What happens when you visit a liver specialist for HCV?

Having been a liver specialist (hepatologist) for many years and seen thousands of patients with hepatitis C (and non-A non-B before we discovered hepatitis C)(Hepatitis C), I am in a great position to let you know what to expect and what you should come prepared for on your visit.

As a hepatologist, there are three main categories of hepatitis C patients I see:  those with a new diagnosis from blood screening or an insurance physical but who have had no further testing; those who are referred from a local primary care physician or gastroenterologist who have had the diagnosis confirmed and want guidance on treatment; and those with more advanced liver disease who likely have failed an older treatment course.

  For any patient with hepatitis C, there are certain facts that I want to know regardless of how you came to see me.  These are:

  1. A complete medical history which includes information about all other medical conditions and prior surgeries, plus a chronological history of your hepatitis C: possible exposures; risk factors; current symptoms; and any diagnostic tests performed already. In addition,  I want to know:
    1. Alcohol and drug use history, even if drug use was years ago and you quit. Alcohol use should be approximated based upon an average number of drinks per week and type of alcohol (beer, wine, hard liquor). Be honest!
    2. Vaccinations for hepatitis A and B
    3. HIV testing in the past (if performed)
    4. Family history of hepatitis and whether spouse has been tested for HCV
    5. Coffee consumption (COFFEE)
    6. Any history of obesity, diabetes, hypertension, heart disease, kidney disease  or skin rashes
  2. There are some general and some very specific tests I will want:
    1. A complete chemistry profile including liver enzymes (AST)
    2. A complete blood count
    3. A prothrombin time if there is any possibility of cirrhosis
    4. An HCV RNA test by PCR to measure the amount of virus in your blood
    5. HCV genotype
    6. Hepatitis A, B and HIV testing if this has not been previously performed
    7. An assessment of the amount of scarring (fibrosis) in the liver.  Historically, this had been done by a needle liver biopsy, but nowadays we use noninvasive tests to answer this question.  This can either be a FibroScan (a form of ultrasound), or a blood test which measures a panel of chemicals associated with scar formation in the liver.

    During your first visit, I am trying to determine a number of things and answer a few questions I will need to best assess your disease severity and potential treatment options. I will also want to assess whether there are any lifestyle modifications which can help stabilize or improve your condition while the evaluation is taking place.

    Hepatitis disease severity is important and may not be readily apparent by how you feel or look to others. The liver has a tremendous reserve such that considerable damage can be present before symptoms develop. Often, however, we can get a good idea of the amount of liver damage from the examination (presence of yellow discoloration of the eyes; red palms; spider veins on face and chest; enlarged spleen; fluid in abdomen; muscle wasting) and history of severe fatigue, confusion, forgetfulness, dark urine, pale-colored stools.  Blood tests also tell us a lot about the condition of the liver.  Although many patients know their AST and ALT levels, and are often quite worried about those numbers; these are generally not helpful in determining severity.  More important is the platelet count, bilirubin, albumin, creatinine and prothrombin time. Occasionally, even with all this information, we are still unable to confidently make an accurate assessment of severity.  A FibroScan or fibrosis blood test can be useful to decide one way or the other.

    Next, I will want to know two things about the virus in your body: how much virus is present and what is the virus genotype.  If you have failed a recent course of therapy, I may also want to know something about whether or not the virus has developed resistance to that treatment.  Almost all of today’s newer therapies require knowledge of four things:

    1. Recent exposure or treatment for hepatitis C
    2. Whether or not cirrhosis is present.  If present, are there any signs of decompensation? (Decompensation).
    3. The viral load (amount of virus in the blood)
    4. The viral genotype (1, 2, 3, 4, 5, or 6)(Genotype)

    Finally, I will discuss treatment options, but will first I will review any important lifestyle modifications. Should you discontinue alcohol or drug use? Generally, yes!  Should you lose weight if obese? Again, generally, yes.  Coffee consumption is actually beneficial and there would be no restriction put on this.  I will review any herbal medications and may restrict their use in the future.

    In discussing treatment, I will review the current treatments available for YOUR SPECIFIC HEPATITIS C GENOTYPE AND SEVERITY. This will be based upon the most recent evidence as presented in the AASLD-IDSA HCV Guidance recommendations (www.HCVguidelines.org). I will review the cost of these very expensive medications and any options if your insurance carrier restricts access. This may require a referral to our pharmacist or nurse for prior authorization approval.

    You will also have an opportunity to ask any questions you may have about anything we have discussed.  It’s often helpful to bring a second set of ears to help you remember what we talked about, and I never restrict your ability to record our discussions if you wish.

    I hope you find this useful.

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