Clinical features
Can be symptomatic or asymptomatic:
- Weakness and malaise, low grade fever
- Nausea, loss of appetite and vomiting
- Pain or tenderness over the right upper abdomen
- Jaundice, dark urine, severe pruritus
- Enlarged liver
- Complications: liver cirrhosis, hepatocarcinoma
Investigations
- Hepatitis B surface antigen positive for >6 months
- Hepatitis B core antibody: Negative IgM and Positive IgG to exclude acute hepatitis B infection
- Liver tests, repeated at 6 months
- HBeAg (can be positive or negative)
- HBV DNA if available
- HIV serology
- APRI (AST to Platelets Ratio Index): a marker for fibrosis
APRI = (AST/ULN) × 100/ Platelet count (109/L)
(ULN: upper limit of normal, usually 40 IU/L) - Alpha fetoprotein at 6 months
- Abdominal ultrasound at 4-6 months
Management
General principles
- Screen for HIV: if positive, refer to HIV clinic for ART: coninfection is a risk factor for disease
progression and some ARVs are active against Hepatitis B virus - If HIV negative: refer to a regional hospital for specialist management
- Antiviral treatment is given to prevent complications and it is usually given for life
- Patients with chronic hepatitis B need periodic monitoring and follow up for life
- Periodic screening for hepatocarcinoma with alfa fetoprotein and abdominal ultrasound once a year
Treat with antivirals if the patient has any one of these:
-
- All persons with chronic HBV infections who have cirrhosis (whether compensated or not)
based on clinical findings and/or APRI score >2, irrespective of liver enzyme levels, HbeAg status
or hepatitis B viral load) - HIV co-infection (use a tenofovir based combination)
- Patients with no cirrhosis (APRI score <2) but persistently elevated ALT on 3 occasion within 6-12 months and viral load >20,000 IU/L (if available) regardless of HbeAg status
- All persons with chronic HBV infections who have cirrhosis (whether compensated or not)
- First line antivirals
Adults and children >12 years or >35 kg: tenofovir 300 mg once a day
Child 2-11 years (>10 kg): Entecavir 0.02 mg/kg
The following patients should NOT be treated
- Patients without evidence of cirrhosis (APRI ≤2) and with persistently normal ALT level and HBV
viral load < 2000 IU/ml (if available)
Health education
- Mangement is lifelong because of the need to monitor hepatitis
- Bed rest
- Urge patient to avoid alcohol as it worsens disease
- Immunisation of household contacts
- Do not share items that the patient puts in mouth (e.g. toothbrushes, cutlery) and razor blades