After my first liver biopsy (and, yes, I was scared of the biopsy needle, but it was all over pretty fast), it was discovered that I had stage 2 fibrosis and inflammation. It was time for action.
—Brian (Hepatitis C Support Project, 2006)
The Medical Evaluation
Clients diagnosed with chronic hepatitis require a full medical evaluation to gather information about the nature of their infection, the severity of the disease, and factors that might affect the course of the disease and its treatment. At some point, clients will probably be referred to a specialist. This chapter focuses on the evaluation of chronic hepatitis, which is caused by the hepatitis B or C virus.
The evaluation of chronic hepatitis can involve several tests:
- Liver panel and other blood tests
- Viral load tests
- Genotype test
- Liver biopsy
Taken together, the results of these tests help a physician assess the disease progression, its prognosis, and the risks and benefits of hepatitis treatment.
A liver panel, also referred to as liver function tests (LFTs), is a series of blood tests to measure the extent of liver injury. It is among the first tests for people who are diagnosed with chronic hepatitis. A liver panel measures levels of enzymes and proteins that, if not within the normal range, might indicate liver damage. However, normal levels on a liver panel do not always mean that the liver is not damaged. People who have cirrhosis, for example, can have normal LFTs. Exhibit 3-1 identifies the tests in a standard liver panel and what each test measures. Other tests might include complete blood counts and other measures to help round out the overall assessment of liver health.
Viral Load Tests
Nucleic acid tests, which measure nucleic acid, can indicate the quantity of virus present in the bloodstream; hence, they are referred to as quantitative viral load tests. These are the best and most specific tests to indicate the presence of viral hepatitis B or C. Nucleic acid is composed of molecules that carry the genetic information used in the development and functioning of organs, such as the liver. The nucleic acid test for hepatitis B is hepatitis B virus (HBV) DNA (deoxyribonucleic acid), and the test for hepatitis C is hepatitis C virus (HCV) RNA (ribonucleic acid). Qualitative HCV RNA tests, which determine whether the virus is present, are used to screen for hepatitis C (see Chapter 2).
The extent of liver damage does not correlate with measures of HBV DNA or HCV RNA. A low viral load does not mean a person has little liver damage, nor does a high viral load necessarily indicate more severe infection or more advanced disease. Clients who are familiar with HIV testing often assume that viral load results for HBV and HCV mean the same as they do for HIV viral load results. Exhibit 3-2 highlights the similarities and differences between the HIV and HBV/HCV viral load tests.
This test identifies the type or strain of the hepatitis virus. HBV has eight genotypes, labeled A–H; genotypes A–D constitute the most prevalent genotypes in the United States. Knowing the genotype of HBV might predict how successful antiviral treatment will be, but more studies are needed.
At least six genotypes (and some subtypes) of HCV exist, but genotypes 1, 2, and 3 are most common in the United States. The genotype of the virus does not change. Once the HCV genotype is determined, another genotype blood test is not needed unless the person clears the HCV infection and then acquires a new HCV infection.
No genotype causes more severe disease than any other, but the genotype has implications for response to antiviral treatment and the duration of treatment. Historically, genotype 1 has been characterized as less treatable, or more difficult to cure, than genotypes 2 and 3. People who had genotypes 2 or 3 were more likely to respond to hepatitis treatment than are people who had genotype 1. However, people who have genotype 1 hepatitis have reason to be treated. Boceprevir and telaprevir were approved by the U.S. Food and Drug Administration (FDA, 2011a; FDA, 2011b) in 2011 to be used in combination with interferon and ribavirin for the treatment of adults with chronic hepatitis C, genotype 1. These medications have demonstrated higher success rates and shorter treatment times for genotype 1, and other new medications are currently in development. Chapter 4 provides information on how genotype factors into hepatitis treatment decisions. Exhibit 3-3 compares genotypes 1 with genotype 2 and 3.
Counselors can help clients understand the significance of their genotypes in the following ways:
- Ask clients what they have been told about genotypes.
- Respond accordingly. Although genotype 1 has historically been less responsive to antiviral treatment than other genotypes, as many as 68 percent of clients who have genotype 1 respond to newer treatments. Types 2 and 3 are more responsive to antiviral treatment than type 1.
- Assure clients that having genotype 1 does not mean that the disease will progress more quickly or that the symptoms will be more severe.
- Tell clients that the most important thing is to follow up with their physician, because all genotypes have possible treatments that are rapidly improving.
- Ask clients, “What does this information mean to you? Does it make sense? How might this information help you decide your next step?”
A liver biopsy involves removing and examining a small number of liver cells that can reveal:
- The extent of liver inflammation.
- The amount of scarring (fibrosis) present.
- Presence or absence of cirrhosis.
- Lesions in the liver.
- Other conditions (e.g., alcoholic liver disease) that might be damaging the liver and the severity of the conditions.
- Possible effects of hepatitis treatment.
Reasons to have a liver biopsy include the following:
- It is the best way to evaluate the health of the liver and the only way to reveal the extent of scarring (if any).
- It can help the physician decide whether antiviral treatment is advisable or needed. Treatment might not be necessary if the liver is healthy, or it might be inadvisable if the patient has other issues that might contraindicate treatment.
- The results can be used when deciding whether to continue antiviral treatment if side effects are severe. Chapter 4 addresses factors to consider in making medical decisions about hepatitis treatment.
As with any surgical procedure, liver biopsies have risks, including pain and internal bleeding. Some clients might feel the risks of biopsy are not worth the potential information gleaned from the procedure. Increasingly, people who have genotype 2 or 3 HCV start antiviral treatment without having a liver biopsy. People who have these genotypes might decide that, because treatment is likely to succeed, they will try treatment regardless of their biopsy results. People for whom antiviral treatment is not as likely to be successful might decide not to go through treatment unless their liver disease is progressing. Thus, the most important factor in determining whether individuals should have a biopsy is how essential the results are to them and to their medical care provider.
Helping Clients Decide Whether to Have a Liver Biopsy
Following are suggestions to help clients decide whether to have a liver biopsy:
- Help clients weigh the potential risks and benefits. Counselors cannot provide medical advice, but they can, with the clients’ medical care providers, help clients understand their choices.
- Listen to clients’ fears, and respond with accurate information.
- Help clients plan how they will cope with pain after the procedure. Some will require medications to treat pain. Taking any medication may be a relapse trigger for someone with a history of drug use. Counselors can explain that taking medications under a medical care provider’s supervision is appropriate to relieve pain; these medications do not necessarily lead to relapse. Untreated pain might be as likely to trigger craving for opioids as the appropriate use of pain medications.
- Help clients find someone to accompany them to the procedure. Patients are required to have someone take them home afterward. A substance abuse treatment program can offer to find a peer or staff person who could take a patient to and from the procedure (Litwin, Soloway, & Gourevitch, 2005).
- Address the positive aspects of a biopsy (e.g., it provides important information that can help clients move forward).
- Help clients work out logistical issues. For some clients, arranging for child care or taking care of other logistical issues present problems.
- Help clients explore ways to pay for the biopsy. Be familiar with medical assistance programs for uninsured clients, and keep a list of physicians who are willing to perform biopsies on people who have a history of drug use. Insured clients need to make sure that their insurance covers the procedure.
- Help clients identify support from family and peers. The additional burden of an illness can make people who are already marginalized feel more isolated. Supportive people can help clients cope with the disease and antiviral treatment side effects and identify potentially dangerous side effects.
Liver Biopsy Procedure
The physician should thoroughly inform the patient about the procedure, including alternatives, risks, benefits, and limitations. The procedure typically takes place at an outpatient surgical center or in a hospital. The patient will need to sign an informed consent form before the procedure. The physician determines preprocedure orders (e.g., when the patient needs to stop eating and drinking; special diet, if necessary; which medications, including over-the-counter, to stop taking (Rockey, Caldwell, Goodman, Nelson, & Smith, 2009).
The biopsy procedure involves the following:
- Patients receive a local anesthetic on the right side of the abdomen to numb the area. The degree of pain anticipated during and after the procedure should be taken into account.
- The surgeon inserts a needle into the liver and extracts a small piece of liver tissue.
- Laboratory personnel examine the liver tissue and provide the physician with the results within a few days.
- Nurses observe the patients for a few hours before they are discharged. Following the procedure, it usually is necessary for patients to lie on their right sides for 3–4 hours to prevent bleeding.
Precautions to take after the biopsy include the following:
- For at least 24 hours, patients should not lift objects heavier than 15 pounds.
- Some patients might be sore where the needle was inserted, or they might experience pain in their right shoulders. These symptoms are temporary and usually go away in a few days.
- With the physician’s approval, patients might take acetaminophen for pain. As is the case for most medical procedures, patients should not take aspirin or ibuprofen for 7 days before or after the biopsy.
Resources for information about liver biopsy are in Appendix C.
A hepatitis evaluation provides information for making informed decisions about antiviral treatment.
HCV evaluation can include the following:
- Liver panel
- Viral load tests
- Genotype test
- Liver biopsy
Counselors can help clients cope with an evaluation of chronic hepatitis by:
- Helping them identify and weigh the risks and benefits of evaluation.
- Exploring the client’s feelings.
- Helping clients plan how they will cope with waiting for and receiving evaluation results.
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)
Center for Substance Abuse Treatment. Addressing Viral Hepatitis in People With Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2011. (Treatment Improvement Protocol (TIP) Series, No. 53.) 3, Evaluation of Chronic Hepatitis.