Hepatitis B Overview

Hepatitis is a general term that means inflammation of the liver. The liver can become
inflamed as a result of infection, a disorder of the immune system, or exposure to alcohol,
certain medications, toxins, or poisons.

 Hepatitis B is caused by infection with the hepatitis B virus (HBV). This infection has
2 phases: acute and chronic.
o Acute (new, short-term) hepatitis B occurs shortly after exposure to the virus.
A small number of people develop a very severe, life-threatening form of
acute hepatitis called fulminant hepatitis.
o Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts
longer than 6 months. Once the infection becomes chronic, it may never go
away completely.
o About 90-95% of people who are infected are able to fight off the virus so
their infection never becomes chronic. Only about 5-10 percent of adults
infected with HBV go on to develop chronic infection.
o HBV infection is one of the most important causes of infectious hepatitis.

 People with chronic HBV infection are called chronic carriers. About two-thirds of
these people do not themselves get sick or die of the virus, but they can transmit it to
other people. The remaining one third develop chronic hepatitis B, a disease of the
liver that can be very serious.
o The liver is an essential organ that the body needs to stay alive. Its most
important functions are filtering many drugs and toxins out of the blood,
storing energy for later use, helping with the absorption of certain nutrients
from food, and producing substances that fight infections and control bleeding.
o The liver has an incredible ability to heal itself, but it can only heal itself if
nothing is damaging it.
o Liver damage in chronic hepatitis B, if not stopped, continues until the liver
becomes hardened and scarlike. This is called cirrhosis, a condition
traditionally associated with alcoholism. When this happens, the liver can no
longer carry out its normal functions, a condition called liver failure. The only
treatment for liver failure is liver transplant.
o Chronic hepatitis B also can lead to a type of liver cancer known as
hepatocellular carcinoma.
o Any of these conditions can be fatal. About 15-25 percent of people with
chronic hepatitis B die of liver disease.

 Hepatitis B is the most common serious liver infection in the world. Worldwide,
about 350 million people are chronic carriers of HBV, of whom, more than 250,000
die from liver-related disease each year.
  In the United States, hepatitis B is largely a disease of young adults aged 20-50 years.
About 1.25 million people are chronic carriers, and the disease causes about 5000
deaths each year.

 The good news is that infection with HBV is almost always preventable. You can
protect yourself and your loved ones from hepatitis B.

Hepatitis B Causes

 The hepatitis B virus is known as a blood-borne virus because it is transmitted from

one person to another via blood.
o Semen and saliva, which contain small amounts of blood, also carry the virus.
o The virus can be transmitted whenever any of these bodily fluids come in
contact with the broken skin or a mucous membrane (in the mouth, genital
organs, or rectum) of an uninfected person.

 People who are at increased risk of being infected with the hepatitis B virus include
the following:
o Men or women who have multiple sex partners, especially if they don't use a
condom
o Men who have sex with men
o Men or women who have sex with a person infected with HBV
o People with other sexually transmitted diseases
o People who inject drugs with shared needles
o People who receive transfusions of blood or blood products
o People who undergo dialysis for kidney disease
o Institutionalized mentally handicapped people and their attendants and family
members
o Health care workers who are stuck with needles or other sharp instruments
contaminated with infected blood
o Infants born to infected mothers

 In some cases, the source of transmission is never known.

 The younger you are when you become infected with the hepatitis B virus, the more
likely you are to develop chronic hepatitis B. The rates of progression to chronic
hepatitis B are as follows:
o 90% of infants infected at birth
o 30% of children infected at age 1-5 years
o 6% of people infected after age 5 years
o 5-10% of infected adults

 You cannot get hepatitis B from the following activities:

o Being sneezed or coughed on
o Hugging
o Handshaking
o Breastfeeding
o Eating food or drinking water
 o Casual contact (such as an office or social setting)

Hepatitis B Symptoms

 Half of all people infected with the hepatitis B virus have no symptoms.

 Symptoms develop within 30-180 days of exposure to the virus. The symptoms are
often compared to flu. Most people think they have flu and never think about having
HBV infection.
o Appetite loss
o Feeling tired (fatigue)
o Nausea and vomiting
o Itching all over the body
o Pain over the liver (on the right side of the abdomen, under the lower rib cage)
o Jaundice - A condition in which the skin and the whites of the eyes turn
yellow in color
o Urine becomes dark in color (like cola or tea).
o Stools are pale in color (grayish or clay colored).

 Many types of acute viral hepatitis have similar symptoms (hepatitis A, hepatitis C).

 Fulminant hepatitis is an unusual illness. It is a severe form of acute hepatitis that can
be life threatening if not treated right away. The symptoms develop very suddenly.
o Mental disturbances such as confusion, lethargy, extreme sleepiness or
hallucinations (hepatic encephalopathy)
o Sudden collapse with fatigue
o Jaundice
o Swelling of the abdomen

 Prolonged nausea and vomiting can cause dehydration. If you have been vomiting
repeatedly, you may notice these symptoms:
o Feeling tired or weak
o Feeling confused or having difficulty concentrating
o Headache
o Not urinating
o Irritability

 Symptoms of liver failure may include the following:

o Fluid retention causing swelling of the belly (ascites) and sometimes the legs
o Weight gain due to ascites
o Persistent jaundice
 o Loss of appetite, weight loss, wasting
o Vomiting with blood in the vomit
o Bleeding from the nose, mouth, or rectum or blood in the stool
o Hepatic encephalopathy (excessive sleepiness, mental confusion, and in
advanced stages, development of coma)

 is B - Describe Your Experience

When to Seek Medical Care

Call your health care provider if you have any of the following:

 Nausea and vomiting that does not go away in 1-2 days

 Yellow skin or eyes
 Dark-colored urine (like tea or cola)
 Pain in the abdomen

Either of these situations also warrants a call to your health care provider:

 You think that you might have been exposed to someone with hepatitis or that you
might be at risk for any reason.
 You have other medical problems and think that you might have hepatitis.

If you are unable to reach your health care provider or have any of the following, go
immediately to a hospital emergency department.

 Vomiting and cannot keep down any fluids

 Severe pain or high fever
 Confusion, delirium, or difficulty awakening

Hepatitis B Diagnosis

Since many people with hepatitis B do not have symptoms, they do not know they have the
disease.

 Hepatitis B is often discovered accidentally when you see your health care provider
for another reason.
 Blood tests done for an annual check-up, insurance purposes, or before surgery may
show abnormalities in the liver blood test results.

If your health care provider determines that you may be at risk for contracting hepatitis, you
will have blood drawn.
  The laboratory will examine the blood to determine how well your liver is
functioning, if this has not already been done.
 Your blood will be tested to determine whether you have been exposed to certain
hepatitis viruses and, possibly, other viruses.
 If you have had a large amount of vomiting or have not been able to take in liquids,
your blood electrolytes may also be checked to ensure that your blood chemistry is in
balance.
 Other tests may be ordered to rule out other medical conditions.

X-rays and other diagnostic images are needed only in very unusual circumstances.

Once you are diagnosed with chronic hepatitis B, you will see your health care provider
regularly.

 At each visit, your blood will be checked to see whether the virus is multiplying in
your blood and how quickly.
 Your liver function tests also will be checked each time.
 These results help decide when it is time to start treatment.

Other tests will be done to determine whether you should undergo treatment or to decide on
the best treatment.

 CT scan or ultrasound - These diagnostic imaging tests are used to detect the extent of
liver damage.
 Liver biopsy - This involves removal of a tiny piece of the liver. It is usually done by
inserting a long needle into the liver and withdrawing the tissue. The tissue is
examined under a microscope to detect changes in the liver. A biopsy may be done to
detect the extent of liver damage or to evaluate how well a treatment is working.

Hepatitis B Treatment

Acute hepatitis B usually goes away by itself and does not require medical treatment. If very
severe, symptoms such as vomiting or diarrhea may require treatment to restore fluids and
electrolytes. There are no medications that can prevent acute hepatitis B from becoming
chronic.

If you have chronic hepatitis B, you should see your health care provider regularly.

Self-Care at Home

The goals of self-care are to relieve symptoms and prevent worsening of the disease.

 Drink plenty of fluids to prevent dehydration. Water is fine; broth, sports drinks, Jello,
frozen ice treats (such as Popsicles), and fruit juices are even better because they
provide calories.
 Avoid medicines and substances that can cause harm to the liver, such as
acetaminophen (Tylenol).
 Avoid drinking alcohol until your health care provider OKs it. If your infection
becomes chronic, you should avoid alcohol for the rest of your life.
  Avoid using drugs, even legal drugs, without consulting your doctor. Hepatitis can
change the way drugs affect you. If you take prescription medications, continue taking
them unless your health care provider has told you to stop. Do not start any new
medication (prescription or nonprescription), herbs, or supplements without first
talking to your health care provider.
 Try to eat enough for adequate nutrition. Eat foods that appeal to you, but try to
maintain a balanced diet. Many people with hepatitis have the greatest urge to eat
early in the day.
 Take it easy. Your activity level should match your energy level.
 Avoid prolonged, vigorous exercise until symptoms start to improve.
 Call your health care provider for advice if your condition worsens or new symptoms
appear.

Avoid any activity that may spread the infection to other people.

Medical Treatment

Acute hepatitis B infection

The most severe effect of acute hepatitis B is dehydration from vomiting and diarrhea.

 If you are dehydrated, your doctor may prescribe IV fluid to help you feel better.

 If you are experiencing significant nausea and vomiting, you will receive medicines to
control these symptoms.

 People whose symptoms are well controlled can be cared for at home.

 If dehydration or other symptoms are severe or if you are extremely confused or

difficult to arouse, you may need to stay in the hospital.

 There is no treatment that can prevent acute HBV infection from becoming chronic.

Chronic hepatitis B infection

The degree of liver damage is related to the amount of active, replicating (multiplying) virus
in the blood and liver. Regularly measuring the amount of HBV DNA in the blood gives a
good idea of how fast the virus is multiplying. The treatments now in use are antiviral drugs,
which stop the virus from multiplying.

 Antiviral agents, while the best therapy known for chronic hepatitis B, do not work in
all individuals with the disease.

 Although there are several antiviral agents for chronic hepatitis B approved by the
U.S. Food and Drug Administration (FDA), research is ongoing. This means that
dosages and treatment recommendations are subject to change.

 Research is ongoing to find medications that work better with fewer side effects.
Antiviral therapy is not appropriate for everyone with chronic HBV infection. It is reserved
for people whose infection is most likely to progress to chronic hepatitis B.

 Decisions to start medications for treatment of hepatitis B are made by you and your
health care provider, often in consultation with a specialist in diseases of the digestive
system (gastroenterologist) or liver (hepatologist).

 The decision is based on results of liver function tests, HBV DNA tests, and,
frequently, liver biopsies after a complete history and physical examination.

 Depending on the results of these tests, you may decide to start therapy or to delay it
until later.

Treatment is usually started when blood tests indicate that liver functions are deteriorating
and the amount of replicating HBV is rising. The interval between diagnosis and starting
treatment can be a year or two or several years. Many people may never require medication.

If you have chronic hepatitis B infection and think you might be pregnant, let your health
care provider know right away. If you are pregnant and think you have been exposed to
hepatitis B, let your health care provider know right away.

Medications

All of the following medications described that are used to treat chronic hepatitis B are
antiviral medications. They stop or slow replication of the virus in the body. This then gives
the liver a chance to heal itself. Although these medications are similar in some ways, they
differ in other important ways. Talk to your health care provider about the best medication for
you.

Interferon alfa-2b (Intron A) - Interferon was the standard treatment of chronic hepatitis B for
several years.

 It both slows the replication of the virus and boosts the body's immune system to fight
the infection.

 This is the first choice of treatment for many people with HBV infection that is likely
to progress, as indicated by lab test results.

 It works best in people who have relatively low levels of HBV DNA but liver
function tests and liver biopsy show that the liver is affected.

 Interferon usually is not given to people whose liver damage has progressed to
cirrhosis, because it can make the damage worse.

 Treatment is shorter than the other medications, but requires regular shots (injections)
and is more expensive than the others. The older forms of interferon are given 3 or
more times a week. Pegylated interferon A (PEG-Intron), a newer form of interferon,
has been slightly altered to last longer in the body, so it can be given only once a
week.
  Interferon has unpleasant side effects in many people. Many describe the side effects
as being like having the flu. For many people, the side effects are so severe that they
cannot continue taking the medication.

 Liver function tests and HBV DNA tests are used to check how well the treatment is
working.

 Interferon stops the infection in about 40% of people. In these people, the infection
usually does not return.

Lamivudine (Epivir) - This medication is considered an alternative for people who cannot or
do not want to take interferon. It also may be prescribed in people with weakened immune
systems.

 Lamivudine (Epivir) slows replication of HBV.

 Lamivudine is taken as a pill and has almost no side effects. The side effects, when
they do occur, are similar to those of interferon but are much milder.

 Liver function tests and HBV DNA tests are used to check how well the treatment is
working.

 Lamivudine works better than interferon in people who already have severe liver
damage (cirrhosis).

 Lamivudine reduces the amount of HBV in the blood in almost everyone who
receives this treatment. In about 40 percent, the amount goes so low that the test
cannot detect the virus.

 In about half of people who take lamivudine as recommended, liver inflammation

goes away (on liver biopsy). In as many as two-thirds, liver function test results return
to normal.

 In most people, however, the virus starts to multiply again as soon as the treatment is
stopped. Sometimes during the treatment, the virus becomes genetically altered
(mutated) and no longer responds as effectively as before to the medication.

 Ongoing research is looking at combining lamivudine with interferon or with other

medications or vaccines to make it work better.

Adefovir dipivoxil (Hepsera ) - This antiviral drug was approved by the FDA in 2002.

 Adefovir slows replication of HBV.

 It is a pill that must be taken every day, like lamivudine.

 It works well even in people whose disease is resistant to lamivudine.

 The virus begins to replicate again after stopping the treatment.

  Adefovir can damage the kidneys. This occurs mostly in people who already had
some kidney problems.

Entecavir (Baraclude) - This antiviral is the newest medication approved for chronic hepatitis
B.

 Entecavir slows replication of HBV.

 It is swallowed either as a tablet or an oral solution.

 Like adefovir, it can be prescribed for people who have become resistant to
lamivudine.

 It must be continued long-term, otherwise the virus begins to replicate again.

 Dosage adjustment is required for individuals with kidney impairment.

Surgery

There is no surgical therapy for hepatitis B.

If liver damage is severe enough that the liver starts to fail, the only treatment that will help is
liver transplant.

 If this should happen to you, your health care provider will talk to you about whether
liver transplant would work for you.
 Liver transplant is a major undertaking with an extended recovery period.
 It also depends on the availability of a matching donor liver.
 If liver transplant becomes a possibility for you, your health care provider will discuss
the risks and benefits with you.

Hepatitis B Other Therapy

No herbs, supplements, or other alternative therapy is known to work as well as antiviral

medication in slowing HBV replication and promoting liver healing in hepatitis B.

 In clinical trials, however, people who took a combination of interferon and a

preparation of Chinese herbs did better than people who took interferon alone or the
herbs alone. However, these results need to be substantiated.
 Research is ongoing to see which herbs may have a helpful effect on hepatitis.
 At this time, no specific herb or herbal preparation is recommended

Next Steps

Follow-up

Follow all instructions that your health care provider gives you.

 Take it easy. Get plenty of rest.

  Drink enough clear fluids to stay well hydrated. Fluids should be free of alcohol and
caffeine.
 Avoid medicines such as acetaminophen (Tylenol) and preparations that contain
acetaminophen, which can be harmful to the liver.
 Do not drink alcohol until your health care provider tells you it is all right.
 Avoid prolonged or vigorous physical exercise until your symptoms improve.
 If symptoms worsen at any time, contact your health care provider

Hepatitis B Prevention

There is a vaccine against the hepatitis B virus (Engerix-B, Recombivax HB ). It is safe and
works well to prevent the disease. A total of 3 doses of the vaccine are given over several
months.

 This vaccine has successfully prevented infection in people exposed to the virus.
 The vaccine is recommended for all children younger than 19 years. It can be given as
part of their normal vaccination series.

The following groups should be vaccinated for hepatitis B:

 All children younger than 18 years, including newborns--especially those born to

mothers who are infected with HBV
 All health care and public safety workers who may be exposed to blood
 People who have hemophilia or other blood clotting disorders and receive
transfusions of human clotting factors
 People who require hemodialysis for kidney disease
 Travelers to countries where HBV infection is common - This includes most areas of
Africa, Southeast Asia, China and central Asia, Eastern Europe, the Middle East, the
Pacific Islands, and the Amazon River basin of South America.
 People who are in prison
 People who live in residential facilities for developmentally disabled persons
 People who inject illegal drugs
 People with chronic liver disease such as hepatitis C
 People who have multiple sex partners or have ever had a sexually transmitted disease
 Men who have sex with men

Hepatitis B immune globulin (BayHep B, Nabi-HB) is given along with the hepatitis B
vaccine to unvaccinated people who have been exposed to hepatitis B.

 These include close contacts of people with HBV infection, health care workers who
are exposed to HBV-contaminated blood, and infants born to mothers infected with
HBV.
 It also includes people who have finished only part of the 3-shot vaccination series.
 Giving the immune globulin and the vaccine together in these situations prevents
transmission of the disease in 80-90 percent of cases.
Other ways to protect yourself from HBV infection:

 If you are sexually active, practice safe sex. Correct use of latex condoms can help
prevent transmission of HBV, but even when used correctly, condoms are not 100%
effective at preventing transmission. Men who have sex with men should be
vaccinated against both hepatitis A and hepatitis B.
 If you inject drugs, don't share needles or other equipment.
 Don't share anything that might have blood on it, such as a razor or toothbrush.
 Think about the health risks if you are planning to get a tattoo or body piercing. You
can become infected if the artist or piercer does not sterilize needles and equipment,
use disposable gloves, or wash hands properly.
 Health care workers should follow standard precautions and handle needles and
sharps safely.
 If you are pregnant or think you might be pregnant, tell your health care provider if
you have any of the risk factors for HBV infection.

Hepatitis B Prognosis

Some people rapidly improve after acute hepatitis B. Others have a more prolonged disease
course with very slow improvement, or with periods of improvement followed by worsening
of symptoms.

A small group of people (about 1% of people infected) suffer rapid progression of their
illness during the acute stage and develop severe liver damage (liver failure). This may occur
over days to weeks and may be fatal.

Other complications of HBV include development of a chronic HBV infection. People with
chronic HBV infection are at further risk for liver damage (cirrhosis), liver cancer, liver
failure, and death.