1. Chronic Hepatitis B Diagnosis When to refer
Dr Yeung Yat Wah
楊日華醫生

2. Screening for HBV Persons born in hyperendemic areas
Men who have sex with men
Injection drug users
Patients on dialysis
HIV patients
Pregnant women
Family, household, and sexual contacts

3. Prevention of infection
Have sexual contacts vaccinated
Use barrier method
Not share toothbrushes or razors
Cover open cuts and scratches
Clean blood spills with detergent or bleach
Not donate blood or sperms
Safe:
Contact sports, sharing food, utensils
Kiss

4. Natural History Selecting patient to treat
Immune tolerance phase
First 3 decades
Very high viral load with normal ALT
Immune clearance phase
Liver damage with high ALT, can be asymp
HBeAg seroconversion
Quiescent phase

5. Evaluation Hx and P/E FHx of liver ds, Hepatitis B, HCC Lab tests
CBP, PI
HBeAg/Ab HBVDNA
USG
Fibroscan
Liver Bx

6. Fibroscan – How it works
Fibroscan is non-invasive, good reproductivity, and easy operations
Patients need to
lay down and
put his right
arm during the
examination

7. Fibroscan – How it works
The probe is placed at the intercostal space of the rib bones
Shear (mechanical) wave is triggered by pressing the button at the probe
The ultrasound will track the
speed of the shear wave
The harder the liver and faster
the speed higher stiffness(LSM);
softer the liver and slower the
speed  lower stiffness(LSM)

8. LSM is highly reproducible
Overall interobserver
agreement ICC: 0.98
Intraobserver
agreement ICC: 0.98
Intraobserver
agreement ICC: 0.98
Study population: 200 patients with chronic liver diseases
800 LSMs were performed
Intraobserver and interobserver agreement were analyzed using the intraclass
correlation coefficient (ICC)
LSM is a highly reproducible and user-friendly technique for assessing liver fibrosis in patients with chronic liver diseases
Fraquelli et al. Gut. 2007

9. Factors Associated with LSM Failure
< ≥ ≥ ≥ ≥ ≥40 60 40 20
LSM failure rate (%)
1.0%
12.4%
16.9%
8.1%
24.9%
BMI (kg/m2)
41.7%
N= N= N= N= N= N=48
Factors associated with LSM failure:
BMI (>30 kg/m2)
Operator experience (<500 examinations)
Age (>52y)
Type 2 diabetes
Time of examination
Castera et al. Hepatology. 2010

10. LSM in CHC: Treatment Effects
Group (n)
Initial LS Range (kPa)
2nd LS Range
(kPa)
LS Change
(median, kPa)
P Value
Sustained virological response (SVR)
Total (95)
-36.8 – (-0.6)
<0.001
F 0-1 (33)
-3.3 – 2.6 (-0.5)
0.042
F 2-4 (57)
-36.8 – 16.7 (-1.0)
0.003
Non-sustained virological response (NSVR)
Total (49)
-14.6 – 23.6 (0.8)
0.557
F 0-1 (10)
-4.3 – 6.4 (0.9)
0.959
F 2-4 (32)
-14.6 – 23.4 (0.3)
0.694
LSM decreases in sustained responders following IFN-based therapy in
patients with chronic HCV
Wang et al. J Gastroenterol Hepatol. 2010

11. LSM in CHB: Treatment Effects
100%
75%
50%
25%
17%
58%
12%
53%
F4 (≥11.0 kPa)
F2 ( kPa)
F3 ( kPa)
F0/F1 (<7.2 kPa)
Before After Before After
Advanced fibrosis before treatment
Cirrhosis before treatment
35%
Study population: 53 patients with cirrhosis; 13 patients with advanced fibrosis
Median treatment duration:
50.5 months
Transient elastography examinations demonstrate that prolonged treatment with NUCs in patients with CHB results in low liver stiffness
Andersen et al., Scand J Gastroenterol. 2011

12. Treatment Aims: sustained suppression
Prevent cirrhosis, hepatic failure, and HCC
Assess treatment response
ALT
Decrease in serum HBVDNA
Loss of HBeAg with + HBeAb
Improvement in histology

13. Candidates for Referral
Cirrhosis
Chronic Hepatitis B
ALT above 2x and HBVDNA 5 log copies
Any ALT elevations with HBVDNA 5 log
Above 40
Liver bx showing active disease or sig fibrosis

14. Monitoring for those who do not need treatment
HBeAg+ with normal ALT
LFT every 3-6 months
More frequent if ALT elevated
For persistent slightly high ALT, consider liver biopsy esp above 40 years of age
In young patients (below 30) liver biopsy is usually not necessary if ALT is persistently normal
HBeAg status every 6-12 months

15. Monitoring for those who do not need treatment
HBeAg negative
Monitor LFT every 3 months during the first year to verify that they are truly inactive
Then every 6-12 months

16. Case sharing (1) HKU student, 20 years old Normal LFT Normal USG
No need to check HBVDNA
HBeAg status

17. Case sharing (2) Young man, 22 years old Normal LFT Normal USG
HBVDNA 9 logs
HBeAg +
Started on oral drugs and referred to HA

18. Case sharing (3) Male 65 years old
Known HB years ago during regular blood check
No regular follow up and monitoring
Recently seen by his family physician and LFT showed ALT 200+, so referred to Medical

19. Case sharing (3)
As his ALT was high an early appointment was given (2 weeks)
New case assessment: P/E normal
Taking his age and deranged LFT into account, an early USG was arranged in a week which showed a 3 cm mass
Confirmed HCC with surgery done and received treatment for his HB

20. Case sharing (4) 44 gentleman seen by GP for years
Known Hepatitis B for years
In recent 3-4 years noted a slightly high ALT around 40+ to 50+
USG showed fatty liver
Continue to monitor

21. Case sharing (4) Came to seek a second opinion
USG showed moderate coarsening suggesting cirrhosis. Spleen was also enlarged to 11.5 cm. Platelet count was low at 100+
HBVDNA was 3 logs
Treated with oral drugs

22. Case sharing (5) Male 55 years old
Known HB during pre-marital check up
No regular follow up
Taking herbs for eczema for a year
Noted ankle and scrotal oedema, seen by GP, noted deranged LFT with ALT 300+, RFT also abn with creatinine 130+, USG showed a few nodules below 1 cm
Adm PWH due to dizziness

23. Case sharing (5)
While waiting for hepatologist assessment came to see me
USG showed a vague large mass 6 cm but PV was patent, Alb normal
? HCC but some element due to herbs?
CT scan confirmed several masses and extensive IVC infiltration and LN involvement

24. HCC screening LFT AFP and USG every 6 months Male HB patients over 40
Female HB over 50
Any Cirrhosis
FHx of HCC in HB patients

25. Cumulative Risk Scores and Projected HCC Risk
Risk predictor
Risk score
Gender
Female
Male 2
Age
30-34
35-39 1
40-44
45-49 3
50-54 4
55-59 5
60-65 6
ALT, U/L
<15
15-44
≥45
HBeAg
Negative
Positive
HBV DNA level, copies/mL
<300 (Undetectable)
106
Cumulative risk score
HCC risk
At 3rd year
At 5th year
At 10th year
0.0% 1
0.1% 2 3
0.2% 4
0.3% 5
0.5% 6
0.7% 7
1.2% 8
0.8%
2.0% 9
3.2% 10
0.9%
5.2% 11
1.4%
3.3%
8.4% 12
2.3%
5.3%
13.4% 13
3.7%
8.5%
21.0% 14
6.0%
13.6%
32.0% 15
9.6%
21.3%
46.8% 16
15.2%
32.4%
64.4% 17
23.6%
47.4%
81.6%

26. ROC Curves for Model Validation
Cut-off risk score: 12
Sensitivity: 0.84
Specificity: 0.73

27. Thank You