Chronic hepatitis encompasses various liver disorders with inflammation and necrosis persisting for over six months, classified mainly by cause and stage. Chronic hepatitis B can manifest with a wide range of symptoms, and its diagnosis involves serological markers and laboratory findings, while treatment options include several antiviral medications depending on the severity and replication status. Chronic hepatitis D may complicate hepatitis B without increasing the likelihood of progression to chronic disease, and treatment is focused on long-term interferon administration.

1. Chronic Hepatitis
Author: dr. Jerrell
VOSmed Medical Course
Jakarta – Bandung – Semarang – Jogjakarta - Surabaya

2. Introduction
• Chronic hepatitis represent a series of liver disorders of varying
cause which hepatic inflamation and necrosis continue 6 months
• Terms :
1) Chronic lobular/persistent hepatitis
2) Chronic active hepatitis
• Classification is based on cause, grade, stages

3. Classification
• By Causes

4. Classification
• By Grading

5. Classification
• By Stage

6. Chronic hepatitis B
• Both the enterically transmitted forms of viral hepatitis, hepatitis
A and E, are self-limited and do not cause chronic hepatitis
• Chronic HBV infection can occur in the presence or absence of
serum hepatitis B e antigen (HBeAg), and generally, for both
HBeAg-reactive and HBeAg-negative chronic hepatitis B, the
level of HBV DNA correlates with the level of liver injury and risk
of progression.

7. Chronic hepatitis B (Clinical manifestation)
• Spectrum of clinical features of chronic hepatitis B is broad,
ranging from asymptomatic infection to debilitating disease or
even end-stage, fatal hepatic failure
• Fatigue is a common symptom, and persistent or intermittent
jaundice is a common feature in severe or advanced
cases. Intermittent deepening of jaundice, recurrence of
malaise, anorexia, as well as worsening fatigue

8. Chronic hepatitis B ( Laboratory findings)
• Laboratory features of chronic hepatitis B do not distinguish
adequately between histologically mild and severe hepatitis
• ALT > AST but after cirrhosis, AST overcome ALT
• Hypoalbuminemia and prolongation of the prothrombin time
occur in severe or end-stage cases

9. Hepatitis B serology
Kondisi
HBsAg HBcAg HBeAg HBV DNA IgM / IgG
anti-HBc
IgG anti-HBs
Infeksi Akut + + + + + (IgM) -
Window
Period - - - - + (IgM) -
Sembuh - - - - + (IgG) +
Kronik
replikatif + + + + + (IgG) -
Kronik non-
replikatif + - - - + (IgG) -
Imunisasi - - - - - +

10. Treatment
• Seven drugs have been approved for treatment of chronic hepatitis
B:
1. injectable interferon (IFN) α and pegylated interferon (long-
acting IFN bound to polyethylene glycol, PEG [PEG IFN]) and
2. The oral agents lamivudine, adefovir dipivoxil, entecavir,
telbivudine, and tenofovir disoproxil fumarate (TDF).
• Management of chronic hepatitis B is directed at suppressing the
level of virus replication

11. Treatment
• No treatment is recommended or available for inactive
“nonreplicative” hepatitis B carriers :
1. undetectable HBeAg
2. Normal ALT
3. HBV DNA ≤103 IU/mL documented serially over time)
• Recommend treatment in HBeAg-positive patients for HBV DNA
levels >2 × 103 IU/mL and ALT above the upper limit of normal

12. Treatment

13. Treatment
• One of the potent oral drugs with a high barrier to resistance
(entecavir or tenofovir) or PEG IFN can be used as first-line
therapy
• For children aged 2 to <18 with HBeAg-reactive hepatitis B (most
children will be HBeAg-reactive; no studies have been done in
children with HBeAg-negative chronic hepatitis B), treatment is
recommended if HBV DNA is detectable and ALT levels are
elevated, but not if ALT levels are normal

14. Hepatitis D(Delta)
• Chronic hepatitis D virus (HDV) may follow acute co-infection with
HBV
• Although HDV co-infection can increase the severity of acute
hepatitis B, HDV does not increase the likelihood of progression to
chronic hepatitis B.
• chronic hepatitis B plus D has similar clinical and laboratory
features to those seen in chronic hepatitis B alone.

15. • The clinical manifestation include Right upper quadrant
discomfort, nausea, vomiting, and in rare case jaundice.
• Diagnosis : HDV RNA detection
• Treatment : long-term IFN for at least a year and, in
responders, extension of therapy until HDV RNA and HBsAg
clearance
Hepatitis D(Delta)- Clinical manifestation

16. References
• Harrison’s Internal Medicine 20th Edition – Chronic hepatitis