Management in

Chronic Hepatitis B

Chronic hepatitis B
HBsAg persistent in blood more than 6 mth

Phase of CHB infection

Immune-tolerant phase
HBeAg-positive immune active phase
Inactive CHB phase (HbeAg-negative immune
inactivate)
HBeAg-negative immune reactivation phase

Immune tolerate phase

Highly replicate, low inflammatory phase
HBeAg +
HBV DNA levels are elevated
ALT normal
Liver biopsy with out sign of inflammation
Duration of this phase : variable, longest in perinatally
infection
Transform to HBeAg-positive immune active phase
No treatment

HBeAg-positive immune active

phase
HBeAg +
Elevated ALT
Elevated HBV DNA level
Liver biopsy liver inflammation
The hallmark of transition from the HBeAg-positive
immune-active to inactive phases is HBeAg
seroconversion
Seroconversion 8-12% per year in adult
Indicated to treat

Inactive CHB phase (HBe-Ag

negative immune inactive)
HBV DNA levels are low or undetectable
ALT normal
HBeAg Anti-HBe positive
Liver biopsy : minimal necroinflammation, but variable fibrosis
(reflecting previous liver injury)
67-80% remain in this phase
4-20% reversion back to HBeAg positive
10-20% HBeAg-negative immune reactivation phase
No treatment

HBeAg-negative immune
reactivation phase
High HBV DNA level
High ALT
HBeAg negative (tend to have lower serum HBV DNA
level than HBeAg positive but are more likely to
experience a fluctuation course exacerbation of
hepatitis)
AntiHBe +
Liver biopsy : inflammation + fibrosis
HBV variants in the precore or core promoter region

Management in chronic hepatitis

History taking + Physical examination
R/O other cause of chronic liver disease
Investigation
Routine lab test : CBC, Liver function test, INR
Serology : HBsAg, HBeAg, Anti-HBe, HBV DNA viral load, HCV,
HIV

Treatment
INF more S/E , 2-11% HBsAg seroconversion
Nucleoside
Lamivudine low genetic resistance barrier
Telbivudine low genetic resistance barrier

Nucleotide
Entecavir high genetic resistance barrier
Adefovir moderate genetic resistance barrier
Tenofovir high genetic resistance barrier

Goal of treatment
The term cure was avoided in treatment of CHB
Decrease the morbidity and mortality related to CHB
Normalized the ALT
Lost of HBeAg with or without detection of anti-HBe
Improvement in liver histology
Immunological cure : lost of HBsAg, sustained HBV DNA
suppression
Virological cure : eradication of virus including the
cccDNA not goal of treatment

Management in
Chronic hepatitis C

Hepatitis C
8% turn to chronic Hepatitis C chronic liver
inflammation
10-30 year liver cirrhosis
1-3%/year develop HCC
6 type of hepatitis C
Type I, III 40%
Type II second most common
IV V VI less common

Work-up for treatment

HCV IgG
HCV RNA viral load
HCV genotype
HBsAg, Anti-HBc, Anti HIV
CBC, LFT, Coagulogram

Indication for treatment

HCV infection patient
Priority of treatment
First priority

Liver cirrhosis (Child purge score < 9)

Liver bridging fibrosis (METAVIR =3)
HIV or HBV comorbid
Indicated for liver transplant

Second priority
Liver significant fibrosis (METAVIR = 2)
Risk of transfer HCV infection to other person
Plan of pregnancy
CKD with dialysis

Drug
Pegylated interferon alfa 2a / 2b
Ribavarin (antiviral drug) treat RSV infection
Boceprevir
Sofosbuvir
Daclatasvir

Thank you