Symptoms and treatment of chronic hepatitis with medications and diet. Hepatitis C - symptoms and treatment, first signs

Viral hepatitis is an infectious disease caused by a group of hepatotropic viruses (reproducing mainly in liver cells - hepatocytes). Currently, the most widely studied viral hepatitis are A, B, C, D (delta) and E.

The special position of viral hepatitis C (HC) among other hepatitis is due to the catastrophic increase in infection with the HC virus in the population and especially young people, which is associated with the growth of syringe drug addiction. Yes, according to materials World Organization healthcare, approximately 1 billion people on the planet are infected with the HS virus. It is quite clear that at such a rate the absolute number is not increasing. favorable outcomes.

Another feature of the HS problem is that viral hepatitis C has not been sufficiently studied both from the standpoint of virus and immunogenesis, and from purely clinical point vision. It is with HS that paradoxical situations are observed when a diagnosis of chronic hepatitis is made, but there are no clinical, anamnestic, and sometimes laboratory data (except for the detection of antibodies to HCV (Hepatitis C Virus) alone).

It is necessary to immediately determine that HS should be considered as one of the components of the global problem of HCV infection, which includes not only acute and chronic hepatitis itself, but also liver cirrhosis and extrahepatic lesions. It is this approach that will help to correctly determine the condition of a particular patient and evaluate laboratory data, foresee the prospects for the development of infection, individually and timely select the necessary adequate therapy and avoid categorical, hasty predictions regarding the fatality of acute and chronic HS.

Clinical forms of hepatitis C

When the HS virus enters the human body, two variants of the infectious process may develop:

The manifest form of HCV infection is acute hepatitis in an icteric or anicteric form, but always with symptoms of hepatitis (intoxication, asthenodyspeptic syndrome, enlarged liver and spleen, etc.);

Asymptomatic (subclinical) form of HCV infection, when there are no complaints or symptoms of hepatitis.

Acute manifest forms of HCV infection (icteric and anicteric) occur as acute HS with varying degrees of disease severity (mild, moderate, severe and malignant). In some cases, a protracted course is observed: with prolonged hyperenzymemia and/or prolonged jaundice(cholestatic variant).

Subsequently, the disease ends:

Recovery (15-25%);

The formation of a chronic infection that occurs like chronic hepatitis with varying degrees of activity.

The asymptomatic (subclinical) form of HCV infection is the most common (up to 70% of all cases of infection), but is practically not diagnosed during acute phase. Subsequently, subclinical forms (as well as acute manifest ones) end with recovery or the formation of chronic hepatitis with varying degrees of activity. It should be emphasized that the course of the asymptomatic form of HS (as well as manifest forms) is accompanied by qualitative and quantitative changes in specific (IgM and IgG) antibodies, as well as certain dynamics of viremia, studied by the level of HCV RNA in the blood. At the same time, changes of varying severity are observed biochemical parameters cytolysis of hepatocytes (hyperenzyme of alanine (ALT) and aspartic (AST) aminotransferases, etc.).

Acute icteric form . The incubation period varies from several weeks (with blood transfusion and its preparations) to 3-6 and rarely up to 12 months (with infection through parenteral manipulations). The average incubation period is 6 months.

Pre-icteric period. The disease often begins gradually, manifesting itself mainly as astheno-dyspeptic syndrome. Patients complain about general weakness, decreased performance, malaise, increased fatigue, loss of appetite, possible nausea, vomiting 1-2 times, a feeling of heaviness in the epigastrium, sometimes aching pain in the right hypochondrium. An increase in body temperature is not a permanent symptom - only 1/3 of patients with HS in the pre-icteric period show an increase in body temperature, mainly within the subfebrile range. In the same period, you can palpate an enlarged, often painful liver. The duration of the initial (pre-icteric) period ranges from 4 to 7 days, but in some patients it can reach 3 weeks. At the end of the pre-icteric period, the color of urine and the color of stool changes.

Jaundice period. With the appearance of jaundice, symptoms of liver intoxication may persist, but more often they decrease or completely disappear. During this period, lethargy, weakness, decreased appetite up to anorexia, nausea, rarely vomiting, pain in the epigastrium and right hypochondrium are characteristic. In all patients, hepatomegaly is detected, sometimes the edge of the liver is sensitive to palpation, and in some patients (up to 30%), an enlarged spleen is detected. The severity of jaundice varies: from weak icterus of the sclera to high color intensity skin.

One of the features of HS is a rather short, compared to other types of hepatitis, period of maximum severity of symptoms of intoxication and jaundice. In the blood serum there is an increase in bilirubin content and a significant increase in the activity of ALT and AST. The thymol test indicators moderately increase, and the sublimate titer decreases. The icteric period lasts from 1 to 3 weeks. Some patients may develop a cholestatic variant of the disease with a duration of jaundice of up to two to three months, itching of the skin (sometimes debilitating) and with biochemical changes in the blood typical for long-term hyperbilirubinemia (high levels of total and conjugated bilirubin, increased performance alkaline phosphatase).

The period of decline in jaundice is characterized by normalization of the patient’s well-being, a decrease in the size of the liver and spleen, a gradual restoration of the color of urine and stool, and a significant decrease in enzyme activity and bilirubin levels.

Outcomes acute hepatitis WITH . Recovery is observed in 15-25% of all cases of acute hepatitis, and in the rest there is a transition to chronic hepatitis, with the gradual (over many years) formation of liver cirrhosis and extremely rarely with the development primary cancer liver - hepatocellular carcinoma.

In most cases, the disease progresses slowly. About 15% of people infected with the virus HS, recover spontaneously (i.e., after hepatitis, no hepatitis C virus RNA is detected in the blood for two years), in 25% the disease is asymptomatic with normal levels of serum aminotransferases or with mild liver damage, i.e., on average 40 % of patients recover clinically. Naturally, when adequate therapy the percentage of favorable outcomes increases.

Of course, factors such as alcohol abuse, drug addiction, substance abuse and poor nutrition largely accelerate and intensify the process of damage to the liver parenchyma, which in turn determines the unfavorable outcome of both acute and chronic HCV infection.

The risk group for developing viral cirrhosis also includes patients suffering from chronic diseases: diabetes mellitus, tuberculosis, collagenosis, chronic diseases of the stomach, intestines, kidneys, etc.

In terms of prognosis, the development of HS along with hepatitis B is alarming: simultaneous infection (co-infection) or combination (superinfection): chronic hepatitis B with the addition of acute HS; chronic hepatitis B and hepatitis B virus (HBV) infection.

In this regard, the tactics and strategy for treating such patients require a differentiated, individual approach in each specific case.

Chronic hepatitis WITH . With HCV infection, more often than with HBV (Hepatitis B Virus), the disease becomes chronic.

Clinical manifestations of chronic hepatitis C (CHC), which develops after an icteric form or after an asymptomatic course of the disease, are very insignificant and are manifested by some astheno-vegetative symptoms: increased fatigue, unmotivated weakness, Bad mood, sometimes loss of appetite. Often the severity of symptoms and complaints is so low that only after a thorough and even biased examination of the anamnesis is it possible to construct a chronology of the disease. Dyspeptic syndrome also weakly expressed or absent - there is a slight decrease in appetite, nausea is possible after fatty, spicy foods, and sometimes there is a disturbing feeling of heaviness in the right hypochondrium. Patients usually associate these symptoms with a violation of nutrition and diet. On examination, an enlarged liver is determined (the liver is 1-1.5 cm below the costal edge with a moderately elastic, smooth, sharp, sensitive or painless edge); in 30-40% of patients the spleen is palpated. Ultrasound reveals hepatosplenomegaly and diffuse changes in the parenchyma of the liver and spleen. Transaminase activity is usually within normal values or 1.5-3 times higher than them. No disruption of protein metabolism is observed. During a serological study, antibodies to HCV of the general pool are recorded, while the RNA of the virus is determined in the blood.

In chronic HS with high process activity, the course of the disease is wave-like and consists of periods of exacerbation and remission. The period of exacerbation is characterized by polymorphism of the clinical picture, but the leading one is astheno-dyspeptic syndrome; jaundice is observed in 10-25% of patients. Sharp changes in laboratory parameters are noted: transaminase activity exceeds normal values by 10 or more times, and indicators of protein and lipid metabolism change. HCV RNA is detected in the blood. Ultrasound reveals hepatosplenomegaly, depleted vascular pattern, echogenic heterogeneity of the parenchyma (granularity) and thickening of the liver capsule.

During the period of remission of chronic HS, the well-being of patients improves, enzyme activity decreases, but hepatomegaly persists, while splenomegaly is recorded in 10-15% of patients. In some cases, viremia may disappear (with the subsequent appearance of viral RNA during the next exacerbation).

The frequency of periods of exacerbations and remissions and the degree of their severity are quite variable, but a certain pattern exists: the more frequent the exacerbations, the longer they are and the higher the activity of ALT and AST, which contributes to the more rapid formation of liver cirrhosis. Precisely when high activity CHC causes extrahepatic manifestations such as arthralgia, low-grade fever, telangiectasias, skin rashes, etc., as well as symptoms of decompensated intestinal dysbiosis (milder forms of dysbiosis - compensated or latent and subcompensated are observed in almost any clinical form of HS).

Repeated exacerbations of CHC, occurring with a high degree of activity, ultimately end in the transition to the next clinical form of HCV infection - viral cirrhosis of the liver, the symptoms of which are well known. However, this usually takes many years.

It should be specifically emphasized that in chronic active HS, extrahepatic manifestations are associated with the development of autoimmune (immunopathological) processes, in the initiation of which the HCV infection virus plays a certain role. Progressive autoimmune pathology(polyarthritis, Sjogren's syndrome, polyneuritis, nephropathy, anemia, etc.) in turn aggravates the course of chronic liver damage, which determines the need to select adequate therapy.

Morphological characteristics . Most patients with chronic infection have moderate or moderate severity of necrotic-inflammatory damage in the liver with a minimal level of fibrosis. The progression of HCV infection is accompanied by a portal and periportal inflammatory reaction with small focal necrosis and massive lymphocytic infiltration. The process of liver damage may intensify: as a result of necrotic changes, connective tissue septa are formed and multilobular (confluent, so-called “bridge-like”) necrosis develops, which characterizes chronic active hepatitis C initial signs liver cirrhosis. The high activity of chronic HS is morphologically characterized by the progression of multilobular necrosis and the formation of multiple connective tissue septa, which in turn disrupts the blood supply and causes chaotic nodular regeneration in the remaining surviving islands of parenchymal cells, which contributes to the formation of “false” regenerative hepatic lobules resulting in macronodular cirrhosis.

Outcomes of chronic hepatitis C . The rate of transition of CHC to cirrhosis of the liver is different: only 10-20% of patients have pronounced activity of the inflammatory process and clinically manifest cirrhosis develops within 10-20 years, while the majority of patients with CHC simply do not live to develop manifest cirrhosis and, especially, liver cancer, dying from other (general somatic) diseases. However, in a number of cases, there is a rapid progression of CHC to cirrhosis of the liver, which depends on many factors, among which are alcohol abuse, toxic effect drugs related somatic diseases, simultaneous infection with viruses C and B (co-infection) or superinfection with HBV, initially inadequate specific therapy for HCV infection. Therefore, knowledge of the chronology and features of development viral infection liver should be taken into account when choosing tactics and strategies for treating HCV infection, especially its chronic forms.

Diagnostics

Specific laboratory diagnosis of HCV infection is based on the detection of specific antibodies to the main antigens of the virus and determination of the RNA of the virus, its quantity and genotype.

Third-generation enzyme-linked immunosorbent test systems for determining antibodies to HCV, where immunoreactive synthetic peptides are used as a binding antigen on the solid phase, are quite sensitive and informative, and their widespread use has increased the percentage of detection of individuals infected with the HS virus.

The so-called definition is widely used. general antibodies to HCV, however, the interpretation of the positive results of such a study is very limited - the presence of general antibodies to HCV only allows us to state the fact of the patient’s contact with the HS virus and does not allow us to judge either the duration of the process, or its completion or progression. There is also no correlation with the severity of the clinical course of HCV infection.

Thus, the detection of only general antibodies to HCV has a screening (indicative) meaning and provides the basis for further comprehensive, including specific laboratory examination. Note that general antibodies to the hepatitis C virus remain in the body indefinitely.

Antibodies of the IgM class to HCV, determined by the enzyme immunoassay method, allow us to speak not only about infection with the HS virus, but with a certain degree of certainty about the acute phase of infection or exacerbation of chronic hepatitis, despite the absence of symptoms of the disease and hyperenzymemia of ALT, AST.

Viral RNA is detected in the cytoplasm of most liver hepatocytes already in the first or second week of infection. Subsequently, the number of viral particles may periodically increase, but this does not always correlate with the presence of RNA in the blood serum or with the degree of inflammatory changes in the liver. Maximum viremia is observed at the beginning acute period diseases. Antibodies appear 6-12 weeks after the onset of hepatitis. First of all, antibodies are detected to structural (nuclear protein-associated) proteins, and then to non-structural proteins - NS3, NS4 and NS5 regions of the genome.

Determination of HS virus ribonucleic acid (HCV-RNA) is carried out using PCR, which with a high degree of accuracy shows the presence or absence of viral RNA in the blood.

The PCR method allows you to determine the viral genotype and its subtype, as well as the amount of RNA (titer or number of genocopies per ml). Determination of the genotype of the virus and its titer (semi-quantitative study) in the patient’s blood is used both for diagnosing HCV infection and for additional assessment of the activity of the viral process and for monitoring the effectiveness of complex, including antiviral treatment. The interpretation of the results obtained is assessed as follows: 1 + (1:1) and 2 + (1:10) - viral RNA is detected in a low titer, the level of viremia is low, 3 + (1:100) - intermediate level viremia and finally 4 + (1:1000) and 5 + (1:10000) - high level of viremia. The disadvantage of the method is its technological complexity and currently quite high economic costs, which does not allow it to be widely introduced into mass production. laboratory examination.

If the test result is positive for antibodies to HCV and there is no clinical picture of hepatitis, the simplest (and correct) decision would be to refer the patient to an infectious disease specialist. To obtain a more complete description, additional examination should be carried out:

Biochemical blood test (so-called liver tests - ALT, AST, GGTP (g-glutamyl transpeptidase), cholesterol, bilirubin, etc.);

Separate determination of antibodies to HCV;

Blood test for virus RNA (PCR) and if it is detected: determination of genotype and titer;

Ultrasound examination of organs is also advisable. abdominal cavity.

The results of such an examination, together with the data of the epidemiological history and physical examination at the first stage, will help to develop the correct treatment tactics and management of a particular patient. There are often situations when the results of a comprehensive examination do not reveal any abnormalities other than the detection of antibodies to HCV. In these cases, it is reasonable to talk about a previously suffered subclinical form of HCV infection. However, given existing probability reactivation (replication) of the virus, the patient should be registered at a dispensary and random laboratory examinations should be carried out 2-4 times a year. Similar recommendations are given to a patient who has suffered a manifest form of HS.

Hepatitis C therapy

Treatment of hepatitis has a number of features and depends primarily on whether acute or chronic hepatitis is diagnosed in the patient.

Acute hepatitis C is a typical infectious disease and in its treatment traditional principles of treatment of viral hepatitis are applied: the nature of the treatment of manifest forms of viral hepatitis (occurring with symptoms of intoxication and jaundice) depends on the severity, however, in all forms, patients must follow a regimen with limited physical activity and diet - table No. 5, and in case of exacerbation of the process - No. 5a. Basic therapy also includes oral detoxification, the use of antispasmodics, enzyme preparations, vitamins, desensitizing agents. Along with the generally accepted basic therapy in modern conditions it is possible to prescribe etiotropic treatment: prescribing interferon inducers and immunomodulators (Amiksin, Neovir, Cycloferon, Immunofan, Polyoxidonium, etc.).

In moderate and even more severe forms of HS, accompanied by severe symptoms of intoxication (prolonged nausea, repeated vomiting, severe weakness, increased jaundice and other signs liver failure), shown intravenous administration glucose-electrolyte solutions, polyvinylpyrrolidone preparations (Hemodez and analogues) in a daily volume of up to 1.5-2 liters under the control of diuresis. In cases of the development of a severe and malignant course, glucocorticoids are added to therapy (prednisolone 60-90 mg per os per day or 240-300 mg intravenously), protein preparations (albumin, plasma), amino acid mixtures (Hepasteril A and B, Aminosteril N-hepa etc.), antihemorrhagic agents (Vikasol, Dicynone, aminocaproic acid), protease inhibitors (Kontrikal, Gordox and analogues), enterosorbents, among which Duphalac is the most preferred. Effective method Plasmapheresis remains the only treatment option for severe forms.

With the development of a cholestatic variant of the course, Usofalk (ursodeoxycholic acid) is prescribed at 8-10 mg/kg body per day once in the evening for 15-30 days, enterosorbents (Polifepam, Enterosgel, etc.). In some cases it is observed positive effect when conducting hyperbaric oxygen therapy(HBO), plasmapheresis sessions, inhalation administration of heparin in combination with laser therapy.

IN pathogenetic therapy GS may also include other drugs: Heptral, Riboxin, Tykveol, Hofitol, Phosphogliv, Karsil, Legalon and analogues. Recently, the drug “Glutoxim” has been used, which selectively acts on virus-infected and unaffected cells and regulates the processes of thiol metabolism.

Considering the fact that in liver pathology there are always disturbances of the intestinal microflora of varying severity, it is recommended to prescribe bacterial preparations that normalize the intestinal microflora - Bifidumbacterin and its combinations, Lactobacterin, Hillak-forte, etc. It is rational to use the complex synbiotic Bifistim, which contains, in addition to bacteria, a multivitamin complex and dietary fiber, the need for inclusion of which was discussed earlier.

Currently, there is no consensus on the advisability of using antiviral drugs interferon group (or other groups) in the treatment of acute HS. There are a number of studies demonstrating the effectiveness of prescribing a 3-month course of interferons (or a combination of interferons with nucleosides) in patients with acute hepatitis. According to the authors, early appointment antiviral drugs significantly reduce the frequency of transition of acute hepatitis to protracted and chronic.

It also seems justified to prescribe drugs with antiviral activity (glycyrrhizic acid drugs - Viusid, Phosphogliv) in the initial period of acute HS.

Chronic hepatitis C . Therapy of patients with CHC includes a number of aspects, among which the deontological one should be highlighted first. Thus, patients with HS must be informed in detail on a certain range of issues related to their disease, in particular, regarding the features of the clinical course, rules of behavior of the patient in everyday life, sanitary and epidemiological nature, possible outcomes with an emphasis on the high percentage of chronicity, use therapeutic activities and means, including specific antiviral drugs and the associated difficulties and problems (duration and high cost of therapy, unwanted side effects, expected effectiveness of treatment). The result of such an interview between the doctor and the patient should be the patient’s conscious desire to be treated, as well as an optimistic attitude towards the upcoming long and persistent therapy.

Currently, a number of medications are used in world practice, the antiviral activity of which has been proven to one degree or another.

The first and main group of antiviral drugs consists of a-interferons (recombinant and natural) - such as: Reaferon, Roferon-A, Intron-A, Interal, Wellferon, Realdiron, etc. It is believed that their antiviral effect based on inhibition of viral reproduction and stimulation of many factors immune system body.

The second group of antiviral agents consists of reverse transcriptase inhibitors and, in particular, nucleoside analogues (Ribavirin, Ribamidil, Rebetol, Ribavirin-vera, Vidarabine, Lobucavir, Sorivudine, etc.), blocking the synthesis of viral DNA and RNA by replacing natural nucleosides and thereby inhibiting viral replication. Remantadine and Amantadine also have an antiviral effect.

The third series of drugs is represented by interferonogens (Amiksin, Cycloferon, Neovir, etc.), the mechanism of action of which is to induce the macroorganism to produce additional amounts of its own interferons.

Treatment of any disease and especially the chronic form of HS requires an exclusively individual approach, since the nature pathological process each individual patient is determined by a number of important components, such as: the patient’s age, the nature of the concomitant pathology, the duration of the disease, the genotype of the virus and the level of viral load, drug tolerance, the presence and severity of side effects. adverse events related to the therapy being carried out and, in the end (and in some cases, at the beginning) - with the economic capabilities of a particular patient.

It is appropriate to note that monotherapy with interferon drugs, initially used in patients with CHC according to the literature (1999-2000) - Intron-A 3 million IU 3 times a week or Wellferon in the same regimen for 12 months, gave positive result from 13 to 48% (meaning normalization of aminotransferase levels and disappearance of HCV RNA in the blood according to PCR data). The results depended on the genotype of the pathogen and included the so-called. positive unstable responses, i.e., the new appearance of RNA in the blood of patients during 6-12 months of observation after completion of treatment.

In order to increase the effectiveness of treatment of chronic viral hepatitis, complex antiviral therapy has recently been used, usually the combined use of a-interferons with nucleoside analogues. For example, the combined use of Intron-A 3 million IU 3 times a week with Ribavirin analogues (Ribamidil, Rebetol, Vidarabine, Lobucavir, Sorivudine, etc.), daily at a dose of 1000-1200 mg for 12 months, allowed us to obtain a stable, sustainable response in 43% of patients, i.e. the absence of HS virus RNA in the blood according to PCR data over the course of 12 months of observation of patients after cessation of such therapy. However, it should be taken into account that nucleoside analogues themselves have a whole range of side reactions, which appear more often when long-term use drugs. The patient should also be warned about these nucleoside reactions.

Among other factors, the positive stable effect is not high enough even combination therapy was explained by the fact that the interferon therapy regimens used did not create a constant therapeutic concentration active substance in the blood and tissues, since the half-life of interferon introduced into the body is 8 hours, while the virus only needs a few hours in the intervals between interferon injections to reach its original concentration again. Replacing the drug Intron-A in the above treatment regimen for patients with CHC with PEG-interferon (PEG-intron, Pegasys) at a dose of 180 mcg in the form of 1 injection per week (the addition of polyethylene glycol to the interferon molecule leads to an extension of the half-life of the active substance in the body to 168 hours) ultimately made it possible to obtain a stable therapeutic response in an average of 72% of all patients treated in this way, of which 94% with pathogen genotypes 2 and 3.

There are reports that such complex therapy, undertaken for 6 months in patients with acute viral hepatitis C, provided a complete cure and eliminated chronicity of the process in almost all patients (98%), regardless of the genotype of the pathogen. The same impressive data were obtained in the treatment of CHC. It should be added that the optimistic results obtained with the use of PEG-interferon are overshadowed by the unacceptably high price of the drug.

Treatment of HS is a rather complex undertaking, therefore, when prescribing and conducting specific therapy, it is appropriate to be guided by the following principles:

It is necessary to detect the RNA of the virus in the blood using PCR data, determine its genotype and the level of viremia (by a quantitative or semi-quantitative method);

Conduct a comprehensive laboratory examination (analysis peripheral blood, biochemical blood test);

Assess the nature of the patient’s concomitant pathology (for example, renal disease with impaired excretory function, cardiovascular, autoimmune diseases, diseases thyroid gland, pronounced abnormalities in the peripheral blood, in particular anemia, thrombocytopenia, leukopenia), which may even be a contraindication for the planned antiviral treatment. Specific therapy is prohibited during pregnancy;

Both acute (and even preferably!) and chronic forms of viral hepatitis are subject to treatment, including those when, in the presence of pathogen RNA in the blood, the RNA of the pathogen is consistently recorded normal level aminotransferases;

Taking into account the possibility of developing tolerance to the medications used or the formation of antibodies to them, at certain stages of treatment it is advisable to change combinations of therapeutic agents from time to time;

The effectiveness of treatment depends more on the duration of treatment than on the dose of the drug (depending on the specific characteristics of the patient, the duration of treatment ranges from 6 to 18 months);

Monthly and, if necessary, more frequent monitoring of clinical and laboratory data, including a detailed analysis of peripheral blood, is required in order to correct possible side effects;

The patient should be remembered and informed that during therapy, chills, fever, myalgia, allergic phenomena, anorexia, depression, thyroiditis, baldness, anemia, leukopenia, thrombocytopenia, and agranulocytosis are possible.

A priori, we should expect lower effectiveness of HS treatment, and sometimes its complete absence in the following cases: in persons with immunosuppression of various origins, in patients with obesity, with a combined chronic process caused by hepatitis C and B viruses, in patients with virus genotype 1b, with high concentration HCV-RNA in the blood, with a long duration of the chronic process (many years), in the presence of autoimmune diseases, in cases where treatment occurs while taking narcotic drugs, and also when treatment is carried out only in one of the two sexual partners with HS (the possibility of reinfection with a virus of the same genotype).

The situation is complicated by the exceptionally high cost of treatment for the patient, since both domestic and foreign antivirals in Russia are not yet included in the register of medicines provided free of charge.

S. N. Zharov
B. I. Sanin, Candidate of Medical Sciences, Associate Professor
V. I. Luchshev, Doctor of Medical Sciences, Professor
State Educational Institution of Higher Professional Education RSMU Roszdrav, Moscow

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Symptoms of hepatitis C

Hepatitis C is one of the most common types of hepatitis, most severely affecting the liver, disrupting its functioning. Moreover for a long time the disease may be generally asymptomatic, which is why the disease is detected too late. As a result, the infected person can become a hidden carrier and distributor of the virus.

Hepatitis C virus (HCV) has two forms: acute and chronic. Immediately after infection, an incubation period begins, sometimes lasting from 6 - 7 weeks to six months. Acute form Symptoms of the disease appear after the end of the incubation period and are expressed by fever, headache, muscle and joint pain, general malaise and weakness. This period is also called anicteric, it lasts 2 ÷ 4 weeks. This is followed by the icteric phase, during which the patient may develop a icteric coloration of the skin, accompanied by pain in the right hypochondrium, vomiting, diarrhea, and lack of appetite. But the first thing that worries you is the color of the urine, which turns brown. Sometimes an anicteric form of the disease can be observed. During the acute phase, the level of bilirubin in the blood increases. It lasts for about a month, after which it begins recovery period lasting for several months. After it, in 15–25% of cases, self-healing can occur or the disease becomes chronic.

Symptoms of chronic hepatitis C

The transition of HCV from the acute to the chronic phase occurs in approximately 80% of cases. Moreover, in women the chronic form occurs less frequently than in men, and their symptoms of the disease are less pronounced. Although sometimes signs of the disease are not noticeable in men, this does not interfere with the inflammatory process that is actively occurring in the liver. As a result, the disease first takes a chronic form, and then develops into cirrhosis or liver cancer.

With asymptomatic chronic hepatitis C (CHC), the disease can be expressed in the following symptoms:

weaknesses;
decreased performance;
loss of appetite.

Periodically during the course of the disease, wave-like exacerbations occur, followed by remissions. But such exacerbations are rarely accepted severe form. Symptoms of HCV in adult patients are most often mild, while children suffer more severely. In them, the disease takes a more aggressive form, accompanied by exacerbation and the occurrence of complications in the form of cirrhosis. Signs of chronic hepatitis C virus (CHC) are worsened by exposure unfavorable factors, which include:

heavy physical or neuropsychic stress;
poor nutrition;
alcohol abuse.

Moreover, the last factor most strongly has a negative effect on the liver of patients with chronic hepatitis C. This occurs due to the fact that patients may develop toxic alcoholic hepatitis, which intensifies the manifestations of chronic hepatitis C and contributes to the occurrence of complications in the form of cirrhosis. Wave-like changes are characteristic not only of the course of the disease, they are also directly reflected in laboratory parameters. Because of this, patients periodically notice increased levels of bilirubin and liver enzymes in their blood.

Moreover, normal values of laboratory parameters are recorded for a long period of time, even in the presence of changes in the liver. This forces laboratory monitoring to be carried out more often - at least once or twice a year. Since HCV symptoms do not always manifest themselves in a pronounced form, you should pay attention to cases of weakness and decreased performance. Having noticed such signs, it makes sense to be examined for the presence of HCV infection.

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Chronic hepatitis is a group infectious diseases, caused various viruses hepatitis, among which the most common viruses are hepatitis B and C. Today the disease is serious problem for doctors around the world, as the number of cases increases every year. This is due to the spread of injection drug addiction and promiscuity of sexual behavior, especially among people young, as well as with an increase in the number of invasive medical procedures. IN recent years The number of cases of infected children born to sick mothers has also increased.

Chronic viral hepatitis is most often detected in young people, many of whom die at the age of 40–45 in the absence of adequate therapy. The progression of the disease is facilitated by the presence of several viral infections in one patient (human immunodeficiency virus, several hepatitis viruses). It should be noted that not all those infected become ill with viral hepatitis; many become virus carriers. They may not know about it for many years, infecting healthy people.

Symptoms of chronic viral hepatitis

Heaviness, pain in the right hypochondrium, general weakness, poor appetite may be symptoms of chronic hepatitis.

This disease is not typical specific symptoms, indicating which particular hepatitis virus the patient is infected with.

The most common symptoms of hepatitis are unmotivated weakness, loss of appetite, weight loss, and nausea. Patients may feel a feeling of heaviness and dull pain in the right hypochondrium. Some patients may experience elevated body temperature (up to 37 C) for a long time, yellowness of the sclera and skin, and itching of the skin. The enlargement of the liver is usually moderate; sometimes the size of the affected organ remains within normal limits for a long time.

The presence of such symptoms may indicate other diseases of the liver, as well as the biliary system of a non-infectious nature, so for diagnosis it is necessary to consult a doctor. The diagnosis is established only on the basis of the results of laboratory and instrumental studies.

Patients with chronic viral hepatitis B, with adequate therapy, have a slightly better prognosis than those suffering from hepatitis C, which is popularly called the “gentle killer.” This is due to the fact that the disease is very long time is practically asymptomatic, quickly leading to cirrhosis of the liver. In many patients, viral hepatitis C is diagnosed already at the cirrhotic stage.

Treatment of chronic viral hepatitis

An infectious disease specialist treats chronic hepatitis.

All patients first of all need a change in lifestyle: normalization of the daily routine (refusal night work, good rest), elimination of factors that negatively affect the liver (abstinence from alcohol, working with toxic chemicals, hepatotoxic drugs). Therapy for the disease is always complex.

Basic principles of therapy

All patients are shown dietary food, you need to stick to the diet all your life. The diet must be complete; in this case, the body needs sufficient quantity protein, fiber, vitamins, macro- and microelements. Fatty foods, fried, spicy, pickled, smoked foods, spices, strong tea and coffee and, of course, any alcoholic beverages are excluded from the diet.
Normalization of the digestive system in order to prevent the accumulation of toxins in the body. To correct dysbiosis, it is advisable to prescribe eubiotics (Bifidumbacterin, Lactobacterin, etc.). For constipation, it is recommended to take lactulose-based mild laxatives (Duphalac). Of the enzyme preparations, it is allowed to take those that do not contain bile (Mezim).
Hepatoprotectors (Heptral, Essentiale Forte N, Rezalut Pro, Ursosan, etc.) help protect the liver from negative influences external factors, and also improve regenerative and reparative processes in the affected organ. The course of treatment is long (2–3 months). Many patients are recommended to repeat the course of taking hepatoprotectors annually.
The use of drugs and dietary supplements based on medicinal herbs, having antiviral (licorice, celandine, St. John's wort), weak choleretic and antispasmodic effects (milk thistle, mint, etc.).
In case of severe asthenovegetative syndrome, it is possible to prescribe multivitamin complexes(Biomax, Alphabet, Vitrum, etc.) and natural adaptogens (schisandra chinensis, eleutherococcus, ginseng, etc.).
Antiviral therapy is one of the main directions in the treatment of chronic hepatitis. There are not many drugs used for such treatment, most often a combination of interferon-alpha and ribavirin is used. Antiviral treatment is prescribed only when the virus is activated, which must be confirmed by test results, and can even last more than a year.

Patients suffering from chronic hepatitis should be monitored by an infectious disease specialist for life. They need regular examination of the condition of the liver, and if dysfunction of the organ is detected, treatment is prescribed. With the right timely treatment and following the doctor’s recommendations, recovery or long-term remission of the disease is possible.

Prevention of chronic viral hepatitis

People with chronic hepatitis and carriers of the virus can full life. It should be noted that in everyday life they do not pose a danger to others. Viral hepatitis cannot be contracted through airborne droplets, a handshake, shared utensils or household items. Infection is possible only through contact with the patient’s blood and other biological fluids, therefore the use of other people’s personal and intimate hygiene items is unacceptable.
Sexual partners need to use barrier contraception, since in 3–5% of cases there is a risk of contracting viral hepatitis through sexual contact.
If an injury occurs with damage to superficial vessels (cuts, scratches, etc.), the patient must carefully treat the wound himself or go to a medical facility to prevent the spread of blood. Patients suffering from this disease should always inform the medical staff of medical institutions and their sexual partners about this.
Use of individual syringes and needles by drug addicts.
For emergency prophylaxis in case of suspected infection, human immunoglobulin against hepatitis B is used. It can be effective only when administered within 24 hours after the suspected infection and only against the hepatitis B virus.

Vaccination against viral hepatitis

Newborns are vaccinated against hepatitis B while still in the hospital.

To date, a vaccine has been developed only against the hepatitis B virus. The risk of infection in vaccinated people is reduced by 10–15 times. Vaccination against this disease is included in the childhood vaccination schedule. Vaccination of newborns, children aged 11 years, and adults who are at high risk of contracting viral hepatitis B (medical workers, students of medical schools and universities, families of patients with hepatitis B and virus carriers, as well as drug addicts) is provided. Revaccination is carried out every 7 years.

Emergency prevention and vaccination against hepatitis C virus has not been developed.

Which doctor should I contact?

If a person is sick with viral hepatitis, he needs to be regularly monitored by an infectious disease specialist and, if necessary, begin antiviral therapy. Additionally, the patient is examined by a gastroenterologist. A consultation with a nutritionist will be helpful.

Chronic hepatitis- inflammatory-dystrophic liver disease lasting more than 6 months. The liver is one of the most important organs in the human body, in addition to participating in digestion (bile secretion), the liver is important "filter"- it is she who cleanses the blood, neutralizing toxic metabolic products, allergens and poisons. Therefore, chronic hepatitis, disrupting the functioning of the liver, leads to irreparable consequences for the human body.

Causes of chronic hepatitis

Chronic hepatitis B associated with the replicative phase (HBeAg-positive replicative chronic hepatitis B)

Clinical and laboratory data in this variant of chronic hepatitis B correspond to active hepatitis.

Patients complain of general weakness, fatigue, elevated temperature body (up to 37.5°C), weight loss, irritability, poor appetite, feeling of heaviness and pain in the right hypochondrium after eating, a feeling of bitterness in the mouth, bloating, unstable stool. The higher the activity of the pathological process, the more pronounced the subjective manifestations of the disease.

When examining patients, attention is drawn to transient yellowness of the skin and sclera (not often), weight loss; with high activity of chronic hepatitis, hemorrhagic phenomena are possible (nosebleeds, hemorrhagic rashes on the skin). The appearance of “spider veins” on the skin, skin itching, “liver palms”, and transit ascites usually indicates transformation into cirrhosis of the liver, however, these same symptoms can also be observed with severe activity of chronic hepatitis.

Objective studies reveal hepatomegaly of varying severity in all patients. The liver is painful, of a densely elastic consistency, its edge is rounded. An enlarged spleen may be palpable, but the degree of enlargement is often insignificant. Severe hepatosplenomegaly with symptoms of hypersplenism is more characteristic of liver cirrhosis.

In some cases, a cholestatic variant of chronic hepatitis B may be observed. It is characterized by jaundice, skin itching, hyperbilirubinemia, hypercholesterolemia, high blood levels of γ-glutamyl transpeptidase, alkaline phosphatase.

In a small number of patients with chronic hepatitis B, extrahepatic systemic lesions involving inflammatory process digestive organs (pancreatitis), exocrine glands (Sjogren's syndrome), thyroid gland (Hashimoto's autoimmune thyroiditis), joints (polyarthralgia, synovitis), lungs (fibrosing alveolitis), muscles (polymyositis, polymyalgia), blood vessels (periarteritis nodosa and other vasculitis), peripheral nervous system (polyneuropathy), kidneys (glomerulonephritis).

However, it should be emphasized that pronounced extra-systemic lesions are much more characteristic of autoimmune hepatitis and the transformation of chronic hepatitis into cirrhosis of the liver.

Chronic hepatitis B associated with the integrative phase (HBeAg-negative integrative chronic hepatitis B)

HBeAg-negative integrative chronic hepatitis B has favorable course. As a rule, this is the inactive phase of the disease. This variant of chronic hepatitis usually occurs without pronounced subjective manifestations. Only some patients complain of mild weakness, loss of appetite, mild pain in the liver area. At objective research In patients, no significant changes in their condition are detected (no jaundice, weight loss, lymphadenopathy and systemic extrahepatic manifestations). However, there is almost always hepatomegaly and very rarely minor splenomegaly. As a rule, the spleen is not enlarged. Laboratory values are usually normal or upper limit normal, the level of alanine aminotransferase is not increased or increased slightly, there are no significant changes in immunological parameters.

Liver biopsies reveal lymphocytic-macrophage infiltration of the portal fields, intralobular and portal fibrosis, and there is no necrosis of hepatocytes.

Markers of the integration phase of the hepatitis virus are detected in the blood serum: HBsAg, anti-HBe, anti-HBdgG.

Radioisotope and ultrasound scanning liver reveals hepatomegaly of varying severity.

Chronic HBeAg-negative (integrative) hepatitis with a high level of alanine aminotransferase in the blood - integrative mixed hepatitis

In this variant of HBeAg-negative (integrative) chronic hepatitis, despite the absence of hepatitis B virus replication markers, high levels of alanine aminotransferase in the blood remain, which indicates ongoing pronounced cytolysis of hepatocytes. It is generally accepted that conservation high level alanine aminotransferase in the absence of signs of viral replication requires the exclusion of the addition of other hepatotropic viruses (integrative mixed hepatitis B+C, B+D, B+A, etc.) or may indicate a combination of viral hepatitis B in the integration phase with other liver diseases (alcohol , drug-induced liver damage, liver cancer, etc.).

HBeAg-negative hepatitis with preserved viral replication (mutant HBeAg-negative variant of chronic hepatitis B)

In recent years, the ability of the hepatitis B virus to produce mutant strains has been described. They differ from typical “wild” strains in that they lack the ability to produce specific antigens. Mutations of the hepatitis B virus are caused by an inadequate weakened response of the body to infection, as well as the introduction of vaccinations against hepatitis B. The cessation of antigen synthesis is considered as an adaptation of the virus to the defense mechanisms of the macroorganism, as an attempt to escape from immunological surveillance.

The mutant HBeAg-negative variant of chronic hepatitis B is characterized by a loss of the ability of the virus to synthesize HBeAg and occurs mainly in patients who have a weakened immune response.

The mutant HBeAg-negative variant of chronic hepatitis B is characterized by the following features:

absence of HBeAg in the blood serum (due to low production it remains in hepatitis) in the presence of markers of HBV replication;
detection of HBV DNA in the blood serum of patients;
presence of HBeAb in blood serum;
presence of HBS antigenemia in high concentration;
detection of HBeAg in hepatocytes;
more severe clinical course of the disease and a much less pronounced response to interferon treatment compared to HBeAg-positive chronic hepatitis B.

F. Bonito, M. Brunetto (1993), Nonaka et al. (1992) reported a severe, clinically manifest course of mugan HBeAg-negative chronic hepatitis B. Morphological picture liver biopsy corresponds to HBeAg-positive chronic hepatitis B, the development of destructive liver damage similar to chronic active hepatitis is possible.

It is assumed that in mutant HBeAg-negative chronic hepatitis there is a high risk of malignancy with the development of hepatocarcinoma.