What are the symptoms and treatment options for hepatitis B?

Symptoms of Hepatitis B

Acute hepatitis B infection is asymptomatic in 60-70% of patients, but when symptoms occur, they include fatigue, poor appetite, nausea, vomiting, abdominal pain, low-grade fever, jaundice, and dark urine, along with clinical signs such as hepatomegaly and splenomegaly. 1

Clinical Presentation

Acute Hepatitis B

• Asymptomatic infection: 60-70% of patients have no symptoms 1
• Symptomatic infection: When present, symptoms typically include:
  • Loss of appetite
  • Nausea and vomiting
  • Fatigue
  • Abdominal pain
  • Low-grade fever
  • Jaundice
  • Dark urine 1, 2
• Physical examination findings:
  • Hepatomegaly
  • Splenomegaly 2

Chronic Hepatitis B

Chronic infection is defined as persistence of hepatitis B surface antigen (HBsAg) for more than 6 months 3. Patients with chronic hepatitis B may experience:

• Immune-tolerant phase: Usually asymptomatic with normal ALT levels despite high viral loads 1
• Immune-active phase: May have persistently elevated ALT levels with liver inflammation and fibrosis development, though many remain asymptomatic 1
• Inactive carrier phase: Typically asymptomatic with normal ALT levels and low viral loads 1
• Reactivation phase: May develop symptoms similar to acute hepatitis 1

Diagnosis

Diagnosis of hepatitis B requires serological testing:

1. Hepatitis B surface antigen (HBsAg): Indicates current infection
2. Hepatitis B surface antibody (anti-HBs): Indicates recovery or vaccination
3. Hepatitis B core antibody (anti-HBc): Indicates previous or ongoing infection 2, 3

Additional tests to determine disease status include:

• Liver function tests (ALT, AST)
• HBV DNA levels
• HBeAg and anti-HBe status 1

Treatment Options

Treatment goals for chronic hepatitis B are to reduce liver inflammation and prevent complications by suppressing viral replication 2. Options include:

First-line treatments:

• Entecavir (0.5 mg daily) - high genetic barrier to resistance 4, 5
• Tenofovir (300 mg daily) - high genetic barrier to resistance 4, 6
• Pegylated interferon alfa-2a - finite treatment duration with possibility of immune-mediated control 1, 3

Treatment indications:

• HBeAg-positive patients with:

  • HBV DNA >20,000 IU/mL and
  • ALT >2× upper limit of normal (ULN) or
  • Significant liver inflammation/fibrosis on biopsy 1

• HBeAg-negative patients with:

  • HBV DNA >2,000 IU/mL and
  • ALT >2× ULN or
  • Significant liver inflammation/fibrosis on biopsy 1

• All patients with compensated or decompensated cirrhosis and detectable HBV DNA 1

Monitoring

Patients with chronic hepatitis B require regular monitoring:

• ALT and HBV DNA levels every 3-6 months
• HBeAg/anti-HBe status every 6-12 months
• Surveillance for hepatocellular carcinoma in high-risk patients 4

Prevention

• Vaccination: Recommended for all infants, unvaccinated children, and adults at risk 7
• Post-exposure prophylaxis: Hepatitis B vaccine within 12-24 hours of exposure is 70-90% effective in preventing infection 1
• Vertical transmission prevention: Tenofovir in the third trimester for pregnant women with high viral load 4

Important Considerations

• Acute hepatitis B rarely requires specific antiviral treatment as more than 95% of adults recover spontaneously 1
• Only patients with severe acute hepatitis B (characterized by coagulopathy or protracted course) should be treated with nucleos(t)ide analogues 1
• Patients with decompensated cirrhosis should not receive interferon therapy due to risk of worsening liver function 1
• Regular monitoring is essential as chronic HBV is a dynamic disease with potential for reactivation 1