Hepatitis C affects different people in different ways. Your personal experience with hepatitis C will be as unique as you are. This chapter reviews the most common signs and symptoms experienced by people with chronic hepatitis C. At first glance, the mere length of the chapter may appear overwhelming. But keep in mind, this is just a list of possibilities. If you have any of the signs or symptoms described in this chapter, it is important that you do not assume they are a result of having hepatitis C. Your health care provider can determine if they are associated with your hepatitis C. Very few people experience all of these signs and symptoms. Many of them will come and go on their own. For troublesome and/or persistent problems, there are things you and your health care provider can do to either make them go away, or make them easier to live with.

You may be wondering what the difference is between a sign and a symptom. A sign is an abnormality that is detected by your health care provider during an examination. A symptom is something you, as a person with hepatitis C, experience because of the virus. Signs and symptoms are discussed together because sometimes a sign is also a symptom. Fever is a good example of something that is both a sign and a symptom. Your health care provider can take your temperature and find out that you have a fever, so it is a sign. But if you have a fever, you can tell you have a fever because your skin is warm, so fever is also a symptom.

There are three sections following this introduction. The first section briefly explains how the hepatitis C virus causes disease. The second section reviews possible signs and symptoms that people with hepatitis C who do not have cirrhosis may experience. The last section reviews additional signs and symptoms that people with hepatitis C who have cirrhosis may experience.

How the Hepatitis C Virus Causes Disease

According to current understanding, the hepatitis C virus (HCV) causes disease in two general ways. The first is by infecting cells. Once inside the cell, the virus directly damages or kills the cell. This mechanism is called cytopathic damage. The second way the hepatitis C virus causes damage is by provoking an immune response. The immune system is your body's way of protecting itself from invading agents such as viruses and bacteria. An overactive or misdirected immune response can damage infected cells and the normal surrounding tissue. This mechanism is called immunopathic damage.

When HCV was first discovered, experts thought the virus infected only liver cells. However, more recent research has revealed that HCV also infects parts of the immune system, specifically the lymphatic system and peripheral blood mononuclear cells. Experts now understand that hepatitis C is not just a liver disease but is a systemic disease, meaning it can affect nearly any organ of the body. As you read the list of possible signs and symptoms associated with hepatitis C infection, you may find some of the symptoms you have been experiencing that you thought were caused by something else may actually be caused by hepatitis C. This is important because knowing why you are having a symptom is often the first step in alleviating the symptom, or making it less troublesome.

Signs and Symptoms of Hepatitis C without Cirrhosis

The possible signs and symptoms of hepatitis C without cirrhosis involve every organ system of the body. Although some of these symptoms can be quite uncomfortable, most of them do not indicate that your liver disease is getting worse. New symptoms should always be discussed with your health care provider so you can work together to keep your life with hepatitis C as active, productive, and enjoyable as possible.

Generalized Signs and Symptoms

Arthralgia

Arthralgia is pain in the joints. Frequent sites of joint pain are the hips, knees, fingers, and spine, although any joint can be a source of pain. Arthralgia associated with hepatitis C can be migratory, meaning the discomfort moves from one location to another over time. You may have pain in your hip one day and in your knee the next. This symptom usually comes and goes, and is rarely present all the time. If you experience joint pain, it is important to talk with your health care provider before taking anything to treat the pain because some over-the-counter pain medicines (such as acetaminophen ) are potentially harmful to the liver. See Appendix VII for a list of substances that may injure and/or stress the liver.

Fatigue

Fatigue is feeling tired. Nearly all people with hepatitis C experience fatigue at one time or another. The fatigue may be mild and relieved by naps or going to bed earlier. However, the fatigue can be severe at times, feeling like near exhaustion even after a full night of sleep. Fatigue experienced by people with hepatitis C may also be accompanied by feelings of anger, hostility, and depression. These feelings may persist even after the fatigue has passed.

Fever, Chills, and Night Sweats

Many people with HCV periodically experience fevers. The fevers are usually low, typically less than 101 degrees Fahrenheit. As the fever comes down, you may experience chills and sweating. You may have fevers only at night. If this happens, you may wake up with your bedclothes and/or your sheets wet with sweat. This experience is called night sweats.

Fluid Retention

Fluid retention occurs when your body holds on to more water than it needs. The extra water leaks into the tissues. If you have fluid retention, you may notice swelling of your feet, ankles, fingers, and/or face. People with fluid retention often have frequent urination, especially at night.

Flu-Like Syndrome

People with hepatitis C can experience periodic flu-like syndromes. These episodes usually last a few days, rarely more than a week. The most common symptoms are fever, chills, headache, fatigue, and muscle aches.

Lymphadenopathy

Lymphadenopathy is swelling of the lymph nodes. Lymph nodes are normally about the size of a pea or a kidney bean. Because HCV infects the lymphatic system, it frequently causes the lymph nodes to swell. The lymph nodes of the armpits, groin, and neck are relatively close to the skin surface, and are usually examined to see if you have lymphadenopathy. If you have lymphadenopathy, it may or may not be painful when you press on the swollen lymph nodes.

Myalgia

Myalgia is muscle pain or aching. People with hepatitis C may experience myalgia. Usually, if you have this symptom, you will experience it as a generalized feeling. However, some people report pain in only one area of the body. This symptom tends to come and go, and is rarely present all the time. If you experience muscle aches or pain, it is important to talk with your health care provider before taking anything to treat the pain because some over-the-counter pain medicines are potentially harmful to the liver.

Pruritus

Pruritus is the medical word for itching. People with hepatitis C sometimes have pruritus. Often, it is limited to the palms of the hands and/or the soles of the feet. However, some people have generalized pruritus, meaning they itch all over.

Sleep Disturbances

Insomnia is difficulty sleeping, and may be part of your experience with hepatitis C. Insomnia occurs in different forms. You may have trouble falling asleep, or you may wake up often during the night. Some people report having unusually vivid, intense, and/or frightening dreams. Such dreams can contribute to insomnia.

Spider Nevi

Spider nevi are small, red, spider shaped spots on the skin. They are usually less than ½ inch around. They are most commonly seen on the face and chest, but can occur anywhere on the skin. Spider nevi are painless and do not itch.

Weakness

People with hepatitis C sometimes experience a sense of weakness. This symptom can vary from mild to severe, and tends to come and go.

Abdominal and Digestive System Signs and Symptoms

Abdominal Pain

You may experience episodes of abdominal pain if you have hepatitis C. Pain on the right side just below the ribs is likely to be from the liver. People usually report this pain as being short, sharp, or stabbing. More constant, cramping pain closer to the middle of chest, but under the ribs, can be due to gall bladder problems that may accompany hepatitis C. You may experience pain elsewhere in the abdomen. If you experience any new pain in the abdomen, it is important for you to tell your health care provider right away so the source of the pain can be determined.

Appetite Changes and Weight Loss

People with hepatitis C frequently experience changes in their appetites. You may find you no longer want the foods you once enjoyed. Many people find they are particularly put off by fatty foods and alcohol. For some, foods that are at room temperature or cold are more appealing than hot foods. The distaste for alcohol is actually good for you because alcohol increases the damage done to the liver by HCV. People with hepatitis C should not drink any alcohol including beer, wine, wine coolers, and mixed drinks. If changes in your appetite are causing you to lose weight, you need to discuss this with your health care provider because good nutrition is particularly important for people with hepatitis C.

Bloating

Bloating is usually described by people with hepatitis C as a feeling of fullness in the abdomen. You may notice your clothes seem tight around your waist. This bloating may or may not be accompanied by weight gain.

Diarrhea and Irritable Bowel Syndrome

Diarrhea can be experienced as unusually loose stools or an increase in the frequency of bowel movements, with or without a change in the consistency of the stool. If the diarrhea is accompanied by cramping abdominal pain and persists, it is often termed irritable bowel syndrome.

Indigestion and Heartburn

Indigestion is usually experienced as an uncomfortable feeling of fullness in the stomach. It is often accompanied by queasiness and burping of a mixture of gas and stomach contents. When this occurs, you may notice a burning in your throat and/or a sour taste in your mouth. Heartburn is experienced as pain or burning in the chest under the breastbone. It, too, may be accompanied by burping of gas and stomach contents. Both indigestion and heartburn can be brought on by and last longer after a fatty meal.

Jaundice

Jaundice is a yellowish discoloration of the skin and/or the whites of the eyes. It is caused by a yellow substance in the blood called bilirubin. The liver normally breaks down bilirubin. If the liver is not working normally, bilirubin can build up in the blood and begin to stain the skin. If the liver starts to work more normally, jaundice will fade or go away.

Nausea

Nausea is the feeling that you may vomit. Hepatitis C may cause episodes of nausea. Although it is usually not accompanied by vomiting, it can be a very uncomfortable and debilitating symptom. If you are having nausea, talk with your health care provider because there are many ways to treat this symptom.

Cognitive, Mood, and Nervous System Signs and Symptoms

Cognitive Changes

Your cognitive ability refers to your ability to think clearly and to concentrate. Some people with hepatitis C notice they have changes in their cognitive ability. This can take several different forms. You may find you cannot concentrate for long periods of time, or may notice your thought processes seem slower than usual. You may have a hard time coming up with words you want to say, or you may just feel mentally tired. These cognitive changes are sometimes called "brain fog." Like other symptoms of hepatitis C, these cognitive changes often come and go.

Depression

Hepatitis C does not directly cause depression, but concerns about the disease and changes it may cause in your life can lead to depression. Some of the symptoms of depression include:

sleeping more or less than usual
eating more or less than usual
hopelessness
helplessness
irritability
lack of interest in your usual activities
feelings of sadness and/or despair most of the time

If you have one or more of these symptoms, you may have depression. You should discuss your feelings and experiences with your health care provider. Depression can seriously interfere with your quality of life, and can make it difficult for you to do what you need to do to take care of yourself. Depression is nothing to be ashamed of, and it can be treated. If you have any of the symptoms of depression, talk to your health care provider right away.

Dizziness

Some people experience dizziness as feeling as if they are going to faint. Others experience dizziness as disorientation, or feeling as if the world is spinning around them. Both of these can be symptoms of hepatitis C. If you are experiencing dizziness, talk with your health care provider because this can be not only troublesome for you, but also dangerous.

Headaches

Headaches can be symptoms of hepatitis C. For some people, the headaches are mild, but for others, the headaches are severe. If you are having headaches, talk to your health care provider before taking any medicines for your headaches because some over-the-counter pain medicines can be harmful to your liver.

Mood Swings

Hepatitis C can sometimes cause mood swings. Some people find this symptom is worse during the winter months.

Numbness or Tingling

A significant number of people with hepatitis C have numbness or tingling in their extremities. Your extremities are those parts of your body that extend from the main part of your body, that is, your arms and legs, fingers and toes. Most people with numbness or tingling feel it in their fingers and toes, but it may extend into the arms and legs. Numbness is a decreased sense of feeling. In its most severe form, the affected areas have no sense of feeling. Tingling can sometimes be painful. People describe painful tingling as feeling like being stuck with pins. This symptom tends to come and go.

Visual Changes

A number of visual changes can accompany hepatitis C infection. You may find you are not seeing as clearly as you once did. Peripheral vision, that is, the ability to see things that are at the sides of your view, can also be diminished. Some people report seeing small specks called "floaters" moving across their view. This can occur when the eyes are open or closed. Another symptom you may experience is dryness of the eyes, or feeling as if there is something scratchy in your eyes. All of these symptoms can come and go.

Other Signs and Symptoms

Blood Sugar Abnormalities

Hepatitis C can cause blood sugar abnormalities, either high or low. High blood sugar causes symptoms such as extreme thirst, frequent urination, fatigue, and weight loss. Low blood sugar causes light-headedness or dizziness, nausea, and weakness. The symptoms of low blood sugar are worst when you have not eaten anything for several hours, and are relieved by eating or drinking something. If you are having any of the symptoms of either high or low blood sugar, tell your health care provider right away.

Chest Pain

Hepatitis C can cause chest pain. However, chest pain can also be a symptom of serious heart or lung disease. If you have chest pain, you must contact your health care provider immediately so he or she can find out the source of your pain.

Menstrual and Menopausal Changes

Women with hepatitis C may have menstrual changes such as irregular periods, spotting, or increased premenstrual symptoms. Menopausal women may experience an increase in menopausal symptoms such as hot flashes and mood swings.

Palpitations

A heart palpitation is involuntarily becoming aware of your heart beating. Palpitations occur in different forms. You may feel your heart is beating harder or faster than usual, or that it is beating irregularly. If you have palpitations, you need to tell your health care provider immediately so he or she can make sure you are not having a problem with your heart.

Sexual Changes

Some people with hepatitis C have a decreased interest in sexual activity. Decreased sexual response and lack of intensity of sexual response have also been reported. Sexual changes can be an upsetting symptom of hepatitis C. If you are experiencing sexual changes, talk with your health care provider, and your spouse or partner. There are things that you, your health care provider, and your partner can do to help you have a satisfying sex life.