“ A Case Management Conference about

HEPATITIS B
A LOVE TO LAST
”
By: Ethyl Joy H. Golosinda
May 30, 2018
SGD 6, College of Medicine
General Objectives:

At the end of this 60 minutes

session, Post-graduate Interns
should be able to diagnose and
properly manage a case of Hepatitis
B
 Specific Objectives:

At the end of this session, the PGI’s should be able:

To elicit pertinent historical data and examination from a patient with a case
of Hepatitis B
• To discuss the approach in the diagnosis and management of patient with
Hepatitis B based on the recent clinical practice guidelines.
• To evaluate the level of functioning of the family using family assessment
tools
• To appraise recent journal applicable to the case
 FLOW OF PRESENTATION

I. History and Physical Examination

II. Family Profile
III. Initial Impression and Differential
diagnoses
IV. Case discussion
V. Evidence-Based Medicine
GENERAL DATA

 MB
 29 years old
 Female
 Married
 Filipino
 Roman Catholic
 Trece Martires Cavite
 1st OPD consult on May 21, 2018
CHIEF COMPLAINT

“Sumasakit ang tiyan”

HISTORY OF PRESENT ILLNESS:
• (+) generalized abdominal pain, sharp in character,
VAS 8/10, non-radiating
• Lasting for 30 mins to 1 hour, 3 episodes per day
• No aggravating, worsening factors

2 years • Relieved by single dose of Al OH + Mg OH +

Simeticone (Kremil S)
• (+) nausea and postprandial vomiting – 2 episodes

PTC per day

• (+) loose watery stools, mucoidy, foul-smelling,
non-bloody – 3 episodes per day
• (-) low-grade fever, jaundice, dark colored urine
HISTORY OF PRESENT ILLNESS:

•(+)intermittent generalized
1 year abdominal pain, relieved by
Al OH + Mg OH +
PTC Simeticone (Kremil S)
HISTORY OF PRESENT ILLNESS:

• Patient underwent pre-employment

medical exam which incidentally
1 week revealed HBsAg reactivity
• She told her husband and found out

PTC that her husband had Hepatitis B

since High school but was lost to
follow-up
HISTORY OF PRESENT ILLNESS:

•The patient and her

husband decided to sought
DOC consult at our OPD for
further evaluation
PAST MEDICAL HISTORY

 (-) Hypertension, DM, Asthma, cancer, cardiac disease

 (-) Thyroid Disease
 (-) PTB
 (-) allergy to food and medications
 Has complete childhood vaccination
 Recent vaccination is Tetanus Toxoid during her 1st pregnancy
 (-) surgery, hospitalization, accident
FAMILY HISTORY

 (+) Osteoarthritis – mother

 (+) Chronic Hepatitis B - husband
 (-)Hypertension, DM, Asthma, Cancer, Stroke, Cardiac
Disease
 (-) Thyroid Disease
 (-) PTB
 (-) blood transfusion
PERSONAL & SOCIAL HISTORY

 High school graduate

 Previously worked as a factory worker involving electronics (2010)
 Currently stays at home to take care of their children but wanted to
apply at a factory involving electronics
 Non – smoker
 Non – alcoholic beverage drinker
 Non – illicit drug use
 PERSONAL & SOCIAL HISTORY

 Lives in a concrete house, with 1 storey, 1 bed and 1 cr, in a subdivision

 w/ good lighting and good ventilation
 Toilet is pour flush
 Drainage is closed
 Water supply is NAWASA
 Drinking water is purified water
 Garbage is segregated and is collected every Wednesday
 No pets inside their house
 No nearby factories, rivers, and flooded areas
MENSTRUAL HISTORY

M – 15 yrs old
I – 30 days, regular
D – 5 days
A– 2-3 pads/day, moderately soaked
S – (-) dysmenorrhea, headache
OBSTETRICS HISTORY

G2P2 (2002)
Bday Gender AOG Delivery Place Assisted By Complicati
ons
April 4, Male Full Term NSD House Midwife none
2009
Feb 22, Male Full Term NSD House Midwife none
2012
GYNECOLOGIC HISTORY

Papsmear (2015) – normal

(-) STDs/STIs
(-) vaginal discharge/pruritus
(-) breast mass
SEXUAL HISTORY

Coitarche: 20 yrs old

Number of lifetime sexual partner: 1
(husband)
(-) Post coital bleeding, dyspareunia
CONTRACEPTIVE HISTORY

 No use of contraceptives
REVIEW OF SYSTEMS
 General: (-) body malaise (-) anorexia (-) weight loss/gain (-)
anemia
 Integument:(-) wound (-) clubbing of nails (-)
hyper/hypopigmentation (-) erythema (-) pallor
 Head and Neck: (-) stiffness (-) mass
 Eyes: (-) blurring of vision (-) eye pain (-) tearing
 Ears: (-) otalgia (-) tinnitus (-) aural fullness (-) difficulty
hearing
 Nose and Sinuses: (-) colds (-) sinusitis
 Mouth and Throat: (-) hoarseness (-) sore throat (-) dysphagia
(-) tongue fasciculation
 Respiratory: (-) cough (-) hemoptysis (-) dyspnea (-) pleuritic
chest pain (-) brady/tachypnea
 Cardiovascular:(-) angina (-) palpitations (-) orthopnea (-)
paroxysmal nocturnal dyspnea
 Gastrointestinal: (-) hematemesis (-) melena (-) hematochezia
(-) retching (-) constipation
 Genitourinary: (-) frequency (-) dysuria (-) flank pain (-)
nocturia
 Vascular: (-) claudication
 Hematologic: (-) easy bruising (-) easy bleeding
 Endocrine: (-) polyuria (-) polydipsia (-) polyphagia
(-) heat/cold intolerance
 Musculoskeletal: (-) muscle pains (-) joint pain (-)
fractures
 Nervous System: (-) body weakness (-) slurring of
speech (-) syncope (-) tremors (-) headache (-) loss
of consciousness
 Autonomic: (-) fecal and urinary incontinence
PHYSICAL EXAMINATION
 GENERAL: The patient is awake, conscious, coherent and oriented to three
spheres. Not in cardiorespiratory distress.
 Weight: 53 kg
 Height: 5’0”
 BMI: 22.9 (normal)

 VITAL SIGNS:
BP = 120/80 HR = 79 RR = 19 Temp = 36.7 O2 sat = 98%

 INTEGUMENT:
(-) jaundice, (-) erythema, (-) cyanosis, good skin turgor, no clubbing
HEENT:
 Head and Neck: Head is symmetrical, no masses, no lesions. Normal,
symmetrical facial expression, (-) CLADS, (-) Distended neck vein
 Eyes: symmetrical, pink palpebral conjunctivae, pupils EBRTL 2-3mm
in size, anicteric sclerae
 Nose: symmetrical external nose, (-) masses, lesions, midline nasal
septum, tenderness
 Ears: (-) masses, (-) discharges, swelling, tenderness
 Oral cavity: Moist, pale oral mucosa, (-) Lesions and masses, Tongue in
midline
No yellowish discoloration under the tongue and palate
 CHEST AND LUNGS: Symmetrical chest expansion, (-) Intercostal
retraction (-) Defects/ Deformities in the chest wall; Bronchovescicular
breath sounds; No palpable chest mass noted
 HEART: (-) precordial bulging (-) heaves and trills, normal rate, regular
rhythm, (-) extra heart sounds and murmurs
 ABDOMEN: symmetrical, flabby, no lesions, no visible
pulsations/peristalsis; normoactive at 12 bpm; non-tender, no palpable
masses; tympanitic on all quadrants; no abdominal girth enlargement
 EXTREMITIES: Full and Equal peripheral pulses, anicteric palm and
soles (-) atrophy, (-) masses, (-) deformity, (-) edema, no limitation in
ROM,
NEUROLOGIC:
 CN I: Not assessed
 CN II: 2-3mm EBRTL
 CN III, IV, VI: Intact and Full EOMs
 CN V: Good masseter tone, equal sensation V1-V3
 CN VII: No facial asymmetry, able to close eyelids
 CN VIII: Intact gross hearing
 CN IX, X: Good swallow, Intact Gag reflex
 CN XI: Good shoulder shrug and SCM tone
 CNXII: Tongue midline, no atrophy
Motor: 5/5 on all extremities Sensory: 100%
MENTAL STATUS EXAM:
General Appearance: Appears to be in the chronologic age of 29. Cooperative,
with eye contact, neat looking.
Psychomotor: straight postured, normal rate of movement
Mood and Affect: congruent, non-irritable, sad-looking
Speech: ordinary rate, normal flow of speech, normal volume, clarity and with
normal quantity.
Cognition: Attention and concentration sufficient, Intact short and long term
memory
Orientation: Oriented to three spheres
Though patterns: coherent, logical, normal flow of though and content.
Level of consciousness: responsive, conscious and coherent.
FAMILY PROFILE
 FAMILY LIFELINE
YEAR EVENT
1988 Her mother (a HS teacher, 20
yrs old) and father (a janitor,
29 yrs old) met in Manila at
work. Her mother got pregnant
with her which was unplanned
that time hence they got
married. She was then forced
to resign her work and moved
with her father in Trece Cavite.
REACTION ADAPTATION
She said that her mother Her father worked as a delivery
and father got worried at truck driver and worked hard for
first because her mother their family. Her mother stayed at
was too young but they home to take care of her.
were also excited because
despite her pregnancy
was unplanned, it was
wanted.

1989 The patient was born in Trece, Being the first born, her
Cavite. parents were still on
adjustment stage of
parenthood hence they
were anxious.
Her mother stayed at home to take
care of her while her father worked
hard for them.
 FAMILY LIFELINE
YEAR EVENT REACTION ADAPTATION

1991 Her 2nd sister was born Her parents were sad and Her parents protected her by
but died due to worried that she might also catch completing her vaccines and bringing
Pneumonia at 3 and die because of the same her to the doctor regularly for check-
months old. illness. up.

2007 She graduated high She was frustrated because she She applied as a factory worker in an
school but due to their wanted to pursue college but was electronics factory in Imus. She was
increasing number of glad that she is able to help her able to help her father to sustain their
family members, she family. Her parents were thankful family needs.
was forced to work to her.
and not to pursue
college.
 FAMILY LIFELINE
YEAR EVENT REACTION ADAPTATION

2008 She met her husband Her parents disapproved of their Secretly, they still continued their
at work. Her husband relationship because she still has relationship.
started to court her many obligations to her siblings.
and eventually they
became a couple.
2009 She got pregnant with Initially, her parents were Her family accepted her son and
her 1st son, it was disappointed but eventually considered him as their source of
unplanned but wanted. accepted their first grandson. happiness. Since she has no work,
She resigned at her her husband decided to transfer work
work and moved in at (worked at a car tint shop).
her husband’s house.
 FAMILY LIFELINE
YEAR EVENT REACTION ADAPTATION

2011 She got pregnant with She and her husband were very They moved-out of their parents’
her 2nd son hence they happy because finally, they got house and settled at their place still in
decided to get married married. Their parents were trece cavite.
and settle their own supportive of them.
family.

2012 Her 2nd son was born. They were very happy since their Her husband worked hard for their
family getting bigger. family.
 FAMILY LIFELINE
YEAR EVENT REACTION ADAPTATION

2018 Since their family is At first, she was worried because They decided to sought consult in our
getting bigger, she she don’t know how she institution so that they could be
decided to apply work contracted the disease (it was evaluated and managed.
again in a factory explained to her that it is
(Electronics) but upon transmitted by blood and sexual
Med exam, it was contact), hence she talked about
found out that her it to her husband. Her husband
Hbsag is reactive. She revealed to her that he was
told her husband about diagnosed with Hep B during HS.
it and found out that he He also said that his father was
has Hep B since diagnosed with Chronic Hep B.
Highschool.
 FAMILY CLASSIFICATION

Family Structure Nuclear

Location Ambilocal
Decision making Democratic
Authority Equalitarian
Social Class Middle Class
Stage of Family Life Cycle Family with Young Children
 FAMILY PROFILE
Income
Age Educational Relation to the
Name Status Religion (per
Sex Attainment index patient
month)

Rizaldy 29 M Highschool RC P14,000 Husband

Highschool
Merlyn 29 M RC - Index patient

Zaldimer 9 S Grade 3 RC - son

John
6 S Grade 1 RC - son
Michael
 ENVIRONMENTAL PROFILE
PARAMETER
House Concrete 1 storey house, well ventilated with 2
windows
Water Purified water (Drinking), NAWASA(Bath and
cooking)
Electricity Meralco
Kitchen Stove with LPG
Toilet Pour-flush system
Garbage Segregated and collected once a week
Drainage Closed
Domestic animals None
 ECONOMIC PROFILE
FAMILY MEMBER INCOME
Rizaldy P 14,000
TOTAL P 14,000
ITEM ALLOTED INCOME PERCENTAGE
Food P 7,500 55 %
House Rent P 3,500 25 %
Electricity P 1,000 7%
Allowance to parents P 600 4%
Transportation P 600 4%
Water P 300 2%
Emergency medical P 500 3%
fund, Load, Education
Total: P 14, 000 100 %
 Monthly Family Budget

4%
8%

Food
House Rent
Electricity
Allowance to parents
27%
60%
 FAMILY MAP

Rizaldy Merlyn

Rain John Michael

 SOME
APGAR I* ALMOST
ALWAYS
OF THE
TIME
HARDLY
EVER

Ako’y nasisiyahan dahil nakakaasa ako sa tulong ng ✓

A aking pamilya sa oras ng mga problema.”

“ Ako’y nasisiyahan sa paraan na nakikipagtalakayan sa ✓

P akin ang aking pamilya tungkol sa aking mga suliranin.”

Ako’y nasisiyahan na tinatanggap at sinusuportahan ng ✓

aking pamily ang aking mga nais gawin tungkol sa mga
G bagong landas para sa aking ikauunlad.”

“Ako’y nasisiyahan sa paraang ipinadarama ng aking

pamilya ang kanilang pagmamahal at pagunawa ng mga ✓
A damdamin kong tulad ng galit, lungkot at pag-ibig.”

Ako’y nasisiyahan na ako at ang aking pamilya ay may ✓

R panahon para sa isa’t isa.”
• Answered by both patient and husband
Total: 10 - The family is highly functional based on the total score of 10 in APGAR Part 1.
 APGAR II

Family Member Age/ Relationship to Quality of

Sex the Relationship
Index Patient
Elimer Anggoling 58/M Father Well
Leonoroa Anggoling 49/F Mother Well
Ignacio Bagacina 63/M Father-in-law Well
Lea Bagacina 61/F Mother-in-law Well
 SCREEM
Component Resources Pathology
Social When there is someone who is No pathology seen
sick in their family, she said
that her parents, sisters and
brothers are ready to help each
other. Actually, the money used
for the expensive tests (P4,500
each = P9,000) done where lent
by her and her husband’s
parents. She also said that
sometimes, she could ask for
help from her friends and
neighbors.
 SCREEM
Component Resources Pathology
Cultural She said that it’s their culture in No pathology seen
their family that whenever
someone got sick, they give
strength and courage to them by
being supportive. They also
don’t believe in herbal
medications especially for
hepatitis B. They don’t believe
that their illness is caused by
Karma.
Component Resources Pathology

Religion Her family is Roman Catholic. They No pathology seen

attend mass every Sunday and
believes that prayers could help
them whenever someone is sick in
their family. They believe that their
sickness is not a punishment from
God.
 Component Resources Pathology

Economic Although every month, they keep Their family income is not
P200.00 for medical emergency, it enough to sustain their daily
is not enough to sustain (both her medical needs.
husband and her medications/lab
tests). They could ask financial
help from their parents but it is still
not enough.
 Component Resources Pathology

Education Although her husband has There are misconceptions

chronic hepatitis B, their about their illness needed to
knowledge about it is not correct.
enough. They know how it is
transmitted but they believe that
it will be the end of their world
because they thought that once
you have hepatitis, you’re
infected for life. She also thought
that her children might also be
infected.
 Component Resources Pathology

Medical There are nearby public hospital Their place of residence is far
and Brgy. Health center near their to our institution. The
residence but they prefer to consult distance might be a problem
in our institution because there’s in terms of their compliance
no available specialty doctor near to their management.
them. They also believe that we
are more specialized than the
hospital near them. They prefer
generic medicines because it is
much cheaper.
 Reaction of Patient to the Illness

“Ano ang iyong pagkakaalam tungkol sa iyong sakit?”

Px: “Ang alam ko ito ay nakakahawa sa pamamagitan daw ng

pakikipagtalik. Noong malaman ko na matagal na palang meron
ang asawa ko at hindi siya nagpagamot, sinisi ko siya dahil
hinawa niya ako. Dapat yung magulang niya, pinagamot siya
kagad.”
 Reaction of Patient to the Illness

“Ano pong naramdaman ninyo noong una niyong nalamang may

Hepatitis B kayo?

Px: “Natakot ako kasi hindi ko alam kung san ko nakuha yung sakit
ko. Nahihiya rin ako kasi ang sabi sakin nakukuha ito sa
pakikipagtalik. Tapos pinapatest pa kami sa HIV, di naman sa wala
akong tiwala sa asawa ko. “
 Reaction of Patient to the Illness

“Ano ang kinakatakot niyo sa inyong sakit?”

Px: “Natatakot ako kasi ang sabi, pag meron daw ako nito, automatic pati
anak ko meron na. Eh meron rin ang asawa ko, wala kaming pera pambili
ng gamot, tapos ang mahal pa nung mga exam. Tapos yung sa HIV,
napanood ko kasi sa TV sa hapon kung paano yung sakit na yun. Pero sa
tingin ko wala naman”
 Reaction of Patient to the Illness

“Ano ang iyong iyong palagay sa iyong sakit?”

Px: “Ang aking sakit ay nakakahawa kaya hindi

na ako makakapagtrabaho.”
 EDUCATION:

 Tama po na ang hepatitis B ay nahahawa sa pamamagitan ng

pakikipagtalik pero maaari rin po itong makuha sa dugo (tulad ng
pagsalin ng dugo, nasugatan ka ng bagay na may dugo ng taong may
Hepatitis B, o maisalin ng inna sa kanyang inna kung habang
nagbubuntis siya ay nakakahawa siya. Maaari naman po kayong
magamot basta po komunsulta kayo sa especialista at sundin ang
gamot na ibibigay niya.
 ACTION

 Ano po ang plano niyong gawin?

Ipapagawa ko ang mga tests namin ng asawa ko, at

iiwasang makipagtalik muna sakanya. Ipapatest ko rin
po ang aking mga anak. Pero yung sa HIV, pag-
uusapan pa namin ng asawa ko. Pero sa tingin ko wala
naman.
ACTION: (Management done at the OPD)

 For Hepatitis Profile

 HBsAg Additional (Upon ff. up):
 Anti-HBs
- HBV DNA level
- VCT 1 & 2
 HBeAg - RPR (Quantitative)
 Anti HBc IgM, IgG
 Anti HAV IgM, IgG
 CBC PC
 AST, ALT
Impact of Illness

Stage II: Impact Phase

 Family Diagnosis
◦ The Bagacina Family is a nuclear type of family and Ambilocal in
location. The family is in the stage of ‘Family with Young Children’
with a highly functional relationship based on APGAR I Score of
10/10.
◦ No pathologies seen in Social, Cultural and Religion
◦ Pathologies were observed in Economic, Education and Medical
◦ Reaction to Illness: Fear of their diagnosis
 Recommendations
Problems Identified Recommendation
- Advise patient to seek help from charity organizations like
PCSO and other support from the government.
- Advise them to seek help from their closest relatives.
- Advise the wife to consider looking for other sources of
Economic income (like business) that will sustain the family’s needs
aside from working at a factory.

- Educate patient regarding the causes, transmission, diagnosis

Education and treatment of hepatitis b
 Recommendations
Problems Identified Recommendation
- Advise the patient and her husband to seek consult of an
Medical infectious specialist for proper treatment.

- Advise to avoid alcoholic beverages

- Advise to eat fruits and vegetables, have enough sleep
Lifestyle
Family Member General Wellness

• Annual BP monitoring
• Self-breast examination
• Annual fecalysis for intestinal parasites
• Annual urinalysis for GUT disorder
• Annual Chest xray
Merlyn, 29 • Annual periodic physical exam
• Dental hygiene and monitoring
• Teach about athing, nails, lice and handwashing
• Family Planning up to age 45 yrs old
• Monitor weight
Family Member General Wellness
• Annual BP monitoring
• Annual fecalysis for intestinal parasites
• Annual urinalysis for GUT disorder
• Annual Chest xray
• Annual periodic physical exam
Rizaldy, 29 • Hepatitis A & B vaccine booster
• Dental hygiene and monitoring
• Teach about athing, nails, lice and handwashing
• Family Planning up to age 45 yrs old
• Smoking cessation, avoid alcohol
• Monitor weight
Family Member General Wellness

• Annual fecalysis for intestinal parasites

Zaldimer, 9 • Annual urinalysis for GUT disorder
• PPD/Direct BCG annually
• Annual periodic physical exam
• Dental hygiene and monitoring
• Teach about bathing, nails, lice and hand washing
• Monitor growth chart & nutrition, sexual
development

John Michael, 6
INITIAL IMPRESSION AND
DIFFERENTIAL
DIAGNOSIS
SALIENT FEATURES

 2 years history of intermittent generalized abdominal pain, sharp in character, VAS 8/10,
non-radiating, Lasting for 30 mins to 1 hour, 3 episodes per day
 No aggravating, worsening factors
 Relieved by single dose of Al OH + Mg OH + Simeticone (Kremil S)
 (+) nausea and postprandial vomiting – 2 episodes per day
 (+) loose watery stools, mucoidy, foul-smelling, non-bloody – 3 episodes per day
 (-) low-grade fever, jaundice, dark colored urine
SALIENT FEATURES

 Patient’s husband history of chronic hepatitis B

 No history of blood transfusion, multiple sexual partner and illicit drug use
 Essentially normal PE
 HEPATITIS B INFECTION
DIFFERENTIAL DIAGNOSIS

Ruling in Ruling out

GERD (+) 2 yrs history of (-) bloatedness
intermittent generalized (-) hyperacidity
abdominal pain, relieved by
antacids

Chronic Cholecystitis (+) 2 yrs history of (-) jaundice

intermittent generalized (-) fever
abdominal pain, relieved by (-) bloatedness
antacids
MANAGEMENT DONE AT THE OPD:

 For Hepatitis Profile

 HBsAg Additional (Upon ff. up):
 Anti-HBs
- HBV DNA level
- VCT 1 & 2
 HBeAg - RPR (Quantitative)
 Anti HBc IgM, IgG
 Anti HAV IgM, IgG
 CBC PC
 AST, ALT
LAB RESULTS:
Hepatitis Profile
5/22/18
HBsAg Reactive
Anti-HBs Non-reactive
HBe Ag Non-reactive
HBc IgM Non-reactive
Anti-HBc Total Reactive
Anti-HAV IgM Non-reactive
Anti-HAV IgG Reactive
LAB RESULTS:
Liver Function
5/22/18
AST 50 ↑ (1.5x)
ALT 39
LAB RESULTS:
CBC
5/16/18
0.63
146
7.4
0.44
0.37
FINAL DIAGNOSIS:

 CHRONIC HEPATITIS B INFECTION, LOW

INFECTIVITY
 IMMUNITY TO HEPATITIS A VIRUS (HAV)
CASE DISCUSSION
A CASE OF HEPATITIS B
Flow of Case Discussion

 Introduction
 Hepatitis screening and vaccination
 Evaluation of patients with chronic hepatitis B
 When to do a liver biopsy or assess for liver fibrosis
 Indications for treatment
 Options for treatment
 Monitoring during treatment
 Monitoring after treatment
 Duration of treatment: Interferon
 Duration of treatment: Nucleos(t)ide analogues
ACUTE VIRAL HEPATITIS

 Is a systemic infection affecting the liver predominantly

 5 Viruses:
 Hepatitis A Virus (HAV)
 Hepatitis B Virus (HBV)
 Hepatitis C Virus (HCV)
 Hepatitis D Virus (HDV)
 Hepatitis E Virus (HEV)
CLINICAL COURSE

 Asymptomatic and inapparent

 fulminant and fatal acute infections
 subclinical persistent infections
 rapidly progressive chronic liver disease with cirrhosis
 Hepatocellular carcinoma
CHRONIC HEPATITIS

 represents a series of liver disorders of varying causes and severity

in which hepatic inflammation and necrosis continue for at least 6
months.
 Includes:
 chronic viral hepatitis
 drug-induced chronic hepatitis
 autoimmune chronic hepatitis
CHRONIC VIRAL HEPATITIS

 Hepatitis A and E
 enterically transmitted forms of viral hepatitis
 self-limited
 do not cause chronic hepatitis
 Hepatitis B and C, Chronic hepatitis D superimposed on chronic
hepatitis B
 the entire clinicopathologic spectrum of chronic hepatitis occurs
CHRONIC HEPATITIS B INFECTION

 Chronic inflammatory disease of the liver secondary to persistent infection with HBV.
 Chronic hepatitis B virus (CHB) infection is a serious problem that affects over 300
million people worldwide.
 Highly prevalent in the Asia-Pacific region.
 Philippines: an estimated 7.3 million Filipinos or 16.7% of adults are chronically
infected with HBV, more than twice the average prevalence in the Western Pacific region.
DIAGNOSTIC CRITERIA

 HBsAg-positive >6 months

 serum HBV DNA >20,000 IU/mL (105 copies/mL) in HBeAg-
positive patients, or >2,000 IU/mL (>104 copies/mL) in HBeAg-
negative patients
 persistent or intermittent ALT/AST elevation
 liver biopsy showing chronic hepatitis with moderate to severe
necrosis & inflammation
HEPATITIS B

 Incubation: 30-180, mean 60-90

 Onset: Insidious or acute
 Age preference: Young adults (sexual and percutaneous), babies, toddlers
 Transmission
 perinatal (vertical transmission)
 Percutaneous (blood transfusion, needle prick, sharing of needles)
 sexual contact
 close person-to-person contact
HEPATITIS B

 Clinical
 Severity: Occasionally severe
 Fulminant: 0.1-1%
 Progression to chronicity: Occasional (1-10%) (90% of neonates)
 Carrier: 0.1-30%
 Cancer: + (neonatal infection)
 Prognosis: Worse with age, debility
 SEROLOGICAL MARKERS OF HBV
Hepatitis B surface antigen (HBsAg)
Hepatitis B core antigen (HBcAg)
Hepatitis B e antigen (HBeAg)
HBV envelope protein and excess coat
particles detectable in the blood in acute and
chronic hepatitis B infection
HBV core protein. The core protein is coated
with HBsAg and therefore not found free in
serum
Viral protein found in the high replicative
phase of hepatitis B. HBeAg is usually a
marker of high levels of replication with
wild-type virus but is not essential for viral
replication
SEROLOGICAL MARKERS OF HBV

Hepatitis B surface antibody (anti-HBs) Antibody to HBsAg. Develops in response to

HBV vaccination and during recovery from
acute hepatitis B, denoting past infection and
immunity
Anti-HBe Antibody to HBeAg. Detected in persons
with lower levels of HBV replication but
also in HBeAg-negative disease (i.e. HBV
that does not express HBeAg)

Hepatitis B core antibody (anti-HBc) Antibody to hepatitis B core (capsid) protein.

Anti-HBc antibodies are not neutralizing
antibodies and are detected in both acute
and chronic infection
SEROLOGICAL MARKERS OF HBV

IgM anti-HBc Subclass of anti-HBc. Detected in acute

hepatitis B but can be detected by sensitive
assays in active chronic HBV

IgG anti-HBc Subclass of anti-HBc detected in past or

current infection
SEROLOGICAL MARKERS OF HBV

HBV DNA HBV viral genomes that can be detected and quantified in serum.
HBV DNA correlates with levels of circulating viral particles. HBV DNA is
measured as IU/mL or copies/mL.
1 IU/mL ~ 5.3 copies/mL, and so values given as copies/mL can be
converted to IU/mL by dividing by a factor of 5. (i.e. 10 000 copies/mL =
2000 IU/mL;100 000 copies/mL = 20 000 IU/mL; 1 million copies/mL = 200
000 IU/mL). All HBV DNA values in the recommendations in these
guidelines are reported in IU/mL.
An undetectable viral load is an HBV DNA level below the level of
sensitivity of the laboratory assay. For sensitive polymerase chain reaction
assays, this is generally a concentration below 15 IU/ml.
WHEN TO TREAT (Harrisons)
When to treat (HSP 2014)
When to treat (WHO 2015)
EASL 2017
 TREATMENT OF HEPATITIS B ACCDG TO
CLINICAL PRACTICE GUIDELINES
Source Treatment Dosage: Costs (Php)
Harrisons (19th IFN-a, PEG IFN-a PEG-IFN a: 180 mcg/wk or 1 IFN – a:
edition) Oral: – 1.5 mcg/kg/wk PEG IFN – a:
1st line – Entecovir (ETV), Tenofovir IFN-a: 5-10 MU 3x/wk ETV: P266.00
(TDF/TAF)
TDF:
2nd line – Lamivudine (LAM), Adefovir
(ADV), Telbivudine (TBV) ETV: 0.5 mg/day LAM: P200.00
TDF: 300 mg/day ADV: P270.00
2017 EASL/ WHO Preferred tx: Entecavir, Tenofovir LAM: 100 mg/day TBV: P219.00
2015 recommendation Not recommended: Lamivudine, ADV: 10 mg/day CLV: P90.00
Adefovir, Telbivudine (d/t drug TBV: 600 mg/day
resistance) CLV: 30 mg/day

2014 HSP 1st line: PEG-IFN a, Entecavir, Tenofavir

2nd line: Lamivudine, Adefovir,
Telbivudine, Tenofovir, Clevudine
(CLV)
Prophylaxis: Recombinant vaccine
COMPLICATIONS OF CHB:

 Liver cirrhosis
 Hepatocellular Carcinoma
EVIDENCE-BASED
MEDICINE
AN APPRAISAL OF THERAPEUTIC JOURNAL
DILEMMA

 In case the patient has elevated HBV DNA load >2,000

IU (For HBe Ag-negative pt), could CLEVUDINE
(cheapest nucleoside analogue @ P90.00 per capsule) be
used as treatment?
 Clinical Question

 Among adult patients with Chronic Hepatitis B, is

Clevudine is comparable to the standard Lamivudine in
terms of Mean reduction of hepatitis B virus (HBV)
DNA levels using Randomized controlled trial (RCT)?
 Evaluating Directness
Does the study provide a direct answer to your clinical question in terms of type
of patients (P), exposure or intervention (E) and outcome (O)? Yes.

Clinical Question Journal

Among adult patients with Among adults with Chronic
Chronic Hepatitis B infection Hepatitis B infection
Patient

Exposure/ Clevudine and Lamivudine Clevudine and Lamivudine

Intervention
Reduction of HBV DNA Load Reduction of HBV DNA Load
Outcome

Method RCT RCT

Appraising Validity
Question 1: Were patients randomly assigned to treatment
groups? YES.
Appraising Validity

Question 2. Was allocation concealed? YES.

Appraising Validity
Question #3: Were baseline characteristics similar at the start of the trial?
YES.
Appraising Validity
4. Were patients blinded to treatment YES
assignments?
5. Were caregivers blinded to treatment YES
assignments?
6. Were study personnel blinded to treatment NO
assignments?
Question #7: Were all patients analyzed under the groups to which they
originally randomized? YES
 Appraising Validity
Question #8: Was follow-up rate adequate? YES
Drop out rate in CLEVUDINE:
Outcome assessed - Analyzed
46 – 45 =1
1/46 x 100= 2.2%

Drop out rate in LAMIVUDINE:

Outcome assessed – Analyzed
46 – 43 = 3
3/46 x 100= 6.5%
 INTERPRETING THE RESULTS
Question #1: How large was the effect of treatment?
 Rt= Risks/Total Participants under the treatment group
12/45= 0.27
 Rc= Risks/Total Participants under the control group
26/43= 0.60
 RR: Rt/Rc
0.27/0.60 = 0.45 – Beneficial
 RRR: (Rc-Rt)/Rc or 1– RR
(0.60-0.27)/0.60 = 0.55 or 55% - Beneficial
 ARR: Rc – Rt
0.60 – 0.27 = 0.33 or 33% - Beneficial
Question #2: How precise was the estimate of
the treatment effect?
 Assessing Applicability
Question #1: Are there biologic
issues that may affect applicability
of the treatment?

YES, the patient is HBeAg-

negative while in the study, the
patients where HBeAg-positive
 Assessing Applicability
Question #2: Are there socio-economic issues
affecting applicability of treatment?

None. The Clevudine 30 mg/tab at P90.00/tab given

once a day for 48 weeks (Total = P30, 240) is much
cheaper than the standard, Lamivudine 100 mg/tab at
P200.00/tab given once a day for 48 weeks (Total =
P67,200).
Individualizing the Results
Question #1: Are the benefits to your patient worth the harm
and the cost? YES.
 Would you offer the treatment to your
patients?
YES.

NNT = 1/ARR
 ARR = 0.33
 NNT = 1/0.33 = 3.03
 Interpretation: You need to treat 3 patients to prevent 1 additional
bad outcome or for 1 of them to benefit
NNT x cost of treatment
 3.03 x P90.00/tab x 336 days = P91,627.2 is the overall cost needed
to treat
 Conclusion

Clevudine is comparable and cheaper

alternative to the standard Lamivudine in
reducing HBV DNA in patients with Chronic
Hepatitis B.