Comprehensive list of all hepatitis c symptoms

[Guest guest]

Comprehensive list of all hepatitis c symptoms

Hepatitis C Symptoms

Janis and FriendsHepatitis 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:Flu-like illnessIndigestion -

gastrointestinal reflux disorderIrritable Bowel syndromeMuscle and joint painMyalgia is muscle pain or achingNight sweatsDepression, mood swingsFatigue - mild to severeAbdominal bloatingDiarrheaHeadachesNumbness in extremitiesMental confusion / 'brain fogItchy skinDizziness & peripheral vision problemsLiver painCognitive dysfunctionShortness of BreathLoss of appetiteVisual ChangesChest PainsChills FeverFacial PuffinessFemale Problems (irregular menses, severe PMS)PalpitationsYellowing of the Skin JaundiceLoss of LibidoSpider NeviSwelling of the lymph nodesOther 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).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.SIGNS AND SYMPTOMS THAT MAY BE ASSOCIATED WITH HEPATITIS C(Tina M. St. , 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.Fatigue and sleep disturbancesFatigue can be described as a sense of excessive tiredness and lack of energy. Many people with hepatitis C will experience fatigue at some stage. Fatigue can impact on work, family relations and other activities. It can cause you to be withdrawn, moody, cranky and irritable, have outbursts of anger and a lack of energy or feelings of physical weakness. A good night’s rest will not always help you overcome fatigue. Fatigue may also be linked to other factors, such as

depression.Problems with sleeping vary widely for people who have hepatitis C and can include difficulty falling asleep, waking up a lot or sleeping excessive amounts. Sleep disturbances are common among the general population and it is often difficult to work out what impact hepatitis C is having on a person’s sleeping patterns. Sleep problems have an impact on a person’s quality of life and can exacerbate other symptoms of hepatitis C, especially fatigue.General lifestyle practices can impact on fatigue and sleeping patterns:eat a well-balanced diet.drink alcohol in moderation or not at all and stop or reduce smoking.do regular moderate exercise.Making adjustments to your day-to-day life may support you to manage fatigue. Have realistic expectations of yourself and what you are able to do. Don’t beat yourself up over feeling tired and lethargic:plan the day’s activities around times that tiredness and

fatigue normally appear. When energy is higher complete extra tasks (e.g. cook food in batches and freeze to eat later);sit down to iron clothes or shower, so you don’t have to support yourself;use equipment that helps you conserve energy. For example, use a washing trolley instead of carrying the washing to the line;pace yourself during the day and allow yourself regular breaks; andtake short naps during the day. However, be aware that excessive sleep can cause people to feel more tired and may cause sleep difficulties at night.Practices that may help manage sleeping difficulties include:set specific sleep times to try to regulate your body clock;allow enough time for eight hours sleep each day. Eight hours sleep is generally enough for an adult, although individual needs will vary;establish a bedtime routine that you do most nights before bed. This may involve washing your face, having a warm drink and

reading a book or magazine;avoid exercising just before sleeping;minimise caffeine intake (such as in coffee and cola drinks) in the afternoon, particularly if sleep is difficult;jasmine tea, camomile tea, lavender scent and warm milk may help to relax people and assist with sleep; and occasional use of sleeping sedatives may provide some relief. Consult your doctor before using sleeping sedatives.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.People with hepatitis C may experience muscle and joint pain. Common sites of joint pain are the hips, knees, fingers, and spine, although any joint can be a source of pain. Pain associated with hepatitis C can move around and come and go. Aches and pains in the muscles are usually experienced as a generalised feeling. However, some people report having pain in only one area of the body.It is generally considered acceptable to take anti-inflammatory medication for muscle and joint pain (following the instructions on the packet). However, you should first consult your doctor about the use of anti-inflammatory drugs.Some people find mild physical activity can help manage muscle and joint pain. Mild physical activity increases blood flow to joints and muscles and can reduce stiffness. Heat packs on the sore area, warm baths and massage may also provide temporary

relief.Some people find benefit in complementary and alternative therapies, such as herbal products or massage. It is best to be advised by a qualified complementary/alternative professional about any therapies or products that could be useful. If you pursue complementary and alternative therapies it is important that you tell your liver specialist and GP of any therapies that you have recently used, are using, or plan to use.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:Insomnia 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 SymptomsAbdominal 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 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 SymptomsCognitive 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

timeIf 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.Blood Sugar AbnormalitiesHepatitis 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.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.Symptoms of Acute Viral HepatitisGeneral 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 HepatitisSymptoms 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 EditorsHarvey Simon, M.D., Editor-in-ChiefMassachusetts Institute of Technology; Physician, Massachusetts General HospitalMasha J. Etkin, M.D., GynecologyHarvard Medical School; Physician, Massachusetts General Hospital E. Godine, M.D., Ph.D., MetabolismHarvard Medical School; Associate Physician, Massachusetts General Hospital Heller, M.D., PediatricsHarvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's HospitalIrene Kuter, M.D., D. Phil., OncologyHarvard Medical School; Assistant Physician, Massachusetts General Hospital C.

Shellito, M.D., SurgeryHarvard Medical School; Associate Visiting Surgeon, Massachusetts General HospitalTheodore A. Stern, M.D., PsychiatryHarvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General HospitalCarol Peckham, Editorial Director Chevins, Publisher--------------------------------------------------------------------------------Hepatitis C and women Hepatitis C can affect women differently from men -http://www.hepcvic.org.au/pdf/Women.pdf Possibly due to the effects of hormones.Women with hepatitis C thinking about using hormonetreatment or any related medications should discusspossible complications with their doctor. There is noevidence that hepatitis C adversely affects pregnantwomen, or her unborn child but there is a low risk oftransmission from mother to baby during birth.Hormonal effectsHormones are chemicals that play a role in themenstrual cycle, reproduction, sexual desire, and inkeeping the body healthy. Hepatitis C may causemenstrual irregularities, particularly if a woman hassevere liver disease as the liver plays a role inregulating hormones.Hormone Replacement TherapyIf women have severe liver

disease they will needto discuss with their doctor or specialist whetherhormones should be used for menopausal symptoms.In some cases, doctors may recommend externalvaginal creams and skin patches rather than pills.Birth controlSome women tolerate the oral contraceptive pill,while others don’t. The same applies for women withhepatitis C. If women are experiencing severe liverdisease, they may not be able to tolerate oestrogenhormones present in oestrogen-based contraceptivepills (the most common pill).In these cases, the progesterone-only pill(‘mini pill’) or Depo-Provera(3 monthly injection) may be preferable. In any case,women with hepatitis C should consult a gynaecologistor women's health specialist to see which birth controlmethods are most suitable for them.Pregnancy and hepatitis CHepatitis C does not affect the ability of women tobecome pregnant.

Women with advanced liver diseasemay want to consult a specialist for more information.The overall risk of transmitting hepatitis C to your babywhile pregnant or during delivery is less than 5%.Women with very low levels of the virus are thoughtto be less likely to transmit hepatitis C to their babies.For women infected with both HIV and hepatitis C, therisk of transmission is higher with transmission ratesof 16% being found.It’s not clear when transmission from mother to babyhappens. Most research indicates that transmissionoccurs during delivery, as hepatitis C cannot crossfrom the mother’s bloodstream into the baby’s blood -stream. However, some studies indicate that trans -mission can occur during pregnancy and is usuallyrelated to invasive procedures such as amniocentesis.Hepatitis C transmission rates are similar for caesareansection and vaginal births. In the

absence of conclusiveresearch about the timing of transmission, it is importantto note that caesarean section is not recommendedas the preferred mode of delivery. The use of forcepsand scalp electrodes should be avoided duringdelivery (if clinically appropriate) as they can breakthe baby’s skin.All babies born to women who have hepatitis C willtest hepatitis C antibody positive at birth because theyinherit their mother’s antibodies. By 18 months, around95% of babies will have cleared their mother’s anti -bodies and test negative for hepatitis C.Women and hepatitis C treatmentCurrent conventional treatment of hepatitis C consistsof two drugs named ‘pegylated interferon’ and‘ribavirin’, called combination therapy. You cannotbegin combination therapy if you are pregnant, likely tobecome pregnant or breastfeeding, because ribavirincan cause severe birth defects.

The effect of interferonon the foetus is unknown. If you are on pegylatedinterferon and ribavirin combination therapy, bothpartners are required to use effective contraceptionso that pregnancy does not occur during, or for sixmonths after treatment has finished.Side effects of interferon can include temporary hairloss and changes in weight – with weight loss beingmore common. Occasionally, auto-immune effectsoccur and those involving thyroid abnormalities tend tobe more common in women, probably because womenmore commonly experience thyroid disease. Recurrentyeast infections have also been reported and attentionto diet can help in this regard.Research has shown that people with high iron levelsdo not respond as favourably to interferon treatment.Some research has shown that women respond betterto treatment than men, possibly because menstruationreduces iron levels.

However, ribavirin has beenassociated with anaemia (low red blood cell count),which affects women more than men. During treatmentyour blood count will be monitored and the dosage ofribavirin adjusted if necessary.If you have started combination therapy for hepatitis Cand believe you may be pregnant, you need to see yourdoctor immediately and let them know. If pregnancyis confirmed, your doctor and/or specialist candiscuss options with you about your pregnancy andtreatment options.Breastfeeding and hepatitis CThe choice to breastfeed is very personal and for mostwomen, breastfeeding is an important and enjoyablepart of being a mother. Hepatitis C has been found inbreast milk – but not in sufficient quantities to transmitthe virus.There is no medical reason for mothers withhepatitis C not to breastfeed their child.If the mother has cracked or bleeding nipples,

andif the infant has cuts or sores on, in or around themouth, the risk of hepatitis C transmission increases.It is recommend that if you have cracked or bleedingnipples to discard the milk from that breast or avoidbreastfeeding until the breast and nipples are healed.To learn more about breastfeeding positions andtechniques that may help to prevent cracked orbleeding nipples, consult a lactation consultant or mid -wife at a maternity hospital or women’s health centreHow does hepatitis C affect children?It is not believed that hepatitis C physically affectschildren any differently from adults or that the naturalprogression of the illness is significantly different.As with adults, children may not experience symptomsof hepatitis C for 10 – 15 years. It is, however,recommended that children with hepatitis C have theirliver monitored regularly as a precaution to check forthe

possibility of any signs of early liver disease.Testing and treatment options for childrenFor those parents who want to know whether or nottheir baby has contracted hepatitis C, an antibody testcan be carried out after 18 months of age. Alternatively,a PCR test could be done at 4-6 weeks with follow-uptesting if necessary. Babies who contract hepatitis C atbirth have a 25% chance of spontaneously clearing thevirus (same as adults who contract hepatitis C) throughtheir own immune response.Treatment for hepatitis C is rarely needed or offered tochildren. Presently, there is limited research into treat -ment for children and inadequate evidence to providegeneral guidelines for their treatment. However, wherethere is evidence of progressive liver disease or fibrosisin children then treatment may be considered an option.The Royal Children Hospital has a specialised unit forchildren

with liver issues.Also seeMenstruating While Pursuing HCV Combination TherapyWeb: http://www.hepatitisaustralia.com/ Available from Hepatitis C This infosheet is intended as a general guide only. It is not intended to replaceexpert or medical advice.Produced by Hepatitis C . Revised June 2009Hepatitis C and WomenWomen with hepatitis C have a number of specialized needs related to their reproductive and sexual health.Women need accurate information to assist them to make informed decisions about their health care needs.1 The impact of hepatitis C on the reproductive and sexual health of women is not well understood and warrants further research.MenstruationMenstrual fluid contains blood and other body fluids. As hepatitis C is transmitted by blood-to blood contact, there is in theory the

possibility of transmitting hepatitis C through contact during menstruation. However, the risk of heterosexual or female-to-female sexual transmission is extremely low and there is no evidence that sex during menstruation increases risk of sexual transmission. In theory, having sex while menstruating can increase the risk of transmitting hepatitis C if your sexual partner has any open cuts, wounds or abrasions. Using dental dams for oral sex, and condoms with male partners will reduce the risk of blood to blood contact.Following standard precautions for infection control will lower the risk of transmitting hepatitis C through menstruation. This includes disposing of used tampons and sanitary pads in hygienic disposal units or in leak proof plastic bags in the general rubbish.Most women’s periods do not change because they have hepatitis C, although some find they miss a period or have shorter periods. It is important to understand that

any change in your menstrual cycle may not be related to having hepatitis C. Any change in a woman’s menstrual cycle should be discussed with a doctor, as it may or may not be related to hepatitis C.Birth controlThe oral contraceptive pill is fine for the vast majority of women with hepatitis C however if you have severe liver disease, you may not be able to tolerate the oestrogen hormones that are in the oral contraceptive pill or in hormone replacement therapy (HRT). This is because the liver may have problems breaking down these hormones. Please consult your doctor for further information on the use of the oral contraceptive pill or HRT.Women with hepatitis C with severe liver damage, or who are experiencing significant symptoms, should discuss the use of the contraceptive pill with their doctor.There are other forms of contraception that can be explored. This includes hormone injections or implants and barrier methods

such as the diaphragm.It is important that all these options are explored with a trusted doctor to find what is best for your situation.MenopauseJust as oestrogen hormones in the oral contraceptive pill can cause problems for women with hepatitis C, hormone replacement therapy (HRT) may also not be well tolerated.The hormonal changes that women with hepatitis C experience as part of menopause are not all associated with the virus—seek the advice of a doctor or an endocrinologist (a hormone specialist) for any problems experienced with menopause and HRT.PregnancyHepatitis C does not reduce the likelihood of a woman becoming pregnant.The risk of hepatitis C transmission from mother to child is low, about 6%. Hepatitis C is more likely to be transmitted during birth than while the baby is inside the mother.Women with low levels of the virus in their blood are unlikely to transmit hepatitis C to their

baby. Women with high levels of the virus, those with serious liver damage or those in the acute phase of infection, have a higher risk of transmitting hepatitis C to their baby.A baby born to a mother with hepatitis C will inherit the mother’s antibodies and test antibody positive until the child is about 15–18 months of age. In most cases, the child’s hepatitis C antibodies naturally disappear after 18 months. Therefore, testing a baby for hepatitis C is not recommended until the baby is older than 2 years. In saying this though, infection can be detected by PCR testing as early as 2–3 weeks. So, if parents are concerned they can ask for this to be done after 4–6 weeks, with follow-up testing if negative. For more information on antibody and PCR testing visit the Know your tests page.Pregnancy is also not considered to cause deterioration of liver disease in women who have hepatitis C.Women with hepatitis C on

treatment (pegylated interferon and ribavirin) are required to use two forms of contraception (one for each partner) to ensure they do not become pregnant during their treatment, and for six months following the end of treatment. This is because pegylated interferon and especially ribavirin can cause birth defects.BreastfeedingThere are no confirmed reports of hepatitis C transmission from mother-to-baby by breast milk. Current scientific opinion remains that there is no significant evidence of HCV transmission through breast-feeding. Scientists have found traces of the virus in breast milk and colostrum (the breast fluid produced by the mother in the first few days of breastfeeding) but not enough to transmit hepatitis C. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists currently recommends that breastfeeding should not be discouraged, as no cases of hepatitis C transmission have been documented by this

route.Damage to the breast such as cracked nipples could pose a possible risk to the baby if blood-to-blood contact occurs through small tears or scratches in or around the baby’s mouth. It is recommended that women with hepatitis C who are breastfeeding should express and discard their breast milk while their nipples are cracked. Treat cracked nipples so they do not bleed and seek help from a breastfeeding counsellor or nurse lactation consultant to discuss ways of preventing cracked nipples.Breast milk supplies a balanced food supply for the baby, as well as protecting the baby from many illnesses especially in the first weeks, however, the final decision whether to breastfeed is entirely up to the mother.References1Gifford, S. M., O’Brien, M. L., Bammer, G., Banwell, C. & Stoove, M. (2003). Australian women’s experiences of living with hepatitis C virus: Results from a cross-sectional survey. Journal of

Gastroenterology and Hepatology, 18, 841–850.SIGNS AND SYMPTOMS OF HEPATITIS C WITH CIRRHOSISApproximately 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 FatigueMost 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.HeadachesSome 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 appetiteSometimes 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 depressionHaving 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 DepressionA 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.Cerebral affect of the hepatitis C virusEvidence 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. " 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. M Forton, of Imperial College School of Medicine, St

'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 2001Q. 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?The liver has no nerves, but the liver is surrounded by a capsule (a bit like a sausage skin). The capsule has nerves in it which are sensitive to stretching and to inflammation and thus some people can occasionally experience pain if the liver becomes enlarged or inflamed. However, there are other causes for pain in that area. The brain is not very good at distinguishing pain from different organs. Liver pain is comparatively rare and usually the pain is actually from the large bowel (colon) as it squeezes bowel contents around (it acts like a wriggling worm and is always active) - thus most of the activity that the brain receives

is from the colon which can "tie itself in figurative knots" sometimes with trapped wind and increased contractions. There are other organs that also lie in close proximity to the liver and could be responsible for discomfort including the gall bladder and the pancreas and the bile ducts. However for the most part the issues are often with the colon, but the liver, even in people without liver disease, can be uncomfortable if the colon is hyperactive.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.Pain or discomfort of the liverPeople with hepatitis C may experience episodes of abdominal pain. Pain or soreness on the right side

just below the ribs could be from the liver.Before attempting to treat pain or discomfort of the liver it is important to discuss symptoms and pain management with your doctor. For some people reducing alcohol consumption to below the levels recommended for the general community or abstaining from alcohol altogether, may bring relief. Using a heat pack over the liver, particularly at night, may also relieve liver pain or discomfort.Pain relief medication, both over-the-counter and on prescription, is generally considered acceptable for temporarily treating liver pain—but there are exceptions. The use of pain medication in people with chronic hepatitis C should first be discussed with your doctor.People who have undergone treatment and are PCR negative six months after treatment ceases should find a noticeable decrease in their symptom. For others, there is usually a decrease in the discomfort after completing

treatment.VISCERAL PAINVisceral 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 PainPain 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 PAINWhen 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 PAINThis 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.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", AMAWHAT

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.CRYOGLOBULINEMIAOne-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 numbnessin 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 PROBLEMSChronic 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.From NATAP http://www.natap.org /Thyroid disease - Thyroid disorders are common in patients with chronic HCV, particularly women [57,58]. One of the largest studies included 630 consecutive patients with HCV (without cirrhosis)

who were compared with 389 subjects from an iodine-deficient area, another control group of 268 persons from an area of iodine sufficiency, and 86 patients with chronic hepatitis B [58]. Mean TSH levels were significantly higher and free T3 and T4 levels significantly lower in patients with HCV than in all other groups. Patients with HCV were more likely than controls to have hypothyroidism (13 versus 3 to 5 percent ), anti-thyroglobulin antibodies (17 versus 9 to 10 percent), and anti-thyroidperoxidase antibodies (21 versus 10 to 13 percent). Another report suggested that thyroid abnormalities were seen predominantly in women [57]. (See "Pathogenesis of Hashimoto's thyroiditis (chronic autoimmune thyroiditis)").Overall, antithyroid antibodies are present in 5 to 17 percent of patients with HCV infection, and thyroid disease, primarily hypothyroidism, occurs in 2 to 13 percent of patients [57,58]. The highest prevalence of both thyroid

antibodies and thyroid disease is found in older women. However, whether or not the prevalence is higher than in age- and sex-matched controls is controversial [59,60].A separate issue is the development of thyroid disease in patients with HCV infection who are treated with interferon alfa. Approximately 1 to 5 percent of such patients develop painless thyroiditis. Other thyroid abnormalities can also occur, including Graves' disease and permanent hypothyroidism, or increased serum antithyroid antibody concentrations without thyroid dysfunction [59-62]. The changes in thyroid function usually appear after three months of therapy, but can occur as long as interferon alfa is given.The risk of any form of thyroid disease is greater in those patients who have increased serum antithyroid antibody concentrations before the initiation of therapy, a finding which suggests that interferon alfa in some way exacerbates underlying thyroid autoimmune

disease. (See "Principles of interferon therapy in liver disease and the induction of autoimmunity", section on Thyroid disease). The presence of antithyroid peroxidase antibodies appears to be the most significant risk factor for the development of thyroid dysfunction during interferon therapy [62]. Other risk factors may include female gender, older age, and the presence of other autoantibodies [60]. Women with chronic hepatitis C and high antithyroid peroxidase antibody titers are at particular risk.Thyroid dysfunction may resolve following the discontinuation of interferon treatment.In summary, all patients receiving interferon alfa should be monitored for thyroid disease, particularly women and patients with preexisting antithyroid antibodies. Interferon therapy usually can be continued while hypothyroidism is being treated. On the other hand, we have usually stopped interferon in patients who develop clinically apparent

hyperthyroidism.MUSCULOSKELETAL- Hepatitis C-associated osteosclerosis is a rare disorder characterized by a marked increase in bone mass during adult life. While most cases have been reported in patients with a history of intravenous drug abuse, it has also been seen with hepatitis C after blood transfusion [85]. Periosteal, endosteal and trabecular bone thickening occurs throughout the skeleton with the exception of the cranium. During active disease, forearm and leg pain are common, bone remodeling (turnover) is high, and bone mineral density is two- to three-fold higher than age-matched norms. The increased remodeling may respond to bisphosphonates or calcitonin, but spontaneous remission has also been described. Abnormalities in insulin-like growth factors (IGF-1 and IGF-II) or their binding proteins may contribute to the increase in bone formation in this disorder

[86].Arthritis is noted in 2 to 20 percent of HCV patients. The arthritis is an evanescent rheumatoid-like picture in two-thirds of the cases and an oligoarthritis in the rest. (See "Specific viruses that cause arthritis").RHEUMATOID ARTHRITIS-LIKE SYMPTOMSHepatitis 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 acuteor 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.FIBROMYALGIAFibromyalgia 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. , 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 MANIFESTATIONSThe 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; 131:1185-1193Necrolytic acral erythema -Necrolytic acral erythema is a pruritic, psoriasis-like skin disease characterized by a sharply marginated, erythematous to hyperpigmented plaques with variable scale and erosion on the lower extremities. In a series of 30 patients who presented with the disorder, all were found to have antibodies

to HCV [81]. Biopsy specimens showed psoriaform changes, keratinocyte necrosis and papillomatosis. Improvement was observed in a patient who had been treated for HCV with interferon alfa (and subsequent relapse nine months after discontinuation). Topical and systemic corticosteroids had a variable benefit. Other reports have confirmed improvementPORPHYRIA 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.Autoimmune idiopathic thrombocytopenic purpura- Anti-HCV antibodies occur in 10 to 19 percent of patients with autoimmune idiopathic thrombocytopenic purpura (ITP). However, the

diagnosis of autoimmune ITP usually predates HCV infection, suggesting that the latter results from the transfusion of blood products [65]. On the other hand, ITP has been reported to develop during interferon therapy for HCV. Thus, the relationship between autoimmune ITP and HCV remains to be clarified.http://www.natap.org/ LICHEN PLANUSOccasionally, 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.Myasthenia gravis -An association between myasthenia gravis (MG) and hepatitis C virus infection has been suggested in case reports [66,67], although a causal association has not been clearly established [68]. MG has also been described in association with administration of interferon, possibly because of exacerbation of preexisting subclinical disease [69,70].http://www.natap.org/OCULAR DISEASE- HCV infection has been associated with a variety ophthalmologic disorders including corneal ulcers (n's ulcer), uveitis, and scleritis [71-73], and sicca syndrome in patients with HCV-related Sjogren's syndrome [74]. In addition, ophthalmologic disorders (retinal hemorrhages, cotton wool spots, and rarely retinal artery or vein obstruction) can occur during

interferon therapy. (See "Administration of combined interferon alfa-2b and ribavirin in the treatment of hepatitis C virus infection").RENAL DISEASE -Glomerular disease may occur in patients with chronic HCV infection. The most common patterns are membranoproliferative glomerulonephritis (usually associated with essential mixed cryoglobulinemia) and, less frequently, membranous nephropathy [75]. Several series have reported that anti-HCV antibodies are nearly universal in patients with both membranoproliferative disease and cryoglobulinemia; the pathogenesis appears to relate to deposition of immune complexes containing anti-HCV and HCV RNA in the glomeruli. (See "Renal disease with hepatitis C virus infection").Interferon alfa is indicated in patients with mixed cryoglobulinemia and membranoproliferative glomerulonephritis. A number of studies have reported a beneficial

response to antiviral therapy in this setting, and the reduction in proteinuria correlates with a fall in HCV RNA [5,75,76]. However, long-term responses to interferon are unusual; maintenance treatment may be required, and renal function is often not improved by treatment.CYCLES AND FLAREUPSHepatitis 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 CIan 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 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:Dr Simon -

Depression in HCVQ Do you know whether hep C related depression is likely to improve after successful combination therapy? I have been clear for almost two years now and have suffered some moderate depressive episodes since. I had hoped they would get better. Maybe I need to give it more time.A For the most part, depression which is directly attributable to the hepatitis C virus is reversible after successful treatment with pegylated interferon and ribavirin. It is very rare for depressive symptoms to continue 2 years after stopping treatment - usually everything has resolved after 6 months. There have been some case reports of persisting depression, but since depression is a problem with many underlying causes (not just hepatitis C), I think you have to be clear that there aren't any other contributory factors. Your GP might want to refer you to a psychiatrist to make

sure nothing has been missed.Q I am experiencing extreme depression six months after my treatment finished. I need to know if my treatment outcome will have been affected by the fact that I have had hepatitis A, B (about 15 years ago) and C, most recently.A The short answer to your question is no, but I shall answer in more detail!The hepatitis A, B and C viruses are all very different in their make-up and their effects on the body. There is evidence that the hepatitis C virus directly affects brain function, although the precise mechanisms for this are still an area of medical research. There is no evidence that the hepatitis B virus affects brain function as it only infects the liver (unlike the hepatitis C virus which can potentially get into all parts of the body as HCV can live in white cells in the blood which then travel to all body tissues). The hepatitis A virus has no lasting effects, since once the body has cleared the

virus, there is no on going action or reaction by the body.Q I've experienced much depression and emotional difficulties over many years. Most probably contracted Hep C around 30 years ago. What baffles me really is: how much of this has been due to the virus affecting my brain?In fact once I was diagnosed 2 years ago it was a kind of relief to know that there was a reason for my difficulties. It may well be impossible to know how much it has affected my brain; it would however be interesting to know that had I not had Hep C would my life have been any different? Also is the damage reversible?A Yes, the virus is significantly associated with depression and a constellation of symptoms which many people like to call "brain fog" including poor memory, lack of concentration and the like. This may be a direct effect of the virus on the brain, but could also in part be related to circulating chemicals which the virus provokes the body

into producing (so called "cytokines").Of course, there are many causes of depression, but hepatitis C is a big player in this. I cannot say whether your life would have been different without the virus, but I suspect so.There is no evidence to suggest that the virus has an irreversible effect on the brain. This is an area of ongoing research with imaging studies of the brain (MRI magnetic resonance imaging) in patients with hepatitis C which we are conducting in the UK and are also being conducted in other countries such as Canada, Spain, Germany and India.Q I have chronic depression and take nusak, an anti depressant, it does seem to help but there are times especially when I am sick when I feel very low. I saw a psychologist here in Cape Town who told me I would have to take them for the rest of my life due to hep c and being in recovery. I hope this isnt the case. I stopped unsuccessful treatment 18 months ago and looking

back at journals I do seem to be better now regarding brain fog but feel as if I've lost 'my spark"A Successful clearance of the virus from the body is the only sure way of stopping or reversing your symptoms. There are new antiviral treatments coming along which may be helpful in the longer term if you haven't been able to clear with pegylated interferon and ribavirin. However, the right dose of an antidepressant can at least restore the chemical imbalance in the brain. Different antidepressants work well in different people and it is a bit of trial and error ("cookery") to find the antidepressant which suits you as an individual - but please remember that most antidepressants do not have an immediate effect and take at least 6 weeks to "kick in" fully.Q As I have cirrhosis and chronic hep C I often wonder whether the symptoms I attribute to 'brain fog' are in fact the first mild stage of encephalopathy, eg - 'Minimal hepatic

encephalopathy - lack of detectable changes in personality or behavior, minimal changes in memory, concentration, intellectual function, and coordination.' Is it possible to tell the difference?I have recently been prescribed amitriptyline as I find it so difficult to sleep and am depressed - is this a good drug? Although I have only been taking it for a week I do not like the side effects although it gives me more sleep.A Actually minimal encephalopathy is quite different from brain fog. The first condition only occurs in people with established cirrhosis of the liver and is due to the fact that the failing liver does not filter out circulating toxins from the gut.In hepatitis C, brain fog occurs without cirrhosis, even in people with minimal or absent liver disease. The liver is perfectly capable of filtering out circulating toxins from the gut, but the symptoms although seemingly similar, are due to the effects of the virus on

the brain (either directly or indirectly, as I have described in other answers.Amitriptyline is a good drug, but it has a series of unacceptable side effects in many patients, including dry mouth and blurred vision. Thus, for the most part, it is not used. It does take about 6 weeks to work.SSRIs such as citalopram do not have these side effects. Mirtazepine is a drug which we use at St 's which does not have these side effects either, but it does have the sedative effect at night to help you sleepQ Do you think there should there be a psychiatrist or psychiatric nurse attached to Hep C departments where anti-depressants are being prescribed to assist alongside treatments?A I agree that psychiatric support is very helpful. In our unit at St s Hospital in Paddington, London, we have a dedicated psychiatric liaison service where patients can be assessed prior to treatment with pegylated interferon and ribavirin and

started on suitable anti-depressants before treatment if they are thought to be at risk or referred over for psychiatric opinions if problems arise during therapy. It is important to have a close relationship with the psychiatric service, but I appreciate that this is not always possible in every centre for various local reasons, which differ in each hospital.Q Before starting treatment on March 1st this year I had severe fatigue, crashing brain fog and feelings of hopelessness and depression. The fatigue would occur soon after getting up and last the whole day. Sleeping in the afternoon seemed to make it worse. After 2 weeks on treatment, I continued to feel very low, and accepted the anti-depressant Citalopram which was offered to me. The first 2 weeks on Citalopram I was desperately anxious, more so than before starting the AD, but I wasnt warned about this. I was told I would feel better within 3 weeks.A Anxiety is a known side

effect of citalopram which occurs in a small percentage of people. It can wear off with time, but often switching anti-depressants is helpful if these symptoms persist. It normally takes up to six weeks for the drug to be fully effective, but most people feel benefit much before that.Q What can you recommend for someone on treatment who will not take anti-depressants or sleeping tablets (neither herbal nor prescribed) because of previous drug use/misuseA I think that it is important to have a good supportive network around you. Many Hep C treatment groups have good liaison with psychiatric services that offer psychotherapy as a non-drug option - it is worth tapping into this in your local area. Different Health Authorities offer different facilities.However, some relaxation treatments are effective (tai-chi, yoga, pilates) as are talking to people in your local hepatitis C support group.Q Six months after a failed 48

wk treatment my depression took me to a critical level a few weeks ago, although I was on the anti-depressant citalopram. After this sad episode my depression is much worse but I am afraid to add any more chemical to my brain for fear of what I may do. Gp has tried me on anxiety Dothiepin for panic attacks but just after two nights I reacted adversely to them and my mood dropped again to crisis point. He now says I should try Mirtazapine, which I am reluctant to do. Do you think I should follow my instinct and allow time to balance my brain chemicals?A Mirtazepine is a good drug which can also help you sleep (as a beneficial side-effect). It isn't addictive. However, I have already addressed the issues of psychotherapy and relaxation techniques. Some people find that acupuncture may help, although I cannot vouch for this (although from personal experience, it cured my painful neck when I had one!).I think you need to give

anti-depressants a fair time to kick in if you do try them - it is at least 6 weeks before they have maximal effect - there is no instant relief from them.Q If the presence of 'genetic sequences of HCV' in post mortem brain tissue is used to validate fatigue/short-term memory loss etc, why should these symptoms persist when SVR has been achieved, as it appears to in many cases? Do you think that the persistence of 'riba-rage' and other symptoms may be related to the creation of neural links, or do you suspect that there may be another cause?A The persistence of symptoms after successful clearance is due to the fact that the brain is slow to respond to change. We believe that the virus causes a population of cells in the brain called microglia to become active and secrete various chemicals which cause the imbalance in the brain which results in the symptoms. We are doing research at the moment with a technique called positron emission

tomography (PET) which can look at the activity of these cells in the brain with a type of brain scan. It would appear from early results from this research and research into other brain conditions that these cells take quite a while to switch off and quieten down - why they remain active and on their guard for a lag phase of several months is really not known at the moment.Q Since finding out about my hep c 10 years ago, I have declined from a confident, out-going, sociable person who has traveled the world to a semi-recluse who spends my time mostly on my own trawling the net finding supposedly liver-friendly products to eat, cosmetics, cleaning products etc, all stuff to keep the strain on my liver to a minimum.We are told we can eat anything in our diets including red meat and dairy products, not too much fat. Although what we eat may not affect the progression of the disease, does it not affect how we feel on a day to day

basis?I love chocolate and cakes etc but am scared to eat them because I have read sugar can act like alcohol on the liver. How much damage would a bar of chocolate do to the liver? This may seem trivial but when you can't drink alcohol, smoke or the other, a bar of choc is like heaven. Is there any research on diet going on at the moment?A Diet is important for liver disease in general. I think there is no harm in eating chocolate cake in moderation. There is some evidence that fish oils have an anti-inflammatory effect in the liver and ingestion of cod liver oil may have a beneficial effect. Professor Margaret Bassendine has just started a major study in Newcastle aimed at looking at the anti-viral effect of fish oils (funded by the British Medical Research Council). Eating fish twice per week is probably just as helpful (oily fish such as mackerel, herrings, sardines, tuna and salmon).Q I'm now 12 months post treatment, which

was successful. However, there are still ongoing problems with bad mood swings and depressive episodes. I didn't use anti-depressants during treatment due to a bad reaction to them in the past and the only medication I take are occasional beta blockers for anxiety. I am concerned about long term brain damage due to the therapy. Is there any evidence of this possibility?A This is an area of ongoing research. There is no evidence of ongoing long term brain damage and for the most part, symptoms do settle in people after 6 months (and up to 12 months). I explained about the microglial cells taking a long time to switch off in a previous answer and it is possible that in different people, the "switch-off" effect takes a longer time - this is an area of active research.There are other causes of depression and you have to be sure that there is no other reason (for example changes in the thyroid gland can cause depression and this can be upset

by interferon treatment - I presume your doctors will have checked this, but it is worth enquiring).Imaging studies on the brain are addressing the issue of longer term damage, but results are yet to be determined (Watch this space)!Q I was wondering if you have an idea why depression associated with hepatitis C comes and goes so much what might be happening in the brain to cause the fluctuations? Do you think it might also have any connection to the immune system fighting the virus, or possibly the inflammation process in the liver, as well as being associated with the virus being in the brain? I find the depression can last for as little as a day or a few days and then other times for many weeks and descend out of the blue. Somehow being able to understand the mechanism, if its possible, helps! I have had hepatitis C for many years and have not had treatment.A The simple answer is that it is not known why this is the case. What

you describe is a very real phenomenon experienced by many.We can postulate that the imbalance in chemicals (neurotransmitters) in the brain is an interplay between chemicals produced by the body in response to the liver and blood infection (circulating cytokines) and the direct effects of the virus on the brain and at any one moment these factors may differ - causing fluctuations which you and many other people experience.This is an area which people are researching actively (including Dr Forton at St 's Hospital in London who pioneered this area of research and Dr Bob Grover at the Hammersmith Hospital in London who is doing the imaging studies). The results of some of these studies will start filtering out in the next 6-12 months and will be posted on this website.Q I suffered terrible depression during the last phase of my treatment (24 weeks inf + riba) but would not take anti-depressants. I am still getting bad

phases of depression though, this week has been awful for me, feeling really down (no reason at all), no urgency to do anything and loss of self interest. My treatment finished on Nov 9th 2006 and I got the all clear, SVR is due on 7th May. I realise that everyone suffers from depression, fatigue, lack of interest at times through their life and it is not a condition of any sort but just life in general.My question is do you think that this sudden depression is due to the after effects of my treatment (as it turns on and off so quickly) or is this normal??A It is not uncommon to get depression after treatment for several months. I have talked about the possible reasons for this in other answers. I think if symptoms persist, you need to be sure that there is no other cause (as I discussed in other answers).With respect to your skin problems, these could make you feel depressed in their own right. I think if they are not healing,

you need to see a dermatologist (skin doctor).With respect to your symptoms compared to other people, your experience is not uncommon, but different people react differently and this is a complex interplay between the type of virus that you have and the genetic make up that you have (which governs the immunological response that your body mounts in order to fight the virus). The battleground is your body and where the various wars take place is individual - this is an area of immunology research. People such as Professor Salim Khakoo in Southampton are working on this question at the moment.Q If, as stated, "Numerous studies have reported associations between chronic hepatitis C virus (HCV) infection and fatigue, depression and impairments in health-related quality of life, which are independent of the severity of liver disease and now the recent detection of HCV genetic sequences in post-mortem brain tissue raises the intriguing

possibility that HCV infection of the central nervous system may be related to the reported neuropsychological symptoms and cognitive impairment.

" Would Dr agree with me that the response by this government and its agencies, such as the Department of Health, the DWP, and Medical Services is a disgrace, and that it amounts to little more than the denial of basic human and statutory rights to sufferers? Would the doctor care to comment on the failure of GPs, consultants, and PCTs to adequately address these issues, and the detrimental influence said negligent failure can have on patients?A Thank you for raising this issue. I agree that there is a big lack of awareness of the effects of the hepatitis C virus on the brain and the poor quality of life that many people endure as a result. This is a problem at Governmental level with respect to the DOH and NHS in general, but also there is poor awareness amongst the medical fraternity (hepatitis C is seen solely as a liver disease, which it is not!).Organisations such as the Hepatitis C Trust are doing their bit to raise awareness and hopefully the involvement of personalities such as Anita Roddick can capture the headlines, as it did with Pamela in the USA.Q I have hep c geno type 1 and have done 48 weeks on treatment with lots of side effects. The virus was

undectable after 12 wks and stayed so until my pcr 6 months after treatment when I was told I was still positive. This news was worse than finding out I had hep c in the first place. I understand this is very difficult to answer, but I was told I must wait for new cure to come on board. I am devastated. Can you please tell me what quality of life I can expect in the mean time? I am a 51 yr old male who works manually hard but right now I dont feel ill just a little tired.A Actually, there are new drug treatments coming along. Professor Geoffrey Dusheiko is a world expert in this field and he is coming to answer your questions on the hepatitis C Trust website next week (May 1st - same time). He can detail the drugs that are around the corner and those that are on the more distant horizon.You don't have to worry - many people with hepatitis C do not ever have any depression. If you just feel a bit tired, there is no reason why you should

suddenly feel depressed, just because of the virus. In some people there is evidence that the virus may never infect the brain (again it is due to specific mutations in the virus and is an area of active research with Professor and Dr Karayiannis at Imperial College in London).I would just have a positive attitude and eat healthily (fish is good as I said before in a previous answer). I would be glad you don't have depression!Q I would like to ask the doctors that my mom (75 years) has been on treatment with pegasys and interferon for close to three months. However, I am very worried about her overall health....she looks drained and always exhausted. She is coughing often with back pains and her facial appearance is not good. I would like to know if these are all side effects of the treatment or should I take her to see the specialist who is treating her. I am worried because I do not want to delay in case

things become complicated. She is seeing a specialist in South Africa as we live in Zambia and there are no facilities here with regard to this disease.A I am not able to answer your question confidently without seeing your mother, but it sounds to me as if she needs to be checked out by a doctor, either locally in Lusaka, Ndola or Livingstone or else going back to see the prescribing physician in South Africa. I would think she needs to be seen by a local Zambian doctor first, to ensure that there is nothing else going on (treatment with pegylated interferon can cause all sorts of issues such as anaemia, thyroid problems and this may be more evident in a 75 year old lady).Q Where can I get info on new treatments, I live in Cape Town where the cost is ridiculous and info is minimal.A The British Liver Trust and the Hepatitis C Trust have reliable websites with validated information on liver disease. However, new treatments are

not always updated on some websites. The Hepatitis C Trust does have a section on new treatments which is regularly updated, particularly after big medical conferences.Professor Dusheiko is coming in to the Hepatitis C Trust next week to talk with you all on new drug treatments - so this should answer most of your questions (May 1st 2007 - same time).Q When my doctor here in Cape Town mentioned brain fog as a possible symptom to expect to experience during my treatment I wasnt sure what to expect...I soon learnt what he meant.! My brain already felt pretty mashed as I'd just done 9 months treatment so it wasnt a great idea to have started so soon in recovery..looking back..I found and still do it really hard to remember anything, conversations, films, names, phone numbers even my own.. my short term memory is mashed and I do think I'm going senile. I have to write everything down so cant go anywhere unless armed with a list. I

find cell food helps, a brain food.. I'm also interested in ibogaine it is supposed to help with viral load and is an anti depressant, Im going to try it as my husband treats addicts using ibogaine and received a load of info on how it helps with hep c...it would be great to get out of the fog! Have you heard anything regarding ibogaine and hep c??A I have replied about the general issues surrounding brain fog in another reply to another question, but ibogaine (which is a plant extract from the root bark of the African plant, Tabenathe iboga) is an unlicensed and unproven treatment in many countries. I know that there has been an American study that has suggested its use in this context as an antiviral agent, but there is no scientific evidence to advocate its use at the moment from proper, large scale clinical trials. While the preparation may work and I have no evidence to say that it doesn't, plant extracts in general (be they ibogaine or

Chinese herbs, for example) have problems in the sense that there is no control over how much active ingredient is in the preparation, nor is there any control over potential impurities that could cause harm. There is a website on ibogaine (www.ibogaine.org and www.ibogaine.co.uk), but I cannot vouch for the validity of what is said on the websites.Q What actually causes the discomfort around the liver area, because the liver itself has no nerves I believe?It can be intermittent; discomfort for several days or weeks then it goes for a while. Could diet have a role to play in this or is it the viral load increasing and decreasing or could it be the bile ducts clogging up in the liver or something?It is hard to put this hep c to the back of the mind while there is a reminder there all of the time (discomfort) saying,' I'm here, I've not gone anywhere, I'm continuing to do damage to your precious liver'. It can have a profound

affect on how you deal with this thing thinking like that, so maybe trying to understand what is happening would help and rather than thinking of it as a time bomb ticking away I could avoid things that would give the discomfort?A You are correct that the body of the liver has no nerves, but the liver is surrounded by a capsule (a bit like a sausage skin). The capsule has nerves in it which are sensitive to stretching and to inflammation and thus some people can occasionally experience pain if the liver becomes enlarged or inflamed. However, there are other causes for pain in that area. The brain is not very good at distinguishing pain from different organs. Liver pain is comparatively rare and usually the pain is actually from the large bowel (colon) as it squeezes bowel contents around (it acts like a wriggling worm and is always active) - thus most of the activity that the brain receives is from the colon which can "tie itself in figurative

knots" sometimes with trapped wind and increased contractions. There are other organs that also lie in close proximity to the liver and could be responsible for discomfort including the gall bladder and the pancreas and the bile ducts. However for the most part the issues are often with the colon, but the liver, even in people without liver disease, can be uncomfortable if the colon is hyperactive.I would not worry about it overly - but it is worth getting your doctor to do an ultrasound if you have not had one as it excludes other things such as gallstones.Q Since some level of depression is inevitable with long term chronic illness, and since SSRIs have only ever been demonstrated to be effective with genuine manic depressives and suicidals, is the large scale treatment of hepatitis C sufferers with anti-depressants to be advised? [Although a crude cudgel, if one asks a depressive what they would do if the symptoms were removed

tomorrow, most fail to find an answer ... if you ask the same question of a hep C sufferer they are likely to give you an extensive list].A You are right that mass treatment with SSRIs is something that needs to be addressed. This is something that is being addressed in a meeting in Prague in June (EISH 8-10th June) as many experts think that this question needs serious attention. You are also right that SSRIs may not be the optimal treatment because there is a cascade of different chemical changes in the brain related to the hepatitis C virus and SSRIs only correct one (albeit major) pathway.Q I had hep c, genotype 3 for approximately 23 years before being diagnosed and subsequently successfully treated (I am now 3 years post-treatment). I have recently had a general health check and everything was found to be normal and in general I feel well, although physical tiredness and general aches have also been an ongoing problem since

treatment.I noticed since treatment that my cognitive skills are deteriorating I now frequently make silly mistakes, like spelling their when I mean there when I am writing/typing and sometimes I seem to have complete blank spots where I cannot seem to concentrate on a single thought but instead get hit with a torrent of half-thoughts completely unrelated to what I am actually doing.I also sometimes find it extremely hard in conversation to come up with a word I am looking for, and often have to settle for more basic or simple words which is frustrating when I want to express myself well.Fortunately it is not for prolonged periods of time but it is frustrating and definitely not something I experienced previous to treatment. I am 44 so hopefully it is not just down to getting older! I do have worries that it is getting progressively worse and wondered whether you have done/or known anyone who has monitored people who did interferon back

in the early 90s to see if they are currently experiencing problems like this, or if they did, have they resolved over time.Lastly, would you agree that it is vital to carry out more research in this area? I think a lot of patients are put off doing treatment because of uncertainty about the short and long term side effects.A These are very distressing symptoms. There has been no research on the long term follow-up from patients treated with interferon as yet, with respect to their brain function. The symptoms so long after treatment are unusual, and you have to be sure that there is no other cause. However, research is being carried out in the UK and particularly in Canada on this issue, but it will be a while before the answers are known.Q I have 3 questions if it is possible for the Prof to answer. They are in regard to my partner who has chronic HCV Virus and advanced liver cirrhosis. He has appt at Edinburgh Liver Unit in

May, has had one unsuccessful HCV combination therapy and is alcohol free for over one year. He has ascites, edema and hepatic encephalopathy and has required hospitalization on approx 4x last year. He has also been treated on 3x occasions for thrombo-phlebitis.1. Joint Pain becoming increasingly worse in ankles, knees, elbows and wrists. Is HCV the cause and how can this symptom be relieved?2. Cramps in hands, legs and feet, mainly at night but can occur anytime without warning. Hands appear to have contractures, big toe sticks up involuntary for hours and calfs distort? Analgesics ineffective and cant be prescribed Quinine. Are there any medicines or alternative remedies to help relieve the pain?3. Brain fog- My partner describes a feeling of things closing in on him, hears voices echoing and is intolerant of people, noise and light. Is this brain fog or can you describe for me please?A These are very important questions.1. Joint pain is associated with hepatitis C and is usually treated effectively with pain killers. However, an opinion of a rheumatologist (joint doctor) is sometimes helpful as pain killers aren't always effective.2. Cramps are very distressing and are commonly caused by imbalances in the salts in the blood. Quinine is usually effective and I cannot think of any reason why your husband should not have a small dose. However, it is important to have a balanced diet with a decent amount of good quality protein (dietary supplements are helpful which the hospital dietician should be able to advise you with, but Ensure and other supplements contain the right balance of minerals to keep things on track. Excess salt is bad though as your husband has ascites).3. It sounds as if your husband has been suffering from something called "hepatic encephalopathy" which is where the

brain is exposed to toxins which are normally filtered out by the liver. This usually only occurs in bad cirrhosis and is not related to the "brain fog" which we have been discussing. It is not specific to hepatitis C, but occurs in all causes of severe cirrhosis. It is treatable with drugs such as lactulose and L-ornithine L-aspartate (very different from the brain fog in hepatitis C which occurs without cirrhosis and is related to the virus, not the liver damage). It responds to liver transplantation.http://www.hepctrust.org.uk/support/live-chat/dr-simon-taylor-robinson.htm

http://Hepatitis Cnewdrugs.blogspot.com/2010/06/comprehensive-list-of-all-hepatitis-c.html