Chronic Hepatitis B Diagnosis When to refer

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Chronic Hepatitis BDiagnosis When to refer

• Dr Yeung Yat Wah
• ?????

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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

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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

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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

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Evaluation

• Hx and P/E
• FHx of liver ds, Hepatitis B, HCC
• Lab tests
• CBP, PI
• HBeAg/Ab HBVDNA
• USG
• Fibroscan
• Liver Bx

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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

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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)

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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
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Factors Associated with LSM Failure
N4172 N3089 N1568
N967 N225 N48
Factors associated with LSM failure

• BMI (gt30 kg/m2)
• Operator experience (lt500 examinations)
• Age (gt52y)

• Type 2 diabetes
• Time of examination

Castera et al. Hepatology. 2010
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LSM in CHC Treatment Effects
Group (n) Initial LS Range (kPa) 2nd LS Range (kPa) LS Change (median, kPa) P Value
Sustained virological response (SVR) Sustained virological response (SVR) Sustained virological response (SVR) Sustained virological response (SVR) Sustained virological response (SVR)
Total (95) 3.0-70.6 2.7-33.8 -36.8 16.7 (-0.6) lt0.001
F 0-1 (33) 3.0-9.0 2.7-8.3 -3.3 2.6 (-0.5) 0.042
F 2-4 (57) 3.6-70.6 3.0-33.8 -36.8 16.7 (-1.0) 0.003
Non-sustained virological response (NSVR) Non-sustained virological response (NSVR) Non-sustained virological response (NSVR) Non-sustained virological response (NSVR) Non-sustained virological response (NSVR)
Total (49) 4.1-49.7 4.1-61.5 -14.6 23.6 (0.8) 0.557
F 0-1 (10) 5.3-17.1 4.1-16.0 -4.3 6.4 (0.9) 0.959
F 2-4 (32) 4.6-49.7 5.9-61.5 -14.6 23.4 (0.3) 0.694
LSM decreases in sustained responders following
IFN-based therapy in patients with chronic HCV
Wang et al. J Gastroenterol Hepatol. 2010
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LSM in CHB Treatment Effects

• 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

Andersen et al., Scand J Gastroenterol. 2011
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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

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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

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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

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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

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Case sharing (1)

• HKU student, 20 years old
• Normal LFT
• Normal USG
• No need to check HBVDNA
• HBeAg status

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Case sharing (2)

• Young man, 22 years old
• Normal LFT
• Normal USG
• HBVDNA 9 logs
• HBeAg
• Started on oral drugs and referred to HA

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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

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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

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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

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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

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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

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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

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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

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Cumulative Risk Scores and Projected HCC Risk
Risk predictor Risk score
Gender  
Female 0
Male 2
Age
30-34 0
35-39 1
40-44 2
45-49 3
50-54 4
55-59 5
60-65 6
ALT, U/L  
lt15 0
15-44 1
45 2
HBeAg  
Negative 0
Positive 2
HBV DNA level, copies/mL  
lt300 (Undetectable) 0
300-9999 0
10000-99999 3
100000-999999 5
?106 4
Cumulative risk score HCC risk HCC risk HCC risk
Cumulative risk score At 3rd year At 5th year At 10th year
0 0.0 0.0 0.0
1 0.0 0.0 0.1
2 0.0 0.0 0.1
3 0.0 0.1 0.2
4 0.0 0.1 0.3
5 0.1 0.2 0.5
6 0.1 0.3 0.7
7 0.2 0.5 1.2
8 0.3 0.8 2.0
9 0.5 1.2 3.2
10 0.9 2.0 5.2
11 1.4 3.3 8.4
12 2.3 5.3 13.4
13 3.7 8.5 21.0
14 6.0 13.6 32.0
15 9.6 21.3 46.8
16 15.2 32.4 64.4
17 23.6 47.4 81.6
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ROC Curves for Model Validation
Cut-off risk score 12 Sensitivity
0.84 Specificity 0.73
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Thank You