Gastroenterology

Hospital Donostia´s Digestive Disorders Unit

The Digestive Disorders Services offered at Hospital Donostia, Guipuzcoa’s main treatment center for congenital bleeding disorders, provide patients with comprehensive care for any digestive tract problems. Blood derivative therapy that hemophiliacs and von Willebrand patients frequently use to control bleeding episodes repeatedly exposes them to different infections, including viral hepatitis.

Once Hematology has determined a patient is infected with the hepatitis B, C or D virus, they are sent to the Digestive Disorders Unit to undergo more exhaustive testing to treat and control the development of the infection. It is important Hematology always be informed of a patient’s status in the event they require some sort of blood derivative therapy

Haemophilia and von Willebrand disease and the hepatitis virus

The hepatitis C virus (HCV) was first described in 1989 by a group of American researchers. It is not currently known exactly how many people have the virus, but it is estimated that the prevalence of the virus has reached alarming levels. In 1997 an epidemiologic report published by the WHO estimated that 3% of the world’s population is infected with HCV, which means more than 170 million people carry the virus.

The hepatitis C virus is parenterally transmitted through contact with infected blood or blood derivatives, which explains the high rate of infection in people with congenital bleeding disorders. Donor blood screenings using EIA and molecular techniques have practically eliminated transmission through blood transfusions.

Transmission of the virus among those living with an HCV-infected individual essentially only occurs when there is contact with the affected person’s blood. Although tight screening measures used on blood donors has helped reduce the risk of virus transmission, hepatitis C continues to be a serious global health issue because it becomes chronic in the majority of patients. This explains why HCV infection is the most common cause of chronic hepatitis C.

It is estimated that in the next 20 to 30 years, 10 - 20% of patients with chronic hepatitis C resulting from HCV will have developed cirrhosis and will have an increased likelihood of developing hepatocellular carcinoma, a primary liver cancer.

Chronic hepatitis C does not develop the same way in all patients and its severity is determined by periodically checking liver enzymes (aminotransferases), ultrasound and hepatic biopsies. A hepatic biopsy, which may not be necessary in all cases, requires careful attention be paid to patients with bleeding disorders (despite the availability of clotting factors).

It is difficult to provide each patient with a long-term prognosis of the disease since many factors directly influence its development.

Generally speaking, persistently normal levels of liver enzymes (aminotransferases ALT/SGPT and AST/SGOT below 40 iu) are associated with slow development of the liver disease, and are thus indicative of a good prognosis. A poor prognosis, however, is associated with high levels of aminotransferases, an indicator of lysis of liver cells.

If lab results are positive for HCV infection, determining viral load and viral genotype is particularly important when deciding what type of treatment the patient is to follow and how they will respond to it.

More than six different hepatitis C viral genotypes have been identified and numbered. Anti-viral treatment can either stop or slow down the development of chronic hepatitis C. A medical specialist should carry out regular patient check-ups, as hepatitis C tends to be asymptomatic in nature.

The current treatments used on this type of disease are proving to be more and more effective. A combination of either standard or pegylated alpha interferons and ribavirin is the treatment of choice, so long as there are no counterindications. However, this treatment is very aggressive and has side effects such as pseudoinfluenza syndrome, insomnia, weight loss, psychological repercussions, etc., which in some cases force patients to stop treatment independent of virologic response.

Several pilot studies on combined therapy in HCV/HIV coinfected patients have been published and all agree that the rate of response to the combined therapy in coinfected patients is similar to that observed in patients not infected with HIV.