1. Background information

Quick info:
The content of this pathway has been agreed and approved by the Dept of Hepatology (LTHT) and the Leeds CCGs.
Clinical content has been provided by Dr Mark Aldersley, Consultant Hepatologists (LTHT) and also sourced from Map of Medicine National Pathways.

2. Information Resources for Patients and Carers

The Hepatitis C Trust

3.  Updates to this Care Map

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Pathway Developed: December 2014
Pathway reviewed: August 2022
To be reviewed: July 2026

4. Hepatitis C - Clinical Presentation

Quick info:
Presentation:

Hepatitis C cannot be diagnosed through clinical features alone, and patients are often asymptomatic. People with chronic hepatitis C may be identified:

• following screening tests for people at high risk (common)
• through follow up, after a diagnosis of acute hepatitis C
• as a result of abnormal liver function tests (LFTs)

Acute hepatitis C infection:

• usually asymptomatic and has a clinically mild course
• occurs after an incubation period of 6-9 weeks
• only 25–35% of people experience symptoms (rarely severe), e.g.:
• mild flu-like illness
• nausea and vomiting
• pain in the right upper quadrant
• jaundice and dark coloured urine (rare)
• rarely presents with fulminant hepatic failure

Chronic hepatitis C infection:
Symptoms tend to be non-specific, e.g.:

• mild to severe fatigue
• muscle aches
• nausea
• depression
• anxiety
• pain or discomfort in the liver
• poor memory or concentration

Signs of liver decompensation may be present in those with advanced liver disease, e.g.:

• jaundice
• ascites
• hepatic encephalopathy
• variceal (often oesophageal) bleeding
• often remains asymptomatic until liver disease is advanced

Ask about:

• intravenous (IV) drug use
• blood transfusions or products recipient prior to September 1991
• high-risk sexual behaviour
• healthcare intervention in an endemic area, e.g., dialysis

Birth in high-endemicity region, e.g.:

• Pakistan
• Egypt
• Romania
• Easter European States
• tattoos or piercings
• occupational risk of exposure

Consider and record risk factors related to poor prognosis:

• excessive alcohol consumption (past and present) - strongly associated with:
• a poor prognosis
• progression to severe liver complications

Weight - a body mass index (BMI) greater than 25 kg/m2 is associated with an increased risk of:

• hepatic steatosis
• disease progression
• smoking - independent risk factor for hepatic inflammation
• age at infection - infection at an older age causes a more rapidly progressing disease
• current age - older age is a predictor of increased progression, independent of length of infection
• male gender - men are more likely to progress to cirrhosis than women

Ethnicity:

• progression of chronic disease may be less rapid in black people
• Asian people may experience more rapid progression to cirrhosis
• co-infection with the following (causes more rapid disease progression to serious illness):
• HIV
• hepatitis B

Examination for any stigmata of chronic liver disease, e.g.:

• organomegaly
• signs of decompensated liver disease

Before proceeding with testing, inform the person about the benefits of being tested and high success rate of oral treatment greater than 95%.

5.  Screening for Hepatitis C in high-risk groups

Quick info:
Screen the following people for hepatitis C using a hepatitis C virus (HCV) antibody test:

• injecting drug users or those who have injected drugs in the past
• those who are blood or organ recipients in the UK and who have received:
• whole blood or organs prior to 1992
• blood products prior to 1986
• babies/children born to women found/known to be infected with hepatitis C
• healthcare workers who have been accidentally exposed to blood where there is a risk of hepatitis C, e.g., needle stick injuries
• people who have:
• unexplained abnormal liver function tests (LFTs) or who present with overt liver failure

Received the following procedures in countries where hepatitis C is common and infection control may be poor (including people who have received blood transfusion products that have not been screened for hepatitis C):

• medical
• cosmetic surgery over sea
• dental treatment
• street shaving
• barbers
• any other invasive treatment
• had tattoos or body piercing where unsterilized equipment may have been used - especially consider tattooing and piercing received in the UK before the mid-1980s or in other countries at any time
• tested positive for:
• hepatitis B see 'Hepatitis B' care map
• HIV

Consider screening the following people, particularly if they have unexplained symptoms:

• people who:
• have, or are currently, snorting, or smoking drugs, e.g., cocaine, particularly if they have shared straws or pipes

Were born in countries where hepatitis C is endemic, e.g.:

• Pakistan
• Egypt
• Middle East
• Eastern Europe (especially Poland, Romania, and Lithuania)
• regular sexual partners of people who are known to have chronic hepatitis C

The following people will usually be routinely screened outside of primary care:
people:

• who intend to donate blood or organs
• with renal failure or who are on dialysis
• healthcare workers
• Anyone who has been in prison (or YOI) and/or shared injecting paraphernalia in prison
• Commercial sex workers and other high risk sexual behaviour
• Close contacts of someone known to be chronically infected with hepatitis C
• Prior to testing, inform the person about the benefits of being tested.

6.  Investigation Abnormal LFTs

Quick info:
Anyone with a raised ALT should be considered for a Hepatitis C test - See 'Abnormal ALT pathway' for more details.

7.  Hepatitis C Screen

Quick info:
Screening test is the Hepatitis C Antibody.
If this is negative the person has not been infected with Hepatitis C.
Check not at risk of acquiring infection e.g., drug use or unsafe MSM - if so consider regular testing.

8a. HBsAg Negative HBcAb Negative

Quick info:
No further action

9a. Hepatitis C Surface Antigen (HBsAg) Positive

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A positive test indicates exposure. To confirm on-going active infection a PCR test for viral RNA is needed.

B) For first tests from primary care the lab will automatically do this they will also request a confirmatory sample.

C) And HCV PCR -ve (HBV, HIV & LFT Negative)
Quick info:
Referral not required
This means previous infection - now cleared.
These needs confirming at three months.
Check the patient is not at risk of acquiring infection e.g., drug using or MSM population - if so consider regular testing.
This would need to be HCV PCR as the antibody is already positive.

D) And HCV PCR -ve (HBV, HIV negative but LFTs Abnormal)
Quick info:
Previous Hep C now cleared
LFTs abnormal so proceed to investigations outlined in the abnormal LFT pathway.

• Harm Reduce Advise & Counselling

Quick info:
Counselling:

• provide the person with information about hepatitis C, and advice on how to prevent transmission of the infection

Advise patients:

• to reduce alcohol consumption, advise the person to avoid drinking alcohol

Risks of transmission:

• use barrier intercourse if hepatitis B virus (HBV) status/vaccination of patient unclear
• do not share toothbrush, razors, hair clippers
• cover open cuts, scratches
• clear blood spills with bleach, disinfectant
• do not donate blood or semen

NB:

• children should not be excluded from school or out of school activities
• food utensils can be shared safely
• HCV PCR Positive Refer Hepatology (Viral Hepatitis Clinic)

Quick info:
Viral Hepatitis Clinic appears on Choose and Book

10. Refer Hepatology (Viral Hepatitis Clinic)

Quick info:

• If patients have had blood tests or dried blood testing or scans, outside Leeds, please ensure the referral includes these results.
• If also HIV positive, then will need referral to both Hepatology and HIV services
• If also Hepatitis B positive, then a single referral to Hepatology will suffice.

11. Red Flag

Quick info:

• Clinically symptomatic acute hepatitis C is uncommon.
• Suspect it in active intravenous drug users, recent tattoos etc presenting with jaundice or symptomatic with high ALT (> 300).
• In this situation the antibody may be negative so request hepatitis C PCR directly and make it clear on the request that acute hepatitis C is suspected. Refer these patients urgently to viral hepatitis clinic. If the patient is very unwell admit through normal procedures at GP's discretion.