Signs and Symptoms of Hepatitis C

Hepatitis C virus
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The signs and symptoms of hepatitis C can vary by the stage of infection. Oftentimes, there are little or no signs of disease, even in the later stages. As a result, infections can go unchecked for years, only presenting with symptoms when the disease is advanced and far more difficult to treat.

From a clinical perspective, hepatitis C infections are typically described as either being acute or chronic.

Symptoms of acute infection are seen in about 15 to 20 percent of cases, often flu-like in presentation with little evidence of liver injury. Among those infected, as many as 50 percent will spontaneously clear the virus within six months of initial infection, with no trace of the virus and oftentimes no awareness they had ever been infected.

Chronic infection occurs when the hepatitis C virus (HCV) does not spontaneously clear but remains in the body, during which time there may be few, in any, signs of infection. If and when symptoms do appear, they can range in severity from a mild fatigue or nausea to complications involving the skin, muscles, and joints. In some cases, the disease never progresses.

End-stage liver disease, by contrast, refers to the point where the liver has been severely damaged and is unable to function. Symptoms are usually highly evident at this stage, often affecting multiple organ systems, including the brain, kidney, and upper digestive tract.

Acute Stage Symptoms

The symptoms of hepatitis C during acute infection, if present, are often non-specific and easily missed. When they do appear, they can resemble those seen in other types of viral hepatitis, in which the build-up of a compound called bilirubin can cause the yellowing of skin and eyes (jaundice), the darkening of urine (choluria), and the production of pale or chalky stools.

More often, however, acute infection will present with symptoms similar to that of the flu, including:

  • fever
  • fatigue
  • nausea
  • vomiting
  • abdominal pain
  • joint pain
  • muscle pain

Symptoms typically resolve on their own, although more severe cases involving jaundice and choluria may take up to a month or more.

Chronic Stage Symptoms

The chronic stage of hepatitis C can persist for decades. During this time, the gradual build-up of fats (called steatosis) and the progressive scarring of tissue (known as fibrosis) can cause damage to the liver. Both of the conditions often develop silently, with as many as 60 to 80 percent of people experiencing little or no signs of illness.

One of the more common symptoms of chronic hepatitis is fatigue. This is caused, in part, by the low-grade inflammation associated with persistent infection, during which the immune system continually floods the body with pro-inflammatory proteins, called cytokines, known to cause extreme exhaustion and malaise.

Symptoms, however, are rarely incapacitating and often difficult to ascribe to liver disease alone. Generalized symptoms can include:

  • fatigue
  • nausea
  • joint pain
  • muscle pain
  • abnormal tingling or burning sensations
  • an uncomfortable "pins and needles" sensation
  • itchy skin
  • raised, bumpy areas of rash
  • dry eyes accompanied by dry mouth

Among people with chronic hepatitis C infection, 10 to 15 percent will advance an irreversible condition called cirrhosis, in which the damage caused by fibrosis is so extensive as to alter the blood flow in and out of the liver. Cirrhosis is staged by the degree of impairment and classified as either compensated or decompensated

Compensated cirrhosis simply means that the liver is functioning relatively well and, as such, may present with minimal symptoms. When present, symptoms can include complications involving the skin, muscles, and joints as the constricted blood supply triggers both an increase in localized blood pressure (known as portal hypertension) and a build-up of bile and other toxins.


Among the possible symptoms:

  • spider veins, mainly on the trunk and face
  • itchy skin
  • pronounced redness on the palms of the hands
  • easy bruising or abnormal bleeding
  • a build-up of fluid in the ankles and feet
  • poor concentration and memory
  • loss of appetite
  • weight loss
  • shrinking testicles
  • erectile dysfunction or loss of libido
  • alcohol intolerance

Decompensated cirrhosis is a more serious condition, which is classified (along with hepatocellular carcinoma, a type liver cancer) as an end-stage disease.

Symptoms of End Stage Disease

The clinical progression of hepatitis C is often invisible during late-stage infection, with many not even aware of their condition until they present with signs of liver failure or cancer. The end stage complications of hepatitis C infection include decompensated cirrhosis and hepatocellular carcinoma (HCC), as well as end-stage renal disease (ESRD).

Decompensated cirrhosis is a serious condition in which the progressive scarring of the liver has left it severely damaged and unable to function. Symptoms are often profuse and progressive and can present in a number of ways, including:

  • persistent fatigue
  • yellowing of skin and eyes
  • tarry or bloody stools
  • a build-up of fluid in the abdominal cavity, causing swelling and distention
  • a distinct "sweet-musty" to "rotten egg" breath odor
  • extreme bruising or bleeding
  • abnormally decreased urine output
  • personality changes, confusion, or tremors
  • increased sleepiness
  • muscle wasting
  • white discoloration or “milk spots” on the nails
  • vomiting of blood

Hepatocellular carcinoma (HCC) is a type of liver cancer that develops almost exclusively in association with cirrhosis in persons with hepatitis C. The symptoms of HCC are similar to those of decompensated cirrhosis and can include:

  • persistent fatigue
  • yellowing of the skin and eyes
  • a build-up of fluid in the abdominal cavity
  • abnormal bruising and bleeding
  • unintentional, extreme weight loss
  • loss of appetite
  • feeling full after eating a small amount
  • delirium, confusion, or coarse “jerking” muscle movements
  • abdominal discomfort, particularly in the upper right quadrant below or just under the ribs

End-stage renal disease (ESRD), more commonly known as kidney failure, can both be caused and complicated by hepatitis C infection. The symptoms of ESRD can vary significantly, particularly between those on dialysis and those who are not, but can often include:

  • persistent fatigue
  • chronic abdominal pain
  • abnormally decreased urine output
  • inability to urinate
  • urine breath odor
  • mottled or uneven, patchy skin discoloration
  • muscle wasting
  • swelling of the legs and feet, or around the eyes
  • nausea or vomiting, particularly in the morning and after meals
  • increased sleepiness
  • repetitive twitchiness of the legs
  • shortness of breath or difficulty breathing
  • mental impairment, confusion

Outcomes of end-stage liver disease are generally poor, with a five-year survival rate of 50 percent in persons with decompensated cirrhosis and 30 percent in those with HCC.

A liver transplant is considered the only option for individuals with end-stage liver disease, although HCV is known to recur in almost 90 percent of cases.


Hoofnagle J. Hepatitis C: the clinical spectrum of diseaseHepatology. 1997; 26(S3):15S-20S.

Lang C, Conrad S, Garrett L, et al. Symptom Prevalence and Clustering of Symptoms in People Living with Chronic Hepatitis C Infection. Journal of Pain and Symptom Management. 2006; 31(4):335-344.