After someone has had chronic hepatitis C (HCV) for a number of years (on average, 10-20), the damaged liver cells that are replaced with scar tissue (fibrosis) becomes extensive, and cirrhosis occurs. Cirrhosis is the description of the extent of scar tissue that has occurred in the liver, often including impaired blood flow to the liver, loss of liver function, and/or an alteration in the structure of the liver.
A healthy functioning liver has a smooth texture. When HCV causes extensive scarring from fibrosis, the liver can become lumpy and nodular. Nodules in the liver form when the free flow of blood throughout the liver is compromised. Blood flow in the liver can be impaired when liver cells have unsuccessfully tried to regenerate inside circular bands of scarring, or nodules that have been cut off from the rest of the liver.
When the liver is still able to carry out most or all of its functions, it is said that the liver is able to compensate for the damage that is being done by the hepatitis C virus. This stage of cirrhosis is called compensated cirrhosis. As with fibrosis, the severity of cirrhosis can vary from mild to moderate or severe. Once compensated cirrhosis reaches the severe range, it is classified as decompensated cirrhosis, because the liver can no longer cope with the damage caused by HCV.
Compensated Cirrhosis Progression
People who have been diagnosed with compensated cirrhosis often have a wide range of experiences. Many people do not have any noticeable signs or symptoms of disease and may feel similarly to when they were in the chronic phase of infection. Some may even have fairly normal test results indicating normal liver functions in the production of albumin, bilirubin, clotting factors, portal hypertension, and sometimes, they’ll also register as having normal liver enzyme levels.
Despite the wide range of test results and experiences of those with compensated cirrhosis, without treatment, the disease progresses to decompensated cirrhosis. While, for some, it can take years to reach decompensation, research has indicated that, on average, patients who are living with compensated cirrhosis from HCV will have a 4% annual rate of decompensation. Additional studies have found that, within 5 years, 18% of patients reach decompensated cirrhosis, and within 10 years, 30% of patients will have progressed to decompensation.
As with all stages of hepatitis C, individual symptoms and disease progression varies significantly.
General Compensated Cirrhosis Symptoms
Not all people who are diagnosed with compensated cirrhosis will experience symptoms, but the symptoms that are more commonly associated with compensation can include:
A reaction or a sensitivity to over-the-counter and prescription drugs
Spider nevi – small, red, spider-like capillaries visible under the surface of the skin on the chest, upper arms, face, shoulder, neck, waist, and upper back
Once the liver is no longer able to compensate for the damage caused by inflammation and scarring from an HCV infection, decompensated cirrhosis has occurred. During decompensation, the liver cannot perform its normal functions, nodules of scar tissue will be visible on an ultrasound, and the liver will be reduced in size. Because the liver is unable to carry out essential functions, serious complications arise, and it’s common for patients to be frequently admitted to emergency care or the hospital.
Once a patient has progressed to decompensated cirrhosis and is experiencing serious complications, they have few options other than liver transplantation. Transplant procedures and expertise have significantly improved in recent years for patients, and transplant survival rates for people who are living with HCV-related decompensated cirrhosis are now around 70% after 5 years. Despite improved procedures and survival rates, donor shortages make it difficult to receive a transplant, and only those whose liver is extremely decompensated will be placed on a liver transplant list.
A very small percentage – around 5% of people with cirrhosis – will progress to liver cancer or hepatocellular carcinoma (HCC). When HCC develops, it usually occurs after decades of living with the hepatitis C virus, and even then, it is almost exclusively found in people who have progressed to compensated or decompensated cirrhosis.
Those who develop liver cancer and who do not have surgery to remove the cancer or a liver transplant have very low survival rates. Typically, someone who is diagnosed with liver cancer and left untreated will only survive for up to five years after HCC is diagnosed. Surgery on patients who have been diagnosed with liver cancer is possible if the cancer has not spread beyond the liver, and further stipulations persist for those who would seek a transplant:
There must be only one tumor, and it is less than 5cm across,
there must be no more than 3 tumors, and they are all less than 3cm across, or
there must only one tumor that is 5-7cm across, and it has not grown in at least 6 months.
This is why it’s important that everyone with chronic hepatitis C be closely monitored and screened by a healthcare provider regularly. Diagnosing, treating, and detecting severe issues early can significantly increase one’s chance of survival and recovery.