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 .