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Q: Do I have chronic hepatitis or acute hepatitis, and how do we determine the difference?
A: The definition of Hepatitis is “inflammation of the liver”; the term “acute” means immediate in onset, and “chronic” indicates that the process has been present longer. The definition of chronic hepatitis is further clarified by the presence of abnormal liver injury tests, or transaminases for more than six months. Viral Hepatitis A does not have a chronic form of hepatitis, when the infection resolves, there is no evidence of liver injury. In Hepatitis B, 10% of patients go on to chronic liver disease and 90% resolve the infection. Unfortunately in Hepatitis C 90% of patients progress to chronic liver disease, cirrhosis and even liver cancer. Chronic Hepatitis caused by any process can, progress to cirrhosis and ultimately hepatocellular cancer.
Q: My doctor has been following my " Liver Function Tests for a few years" What do these tests tell you about my liver. They have gone up this year, which is why I was referred to you. Has my liver gotten worse?
A: We usually perform AST and ALT (or alanine aminotransferase and aspartate aminotransferase). These are liver injury tests, better known as “transaminases.” These tests are markers of inflammation and liver injury and not function. In Hepatitis C as opposed to other forms of liver disease, the level of abnormality or the height of these blood tests though does not correlate with the level of liver injury. These will be markers that will be followed during the course of therapy for hepatitis C.
Q: Do I need a Liver biopsy or can the extent of my disease be determined by blood testing.
A: Liver biopsy is the “Gold Standard” test to determine the level of liver injury. Transaminases (AST / ALT) are tests of liver injury not function even though we still call them liver function tests. Laboratory evaluation can suggest the presence of severe liver injury and the possibility of cirrhosis but biopsy is important to confirm the level of scarring and the severity of the injury, especially in Hepatitis C.
Q: Tell me about the Liver biopsy, including how is it performed?
A: The liver is located in the right upper quadrant (RUQ) under the rib cage. The biopsy is an outpatient procedure where the rib space and the surrounding tissue is anesthetized, and a special needle is placed into the liver to obtain specimens for assessment. The liver biopsy allows accurate “staging of the severity of disease”, through assessment of inflammatory activity, and the degree of scarring or fibrosis. Usually all diseases in the liver are diffuse involving all of the liver tissue equally therefore small pieces of liver tissue will gives all of the information we need.
The biopsy also permits identification of alternative pathologic processes such as alcoholic liver injury. And it may allow us to exclude histologic conditions that require special consideration in treatment and monitoring such as cirrhosis.
The percutaneous (through the skin) route is the method of choice for performing the biopsy. On occasion we will have the biopsy performed by a radiologist using X-Ray, for radiologic guidance. A biopsy can also be obtained laparoscopically or surgically through an abdominal incision.
Q: What does the viral titer or viral load tell me about my disease or treatment?
A: The level of virus in the blood stream or the quantitative PCR test for viral RNA in the case of Hepatitis C does not really tell us about the ability to resolve the infection with therapy, nor does it tell how severe the infection is. It may impart some risk of transmissibility i.e. the higher viral titers may be easier to transmit.
Q: What determines whether I am currently infected with Hepatitis C?
A: In the determination of hepatitis C infection, usually hepatitis C antibody (HCV Ab) is determined first, this indicates past contact with the virus. The antibody does not differentiate between a resolved infection and an active infection. Because this test is indeterminate, we need to proceed to confirmatory assays. Usually the RIBA (or radioimmunoblot assay) is done first and is commonly done by your medical doctor.
Hepatitis C PCR, (which tests specifically for viral RNA is the most sensitive for the detection of hepatitis C. It is also the one marker that will help us determine resolution or cure of the hepatitis C viral infection after treatment has been completed.
Q: You mentioned at our initial encounter that other lab tests were done. What other specific tests have you done, why and what information do these tests give you?
A: The tests that we have performed as a baseline are iron studies and ANA (or antinuclear antibody), and other tests of metabolic, genetic, and immunologic liver diseases. On occasion, alternative disorders of the liver are found, and therapy would be altered based on these findings. We usually would perform AST and ALT (or alanine aminotransferase and aspartate aminotransferase). These are liver injury tests, better known as “transaminases.” These tests are markers of inflammation and liver injury. In Hepatitis C as opposed to other forms of liver disease, the level of abnormality though does not correlate with the level of liver injury. These will be markers that will be followed during the course of therapy for hepatitis C.
We would normally perform an ultrasound as an imaging study of the liver.