What should be done for someone who is Hepatitis B surface antigen (HBsAg) positive and hasn't had a check-up in 17 years, despite having no symptoms?

Management of HBsAg-Positive Individual Without Check-up for 17 Years

Your husband needs immediate medical evaluation including liver function tests, HBV viral load, and assessment for liver damage, as chronic hepatitis B infection can silently progress to serious liver disease even without symptoms. 1

Initial Evaluation Needed

• Complete serological testing to confirm chronic HBV infection status (HBsAg, HBeAg, anti-HBe, HBV DNA levels) 1
• Liver function tests including ALT, AST, bilirubin, albumin, and prothrombin time to assess liver health 2
• HBV DNA viral load measurement to determine level of viral replication 1
• Complete blood count with platelet count to check for signs of advanced liver disease 2
• Abdominal ultrasound to assess liver structure and rule out complications like cirrhosis or hepatocellular carcinoma 1, 2

Disease Staging

• Liver fibrosis assessment through non-invasive methods (elastography) or liver biopsy if indicated 1, 2
• Determination of disease phase (immune tolerant, immune active, inactive carrier, or HBeAg-negative chronic hepatitis B) 1
• Screening for hepatocellular carcinoma if indicated based on risk factors (Asian men >40 years, Asian women >50 years, Africans >20 years, family history of HCC, or cirrhosis) 1

Treatment Considerations

• Treatment decisions will be based on HBeAg status, HBV DNA levels, ALT levels, and stage of liver disease 1
• First-line treatment options may include pegylated interferon alfa-2a, entecavir, or tenofovir depending on clinical presentation 1, 3
• The goal of treatment is to suppress viral replication and reduce inflammation to prevent progression to cirrhosis and hepatocellular carcinoma 4, 3

Long-term Monitoring

• Regular monitoring with liver function tests every 3-6 months 1
• Periodic measurement of HBV DNA levels 1
• Ultrasound surveillance for hepatocellular carcinoma every 6 months if at high risk 1
• Lifelong follow-up is essential even for inactive carriers as reactivation can occur 1

Additional Recommendations

• Screening for other infections including HIV, hepatitis C, and hepatitis D 1
• Vaccination against hepatitis A to prevent additional liver injury 1
• Avoidance or limitation of alcohol consumption 1
• Testing and vaccination of household members and sexual contacts 1
• Use of barrier protection methods (condoms) for sexual partners who are not immune 1

Common Pitfalls to Avoid

• Assuming no liver damage due to absence of symptoms - chronic HBV can silently progress to advanced liver disease 1
• Delaying evaluation due to normal feeling - up to 40% of patients may have significant liver disease without symptoms 1
• Failing to screen family members and close contacts who may also be infected 1
• Not considering hepatocellular carcinoma screening in appropriate risk groups 1

The 17-year gap in monitoring is concerning as chronic HBV infection can progress silently. Even with normal ALT levels, patients can have significant liver damage, especially those with HBeAg-negative chronic hepatitis B 1. Prompt medical evaluation is essential to determine disease status and appropriate management.