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Chronic Hepatitis B Diagnosis When to refer. Dr Yeung Yat Wah 楊日華醫生. Screening for HBV. Persons born in hyperendemic areas Men who have sex with men Injection drug users Patients on dialysis HIV patients Pregnant women Family, household, and sexual contacts. Prevention of infection.
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Chronic Hepatitis BDiagnosis When to refer Dr Yeung Yat Wah 楊日華醫生
Screening for HBV • Persons born in hyperendemic areas • Men who have sex with men • Injection drug users • Patients on dialysis • HIV patients • Pregnant women • Family, household, and sexual contacts
Prevention of infection • Have sexual contacts vaccinated • Use barrier method • Not share toothbrushes or razors • Cover open cuts and scratches • Clean blood spills with detergent or bleach • Not donate blood or sperms • Safe: • Contact sports, sharing food, utensils • Kiss
Natural HistorySelecting patient to treat • Immune tolerance phase • First 3 decades • Very high viral load with normal ALT • Immune clearance phase • Liver damage with high ALT, can be asymp • HBeAg seroconversion • Quiescent phase
Evaluation • Hx and P/E • FHx of liver ds, Hepatitis B, HCC • Lab tests • CBP, PI • HBeAg/Ab HBVDNA • USG • Fibroscan • Liver Bx
Fibroscan – How it works • Fibroscan is non-invasive, good reproductivity, and easy operations • Patients need to • lay down and • put his right • arm during the • examination
Fibroscan – How it works • The probe is placed at the intercostal space of the rib bones • Shear (mechanical) wave is triggered by pressing the button at the probe • The ultrasound will track the • speed of the shear wave • The harder the liver and faster • the speed higher stiffness(LSM); • softer the liver and slower the • speed lower stiffness(LSM)
LSM is highly reproducible Overall interobserver agreement ICC: 0.98 Intraobserver agreement ICC: 0.98 Intraobserver agreement ICC: 0.98 • Study population: 200 patients with chronic liver diseases • 800 LSMs were performed • Intraobserver and interobserver agreement were analyzed using the intraclass • correlation coefficient (ICC) LSM is a highly reproducible and user-friendly technique for assessing liver fibrosis in patients with chronic liver diseases Fraquelli et al. Gut. 2007
Factors Associated with LSM Failure 60 LSM failure rate(%) 41.7% 40 24.9% 20 16.9% BMI (kg/m2) 12.4% 8.1% N=4172 N=3089 N=1568 N=967 N=225 N=48 1.0% Factors associated with LSM failure: 0 • BMI (>30 kg/m2) • Operator experience (<500 examinations) • Age(>52y) • Type 2 diabetes • Time of examination <25 ≥25 ≥28 ≥30 ≥35 ≥40 Castera et al. Hepatology. 2010
LSM in CHC: Treatment Effects LSM decreases in sustained responders following IFN-based therapy in patients with chronic HCV Wang et al. J Gastroenterol Hepatol. 2010
LSM in CHB: Treatment Effects 100% 25% F4 (≥11.0 kPa) F3 (8.1-10.9 kPa) F0/F1 (<7.2 kPa) 53% 75% F2 (7.3-8.0 kPa) • Study population: 53 patients with cirrhosis; 13 patients with advanced fibrosis • Median treatment duration: • 50.5 months • Transient elastography examinations demonstrate that prolonged treatment with NUCs in patients with CHB results in low liver stiffness 100% 100% 12% 50% 58% 17% 35% 25% 0 Before After Before After Advanced fibrosis before treatment Cirrhosis before treatment Andersen et al., Scand J Gastroenterol. 2011
Treatment • Aims: sustained suppression • Prevent cirrhosis, hepatic failure, and HCC • Assess treatment response • ALT • Decrease in serum HBVDNA • Loss of HBeAg with + HBeAb • Improvement in histology
Candidates for Referral • Cirrhosis • Chronic Hepatitis B • ALT above 2x and HBVDNA 5 log copies • Any ALT elevations with HBVDNA 5 log • Above 40 • Liver bx showing active disease or sig fibrosis
Monitoring for those who do not need treatment • HBeAg+ with normal ALT • LFT every 3-6 months • More frequent if ALT elevated • For persistent slightly high ALT, consider liver biopsy esp above 40 years of age • In young patients (below 30) liver biopsy is usually not necessary if ALT is persistently normal • HBeAg status every 6-12 months
Monitoring for those who do not need treatment • HBeAg negative • Monitor LFT every 3 months during the first year to verify that they are truly inactive • Then every 6-12 months
Case sharing (1) • HKU student, 20 years old • Normal LFT • Normal USG • No need to check HBVDNA • HBeAg status
Case sharing (2) • Young man, 22 years old • Normal LFT • Normal USG • HBVDNA 9 logs • HBeAg + • Started on oral drugs and referred to HA
Case sharing (3) • Male 65 years old • Known HB years ago during regular blood check • No regular follow up and monitoring • Recently seen by his family physician and LFT showed ALT 200+, so referred to Medical
Case sharing (3) • As his ALT was high an early appointment was given (2 weeks) • New case assessment: P/E normal • Taking his age and deranged LFT into account, an early USG was arranged in a week which showed a 3 cm mass • Confirmed HCC with surgery done and received treatment for his HB
Case sharing (4) • 44 gentleman seen by GP for years • Known Hepatitis B for years • In recent 3-4 years noted a slightly high ALT around 40+ to 50+ • USG showed fatty liver • Continue to monitor
Case sharing (4) • Came to seek a second opinion • USG showed moderate coarsening suggesting cirrhosis. Spleen was also enlarged to 11.5 cm. Platelet count was low at 100+ • HBVDNA was 3 logs • Treated with oral drugs
Case sharing (5) • Male 55 years old • Known HB during pre-marital check up • No regular follow up • Taking herbs for eczema for a year • Noted ankle and scrotal oedema, seen by GP, noted deranged LFT with ALT 300+, RFT also abn with creatinine 130+, USG showed a few nodules below 1 cm • Adm PWH due to dizziness
Case sharing (5) • While waiting for hepatologist assessment came to see me • USG showed a vague large mass 6 cm but PV was patent, Alb normal • ? HCC but some element due to herbs? • CT scan confirmed several masses and extensive IVC infiltration and LN involvement
HCC screening • LFT AFP and USG every 6 months • Male HB patients over 40 • Female HB over 50 • Any Cirrhosis • FHx of HCC in HB patients
ROC Curves for Model Validation Cut-off risk score: 12 Sensitivity: 0.84 Specificity: 0.73