Difference between revisions of "Hepatitis B"

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(Evaluation)
 
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==Differential Diagnosis==
 
==Differential Diagnosis==
 +
{{Acute hepatitis causes}}
  
 
==Evaluation==
 
==Evaluation==
*AST, ALT > 1000s
+
*[[LFTs]]
*Elevated bilirubin
+
**AST, ALT > 1000s
*Elevated alk phophatase
+
**Elevated bilirubin
 +
**Elevated alk phophatase
 
*Elevated INR
 
*Elevated INR
*Acute hepatitis panel:
+
*CBC, BMP
{| class="wikitable"
+
*Assess for alternative etiologies of symptoms as appropriate (see: [[jaundice]], [[RUQ pain]], [[nausea/vomiting]]
! Anti-hepatitis A, IgM
+
{{Acute hepatitis panel}}
! Hepatitis B surface antigen
+
 
! Anti-hepatitis B core, IgM
+
 
! Anti-hepatitis C
+
{| {{table}}
! Interpretation
+
| align="center" style="background:#f0f0f0;"|'''Clinical Scenario'''
 +
| align="center" style="background:#f0f0f0;"|'''HBsAg'''
 +
| align="center" style="background:#f0f0f0;"|'''anti-HBc'''
 +
| align="center" style="background:#f0f0f0;"|'''anti-HBs'''
 
|-
 
|-
| Positive
+
| Susceptible to infection||negative||negative||negative
| Negative
 
| Negative
 
| Negative
 
| Acute hepatitis A
 
 
|-
 
|-
| Negative
+
| Immune due to natural infection||negative||positive||positive
| Positive
 
| Positive
 
| Negative
 
| Acute hepatitis B
 
 
|-
 
|-
| Negative
+
| Immune due to Hep B infection||negative||negative||positive
| Positive
 
| Negative
 
| Negative
 
| Chronic hepatitis B infection
 
 
|-
 
|-
| Negative
+
| Acutely infected||positive||anti-HBc- positive;       IgM anti-HBc- positive||negative
| Negative
 
| Positive
 
| Negative
 
| Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
 
 
|-
 
|-
| Negative
+
| Chronically infected||positive||anti-HBc- positive;       IgM anti-HBc- negative||negative
| Negative
 
| Negative
 
| Positive
 
| Acute or chronic hepatitis C; additional tests are required to make the determination
 
 
|}
 
|}
  
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*Supportive care for acute disease
 
*Supportive care for acute disease
  
===Post Exposure Prophylaxis===
 
 
{{Hepatitis B post exposure prophylaxis}}
 
{{Hepatitis B post exposure prophylaxis}}
 +
 
==Disposition==
 
==Disposition==
 
*Consider admission for:  
 
*Consider admission for:  

Latest revision as of 18:07, 4 June 2020

Background

  • Blood-borne virus
  • Incubation period: 1-3 months
  • Virus can cause acute, chronic, or asymptomatic infection

Clinical Features

Differential Diagnosis

Causes of acute hepatitis

Evaluation

  • LFTs
    • AST, ALT > 1000s
    • Elevated bilirubin
    • Elevated alk phophatase
  • Elevated INR
  • CBC, BMP
  • Assess for alternative etiologies of symptoms as appropriate (see: jaundice, RUQ pain, nausea/vomiting

Acute Hepatitis Panel

Anti-hepatitis A, IgM Hepatitis B surface antigen Anti-hepatitis B core, IgM Anti-hepatitis C Interpretation
Positive Negative Negative Negative Acute hepatitis A
Negative Positive Positive Negative Acute hepatitis B
Negative Positive Negative Negative Chronic hepatitis B infection
Negative Negative Positive Negative Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
Negative Negative Negative Positive Acute or chronic hepatitis C; additional tests are required to make the determination


Clinical Scenario HBsAg anti-HBc anti-HBs
Susceptible to infection negative negative negative
Immune due to natural infection negative positive positive
Immune due to Hep B infection negative negative positive
Acutely infected positive anti-HBc- positive; IgM anti-HBc- positive negative
Chronically infected positive anti-HBc- positive; IgM anti-HBc- negative negative

Management

  • Supportive care for acute disease

Hepatitis B Post-Exposure Prophylaxis

Treatment is generally initiated after coordination with occupational health and infectious disease service and based the the exposed patient's vaccination history[2]

Unvaccinated

  • If the source is HBsAg(+) then give HBIG x1 and initiate HBV vaccine in two separate sites
  • If source is HGsAG(-) then start the HBV vaccine series
  • If source blood is unavailable and high risk then give HBIG x1 initiate the HBV series
    • If source blood is low risk and unavailable then begin HBV series

Previously vaccinated non responder (one series)

Non responder status is defined as anti-has <10mIU/mL

  • If the source is HBsAg(+) then give HBIG x 1 and begin revaccination series
    • Can also opt to perform second HBIG administration in one month
  • If source is HBsAg(-) then no treatment is needed
  • If source blood is unavailable and high risk then treat as if HBsAg(+)

Previously vaccinated non responder (two series)

Non responder status is defined as anti-has <10mIU/mL

  • If the source is HBsAg(+) then give HBIG x2 and no HBV series
  • If source is HGsAG(-) then no treatment is needed
  • If source blood is unavailable then initiate the HBV series

Treatment Dosing

No contraindications for pregnancy or breast feeding

  • HBIG 0.06 mL/kg IM
    • Give in opposite arm from hepatitis B vaccine if patient also receiving vaccine
  • Vaccination series: HBV vaccine options:
    • Engerix-B 20mcg IM
    • Recombivax HB 10mcg IM

Disposition

  • Consider admission for:
  • INR >2, Bilirubin >30, hypoglycemia
  • Any GI bleeding
  • Intractable pain, inability to tolerate PO
  • Significant comorbidity/immunocompromised or age >50 years

See Also

External Links

References

  1. Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  2. Postexposure prophylaxis to prevent hepatitis b virus infection. CDC MMWR http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a3.htm?s_cid=rr5516a3_e