Hepatitis-B

Hepatitis B virus

Viral hepatitis includes hepatitis A, B, C, D, and E. It has been estimated that there are more than 500 million hepatitis patients in the global population. One million four hundred thousand people die from it each year. It is the 7th most prevalent cause of death worldwide, and 60-80% of chronic hepatitis B patients will progress to liver cancer and die eventually.

Hepatitis B virus

Hepatitis B virus is considered to be a major health problem worldwide. At least 350 million people around the world are chronically infected, and 70% of these patients are in the Asia Pacific region. It is estimated that from the global population, 1 million people die from Hepatitis B and C per year, 600,000 from hepatitis B virus and 350,000 from hepatitis C virus. Of these deaths, they died from cirrhosis and complications from late stages of cirrhosis and have 10 times increased risk of liver cancer.

Hepatitis B infection

It can be found in both men and women of all ages. If infants are infected, it indicates infection during delivery. More than 60% of infection occurring in Asians is via mother-to-child. It is most commonly found in adolescents, which have up to 3 times the infection rate of children. In Thailand, 20 years ago the carrier rate was approximately 10%, but the rate has now decreased to 3-8% due to the fact that vaccination has been provided to infants since 1992. It is anticipated that more than 80% of infants have received the vaccine from 1996 onwards.

Transmission of hepatitis B virus

  1. From blood and all types of blood products received.
  2. From mother-to-child, not via the placenta, but via contaminated blood during delivery.
  3. From sexual intercourse.

Diseases caused by hepatitis B virus infection

  1. In adults more than 95% of acute hepatitis is completely cured, but only 20-25% of perinatal infected adults recover from this condition.
  2. Less than 5% of adults after the first infection end up with a chronic infection. This group includes 30% who are carriers and 70% who develop chronic cirrhosis. 75-80% of persons with perinatal infection will develop the chronic type.

Disease progression

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Acute hepatitis symptoms caused by hepatitis B virus
  1. No symptoms, but present with immunity against hepatitis B virus.
  2. Flu-like symptoms, with or without fever. Major symptoms include fatigue, muscle pain, nausea, vomiting, loss of appetite, weight loss. Joint pain and rash may be found in some patients. This phase takes around 1 week.
  3. Jaundice, dark urine, yellowish skin and white of the eyes (icteric phase). Jaundice might not be found in some patients. After the worst icteric phase, fatigue symptoms will gradually subside, which means the liver has entered a recovery phase. Icteric symptoms will gradually subside and finally return to normal. This phase takes around 4-8 weeks.

Chronic hepatitis symptoms caused by hepatitis B virus

Chronic hepatitis mostly presents with no symptoms. Some patients may have fatigue intermittently, but this can be self-recovered. Patients will realize that they are infected with the hepatitis B virus once they are diagnosed with hepatitis and followed up. This condition turns into chronic hepatitis, cirrhosis, and liver cancer. However, hepatitis may not be detected in some patients at all, but the virus can be found in their blood tests.

Cirrhosis symptoms

Patients in the early phase of cirrhosis do not generally present with symptoms or abnormalities. They can still perform their regular activities the same as usual. Symptoms present when they gradually lose their liver function. Signs and symptoms are divided into 2 categories:

1.Symptoms caused by loss of liver cell function that contribute to abnormality of nutrient and energy production, as well as toxin eradication. Symptoms include:

  • Fatigue, loss of appetite, nausea, vomiting, weight loss
  • Yellowish skin and white of the eyes
  • Ascites, leg edema
  • Dark, dry, and itching skin with no more lesions or rashes
  • Nose bleeding, scurvy, bleeding on pillow
  • Bruised skin, bruising easily
  • More sensitive to drugs, bacteria, or toxins than usual
  • Sick often, sepsis, infected ascites
  • Lethargy, drowsiness, confusion, or coma

2. Symptoms caused by liver fibrosis

  • Hematemesis, black stool, bloody stool due to a rupture or aneurysm in the esophagus
  • Enlarged spleen
  • Pale, low platelets, low white blood cells
  • Liver cancer: Patients with cirrhosis caused by the hepatitis B virus have a chance of developing liver cancer of up to 3-5% per year. Patients will lose weight, be pale, have yellowish skin and white of the eyes, and feel of a lump in the bowel.

Hepatitis B virus testing

1.Blood tests to detect the virus and to measure liver function:

  • Carriers: only the virus will be detected, but liver function will be normal.
  • Chronic hepatitis or cirrhosis: both the virus and abnormal liver function will be detected.

2. HBV viral load: This test will inform how much of the virus is in the blood stream and is useful in some patients who have virus mutations. A result showing false positive means the virus is not detected in the blood stream, but patients have hepatitis. Viral load test helps to confirm if the hepatitis B virus is the true cause of hepatitis.

3. Liver biopsy: The benefit of this test is to tell the degree of severity of liver pathology. Biopsy will be performed when treatment preparation is needed.

4. Transient elastography (Fibroscan®): This non-invasive test helps to detect liver fibrosis and to see if emergency treatment is needed.

Treatment of hepatitis B virus

Acute hepatitis

To date, there is no medicine for acute hepatitis treatment. The body can mostly heal and recover itself. Resting for about 4-8 weeks is typically recommended. Patients can consume food as normal, but nausea and vomiting may occur at the initial stage. Patients should avoid taking greasy foods due to less bile function, however, patients can take as usual if they do not have problems with fatty food digestion. Sweet drinks are not necessary, except when patients cannot take foods at the early stage, they can consume sweet drinks and fruit juices so as to have enough calories. When the symptoms are better, patients should stop taking them, since taking those heavily may cause a fatty liver. Other recommendations include: not drinking alcohol, or taking food supplements or herbs with unknown ingredients and their complications, not taking any medicines causing adverse effects on the liver.

Chronic hepatitis

Nowadays, we do not use the term “healthy carrier,” but chronic hepatitis is categorized into 2 phases, a remission phase and a relapse phase. It is recommended that women of child-bearing potential who are not in the relapse phase with severe conditions, i.e. a pathological test found cirrhosis, should have children as desired first prior to getting treatment assessment.

The reasons why chronic hepatitis patients need to be treated include:

  • Chronic infection of hepatitis B virus is a cause of illness and death
  • High rate of liver failure while our body is trying to eradicate the hepatitis B virus
  • High cost when it becomes cirrhosis and complications of late stage cirrhosis occur

Objectives of chronic hepatitis treatment are:

  • To eradicate viral infection
  • To reduce viral replication
  • To reduce liver tissue inflammation
  • To prevent cirrhosis and complications of late stage cirrhosis
  • To reduce chances of primary liver cancer
  • To reduce the mother-to-child infection rate in case of high viral load in pregnant women
  • To prevent viral relapse in patients who received chemotherapy or immunosuppressants

Treatment indication

  1. Patients with chronic infection more than 6 months
  2. Liver function abnormalities more than 2 times the upper normal limit
  3. Viral load in the blood stream of more than 2,000 iu/cc
  4. Hepatic Activity Index (HAI) equal to 4 or higher, or METAVIR equal to 2 or higher
  5. Liver fibrosis value represented with transient elastography test more than 7 kPa
  6. Patients with cirrhosis from the hepatitis B virus detected from blood tests
  7. Patients in the early stage of hepatic failure
  8. Patients who preparing for a liver transplant
  9. Patients who need to receive immunosuppressants
  10. Third trimester pregnant women with a viral load in the blood stream more than 2,000,000 iu/cc

Instructions for chronically infected patients

  1. Stop donating blood.
  2. Stop drinking alcohol and any alcoholic beverages. Do not take food supplements, herbs, or other medicines with unknown ingredients and side effects.
  3. Do not use cutlery, i.e. razor, nail cutters, with others. Use an uncontaminated spoon when taking food with others.
  4. When getting married, your partner should have a blood test to measure immunity against the virus. If your partner doesn’t have antibodies, vaccination is recommended at least 6 months prior to marriage. If there is only a short time available, contraception should be used until immunity is built up.
  5. Vaccination in all children of parents infected with the virus is recommended.
  6. Family members of infected patients should be advised to have a virus test. Vaccination is also recommended in persons without antibodies against the virus. Any infected person should consult a doctor.
  7. Patients with a virus infection should see a doctor to have a virus test and liver function test at least one time per year, except in the event that the virus infection becomes chronic hepatitis or cirrhosis, patients should come to see doctor regularly.
  8. Patients with chronic hepatitis should avoid heavy exercise or competition.
  9. Rest and get enough sleep, particularly in chronic hepatitis patients.

 

Complications of untreated hepatitis B virus

  1. May have risk of acute liver failure. Sometimes, this is life-threatening, because the group of people with chronic infection is more likely have an internal immune response activated by internal 2-7 times/life span.
  2. Chronic hepatitis.
  3. Cirrhosis and chronic liver failure and other complications from cirrhosis.
  4. Patients who have cirrhosis caused by the hepatitis B virus are 30-200 times more likely to develop liver cancer than healthy people.

Cancer screening

  1. All men aged 40 years or above and women aged 50 years or above who are infected with hepatitis B virus should receive a screening test.
  2. Patients with cirrhosis at all ages.

Screening by ultrasound technique or measurement of cancer biomarker (alfa-fetoprotein) should be performed annually. Patients with cirrhosis should receive a screening test every 6 months or every 3 months in patients having risk factors.

Conclusion

The hepatitis B virus can cause a severe pathological condition of the liver; however, this can be prevented by vaccination, particularly in persons whose work relates to blood or blood products or to other people who are at risk of infection, i.e. family members, etc. Thus, it is the doctor’s responsibility when a virus infection is detected, to not only to give instructions to the infected patients, but to also give instructions to individuals close to them about treatment and prevention in order to help eradicate the hepatitis B virus from the world.