Hepatitis B
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Vaccine preventable, communicable disease of the liver caused by the hepatitis B virus.
B.Global health problem.
C.Acute or chronic forms.
Incidence
A.More than 250 million carriers worldwide.
B.600,000 deaths annually in the world.
C.In the United States, the rate of hepatitis B-related hospitalizations, cancer, and death has doubled in the last decade.
Pathogenesis
A.Transmission through activities that involve percutaneous or mucosal contact with infectious blood or body fluids.
Predisposing Factors
A.Intravenous (IV) drug use that involves sharing needles.
B.Birth from an infected mother (vertical transmission).
C.Needle sticks: Healthcare worker.
D.Sex with an infected partner.
E.Travel to region that has high infection rates (e.g., Asia, Pacific Islands, Africa, Eastern Europe).
Subjective Data
A.Common complaints/symptoms.
1.Fever.
2.Fatigue/malaise.
3.Headache.
4.Nausea.
5.Vomiting.
6.Right upper quadrant (RUQ) pain.
7.Loss of appetite.
8.Itching.
9.Myalgias.
B.Common/typical scenario.
1.Onset of symptoms.
2.Vaccination history.
3.Recent travel.
4.Food history.
C.Family and social history.
1.Sexual activity (unprotected intercourse, gender, multiple partners).
a.IV drug use.
b.Alcohol use.
c.Living situation (infected roommate or partner).
d.Family history of hepatitis B.
2.Dialysis.
D.Review of systems.
1.See common complaints in previous section (jaundice, dark urine, clay-colored stool).
Physical Examination
A.Acute illness.
1.Jaundice.
2.Scleral icterus.
3.Fever—low grade.
4.RUQ tenderness.
B.Chronic illness.
1.Fatigue.
2.Anorexia.
3.Nausea.
4.Mild RUQ tenderness.
C.Fulminant illness: Onset of liver failure as manifested by encephalopathy and systemic dysfunction within 8 weeks of the recognition of liver disease.
1.Ascites.
2.Hepatic encephalopathy.
3.Gastrointestinal (GI) bleeding.
Diagnostic Tests
A.Lab tests.
1.Hepatitis B surface antigen, surface antibody, core antibody, IgM antibody.
2.Antibodies for hepatitis A, C, D, and E.
3.HIV.
4.Complete blood count (CBC).
5.International normalized ratio (INR).
6.Liver function tests.
7.Iron studies.
8.Alpha fetoprotein (AFP).
B.Imaging.
1.Abdominal ultrasound (US).
2.Abdominal MRI.
C.Liver biopsy if indicated.
Differential Diagnosis
A.Hepatitis A, C, D, or E.
B.Alcoholic hepatitis.
C.Autoimmune hepatitis.
D.Acute drug-induced liver injury (DILI).
E.Hemochromatosis.
F.Wilson’s disease.
Evaluation and Management Plan
A.General plan.
1.Supportive care.
a.The likelihood of liver failure from acute hepatitis B is less than 1%.
b.Likelihood of progression to chronic hepatitis B is less than 5% in an immune competent adult.
B.Patient/family teaching points.
1.Vaccination of close contacts.
2.Safe sex practices.
C.Pharmacotherapy.
1.Antiviral medication—Tenofovir or entecavir for patients with acute liver failure or severe
disease (elevated bilirubin, coagulopathic).
2.Fulminant hepatitis—refer for liver transplant.
D.Discharge instructions.
1.Follow-up with pneumocystis pneumonia (PCP) or hepatologist.
2.Avoidance of alcohol or drugs that could harm the liver.
3.Do not share: Toothbrush, razor, needle.
4.Limit sexual partners, perform safe sex practices.
5.Call for fever, vomiting, bloody or black stool, dark urine, jaundice, ascites.
Follow-Up
A.See PCP if mild course.
B.Antiviral medication as prescribed.
C.Repeat lab tests to monitor recovery.
D.Vaccination for hepatitis A if indicated.
Consultation/Referral
A.Hepatologist to manage if condition becomes chronic hepatitis B.
B.Transplant center per hepatologist.
Special/Geriatric Considerations
A.Hepatitis D coinfection: Requires the presence of hepatitis B virus for infection. Should be treated by a hepatologist with peg interferon.
B.Pregnancy: Child born to a hepatitis B mother receives immunoglobulin as well as vaccination after delivery.
C.Fulminant failure: Consider for transplant.
Bibliography
Centers for Disease Control and Prevention. (n.d.). Hepatitis B questions and answers for health professionals. Retrieved from https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm
Lok, A. (2017, September 29). Hepatitis B virus: Overview of management. In J. Mitty (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/hepatitis-b-virus-overview-of-management
Mayo Clinic. (n.d.). Hepatitis B. Retrieved from https://www.mayoclinic.org/diseases-conditions/hepatitis-b/symptoms-causes/syc-20366802.
Pyrsopoulos, N. T. (2018, August 1). Hepatitis B workup. In B. S. Anand (Ed.), Medscape. Retrieved from https://emedicine.medscape.com/article/177632-workup