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Gastrointestinal & Hepatic System

Chronic Hepatitis B Infection

Persistent infection with the Hepatitis B virus (HBV) for more than 6 months (defined by presence of HBsAg). Can lead to chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC).

Also known as: Chronic HBV, Hep B Carrier

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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)

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