Complications of Hepatitis C Virus Infection

Ascites

Ascites is the term for the accumulation of fluid in the abdomen
secondary to liver disease. It is not specific to hepatitis
infection, but may be caused by any liver condition which results
in decreased protein metabolism and increased portal hypertension
(increased blood pressure in the liver).

Proteins, especially albumin, play a critical role in maintaining
the correct balance of fluids in the body. Albumin, which is
synthesized in the liver, helps "hold" fluid (plasma) in the blood
stream. When the liver is unable to produce the necessary amount of
albumin, plasma leaks through the walls of blood vessels and
accumulates in the abdominal space.

The scar tissue present in many sick livers impairs the flow of
blood through the liver by way of the portal vein. This increased
resistance to blood flow through the liver results in higher
pressure within the portal vein, called portal hypertension. This
increased "back-pressure", combined with low levels of albumin,
allow fluid to be forced out of the blood vessels into the abdomen,
resulting in ascites.

 

Ascites can be "drained off" through a procedure called
Pericentesis. A needle connected to a vacuum jar is inserted into
the abdomen, and the fluid is removed. Although this may provide
some temporary relief for patients with advanced liver disease, the
fluid generally builds back up in the abdomen within a few days.

Arthritis and Cryoglobulinemia

Cryoglobulinemia is a condition in which certain proteins in the
blood clump together when exposed to cold temperatures. The
"clumped" proteins tend to deposit in the joints and very small
blood vessels, causing pain. The most common symptoms are weakness,
arthralgia (joint ache), and purpura (purple bruises). The extent
of illness caused by cryoglobulinemia varies from person to person.
Any or all organs or body systems may be affected, including the
skin and joints, nerves, kidneys, and liver.

Cryoglobulinemia is not common. Its cause is not known, but there
is an association with the hepatitis C virus.

Bleeding

The liver plays an important role in the production of substances
that assist in the clotting process. Clotting is essential for the
sealing off and healing of cuts and other wounds. When the liver is
sick, patients may notice that they bruise very easily, and minor
cuts or scrapes bleed for much longer.

Patients who have coagulopathies (bleeding disorders) have to use
extreme caution to avoid injury or trauma. An injury that might
produce moderate bleeding in a healthy person might result in very
serious or even life-threatening bleeding for a patient with liver
disease.

Hepatitis patients need to avoid the use of common drugs which
impair clotting, such as aspirin and acetaminophen. Hepatitis
patients who have to take "blood thinners" (anticoagulants) for
other medical conditions must use extreme caution and be prepared
to seek medical intervention if bleeding starts.

Edema

Edema is the accumulation of fluid in the tissues of the
extremities (such as in arms or legs). For hepatitis patients,
edema is caused by the same mechanisms described in the section
above (see Ascites). Edema can be resolved, or at least relieved,
by elevating the extremity above the level of the heart. Since
water runs downhill, gravity will assist the fluid to return to
normal circulation.

Edema can occur in almost anyone who keeps an extremity in a
"downhill" position for an extended period. If you have ever taken
a long trip in a car or an airplane with your shoes off, you may
have noticed that you have trouble getting your shoes back on at
the end of the flight.

Hepatic Encephalopathy

Hepatic encephalopathy is a condition that results from the liver's
failure to remove abnormally high levels of ammonia from the blood.
Ammonia has a direct and serious effect on brain tissue, and is a
byproduct of protein metabolism. Although medications exist that
can treat encephalopathy, failure to adequately treat this
condition will result in confusion, disorientation, hallucination,
stupor and coma.

Jaundice and Pruritus

Jaundice (also called Incterus) is a yellow discoloration of the
skin and eyes. It is caused by excessive amounts of bilirubin in
the blood. When liver cells are sick or damaged, the liver cannot
convert the bilirubin into the form necessary to allow it to be
excreted from the body. Jaundice may be transient, and can begin
when total blood levels of bilirubin concentrations exceed 2.5
mg/dl (milligrams per deciliter). The color of urine may become
darker, while stools may become lighter-colored. In cases of viral
hepatitis, fever, chills, pain, loss of appetite and fatigue may
accompany the onset of jaundice.

Pruritus (itching) often occurs with jaundice, and results from
bile salts being deposited in the skin. This is not common in
patients with hepatitis C, but when it occurs, it may be very
difficult to treat. If the itching is due to bile salts, the
condition will not respond to creams, lotion, or other "home
remedies." Only medications which improve the flow and excretion of
bile will decrease the symptoms.

 

Kidney Damage

When the body is attacked by a virus, it creates substances called
antibodies which attack viruses, bacteria, parasites and other
foreign invaders, collectively referred to as antigens. When
antibodies are produced as a result of a foreign invasion, they
attach themselves to the antigen, rendering the antigen incapable
of infecting cells. The combined antigen and antibody is referred
to as an "antigen-antibody (AgAb) complex."

These AgAb complexes are fairly large, as microscopic things go.
When they pass through the kidney, they can "clog" the filtering
membrane, resulting in a condition called Membranoproliferative
Glomerulonephritis. This condition allows protein to be lost in the
urine, which can eventually contribute to muscle wasting and
ascites, and in rare cases, causes renal failure.

Thyroid Disease

Thyroid disease is common is the general population, but even more
common among hepatitis patients. Both hypothyroid (too little) and
hyperthyroid (too much) can occur, and can be medically managed
quite easily. In some cases, thyroid disorders can develop during
Hepatitis C Virus therapy, and may persist after the conclusion of therapy.

Varices

Varices are veins which have been stretched and distorted by
increased pressure resulting from impaired blood flow through the
liver. Common sites for varices are the esophagus, stomach and
rectum. Varices are thin-walled veins under high blood pressure,
and bleeding is a common problem. In some instances, esophageal
varices can rupture and massive bleeding can ensue, resulting in
vomiting and ingestion of large amounts of blood. If uncontrolled,
bleeding varices can result in death.

The picture is further complicated by the fact that hepatitis
patients may have greater difficulty with clotting, prolonging the
bleeding period.

Wasting (Muscle Loss)

The liver plays a central role in the metabolism of protein.
Protein is the building-block of body tissues, so when protein
metabolism is impaired by a sick liver, the body can begin to break
down muscle tissue to obtain the protein necessary for other
metabolic processes. Protein is also necessary for the liver to
synthesize albumin, so decreased protein synthesis can contribute
to the development of ascites and edema.

If you have hepatitis, you should consume an adequate amount of
protein to avoid muscle wasting. However, a by-product of protein
metabolism is ammonia, which the liver has to metabolize in order
to excrete. A sick liver may not be able to remove the increased
amounts of ammonia produced by a high protein diet. This can cause
abnormally high levels of ammonia to accumulate in the blood, which
can cause severe neurological impairment, a condition called
hepatic encephalopathy.