Chronic Hepatitis

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This refers to chronic inflammation of the liver of more than 6 months duration, with persistently elevated liver function tests. Chronic hepatitis can progress to liver cirrhosis, portal hypertension with upper gastrointestinal bleeding, hepatic encephalopathy and hepatocellular carcinoma.

Immunisation against Hepatitis B is now available for children under the Expanded Programme on Immunisation (EPI). Adults in endemic areas including Ghana should be immunised against Hepatitis B infection after initial assessment of their immunological status regarding previous exposure to the virus.

Long-term monitoring for disease activity and hepatocellular carcinoma screening with six-monthly Hepatitis B viral DNA quantification, LFTs, abdominal ultrasound and alpha fetoprotein is mandatory for patients with chronic hepatitis B.

Cause

  • Hepatitis B virus (HBV)
  • Hepatitis C virus (HCV)
  • Hepatitis E virus (genotype 3)

Symptoms

  • Usually asymptomatic
  • Mild non-specific symptoms
  • Recurrent fever
  • Arthralgia
  • Malaise
  • Jaundice
  • Lethargy

Signs

Stigmata of chronic liver disease

  • Palmar erythema
  • Clubbing
  • Dupuytren’s contracture
  • Parotid enlargement
  • Gynaecomastia
  • Testicular atrophy
  • Spider naevi

Signs of decompensated liver disease

  • Jaundice
  • Ascites
  • Encephalopathy
  • Peripheral oedema (hypoalbuminaemia)
  • Purpura/skin bruising (coagulopathy)

Investigations

  • FBC
  • LFTs
  • INR
  • HIV
  • Baseline Alpha-Feto-protein
  • Abdominal ultrasound scan
  • Liver biopsy

Chronic Hepatitis B

  • Hepatitis B surface Antigen (HBsAg)
  • HBc IgG
  • Hepatitis-B-e-antigen (HBeAg) & Anti-HBe
  • Hepatitis B Viral Load

Chronic Hepatitis C

  • Hepatitis C Virus (HCV) antibody testing
  • HCV RNA
  • HCV genotyping

TreatmentTreatment Objectives

  • To prevent disease progression and complications
  • To prevent hepatic encephalopathy
  • To improve synthetic liver function through viral suppression
  • To prevent transmission

Non-pharmacological treatment

  • Prevention of transmission to partners (e.g. protected sex, not sharing of toothbrushes and sharps, blades, needles, body piercings, tattoos, cultural scarification practices, circumcisions etc.)
  • Lifestyle/dietary advice
  • Spouse/household screening

Pharmacological treatment

Chronic Active Hepatitis B (HBeAg positive or HBeAg negative)

1st Line Treatment Evidence Rating: [A]

  • Pegylated Interferon alfa-2a, subcutaneous,

OR

  • Tenofovir, oral,

OR

  • Entecavir, oral,

2nd Line Treatment

Evidence Rating: [A]

  • Lamivudine, oral,

Decompensated liver cirrhosis/ Fulminant Liver failure from

Chronic Hepatitis B

1st Line Treatment Evidence Rating: [A]

  • Tenofovir, oral,

OR

  • Entecavir, oral,

2nd Line Treatment

Evidence Rating: [A]

  • Lamivudine, oral,

Patients with Chronic Hepatitis B undergoing chemotherapy or immunosuppressive treatment

1st Line Treatment Evidence Rating: [A]

  • Tenofovir, oral,

OR

  • Entecavir, oral,

2nd Line Treatment

Evidence Rating: [A]

  • Lamivudine, oral,

Referral Criteria

Refer all cases of chronic hepatitis B infection to a specialist, especially those who have failed first-line anti-viral therapy or had adverse reactions to anti-viral therapy or have liver-related complications (e.g. liver cirrhosis, liver failure, liver mass, signs of portal hypertension, ascites, peripheral oedema, hypoalbuminaemia). Pregnant individuals and patients with hepatitis B co-infections (e.g. HIV/Hepatitis C) as well as those requiring chemotherapy or other immunosuppressive therapy should also be referred to a specialist.

Table 2-1: Post-exposure management of healthcare workers after occupational exposure to Hepatitis B infection

*HCW Status

Post-Exposure Testing

Post-Exposure Prophylaxis

Post-Vaccination Anti-HBs

Source

Patient

*HCW

Anti-HBs

§HBIG

HBV

Vaccination

Documented Responder (> 3 Doses Received)

No action required

Documented Non-Responder (After > 6 Doses)

Positive

-

§HBIG Twice (One Month Apart)

-

No

Negative

-

No Action Required

Response Unknown (After >3 Doses)

Positive/ Unknown

<10 MIU/ml

§HBIG Once

Revaccinate

Yes

Negative

<10 MIU/ml

None

Revaccinate

Yes

Any Result

>10 MIU/ml

No action required

Unvaccinated/ Incomplete Vaccination

Positive/ Unknown

-

HBIG once

Complete Vaccination

Yes

Negative

-

None

Complete Vaccination

Yes

*HCW: Healthcare worker

§ HBIG: Hepatitis B Immunoglobulin as soon as possible when indicated (0.06 ml/kg IM)

Note: Anti-HBs Titre should be performed 1-2 months after last dose of HBV vaccination series but ~ 4-6 months after HBIG to avoid detection of passively administered Anti-HBs. 

  • Responder: person with Anti-HBs > 10 MIU/ml after 3 or more HBV vaccination doses
  • All HCWS who have Anti-Hbs < 10 MIU/ml, unvaccinated or incomplete vaccination and sustain exposure to a source patient who is HBsAg-positive/ unknown HBsAg status should undergo HBsAg screening as soon as possible after expo- sure and follow up testing ~ 6 months later (HBsAg + Anti-HBc).

Chronic Hepatitis C (Genotype 2 & 3)

1st Line Treatment Evidence Rating: [A]

  • Pegylated Interferon alfa-2a, subcutaneous,

Or

  • Pegylated Interferon alfa-2b, subcutaneous,

And

  • Ribavirin, oral,

Chronic Hepatitis C (Genotype 1 & 4)

1st Line Treatment Evidence Rating: [A]

  • Pegylated Interferon alfa-2a, subcutaneous,

Or

  • Pegylated Interferon alfa-2b, subcutaneous,

And

  • Ribavirin, oral,

Referral Criteria

Refer all cases of chronic hepatitis C infection to a specialist, especially those who have failed first-line anti-viral therapy or had adverse reactions to anti-viral therapy or have liver-related complications (e.g. liver cirrhosis, liver failure, liver mass, signs of portal hypertension, ascites, peripheral oedema, hypoalbuminaemia). Pregnant individuals and patients with hepatitis C co-infections (e.g. HIV/Hepatitis B) as well as those requiring chemotherapy or other immunosuppressive therapy