold weather or
emotional stress may trigger a fibromyalgia
episode or make ongoing symptoms worse.
A study at the Oregon
Health Sciences University and Portland
Adventist Hospital suggests hepatitis C may
trigger fibromyalgia ("Fibromyalgia: A
prominent feature in patients with
musculoskeletal problems in chronic
hepatitis C, A report of 12 patients," by A.
Barkhuizen,
G.S. Schoepflin, and R.M. Bennett, Journal
of Clinical Rheumatology, Vol. 2, No. 4,
August 1996) .
This study is the first to
show a link between the two illnesses.It was
determined that the between the hepatitis C
virus and fibromyalgia followed three
distinct patterns:In nine patients,
fibromyalgia developed as a long-term
complication of the hepatitis, arising on
average 13.4 years after the virus was
acquired.In two patients, fibromyalgia arose
simultaneously with the hepatitis C
infection.In one patient, pre-existing
fibromyalgia was significantly worsened by
the hepatitis C.
It is unknown why the hepatitis C virus and
fibromyalgia may be linked, but the authors
suggest that hepatitis C causes chronic
activation of the immune system that leads
to muscle aching, fatigue, mental changes,
sleep abnormalities, and alterations of the
neuroendocrine system.The patients with both
hepatitis C and fibromyalgia could be
distinguished from most other patients with
fibromyalgia alone because they had symptoms
unusual to fibromyalgia. These symptoms
included synovitis (inflammation of the
membrane around a joint, bursa, or tendon)
and vasculitis (inflammation of a blood or
lymph vessel). In addition, laboratory
findings pointed to a disease process other
than fibromyalgia.
DERMATOLOGICAL
MANIFESTATIONS
The main dermatologic
disorders in HCV infection include (1)
vasculitis (mainly cryoglobulin-associated
vasculitis, the cause of which is HCV in
most cases, and, possibly, some cases of
polyarteritis nodosa); (2) sporadic
porphyria cutanea tarda; (3) cutaneous
and/or mucosal lichen planus; and (4)
salivary gland lesions, characterized by
lymphocytic capillaritis, sometimes
associated with lymphocytic sialadenitis
resembling that of Sjoegren's syndrome.
Hepatitis C virus is the
cause of, or is associated with, various
dermatologic disorders. In patients with
such disorders, HCV infection must be sought
routinely because antiviral therapy may be
beneficial in some of them. - Arch Dermatol.
1995; 131:1185-1193
PORPHYRIA CUTANEA
TARDA (PCT)
Porphyrins are a group of
compounds that are mainly synthesized in the
bone marrow. They play an important role in
many chemical reactions in the body, e.g.
with proteins to build hemoglobin. They are
later converted to bile pigments mainly in
the liver. Porphyrinuria increase of
porphyrins in theurine) may be caused by
chronic liver diseases. Hepatitis C is a
major cause of porphyria throughout the
world and may cause many symptoms, including
excess blood iron - important in conjunction
with an interferon therapy (since elevated
blood iron seems to reduce the effect of
interferon).
Porphyria cutanea tarda is
a rare deficiency of a liver enzyme
essential for cellular metabolism. The
enzyme deficiency may cause sun exposed skin
to blister, ulcerate, turn dark, or bruise.
Hair may increase on the forehead, cheeks,
or forearms, and the urine may turn pink or
brown. It now appears that hepatitis C is
the most common trigger of porphyria in
people who are predisposed. Topical
sunscreens do not prevent the skin lesions.
Avoidance of alcohol and removal of iron by
repeated phlebotomy (blood removal) or
taking medication that binds to iron
sometimes helps. Chloroquine (an
anti-malaria drug), which removes a toxic
by-product of the enzyme deficiency, may
help, as well.
LICHEN PLANUS
Occasionally, people with
chronic hepatitis C develop a skin condition
called lichen planus. It is a grouping of
small, itchy, irregular, flat-topped
reddened bumps. The bumps often have a
network of very fine gray lines on their
tops. The bumps show up most often on the
wrists, shins, lower back, or genitals.
Lichen planus also frequently occurs in the
mouth, where it looks like a white, net-like
plaque. It sometimes shows up as mouth
ulcers and can be treated with a steroid
mouth rinse called Dexamethasone Elixir or
Nystatin tablets.
CYCLES AND FLAREUPS
Hepatitis flareups tend to
occur in cycles, where for a while you may
feel pretty good, then bad (maybe days to
weeks for each period), then good again.
It can be frustrating to
obtain some relief, but then not know
whether you have recovered or if you are
merely between cycles.
Some people claim that
they begin to feel better in the Spring,
then start to feel worse again in
August/September, with a low point usually
around November/December.
Sleep and Hepatitis
C
Ian Campsall, MA
"If hepatitis C makes me feel
so tired, surely sleeping more would help,
wouldn’t it?" How many persons with
hepatitis C have asked themselves this
question, and how many have come to the
conclusion that no matter how much
they sleep, they just can’t sleep
enough—that sleep, itself, doesn’t seem to
work?
There has been little if any
research done on the question of the effects
of hepatitis C on sleep, and, as a result,
patients and doctors must grapple with the
problem without the benefit of solid data.
Sleep, itself, is not fully understood, and,
while advances are being made in the
diagnosis and treatment of hepatitis C,
there is still much that remains to be
discovered. The result, as with many issues
and symptoms related to hepatitis C, is that
patients are faced with a confusing and
frustrating set of symptoms on which medical
science can currently shed little light.
However, it is possible to bring some
greater measure of clarity to the subject by
examining the facts concerning sleep, and by
relating the experiences of persons with
hepatitis C in that context.
Sleep is, quite simply, as
fundamental to life as water, air, or food.
In the first stage of sleep the muscles
relax and the brain waves become irregular
and rapid; in the second stage the brain
waves grow in size and are accompanied by
bursts of electrical activity. During the
third and fourth stages, deep sleep,
characterized by large slow waves, occurs.
Approximately an hour later dream state, or
REM (rapid eye movement), sleep begins. Your
eyes are in constant motion, and your brain
waves are almost the same as when you are
awake. REM sleep may comprise only 25% of
the total hours we spend sleeping, but it is
vital to feeling well-rested and alert.
When a disruption in a
person’s sleep pattern or rhythm occurs, he
or she may experience an inability to
concentrate or focus, irritability or
moodiness, loss of energy or fatigue, and a
general decline in quality of life—symptoms
surprisingly similar to those produced by
hepatitis C itself. Sleep related problems
have reached epidemic proportions in North
America. A recent Gallup Poll found that one
in two Americans suffers from sleeplessness
or insomnia at some point in their lives,
and, furthermore, that 30-40 million
Americans are afflicted with serious sleep
disorders.
For the person living with
hepatitis C the situation is further
complicated by the fact that they are
already coping with an illness that has
serious physical and psychological
consequences, both of which have
repercussions on a person’s ability to rest.
The interrelated array of systems that
regulate sleep are affected by the damage
inflicted by hepatitis C to the body, and
the trauma wreaked on the mind by the fear,
frustration, and stress of having to cope
with the disease. As one hepatitis C
sufferer stated, "I can’t tell if I am
exhausted, or sick, or just sleep-deprived
and crazy. [Sleeplessness] has interfered in
an EXTREME manner with my ability to work. I
do not remember the feeling of being totally
rested, and energetic."
People with hepatitis C
suffer from the same sleep disorders as
anyone else, but the combination of general
stress and the mayhem caused throughout the
body by the hepatitis virus seems to make
the symptoms more erratic and disruptive.
Reported symptoms include constantly having
to get up to urinate, being unable to sleep
for more than an hour, sudden violent
awakenings without any apparent cause,
feeling extremely hyper, and sleep terrors.
Not surprisingly, many people also find that
the pain caused by hepatitis C makes falling
asleep difficult. One man found that his
liver was so swollen that he was unable to
sleep on his left side. However, the most
common sleep symptom reported is not feeling
rested or refreshed in the morning, but,
rather, feeling even more exhausted than
before going to bed.
Sleep apnea is one of the
most common sleep disorders and affects
nearly 10 million Americans. Persons who
have this disorder experience a temporary
stoppage of breath that may last up to ten
seconds and causes the person to awaken
briefly as he or she gasps for breath.
Many hepatitis C patients
suffer from sleep apnea; however, as it is
also related to age and weight, apnea is
most likely more closely linked to
peripheral symptoms of hepatitis C, such as
weight gain, than the disease itself. A
device known as a CPAP (continuous positive
airway pressure) can be placed in the mouth
before sleep to prevent the airway from
closing and allow the patient to sleep
normally.
Another disorder that many
hepatitis C patients have to contend with is
restless legs syndrome (RLS), which is
characterized by an urge to move the legs in
order to relieve uncomfortable sensations
that are often described as a creeping or
crawling, or tingling, cramping, burning or
just pain. Some patients have no definite
sensation other than the need to move their
legs. RLS is an often reported incident on
many of the hepatitis C internet chat and
support groups, and has been in quite a few
cases the symptom that led to the diagnosis
of hepatitis C. Several studies have linked
RLS with the neurological complications
associated with hepatitis C virus infection,
either directly or through hepatitis C
related fibromyalgia, as well as with nerve
damage in the legs due to diabetes, kidney
problems or alcoholism. RLS can also be the
result of a pinched nerve root caused by
arthritis in the lower back. Most cases of
RLS respond well to medical treatment.
Other symptoms of RLS
include: a need to move the legs to relieve
the discomfort by stretching, bending,
rubbing the legs, tossing and turning in
bed, or getting up and pacing the floor. The
discomfort increases when lying down,
especially while trying to fall asleep or
during other forms of inactivity, but is at
its worst late in the day and at night.
Various drugs have been used
successfully in the treatment of RLS:
benzodiazepines, the L-Dopa family, and, in
serious cases, opiates and methadone.
However, as some of these drugs can be
harmful to the liver, make sure that your
doctor is aware or your medical condition
when discussing possible forms of treatment.
The use of melatonin
to relieve sleep disorders has become
something of a recent fad, and has received
a great deal of coverage and hype from the
media, but scientists remain sceptical about
its current status as a "wonder drug." The
exact nature of how melatonin affects how
sleepy we feel is not yet clear, but it has
been proven that it is effective in quickly
relieving jet lag. However, as so little is
known about its function in sleep, and as it
has been linked to autoimmune hepatitis,
melatonin remains a drug that should be
monitored for further developments and
studies.
Recently, however, scientists
have shown that another natural substance,
jasmine, is quite effective in
inducing sleep. According to Reuters,
"researchers found that when people slept in
a jasmine-infused space, they moved less
during the night. Although people slept the
same amount each night, jasmine-smellers
reported feeling less anxiety when they woke
up." The study also showed that lavender as
well "appeared to help with sleep and later
awareness . . . but its benefits were not as
noticeable as those seen with jasmine."
The most effective strategy
for maximizing energy levels and minimizing
sleep related problems is establishing a
consistent sleep schedule. The importance of
being consistent is evident in the fact that
many people living with hepatitis C have
reported that getting up so much as five
minutes too early can leave them feeling
fatigued for several days afterwards. That
is not to say that you should be a prisoner
of your schedule. Design your day to allow
as much flexibility as possible, while still
allowing time to rest, and make sure that
you get to bed ON TIME. Be open and frank
about the importance of being consistent
with friends, family, and co-workers to
avoid misunderstandings.
Furthermore, eat a
nutritional diet including a variety of
vegetables, fruit, and fibre-rich
carbohydrates. Try to avoid animal proteins
(especially those high in fat), and foods
that are high in saturated fat and sugar.
Maintain a regular exercise regimen, but do
not exercise just before bed. Drink at least
eight full glasses of water daily. Your
doctor can recommend vitamins that you can
take on a regular basis including
multi-vitamins and minerals without iron,
such as vitamin E (400-800 IU), selenium
(100-200mcg), omega (fish) oil (1000mg).
However, never take high doses of
supplements. Tobacco, street drugs, and
alcohol are all linked to many sleep
disorders and should be avoided.
There is one final
recommendation. Laugh. Research conducted by
William Fry, M.D., a professor emeritus in
psychiatry at Stanford University Medical
School, has demonstrated that laughter
stimulates the immune system. Spend time
doing things that you enjoy, and that give
you pleasure. Remember, nothing will help
you fall asleep faster than knowing that you
have accomplished something with your day,
and feeling that you are an active
contributor to the community in which you
live.
The following organizations
offer support and advocacy services:
Copyright January 2003 – Hepatitis C Support
Project – All Rights Reserved. Permission to
reprint is granted and encouraged with
credit to the Hepatitis C Support Project
Visit our web site at
www.hcvadvocate.org
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Please see our
Related Conditions
pages for more information on symptoms
related to HCV. |
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Reviewed May 1 2004 |
