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CHRONIC HEPATITIS B

WHAT TO DO AFTER
DIAGNOSIS

Prof Teo Eng Kiong


Dy CMB (Medical Disciplines) and
Chief, Department of Gastroenterology
Changi General Hospital

Scope of Discussion

Definition of chronic hepatitis B

Risk of chronic hepatitis B

Aims of monitoring

Measurements to monitor

Frequency of monitoring

Summary of recommendations

Definition in Chronic Hepatitis B


Chronic

Presence of HBsAg > 6 months

Active

hepatitis B

viral replication:

HBeAg+
HBV DNA > 5 logs copies or 20000 units/ml

HBeAg HBV DNA > 4 logs copies or > 2000 units/ml

Definition in Chronic Hepatitis B

Immune clearance:

Cirrhosis:

Elevated ALT > 2 x ULN.


Significant inflammation on histology
No other causes for liver inflammation
Histology
Clinical- portal hypertension
Radiological
Fibrosis scan or elastography

Decompensation:

Elevation of PT, INR, Bilirubin


Reduction in albumin
CTP score >6

Risk of Chronic Hepatitis B

Development of:

Primary Liver Cancer (HCC)


Liver cirrhosis:
HCC
Liver failure
Portal hypertension
Ascites
Bleeding varices

Infection

Others
Immune complex diseases

Risk of Chronic Hepatitis B

Likelihood:

HCC:
50x to 200x
Through cirrhosis or direct carcinogenic effect of the virus.
Risk increase with higher HBV DNA levels.*
Other factors includes genotype, age of patient and alcohol
consumption.
Treatment with reduction in HBV DNA reduces risk of HCC
development.^

*Cleve Clin J Med. 2009 May;76 Suppl 3:S6-9.Risk of hepatocellular carcinoma in hepatitis B and prevention through treatment.Sherman M.
^N Engl J Med. 2004 Oct 7;351(15):1521-31.Lamivudine for patients with chronic hepatitis B and advanced liver disease.Liaw YF et al

Risk of Chronic Hepatitis B

Liver cirrhosis and complications:

Cirrhosis
Increases with increase duration of active disease.
2 to 5.4 per 100 person years with a 5-year cumulative incidence
of cirrhosis of 8% to 20% .^
Mortality rate at 5 years is 16% for those with compensated
cirrhosis and is 65% to 86% for decompensated cirrhosis.#

Ascites and Variceal bleeding


Depends on the portal pressure.
Increase with worsening cirrhosis.

Death:

25% of chronic hepatitis B patients die from Hep B related


#Fattovich G, Giustina G, Schalm SW. et al. Occurrence of hepatocellular carcinoma and decompensation in western European patients
liver cirrhosis or liver cancer.*
with cirrhosis type B. Hepatology. 1995 ;21:77-82

^Fattovich G. Natural
history of hepatitis B. Journal of Hepatology. 2003 ;39:S50-S58

*WHO Hepatitis B Fact sheet.

Aims of Monitoring Patients


with Chronic Hepatitis B
1. Monitor for suitability to start treatment.

Appropriate treatment results in clinical


improvement.*

2. Monitor for early detection of complications.

Institute early intervention for management of ascites.


Screening and management of varices.
Screening and management of HCC.
Early listing for transplant if necessary.

*N Engl J Med. 2004 Oct 7;351(15):1521-31.Lamivudine for patients with chronic hepatitis B and advanced liver disease.Liaw YF et al

Early Intervention of Complications

Ascites:

Restrict salt intake.


High degree of suspicion for Sponteous Bacterial
Peritonitis and institute appropriate therapy.

Varices:

Screening for varices for all patients with established


cirrhosis.
Higher yield if associated with low platelets.
Primary prophylaxis either with banding or non-selective
beta-blockade shown to be effective in decreasing the
likelihood of first bleeding episode.

Early Intervention of Complications

HCC:

Clearly shown to benefit from early detection.

Surgical resection remains the mainstay for effective


treatment of HCC.

Resectability depends on:


Size

< 5 cm

Underlying liver disease

CTP A

Anatomical considerations

Early Intervention of Complications

HCC:

Doubles in size every 3 to 4 months.


Curative resection dependent on size among other
factors.
A 2 cm tumour enlarged to 8 cm within 8 to 9 months.
Early HCC is asymtomatic.
Patient may go from curative to non-curative within a
year if not adequately screened.

Early Intervention of Complications

To monitor for indications for liver transplant:


Need to wait on the transplant list.
Patients who are well will not need transplant.
Patients who are too sick have relatively worse
outcomes with liver transplant.
Unable to accurately timed the availability of organ in
cadaveric transplant.
Need preparations for liver transplant.

Measurements to Monitor

For suitability for treatment:


ALT
HBV DNA

For HCC development:


AFP
U/S

liver/abdomen

For decompensation:
Albumin
Bilirubin
INR

Measurements to Monitor

Most physicians will monitor:


LFT
AFP
U/S abdomen

HBV DNA- no clinical impact currently when ALT is


persistently normal.
INR - to do only when LFT shows decompensation.

Frequency of Monitoring

Rationale based on doubling time of HCC.


May be more frequent in patients at high
risks of HCC development.

Advance cirrhosis

Strong family history of HCC

Need to consider cost of and compliance to


screening.

Frequency of Monitoring

Most physicians will recommend:

3 to 6 monthly screening.
To do blood test and ultrasound of the abdomen at the
same time.
Proceed to other modalities of investigations only if
the above tests are abnormal.

Summary of Recommendations
Chronic hepatitis B is a chronic illness with
significant morbidity and mortality.
Early institution of appropriate treatment can
result in an improved outcome.
Regular follow-up is an established way to
detect complications early.

Summary of Recommendations
Most physicians will review their patients 3 to 6
monthly.
Each review will require the patients to have

LFT
AFP
Ultrasound of abdomen

Need to inform patient to need and aim of regular


follow-up.
Refer for appropriate treatment if certain
endpoints are met.

Thank You