Chronic Hepatitis B Serologies & Management in Primary Care
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Show notes:
I love GI, but something about Hepatitis - specifically Hepatitis B serologies - is super confusing for not just me, but most clinicians. And it's something that will continue to come up time and again in primary care, whether it was a lab you ordered or one of your colleagues.
Chronic Hepatitis B Serologies & Management in Primary Care
In this video you’ll learn:
Your role as a PCP in the assessment and management of chronic hepatitis B
How to determine who gets treatment and who doesn't
How to interpreting Hep B serologies
When to refer to GI
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Liz Rohr (they/she) | Real World NP (00:00.175)
Hey there, it's Liz Rohr from Real World NP and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So in this video, I'm going to be talking about chronic hepatitis C. That is 100 % not what this is about. This is about chronic hepatitis B. So sorry about that. Your role as a primary care in the assessment and monitoring and then when to refer to GI.
touching on some of the lab interpretation as well. So before I jump in, a couple of notes. Number one, this is based on the AASLD guidelines. I've also made videos on hepatitis B and C serologies as well as LFT interpretations. So if you haven't looked at those already or watched those already, definitely go back and do so because it will be a little bit grounding as I'm kind of referencing them based on you knowing that stuff already in this video.
So yeah, to jump right in though, management, so your role is to really assess, see where they're at, and then make that decision of when they need to be seen in GI. So if you've already watched the Hep B video, I'll just remind you that hepatitis B infections, about 90 to 95 % of people will clear it on their own. And then when they have persistently have hepatitis B surface antigen for greater than six months, it's considered to be a chronic infection.
The management, some people get treatment and some people don't. And the management and the assessment going forward is dependent on a couple of different factors. number one, cirrhosis, and I'll kind of tie these all back in. So just as an overview, it really depends on if they have cirrhosis or not, if they have liver inflammation or not, what the immunologic response is to the infection, which I'll get to as a lab test. The viral load, how much actual virus the body has. The genotype, the type of hepatitis B.
And risk factors for disease progression. So a couple of things like being over the age of 40, having a family history of liver cancer or liver problems, and then the comorbidities and comorbid infections that may or may not be coming alongside of it. And one of the things I want to make as a disclaimer, well, first I have a cheat sheet dump below this video because there's a lot of information in here and it can get a little bit confusing with all the different names and the letters. And then a disclaimer is that what I'm talking about are adult patients that are
Liz Rohr (they/she) | Real World NP (02:19.573)
are more or less straightforward. The ones that don't necessarily have a complicated case or multiple comorbidities, like that kind of thing. So any of those kind of more complex cases definitely need to be seen by GI. Most of these patients are going to need to be seen by GI anyway, but you can start with a couple of things first. So in this particular situation, the first thing that I recommend doing that I do is assessing their history. So do they have any sense of where this infection came from? Were they born with this infection?
Do they use IV drugs? Did they get a blood transfusion? Did they get any tattoos? Things like that, trying to think about if there's any idea around that. And then when it comes to family history, it's really important to assess if they have hepatitis B, if they have a family history of liver cancer or liver disease, again, because that affects their own personal prognosis, which is a little bit outside of primary care, but it's important information to gather for the GI to make that assessment.
So you want to assess their symptoms, right? So are they having any signs of acute liver decompensation or things like that, like abdominal pain, jaundice, vomiting, ascites, et cetera, et cetera. And then there's a couple of testing things that you can do to kind of drop yourself in and see what's going on, because that's the main thing with all the hepatitis serologies is that the reason you get so many of them is that you're getting a sense of the history of what the status is.
So I'm not gonna get super into all the hepatitis B serologies, the regular ones, quote unquote, as I talked about that in the other video, so definitely go back and check that out. But you wanna start with the basic ones. And then there's a couple of other ones you wanna assess, particularly with chronic hepatitis B. So two things, one is that there is a, you may remember from school, the hepatitis B E antigen, without getting too much into the weeds, basically what it's referring to is how
rapidly replicating is the virus right now and that will make a strong determination about treatment versus monitoring. There's also the antibody to HbE which is kind of the same path as the previous hepatitis basic serologies that you get the antigen first and then once it goes away it turns into an antibody but so you want to look at both of those. And then the HbV DNA, the hepatitis B virus viral load is really important as well for assessing the status and determining if they need treatment versus monitoring.
Liz Rohr (they/she) | Real World NP (04:41.822)
A couple of other blood tests you definitely want to consider doing, you need to do, is LFTs for sure, but also HIV, hepatitis C, and again, I talk about that in the hepatitis C video, but starting with an HCV antibody, hepatitis C antibody, and then the RNA level, if that's positive, to get the viral load. And then hepatitis D is another lab that's a little bit contentious. So some people...
Recommend only if they've ever used IV drugs or if they're from certain parts of the world, southern and eastern Europe, I believe are areas. However, some liver specialists recommend doing a one-time test for everybody who has hepatitis B. So one other thing I forgot to mention is hepatitis A screening. You want to make sure that either they've had a vaccination in the past or you want to screen to see if they're immune already because if somebody
is an immune and they get hepatitis A on top of hepatitis B, that can be really dangerous. You want to make sure that their vaccination status is up to date. The two other things you want to assess for when it comes to chronic hepatitis B is looking for liver cancer. And so it's pretty simple, just doing a liver ultrasound. And that needs to go ongoing monitoring. So usually about every six months, you want to be looking to see if they have any masses or new masses or changing masses, things like that.
And then the last part of it, in terms of gathering data, is what is their fibrosis score? So you want to see if they have no fibrosis all the way up to suggestive of cirrhosis. And there's two main tests for that. So historically, used to be that patients would get a liver biopsy. But luckily, with these newer tests, we don't necessarily need to do that, depending on the situation. there is a liver.
cirrhosis, serum fibrosis panel. I'm looking down at my notes so I don't miss them up. There are some brand names. I'm going to try not to use the brand names though. So serum fibrosis panel or with something called vibration controlled transient elastography. And I am going to use the brand name because most people know it by that, which is fibroscan. And it's a special type of scan that most GI offices will have. And in my experience anecdotally, a lot of GI specialists prefer that test because
Liz Rohr (they/she) | Real World NP (06:49.59)
It's readily available in their office. It's quick, it's easy. And I think that it feels like they get more information based on that. And either test that you use, if you're in a rural setting or if you have limited access to the specialists, likely you're going to use the fibrosis serum test. And either test that you use is going to give you a score from zero to four, zero being no fibrosis and four being consistent with cirrhosis. So yeah, so kind of to recap, you're getting that history assessment.
You're getting some labs to kind of drop you into where you are in the actual infection. And then going forward, I could go on forever. And there are different caveats for different lab results. Definitely check out the cheat sheet down below this video to kind of give you the overview of the general steps. But typically speaking, what you're looking at is do they, first of all, what is the viral load? How much virus is there?
Secondly, how inflamed is the liver? So what is the ALT level in particular? And then the last one has to do with that HbE antigen. So how much replication is going on of the virus? And those three factors together give you the most information about whether or not the patient needs to be treated or monitored. So.
Yeah, I definitely recommend downloading the cheat sheet and reviewing it because the general highlight is that somebody is HbE antigen negative, so it's not actively replicating. They're also showing signs of liver inflammation. The ALT is two times the upper limit of normal. And in that particular scenario, if their viral load is over 2,000, in that case, those patients may need treatment.
But if they're not in that category, there's a lot of caveats and it's kind of a lot of numbers and letters and all that. So it's just best to kind of review it down below the video to download it for yourself. But yeah, so typically when it comes to referring to GI, most cases, I'm gonna recommend that you send them to GI because there are so many caveats to think about.
Liz Rohr (they/she) | Real World NP (08:53.17)
even if they don't have any other comorbidities of HIV and hep C and immunocompromised or they're pregnant or anything like that, or they have decompensated cirrhosis, those patients definitely need to go. But in terms of the other ones, it just really depends on your comfort level, your knowledge base and your collaboration with your team and your supervisor. And then the other caveat to think about is that you can, you can...
broaden that scope into primary care, especially if you're in rural medicine. But what it's probably gonna take is making some cold calls. And I've talked about that in another video as well, which I can also link down below this video. But basically calling a GI specialist to consult about a case, what their suggestions are about testing, monitoring, if they need to be seen by a GI or not, that kind of stuff. So yeah, so that's probably where I'd leave it there.
But again, I leave some more information in the cheat sheet down below this video and hopefully that is helpful for you. But let me know if you have any other questions. I'd love to chat more. And if you like this video, hit like and subscribe and share with your NP friends so together we can reach as many new nurse practitioners as possible to help make their first years a little bit easier. And another thing is that it's not open right now, but the lab interpretation crash course for new nurse practitioners goes really in depth into liver function tests.
CBC, CMP, all those other tests on your kind basic labs. If you want to sign up for that on the wait list, it's realworldmp.com slash labs, and then you'll get notified as soon as it opens. But thank you so much for watching. Let me know if you have any questions, and I'll see you soon.
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