Hepatitis B

What is Hepatitis B?

Hepatitis B infection is a serious global health concern. This dangerous liver infection is caused by the Hepatitis B virus and is usually spread through body fluids such as blood, semen, and vaginal secretions. The good news is that most healthy adults (more than 95%) can naturally get rid of the infection. In some instances, people may show symptoms, while others don’t experience any symptoms at all and only find out they have the disease during routine screening.

The effects of Hepatitis B can differ in people, with some showing signs during the initial infection and others only during long-term illness. When someone is first infected, they can display varying symptoms from subtle sickness, yellowing of the skin and eyes (jaundice), or more severe cases of liver inflammation. In prolonged cases, people may not exhibit any symptoms, or they can progress to chronic liver disease, liver scarring (cirrhosis), or even liver cancer.

Initial symptoms often include a loss of appetite, nausea, vomiting, abdominal pain, and jaundice. In severe cases of liver damage, symptoms can escalate to include more pronounced jaundice, confusion or altered consciousness due to liver damage (hepatic encephalopathy), fluid buildup in the abdomen (ascites), bleeding in the gut due to swollen veins in the lower esophagus (esophageal varices), blood clotting problems (coagulopathy), or infections.

Diagnosis is done through blood tests in people who show signs or symptoms and are at risk of the disease. More details about this process will be discussed later.

What Causes Hepatitis B?

Hepatitis B is a virus that can be passed from infected individuals to those who are not immune. There are several ways this can happen:

1. Through what’s called horizontal transmission. This means the virus is spread through sexual contact or contact between mucous membranes like the mouth or nose. This often happens during unprotected sex or drug use with shared needles. This mainly happens in areas where there are a fairly small number of people with Hepatitis B.

2. The virus can also be spread vertically, from mother to newborn during childbirth. This is more common in areas where a larger number of people have Hepatitis B.

Sexual contact can include unprotected intercourse, and mucous membrane contact can involve contact with an infected person’s saliva, vaginal fluids, semen, or blood.

Areas can be classified by how common Hepatitis B is. This is based on what percentage of people have a marker for the virus, called Hepatitis B surface antigen (HBsAg), in their blood. Areas where 8% or more of the population are positive are considered high prevalence, 2-7% is considered low to intermediate prevalence, and less than 2% is low prevalence.

Risk Factors and Frequency for Hepatitis B

Hepatitis B virus (HBV) infection is a major global public health issue due to its potential to become chronic, leading to serious illnesses and death. Despite the availability of vaccines, the global rate of hepatitis B is increasing. The reasons for this include limited access to healthcare and a lack of health education. In the United States, the incidence of hepatitis B is lower than in Asia and Africa, thanks to better access to healthcare and more widespread use of vaccines and preventive measures.

Here are some statistics about HBV infection in the United States:

• Every year, there are about 60,000 new cases.
• Over 2 million people live with chronic hepatitis B.
• The infection is more common among black, Hispanic, and Asian populations than white populations.
• People younger than 12 who were born in the U.S. have a lower rate of hepatitis B.
• About 5-10% of chronic end-stage liver disease cases and 10-15% of hepatocellular cancer cases are caused by hepatitis B.
• Hepatitis B causes approximately 5,000 deaths each year.

And here are some important global statistics:

• 350-400 million people worldwide have chronic hepatitis B.
• Asian Pacific Islanders, Alaskan Eskimos, and Australian aborigines have a high prevalence of hepatitis B.
• Geographical regions with a high prevalence of hepatitis B include the Indian subcontinent, sub-Saharan Africa, and central Asia.
• The prevalence of hepatitis B has decreased since the hepatitis B vaccination program began.
• There are 10 identified genotypes of hepatitis B (A-J).

High-risk groups for hepatitis B include intravenous drug users, infants born to infected mothers, men who have sex with men, patients and workers in hemodialysis, healthcare workers, and people living in the same household as someone with chronic HBV. Most cases of HBV globally are contracted from mother to child during birth.

Signs and Symptoms of Hepatitis B

People infected with the Hepatitis B virus (HBV) might not show any symptoms at first. In some instances, depending on the specific type of the virus, they might never develop symptoms. In such cases, a thorough understanding of the patient’s health history is crucial to determining the diagnosis. However, when symptoms do arise from acute HBV infection, they can look like “serum sickness-like syndrome,” manifesting as fever, skin rash, joint pain, and inflammation. These symptoms usually go away when jaundice appears. Other symptoms can include feeling tired, having stomach pain, feeling nauseated, and not wanting to eat.

Taking a detailed history should always focus on their lifestyle, including sexual habits, illicit drug use, and profession, especially those in high-risk jobs like healthcare or sex work. Also, living with someone with HBV infection is significant. It’s important to test those who fall into high-risk groups, like healthcare workers and drug users who inject, as well as those who hail from areas where HBV is prevalent. Notably, individuals with certain mental health conditions such as bipolar disorder, schizophrenia, or manic disorder are more likely to contract HBV infection during manic states, as they may engage in risky sexual activities such as unprotected sex.

A physical examination should also look for signs of chronic liver disease. These signs include yellowing of the skin and eyes (jaundice), fluid accumulation in the abdomen (ascites), enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), redness of the palm (palmar erythema), hand deformity (Dupuytren contractures), tiny red widened blood vessels on the skin (spider nevi), breast enlargement in men (gynecomastia), swollen veins resembling a head of Medusa (caput medusa), and confusion due to liver damage (hepatic encephalopathy). These signs hint at possible issues like high blood pressure in the vein that supplies the liver (portal hypertension) and scarring of the liver (cirrhosis).

Issues outside of the liver (extrahepatic manifestations) might include conditions affecting arteries (polyarteritis nodosa) or the kidney’s filtration system (glomerular diseases) such as membranous nephropathy and less frequently, membranoproliferative glomerulonephritis. A severe form of anemia where the bone marrow does not create enough new blood cells (aplastic anemia) can also occur.

Testing for Hepatitis B

The process of diagnosing Hepatitis B involves not just a physical examination, but also a patient’s medical history, laboratory tests, and even imaging. Initial symptoms of this disease are usually nonspecific and can take different forms, such as lack of appetite, nausea, vomiting, stomach pain, dark urine, clay-colored stools, and jaundice. In more severe cases, patients can experience confusion, comas, gastrointestinal bleeding, coagulation disorders, or infections, all related to liver damage.

To clarify, Hepatitis B manifests either as a chronic inactive infection, or as a set of acute hepatitis symptoms, known as chronic active hepatitis. It’s important to note that the diagnosis largely depends on physical examination and patient history, as well as testing for certain virus-related substances in the blood.

For instance, 1-12 weeks after the initial Hepatitis B infection, a primary viral substance known as hepatitis B surface antigen (HBsAg) is mostly detectable through lab tests. However, the presence of this antigen typically disappears after 6 months. Following its disappearance, there’s what doctors call a “window period” or “serological gap”, when the related antibodies, anti-HBsAg, start to show up. Around this time, other viral substances might not be detectable in lab testing.

The initial stages of immunity building involve breaking down the virus’s protective shell, which allows exposure of more viral substances and results in liver enzyme elevation. As liver inflammation occurs, laboratory measurements may still remain within normal ranges. Therefore, liver tests should not be the only method to diagnose suspected Hepatitis B infection.

When antibodies to HBsAg are present, this indicates vaccination. But if one has antibodies to HBeAg, it might suggest a chronic infection state. If these antibodies develop spontaneously, it signals a transition from an acute, immune-active phase to an inactive carrier state, which is referred to as seroconversion. Earlier seroconversion usually leads to better outcomes, but delayed seroconversion associated with recurrent reactivation and remission may increase the risk of complications like liver cirrhosis, leading to poorer outcomes.

If someone has been positive for HBsAg for longer than 6 months, it implies that the Hepatitis B infection is chronic, not acute. Several groups of people ought to be screened for Hepatitis B, such as individuals born in regions with high Hepatitis B prevalence, people with a history of illicit intravenous drug use, men who have sex with men, pregnant women, and HIV patients, among others.

All these evidences are being interpreted through serologic markers. Being positive for HBsAg signals acute or chronic infection, while the presence of anti-HBs suggests recovery from acute infection or vaccination-induced immunity. HBeAg is associated with high viral load and anti-HBe indicates a low replication phase. Anti-HBc IgM signifies acute infection or the presence during the window period. This may also be present during a flare-up of chronic infection. Anti-HBc IgG implies exposure to infection.

Additional markers include Hepatitis B viral DNA and genotyping, useful for determining viral load and disease progression, and response to treatment with interferons, respectively.

Treatment Options for Hepatitis B

Prevention is key when it comes to managing hepatitis B. As of 2019, there are two types of hepatitis B vaccines available in the United States: single-antigen vaccines and combination vaccines.

In 95% of cases, healthy adults are able to naturally resolve acute hepatitis B without specific treatment. For those with severe disease, anti-viral treatment may be necessary. These are cases where certain symptoms or medical measurements indicate a more severe infection.

Treating chronic hepatitis B involves checking for other present infections, such as HIV or other types of hepatitis, assessing severity, and checking virus levels. The severity depends on factors such as physical examination, blood tests, and liver tissue sampling. Testing and imaging techniques are useful for cases with normal liver enzyme levels, but for fluctuating or high levels, a liver biopsy is needed to decide if antiviral treatment is necessary.

There are several medications approved by the FDA for treating chronic hepatitis B. These include interferon medications and nucleoside and nucleotide analogs. Entecavir and tenofovir are the first choices for acute hepatitis B infection due to their resistance against becoming ineffective. Although combination versions of entecavir exist, studies show they are no more effective than taking entecavir alone.

Mother-to-baby transmission of hepatitis B continues to contribute significantly to the global number of hepatitis B cases. Giving tenofovir to HBsAg-positive and/or HBeAg-positive mothers was found to be helpful in reducing certain levels in both mothers and their babies.

Taking oral nucleos(t)ide to suppress viral replication and lower the amount of virus in the body has been successful. Lamivudine was the first effective suppressant, but was associated with high drug resistance. Studies have shown entecavir to be a better option than lamivudine.

Patients in the immune-tolerant phase of hepatitis B infection were not recommended for antiviral medications. This phase of the infection is characterized by normal liver enzymes and HBV DNA levels. However, these antivirals couldn’t properly control viral levels due to high circulating levels of HBV DNA. Studies investigating the difference between single and combined therapy have so far not shown a significant difference.

Preventing further transmission of hepatitis B is extremely important. Lifestyle modifications include reducing intake of substances that can potentially damage the liver, like alcohol and certain medications or herbal supplements.

The goals of antiviral therapy include suppressing the hepatitis B virus, reducing liver inflammation, and preventing the disease from developing into liver cirrhosis and liver cancer. A successful treatment is indicated by normal liver enzyme levels, undetectable hepatitis B DNA, and a reduction in inflammation and fibrosis in liver tissue.

Surgical intervention is only necessary for severe liver disease requiring transplantation.

What else can Hepatitis B be?

When trying to diagnose the cause of hepatitis B, doctors have to consider a wide range of possibilities. This is due to the vague symptoms such as fatigue, stomach pain, nausea, and throwing up. They could all be signs of various types of hepatitis like hepatitis A, C, and E, or even other liver-related conditions like alcoholic hepatitis and autoimmune hepatitis. To figure out the real cause, doctors have to ask the right questions about a patient’s medical and general history and conduct relevant lab tests.

Another condition that doctors might consider is iron overload, also known as hemochromatosis. This can show similar signs to hepatitis B such as pain in the abdomen and unusual liver enzyme levels. However, some things point more towards hemochromatosis than hepatitis B, such as an overall change in the color of the skin and issues with managing blood sugar levels.

Wilson’s disease, a condition where there is too much copper in the body, is another possible diagnosis. It can lead to mental health problems due to an excess of copper in a particular part of the brain. A signal of Wilson’s disease is the presence of unique rings in the eyes, but this isn’t always present and needs a specialist eye doctor to confirm. Lab tests that might suggest Wilson’s disease include low levels of a protein called ceruloplasmin in the blood and high levels of copper in the urine. If these results are abnormal, a liver specialist would need to do further testing.

In summary, while figuring out a hepatitis B diagnosis, other conditions that doctors might think about include:

• Alcoholic hepatitis
• Autoimmune hepatitis
• Liver scarring (cirrhosis)
• Liver damage from medication or toxins
• Iron overload (hemochromatosis)
• Hepatitis A
• Hepatitis C
• Hepatitis D
• Hepatitis E
• Liver cancer
• HIV
• Wilson’s disease

This extensive list shows why doctors must carefully evaluate all symptoms and test results to come to an accurate diagnosis. It’s a fine balance of good detective work and scientific evidence.

What to expect with Hepatitis B

Acute Hepatitis B infection, often called HBV, can be managed by addressing the symptoms and in cases of people with a healthy immune system, it can even resolve by itself. However, if it advances to a chronic condition, the risk for developing severe illnesses like liver cancer, cirrhosis, or total liver failure increases. The level of this risk can vary depending on the specific type of the virus and how it was transmitted. For instance, getting the virus from mother to child during birth (vertical transmission) generally leads to a higher risk of long-term complications than getting it from person to person (horizontal transmission).

Possible Complications When Diagnosed with Hepatitis B

Hepatitis A and hepatitis E don’t progress to a chronic or long-term state, unlike Hepatitis B Virus (HBV) infection, which does have a potential to become chronic. This chronic stage of hepatitis B can lead to serious health issues like an abnormally high blood pressure in the veins entering the liver (portal hypertension), scarring of the liver (cirrhosis), complications related to cirrhosis, and even liver cancer (hepatocellular carcinoma). Therefore, it’s really important for patients with HBV infection to get their condition regularly monitored. Consulting a specialist is strongly advised.

In cases where HBV infection leads to severe liver failure, one needs to urgently investigate the possibility of a liver transplant and should do so at a specialized liver transplant center.

Preventing Hepatitis B

Educating patients plays a crucial role in preventing HBV (Hepatitis B Virus) infection. This is especially important for expectant parents, particularly those from areas where this disease is very common. They should be taught about the significance of vaccines and dispel any false notions related to vaccination.

In addition to this, patients should be counseled about staying away from risky behaviors that can increase their susceptibility to the infection. Such behaviors include promiscuous sexual activity or abusing drugs that are injected directly into the veins. Furthermore, they should be cautioned not to share personal items like razors, toothbrushes, or hair combs. This is because the virus can be transmitted through contact with the mucous membranes or minor skin injuries.