Hepatitis C Pathway - Adult Leeds

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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 Rebecca Jones and Dr Mark Aldersley Consultant Hepatologists (LTHT) and also sourced from Map of Medicine National Pathways.

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3.  Updates to this care map

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Pathway Developed: December 2014

To be reviewed: December 2016

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4.  Hepatitis C - clinical presentation

Quick info:

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:
    • cause of approximately 20% of acute hepatitis
    • 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), eg:
      • 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, eg:
    • 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, eg:
    • 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, eg dialysis
  • birth in high-endemicity region, eg:
    • Pakistan
    • Egypt
    • Japan
    • Eastern Europe
  • 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, eg:

  • organomegaly
  • signs of decompensated liver disease

Before proceeding with testing, inform the person about the benefits of being tested.

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5.  Screening for hepatitis C in high-risk groups

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Screen the following people for hepatitis C using an 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, eg needlestick 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
      • dental treatment
      • street shaving
      • barbers
      • any other invasive treatment
    • had tattoos or body piercing where unsterilised 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, eg cocaine, particularly if they have shared straws or pipes
    • were born in countries where hepatitis C is endemic, eg:
      • Pakistan
      • Egypt
      • Middle East
      • Eastern Europe (especially Poland and Lithuania)
      • Japan
    • 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 who perform invasive or exposure-prone procedures, eg surgeons
  • 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.

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6.  Investigation Abnormal LFTs

Quick info:

Anyone with a raised ALT should be considered for a Hepatitis C test

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7.  Hepatitis C Screen

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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 regular infection e.g. drug using - if so consider regular testing.

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8.  Hepatitis C Antibody Positive

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

For first tests from primary care the lab will automatically do this.

They will also request a confirmatory sample.

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9.  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 (> 200). 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.

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10. Investigations

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Anybody with a positive Hepatitis C antibody is at risk of other blood-borne viruses and Hepatitis B Surface Antigen and Core

Antibody and HIV tests should also be requested.

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11. And HCV PCR -ve (HBV, HIV & LFT Negative)

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This means previous infection - now cleared.

This needs confirming at three months.

Check the patient is not at risk of regular 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.

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12. 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 next box.

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14. Investigations

Quick info:

These patients need to be referred with the following test results:

Hepatitis C Antibody & Hepatitis C PCR and genotype (genotype may need requesting separately at present)

Hepatitis B Surface Antigen and Core Antibody

HIV

Do the following tests if not already performed

(a) Ultrasound of liver and upper abdomen

(b) Liver function tests (Bilirubin, ALT, ALP, Albumin) (c) Full blood count

(d) Liver autoantibodies (ANA, AMA, LKM, SMA) (e) Immunoglobulins (IgA, G, M)

(f) Ferritin

(g) Thyroid function tests

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15. Repeat HCV PCR After 3 months (See text if possible recent exposure in high risk patient e.g. IVDU)

Quick info:

If negative, as above.

If positive proceed to 'HCV PCR Positive' box.

If a patient is known to have had recent exposure to a hepatits C infected person and shared high risk activities then it may be worth repeating the PCR at a shorter interval.

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16. Repeat HCV PCR After 3 Months and Repeat LFTs

Quick info:

Repeat Hepatitis C PCR at three months to confirm still remains negative.

Anybody with a positive Hepatitis C antibody is at risk of other blood-borne viruses and Hepatitis B and HIV tests should also be requested.

An abnormal ALT needs an explanation and needs investigating (See abnormal ALT pathway for information).

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17. 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.

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20. HCV PCR Positive Refer Hepatology (Viral Hepatitis Clinic)

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Viral Hepatitis Clinic appears on Choose and Book

Key Dates

Published: 15-Jan-2015, by Leeds
Valid until: 28-Feb-2018

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