2015 Outpatient Chronic Hepatitis B Management

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1 2015 Outpatient Chronic Hepatitis B Management

2 Hepatitis B

3 Hepatitis B Info 70% of acute infections are subclinical More severe symptoms when in addition to other liver disease Fulminant Hepatitis <2% is largely seen with coinfection with hep C or delta Transmission: Parenteral, perinatal or sexual

4 Screening For Hepatitis B Immigrant Risk, Higher Risk is Certain Regions All of Africa All of Asia: especially SE Asia, China, Korea, Indonesia, Philippines, Pacific Islands Middle East, except Israel South America except Argentina, Chile, Paraguay, Uruguay Eastern Europe except Hungary Malta and Spain Parts of Caribbean and Central America Native People of the Arctic

5 US Children of parents from endemic areas (8% positive) Household or sexual contact with HBsAg+ Men who have sex with men Individual with multiple partners or STIs Correctional Facilities IV Drug Users Dialysis or Immunosuppressives HIV or HCV Pregnant Screening For Hepatitis B Higher Risk Groups

6 Hepatitis B Findings Symptoms of Acute Hepatitis B 30% Anorexia, nausea, jaundice, RUQ pain. 70% milder anicteric, few symptoms Exam Acute Hepatitis B Hepatomegaly RUQ tenderness Jaundice Symptoms of Chronic Hepatitis B Usually none

7 Hepatitis B Markers HBsAg Patient is infected with the virus HBsAb/anti-HBs Patient is usually immune HBeAg Active viral replication Usually ongoing liver disease Highly infectious Absent in some mutant strains Anti HBe Usually reduced viral replication Inactive disease when with HBsAg Less infectious HBV DNA Viral Load by PCR Elevation indicates active disease IgG Anti HBc (core antibody) Indicates contact with Hepatitis B May or may not still be infected IgM Anti HBc Has been infected with HBV in last 6 months in most cases

8 Acute HBsAg+ Hepatitis B Serology Anti-HBc+(IgM then IgG) HBe Ag+ (usually) HBV DNA elevated Past Infection Anti-HBs+ IgG Anti-HBc+ Immunized Anti-HBs+ (isolated)

9 Chronic Hepatitis B Serology Chronic 5-10% of patient go on to chronic Hep B Older age exposure less likely to progress to chronic Hepatitis B HBsAg present for >6 months implies chronic infection HBsAg with IgG Anti-HBc and no IgM Anti- Hbc also indicates chronic Hep B 0.5% per year will clear their chronic HBsAg

10 Do I Care About Core Antibody? Immune Modulation Organ Donation Isolated Anti-HBc Window period after acute infection HBsAg below detection HBsAb below detection False Positive

11 Chronic Hepatitis B Initial Evaluation H and P coinfection, alcohol FH of liver disease, HCC Assess Function LFT, CBC with PLT, INR Assess Replication HBeAb, HbeAg, HB DNA PCR Hep A Test and Immunize (0+6 months) Hepatocellular Cancer Screening RUQ US now and q 6 months Timing of screening initiation depends on ethnicity, gender, age, and amount of inflammation Comorbid Disease Testing Hep C, HIV, +/-Hep D, +/-Hemochromotosis

12 Chronic Hepatitis B Follow Up All Chronic Hep B Increases Risk for Hepatocellular Carcinoma (rare exceptions) Q 6 months RUQ US AFP no longer recommended for screening Monitor clinically for signs of cirrhosis and immune complex disease

13 Tolerant State

14 Chronic Hepatitis B Treatment Offer evaluation with hepatology to anyone who was interested It pt is surely going to see hepatology, consider holding off on extensive evaluation as it will be repeated If ALT <2x normal, low viral load, and HBeAG-, follow q 6 months If ALT>2X normal, increased viral load, possible treatment If DNA elevated but HBeAG negative, possible treatment for mutant HBV Treatment is complex and often not curative Liver biopsy can be used to clarify risk and damage

15 Replicative phase: Immune tolerance Replicative phase: Immune Clearance HBe negative High activity Chronic Hepatitis Mutant? HBe negative Low activity Chronic Hepatits Low/non replicative Inactive Carrier Cirrhosis Detectable Cirrhosis Undetectable

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