Hepatitis C Disease Phases

Reviewed by: HU Medical Review Board | Last reviewed: March 2015.

Most people who acquire hepatitis C (HCV) progress through typical phases, starting with acute illness and progressing to chronic disease. About 20% of people infected with HCV will spontaneously clear the virus after the acute phase. The remaining cases of acute illness will progress to chronic HCV.

Chronic HCV infection is characterized by gradual, progressive damage to the liver. The virus infects liver cells (hepatocytes) and eventually kills them, resulting in scarring called fibrosis. The liver is able to repair itself to some extent. However, over decades, fibrosis accumulates, the structure of the liver changes, and liver function declines.

Metavir scoring system

0 - No scarring
1 - Minimal scarring
2 - Scarring has occurred and extends outside the areas in the liver that contain blood vessels
3 - Bridging fibrosis is spreading and connecting to other areas that contain fibrosis
4 - Cirrhosis or advanced scarring of the liver

Damage to the liver is evaluated using results obtained from a liver biopsy or noninvasive procedure. These results determine the grade or stage of liver fibrosis. There are various scoring systems, depending on which procedure is used. The Metavir scoring system is most commonly used when a liver biopsy is performed. A fibrosis score from 0 to 4 is used to stage the extent of fibrosis and grade the degree of inflammation.

Learn more about liver biopsy and staging of liver disease.


Cirrhosis is a serious condition that may occur with HCV, in which damaged liver tissue is replaced by severe scarring. The early symptoms of cirrhosis include fatigue, nausea, stomach pain, decreased appetite and weight loss. Severe cirrhosis has many complications, including edema (fluid build-up in the ankles and legs), ascites (fluid accumulation in the abdominal cavity), esophageal varices (enlarged, fragile blood vessels in the esophagus), and hepatic encephalopathy (mental confusion caused by high level of toxins in the blood). Having cirrhosis can increase a person’s chances of developing liver cancer (sometimes called hepatocellular carcinoma). Approximately 1 in 50 people with cirrhosis develop this type of cancer. 1

Studies have found that up to 50% of people with chronic HCV infection eventually develop cirrhosis.2,3 In a person with chronic HCV, cirrhosis typically develops gradually. About 20% to 30% of people with chronic HCV infection will develop cirrhosis over a 20- to 30-year period.1

Cirrhosis, has two phases, compensated and decompensated. Compensated cirrhosis means that the liver is still functioning relatively well. In fact, a person with compensated cirrhosis may be asymptomatic. The early symptoms of cirrhosis include:

  • Fatigue
  • Loss of appetite
  • Weight loss
  • Weakness

As cirrhosis advances, the symptoms may include 1:

  • Jaundice (yellowing in the skin or whites of eyes)
  • Itchy skin (pruritus)
  • Muscle cramping
  • Spider veins
  • Swelling (edema) in the lower extremities (feet and legs)
  • Difficulty taking a full breath
  • Feeling full in the belly area
  • Nausea

Decompensated cirrhosis means that the liver is not functioning well. Three serious complications may occur with decompensated cirrhosis:

  • Portal hypertension. Portal hypertension is increased pressure in the liver’s blood vessels. This pressure can cause varices, which are enlarged veins that can burst. Varices usually form in the upper digestive tract, particularly the esophagus.
  • Ascites. Ascites refers to a swelling of the abdomen, resulting from a retention and build-up of fluid in this area.
  • Hepatic encephalopathy (HE). HE is a brain disorder that develops when the liver is unable to remove toxins from the body. HE may result in impaired concentration, sleep disturbances, confusion, or coma.

Other general symptoms throughout the body can result from loss of liver function due to cirrhosis, reflecting the important role of the liver in maintain a range of basic body functions. 1

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