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Referral and warning signs
When to refer
Refer ALL patients diagnosed with chronic Hepatitis B to a specialist (Gastroenterologist/Hepatologist/Infectious Diseases) for: Assessment of disease phase and severity. Decision regarding antiviral treatment initiation. Management of antiviral therapy and monitoring. HCC screening. Management of cirrhosis complications.
Red flags
- Signs of liver decompensation (jaundice, ascites, encephalopathy, variceal bleeding)
- Signs suggestive of HCC (weight loss, palpable liver mass, rising AFP)
- Development of significant side effects from antiviral therapy
- Pregnancy in HBsAg+ woman (requires assessment for treatment/infant prophylaxis)
Signs and symptoms
- Often asymptomatic for many years.
- May have non-specific symptoms: Fatigue, malaise, mild RUQ discomfort.
- May present with symptoms of complications:
- - Cirrhosis: Jaundice, ascites, peripheral oedema, splenomegaly, easy bruising.
- - Portal Hypertension: Oesophageal/gastric variceal bleeding (haematemesis/melaena).
- - Hepatic Encephalopathy: Confusion, altered mental status, asterixis.
- - Hepatocellular Carcinoma (HCC): Weight loss, worsening RUQ pain, palpable liver mass, decompensation.
- Acute flares (reactivation) can occur, mimicking acute hepatitis.
Risk factors
- Perinatal transmission (mother to child - most common route to chronic infection globally)
- Exposure in early childhood
- Lack of HBV vaccination
- Risk factors for HBV acquisition (see GI017)
- Male gender
- Older age
- High HBV viral load (HBV DNA)
- HBeAg positivity
- Co-infection with HCV, HDV, or HIV
- Alcohol consumption
- Family history of HCC
Diagnosis
Clinical assessment
Diagnosis confirmed by persistent HBsAg positivity for >6 months. Assess phase of infection (immune tolerant, immune active/HBeAg+, immune control/inactive carrier, HBeAg-negative chronic hepatitis) based on HBeAg/Anti-HBe status, ALT levels, and HBV DNA levels. Assess stage of liver disease (presence of cirrhosis).
Investigations
- Hepatitis B Serology: HBsAg (+), Anti-HBc Total (+), Anti-HBc IgM (-), HBeAg (+/-), Anti-HBe (+/-), Anti-HBs (-).
- HBV DNA quantification (Viral Load): Key for monitoring and treatment decisions.
- Liver Function Tests (LFTs): ALT/AST (persistently elevated ALT suggests active inflammation), Bilirubin, Albumin, INR/PT.
- Assessment of Fibrosis/Cirrhosis:
- - Non-invasive markers: APRI score [(AST/ULN) x 100 / Platelet count], FIB-4 score.
- - Transient Elastography (FibroScan): Measures liver stiffness.
- - Liver Biopsy (less common now for staging, used if diagnosis uncertain or discordance).
- Screening for Co-infections: Anti-HCV, Anti-HDV (if relevant), HIV test.
- Screening for Hepatocellular Carcinoma (HCC): Abdominal Ultrasound and Alpha-fetoprotein (AFP) every 6 months for patients with cirrhosis or other high-risk groups (e.g., Asian males >40, family history HCC).
Diagnostic criteria
HBsAg positive for > 6 months.
Management
Non-pharmacological management
- Regular monitoring (LFTs, HBV DNA, HCC screening).
- Avoid alcohol.
- Maintain healthy weight.
- Vaccination against Hepatitis A.
- Counseling on transmission prevention (safe sex, avoid sharing sharps/razors/toothbrushes).
Pharmacological treatment
- Goal: Suppress HBV DNA replication, normalize ALT, prevent progression to cirrhosis/HCC.
- Treatment Indications (Based on combination of HBV DNA level, ALT level, HBeAg status, and severity of liver disease/fibrosis - Refer to National/International Guidelines):
- - Generally treat if significant HBV DNA AND elevated ALT OR evidence of moderate/severe fibrosis/cirrhosis.
- - All patients with cirrhosis and detectable HBV DNA should be treated.
- - All patients with HBV/HIV co-infection should be on ART regimen containing Tenofovir.
- Preferred Antiviral Agents (Long-term/indefinite therapy usually required):
- - Tenofovir disoproxil fumarate (TDF) 300mg PO once daily.
- - Entecavir 0.5mg PO once daily (1mg daily if lamivudine-resistant).
- - Tenofovir alafenamide (TAF) 25mg PO once daily (newer, potentially less renal/bone toxicity than TDF).
- - (Older agents like Lamivudine, Adefovir, Telbivudine less preferred due to lower efficacy/higher resistance).
- - Pegylated Interferon alfa: Finite duration therapy, less used now due to side effects/lower efficacy than Nucs.
- Management of Complications:
- - Cirrhosis/Portal Hypertension: Beta-blockers (Propranolol/Nadolol) for primary/secondary variceal bleed prophylaxis, diuretics for ascites, Lactulose for encephalopathy.
- - HCC: Specialist management (surgery, ablation, chemoembolization, systemic therapy).
Monitoring
- During Treatment: Monitor HBV DNA and ALT levels (e.g., every 3-6 months initially, then 6-12 monthly once suppressed). Monitor HBeAg/Anti-HBe seroconversion.
- Monitor for drug side effects (esp. renal function/phosphate with TDF).
- Monitor for development of resistance (if older agents used or adherence poor).
- Continue regular HCC screening (Ultrasound +/- AFP every 6 months) in patients with cirrhosis or high risk, even if virally suppressed.
Complications
- Chronic Hepatitis (inflammation)
- Liver Cirrhosis
- Portal Hypertension (Varices, Ascites, Encephalopathy, Splenomegaly)
- Hepatocellular Carcinoma (HCC)
- Acute-on-chronic liver failure (often triggered by reactivation or superinfection)
- Extrahepatic manifestations (e.g., polyarteritis nodosa, glomerulonephritis)
Prevention
- Universal infant HBV vaccination.
- Catch-up vaccination for unvaccinated children/adolescents.
- Vaccination of high-risk adults.
- Screening of pregnant women and administration of vaccine +/- HBIG to infants born to HBsAg+ mothers.
- Blood safety, safe injection practices, safe sex.
Patient education
- Explain chronic HBV infection, potential for progression, lifelong nature.
- Mode of transmission and how to prevent spread to others (safe sex, no sharing sharps).
- Critical importance of avoiding alcohol.
- Need for regular long-term monitoring (blood tests, ultrasound).
- Indications for and goals of antiviral therapy (suppression, not cure).
- Importance of adherence if on treatment.
- Need for vaccination against Hepatitis A.
- Screening of family members/sexual partners.
Uganda-specific notes
High HBV prevalence. Perinatal transmission and early childhood infection common routes. Tenofovir (often within ART regimens for co-infected) and Entecavir are key antivirals. Access to HBV DNA, FibroScan, specialist care limited. HCC screening crucial but challenging.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 6, Section 6.5.2
- National Hepatitis B Guidelines, MOH Uganda
(Primary reference for detailed management)