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home - Liver - Hepatitis B - Hepatitis B Overview Written by Dr Sebastian Zeki
Knowledge


Understands the serological interpretation categorisation and
investigation of patients with chronic hepatitis B and/or C with
particular emphasis on the need for treatment and surveillance

Recognises the particular populations at risk
Aware of national and international agreed guidelines on viral
hepatitis management and use of interferon and antiviral drugs

Aware of hepatitis B reactivation in the context of immunosuppression
Skills
Uses appropriate diagnostic modalities including serology
genotyping viral load measurements liver biopsy and related
investigations

Monitors anti-viral and immunomodulatory therapies with appropriate
investigations

Behaviours
Communicates effectively with patients and relatives in the context of
viral liver disease and underlying social and psychological risk factors

Marshals multi-disciplinary support networks and in particular
recognise the crucial role of nurse practitioners in disease
management

Also...

Knowledge


Identifies patients with acute hepatitis B and can a rtain the
severity of their illness

Defines the different phases of chronic hepatitis B infection with a
clear understanding of serological results

Appreciates risks of transmission to close contacts
Has awareness of indications for therapy in both HBeAg positive and
negative hepatitis and the potential influence of genotype on choice of
therapy

Identifies patients where prophylaxis is required to prevent
reactivation and vertical transmission

Can determine an appropriate surveillance programme for those
patients with varices and/or hepatocellular carcinoma

Identifies patients who are appropriate candidates for liver transplant


Skills
Demonstrates ability to take a relevant history perform examination
and organise appropriate investigations

Able to advise risks of viral transmission
Interprets results of blood tests for hepatitis B antigen and antibody
Appreciates when liver biopsy is appropriate
Be able to select the most appropriate treatment and how to monitor
patient response

Able to select appropriate imaging techniques for evaluation of
abnormal results
Behaviours
Appreciates the cultural differences in the ethnic populations infected
and the influence this may have on screening


Provides advice and education to families and shows appreciation of
the potential difficulties that may arise

Understands the importance of cooperation with virologists and staff
in other clinical laboratories

Hepatitis B Overview

Hepatitis B Profile 8 7 6 5 4 3 2 HBeAg Chronic HBV infection It is defined as the persistence of HBsAg for > 6 months.HBeAg-negative with normal ALT and low/ -ve HBV DNA are in an inactive carrier state- good prognosis and no antivirals are needed.If HBeAg-negative patients have an elevated serum ALT, test for HBV DNA to exclude persistent HBV (wild type or mutant) replication. Past HBV infection Previous HBV infection is characterized by the presence of anti-HBs and IgG anti-HBc.Immunity to HBV infection after vaccination is indicated by the presence of anti-HBs only. Acute hepatitis This is based on the detection of HBsAg and IgM anti-HBc.Initially, HBeAg and HBV DNA, are present.During recovery: HBV DNA disappears, HBeAg to anti-HBe seroconversion occurs, and subsequently HBsAg to anti-HBs seroconversion happens. HBeAg to anti-HBe seroconversion occurs early in patients with acute infection, prior to HBsAg to anti-HBs seroconversionHBeAg to anti-HBe seroconversion usually assoc. with dec. in serum HBV DNA and remission of liver disease -HBsAg disappears then hepatitis B surface antibody (anti-HBs) appears immediately (for life)- sometimes there is a gap of weeks so can make dx by detection of IgM antibodies against hepatitis B core antigen (IgM anti-HBc)-If HBsAg and anti-HBs co-exist then patient is hepatitis B virus carrier Diagnosis of Hepatitis B Isolated anti-HBcSignificance of this is unclear.Only 10% have detectable HBV DNA.The risk is highest when livers from anti-HBc positive donors are transplanted.Hepatitis serology should be repeated.If anti-HBc remains +ve after repeat testing, test IgM for HepBcore to rule out recent infection.Also test for HBV DNA to exclude low level chronic HBV infection. Hepatitis B core antigen and antibody This is intracellular antigen that is expressed in infected hepatocytes and not detectable in serum.Anti-HBc IgM can be detected up to 2 years after an acute infection, and during exacerbations.It also persists in association with HBsAg in those who progress to chronic HBV infection.Become IgG in those who recover from acute hepatitis B . Hepatitis B SAg and AbThis is the serologic hallmark of HBV infection-detected by radioimmunoassays (RIA) or enzyme immunoassays (EIA).They appear around 5 weeks after an acute exposure to HBV, before patients become symptomatic, or the ALT rises. Hepatitis B e antigen and antibody.This is a secretory protein that is processed from the precore protein.e-antigen is a marker of HBV replication and infectivity.The presence of HBeAg is usually associated with high levels of HBV DNA in serum and higher rates of transmission of HBV infection from carrier mothers to their babies. Serologic diagnosis of hepatitis B virus infection Diagnostic Presentations:Occult HBV infection — =HBV DNA positive but HBsAg negativeHep B Positive status depends on presence of anti Hbc Anti HBc IgM Anti HBc IgG HBsAg Anti HBs Interpretation +ve-ve-ve-ve-ve-ve -ve-ve+ve-ve-ve+ve +ve+ve+ve-ve-ve+ve -ve-ve+ve+ve-ve+ve Acute HBV infectionEarly acute HBV infectionResolved acute HBV infectionNot infectedPrior vaccination for HBVNot infectedChronic HBV infection Written by Dr Sebastian Zeki Interpretation of Hepatitis B tests Important diagnostic tests Relative concentration of reactants Symptoms SGPT (ALT) Months after exposure Level of detection Anti-HBc Anti-HBs HBsAg Anti-HBc “Core window” HBV particles DNA polymerase Anti-HBc (anti-HBc) Anti-HBc Later Early Convalescence HBSAg (anti-HBc) Prodrome acute disease HBSAg Incubation period 1

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