Incidentally detected hepatitis b what next

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  • 1. Incidentally detected Hepatitis B - what next? Presenter: Pankaj Bagesar – Kasturba Hospital, Mumbai Moderator: Ujjal Poddar – Pediatric Gastroenterologist, SGPGI, Lucknow Panelists: Winita Hardikar - Pediatric Hepatologist, Royal Children's Hospital, Australia Philip Abraham – Gastroenterologist, Hinduja hospital, Mumbai Malathi Sathiyasekaran - Pediatric Gastroenterologist, Kanchi K C Trust Hospital, Chennai
  • 2. Incidentally detected Hepatitis B – what next?
  • 3. History A 12 year old boy, 2nd by birth order admitted with c/o ➢ Yellowish discolouration of eyes –20 days ➢ Dark yellow urine --20 days ➢ Abdominal pain 15 days back which lasted for 3 days
  • 4. History • • • • No h/o fever, bleeding, pruritus. No family history of jaundice . No h/o blood transfusion. Pt had not taken Hep A or B vaccine • Past history: similar complaints 5 years ago, recovered completely in few days
  • 5. Examination On Examination ❖ Vitals stable ❖ Icterus ++ ❖ No pallor ❖ No lymphadenopathy ❖ No peripheral stigmata of CLD
  • 6. Examination P/A – no distension /dilated veins umbilicus inverted, soft , non tender. Liver – 3 cm below costal margin, sharp margins, smooth surface, firm in consistency, with left lobe palpable. Liver span 9 cms Spleen -2 cm, soft. • Rest systemic examination was normal
  • 7. Diagnosis • PROVISIONAL DIAGNOSIS – HEPATITIS ? 2nd episode Chronic liver disease with acute exacerbation D/D -- Wilson’s disease -- Autoimmune Hepatitis -- Hepatitis B
  • 8. Investigations LFT : ALT - 469 AST - 499 T. BILIRUBIN -9.5 D. BILIRUBIN-3.9 ALPO4 -231 CBC –Hb 12, TLC 8500, P-54% ,L 45 %,E 1%, Acute hepatitis T.PROTEINS- 7.0 gm% ALBUMIN – 3.8gm% GLOBULIN – 3.2gm% PT-19/14, APTT -34/30 INR –1.12 PLT 3.8 x105
  • 9. Investigations • USG Abdomen was showing hepatomegaly with normal echo texture. Mild splenomegaly
  • 10. Serology • • • • Anti-HAV IgM –positive HBsAg - positive Anti-HCV- negative Anti-HEV IgM - negative
  • 11. Treatment • Patient was given symptomatic treatment.
  • 12. Impression • Acute hepatitis A on chronic liver disease (hepatitis B)
  • 13. Follow up investigations • Repeat LFTs 13/11 19/11 T. prot 7.2 7.0 Albumin 3.6 3.5 T. Bili 5.4 4.2 D.Bili 3.9 1.7 SGPT 503 573 SGOT 497 443 30/11 7.0 3.5 2.4 0.8 102 68
  • 14. Follow-up • After 6 months, LFTs normalized completely • HBsAg remained positive What next?
  • 15. Replicating markers of the patient
  • 16. PATIENT ON FOLLOW-UP AFTER 6 MONTHS • HBeAg – NEGATIVE • HBV DNA –1,200 IU/ml • LFT- ALT 34 AST 23 What is the diagnosis and what to do next? ❖Low replicating or inactive carrier ❖ALT monitoring: 6-12 monthly
  • 17. How to classify chronic HBV infection?
  • 18. Chronic hepatitis B Immune tolerant (IT) HBeAg+ Anti HBeDNA>106 IU/ml ALT< 2 times ULN Immune clearance (IC) Low replicating (LR) HBeAg+ Anti HBeDNA>20,000 IU/ml ALT> 2 times ULN HBeAgAnti Hbe+ DNA:-/<2,000 IU/ml ALT< 2 times ULN e - negative hepatitis (ENH) HBeAgAnti Hbe+ DNA>2,000 IU/ml ALT> 2 times ULN
  • 19. How to interpret HBV serology?
  • 20. Interpretation of reports Investigations Acute Hep B Chr Hep B with activity Chr Hep B (immune tolerant) Chr Hep B (inactive carrier) HBsAg + + + + IgM anti HBc + - - - +/- + + - Anti HBe - - - + HBV DNA ++ +++ (>105) +++++ (>107) +/- (<104) ALT Very high Raised N N Liver bx Not done Necro-infla+ fibrosis Near normal Normal HBeAg
  • 21. Approach of HBsAg +ve patient What investigations? Biochemical activity: ALT Replicating status: HBeAg, anti HBe, DNA (quantity) When to treat and with what?
  • 22. Treatment of horizontally acquired chr. HBV in children Approved drugs: Interferon, lamivudine, adefovir Indications:(Immune clearance or immune reactive*) ❖ Chr. HBV: HBsAg >6months ❖ Biochemical activity: ALT> 2 times ULN ❖ Replicating virus: HBeAg+, anti HBe-, HBV-DNA> 105 copies/ml ❖ Histological activity: Liver biopsy active hepatitis ❖ Age:>2 yrs AASLD 2009. J Pediatr Gastroenterol Nutr 1999: 29; 163-170
  • 23. INFANT BORN TO HBsAG POSITIVE MOTHER • HB vaccine with HB immunoglobulin within 12 hrs after birth. • HBIG – Dose 0.5 ml I.M • Vaccine –birth , 1 mth , 6 mth . • Dose - 10 micro gm / 0.5 ml . • If immunoglobulin not given then vaccine – 0 ,1 , 2 mths with additional dose at 9-12 mths .