CHRONIC HEPATITIS B INFECTION

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
  • 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