Hepatology

Immune Tolerant Phase: Common in younger patients infected perinatally or in childhood. Characterized by high HBV DNA (>1×10⁷ IU/mL) and normal ALT. Risk of progression to fibrosis is low, but patients should be monitored every 6–12 months with ALT, HBV DNA, HBsAg, and HBeAg status. Fibroscan should be performed every 2–3 years​

Immune Active Phase: Patients exhibit elevated ALT and HBV DNA (>2000 IU/mL). Immediate treatment with Tenofovir or Entecavir is recommended to suppress viral replication and reduce liver inflammation. Monitoring involves 3–6 monthly checks during active treatment, then 6–12 months once stable

Inactive Carrier: Patients are HBeAg negative, with low or undetectable HBV DNA. Monitor for ALT flares and reactivation every 6–12 months. Treat if reactivation occurs​

Cirrhotic Patients:All require antiviral therapy irrespective of HBV DNA levels to prevent further decompensation and HCC development.Perform 6-monthly ultrasound and AFP for HCC surveillance and refer for varices screening if Fibroscan >20 kPa or platelets <150​

Special Situations:

• Hepatitis B Reactivation: Treat reactivation aggressively if ALT is elevated and HBV DNA >2000 IU/mL.
• Pregnancy: Use Tenofovir from 32 weeks if maternal HBV DNA >10⁶ IU/mL to prevent vertical transmission. Infants require HBV vaccine and immunoglobulin within 24 hours of birth

Treatment protocols often vary from trust to trust – here is a summary of the NUTH ( Newcastle guidelines)

Induction Therapy:Start with Prednisolone 40 mg daily. Taper weekly by 5 mg to reach a maintenance dose of 10 mg, adjusting based on therapeutic response (normalization of ALT and IgG). Consider Budesonide in non-cirrhotic patients for fewer systemic side effects.

Maintenance Therapy:Alternatives include Mycophenolate Mofetil for Azathioprine intolerance or Tacrolimus for refractory cases.Azathioprine is the first-line option (1 mg/kg/day). It is contraindicated in acute presentations with jaundice and requires TPMT testing before initiation​

Monitoring: Patients in remission need 6-monthly clinic reviews and blood tests every 3 months. Cirrhotic patients require additional HCC surveillance with ultrasounds every 6 months​.

Prognosis: Withdrawal of immunosuppression may be considered after 2–3 years of sustained biochemical remission, although relapse rates are high​

First Line: Ursodeoxycholic acid (UDCA) 13–15 mg/kg/day. Evaluate response after 12 months using ALP and bilirubin thresholds (e.g., POISE criteria: ALP >1.67x ULN indicates incomplete response)​

Second Line: Obeticholic acid or Bezafibrate for patients who do not respond or are intolerant to UDCA. Start at low doses (e.g., Obeticholic acid 5 mg/day) with close monitoring

Surveillance:

Cirrhotic patients need biannual imaging and AFP for HCC surveillance. Bone density assessment is recommended every 5 years due to the risk of osteoporosis​

Management of Symptoms:

• Itch: Options include cholestyramine, rifampicin, or gabapentin. Regular iron studies are advised as iron deficiency may exacerbate symptoms​
• Fatigue: No proven therapies; screen for and treat contributing factors such as thyroid dysfunction or vitamin deficiencies.

Therapy:

While there are no licensed long-term therapies, UDCA (13–15 mg/kg/day) may improve liver biochemistry but does not alter long-term outcomes.Regular Fibroscan helps monitor disease progression

Surveillance:

Annual CA19-9 and AFP with imaging every 6 months to monitor for cholangiocarcinoma or HCC.Patients with concomitant IBD require annual colonoscopy with biopsies to screen for colorectal cancer​

Referral Criteria:

Transfer to a specialized center if encephalopathy, INR >2, or bilirubin >300 μmol/L is present. Early intubation and ventilation should be considered for safe transport​. Discussion with teriatry center when PT is increasing and approaching 50.

Management:Initiate N-Acetylcysteine (NAC) for both paracetamol and non-paracetamol etiologies.Correct coagulopathy judiciously; avoid routine INR correction unless invasive procedures are planned​. Regularly monitor blood glucose to prevent hypoglycemia. Sodium levels should be kept at 140–145 mmol/L to minimize the risk of cerebral edema​.