Hepatitis B Case Study: Lab Interpretation for New Grad NPs

Jan 6

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Show notes:

Hepatitis B lab interpretation can feel like a total mind-bender. The lab names alone are like an alphabet soup!

Overall, there's a lot to say about Hepatitis B, but in this case study I'll be walking you through a case study of elevated liver enzymes, and how you'd approach testing for Hepatitis B.

Ordering and Interpreting Hepatitis B Labs

In this video you'll learn:

Which labs to order
What they mean
The next steps depending on your results, and when to refer to GI

Hepatitis B Labs Cheat Sheet

Here's a cheat sheet we made to go with this episode! Download yours here.

Lab Interpretation Crash Course

If you liked this episode, it's a sneak preview of how we cover labs inside our comprehensive Lab Interpretation Crash Course. It covers CBC, CMP, Urinalysis, Dipstick & Microscopy, TSH, Lipids & top Endocrine labs in primary care, and comes with lifetime access and continuing education credits! Check it out here.

If you liked this post, also check out:

0:00
hepatitis B can be super confusing
0:02
whether it's the knowing which lab to
0:04
order how to interpret them and then the
0:05
alphabet soup that seems to appear when
0:07
you look in your order set in your EHR
0:09
I'm gonna be talking all about that
0:11
today so if you're new here I'm Liz Rohr
0:12
from real-world NP and you're watching
0:14
and few practice made simple the weekly
0:16
videos to help save you time frustration
0:18
and help you learn faster so you can
0:20
take the best care of your patients so
0:22
there's a whole bunch that I could say
0:23
about hepatitis B it's a really big
0:25
topic I'm focusing on the evaluation
0:27
specifically related to elevated lfts
0:29
which I talked about in this video I'm
0:32
going to link to on the top right corner
0:33
if you want to watch that if you haven't
0:34
watched already to go back and do that
0:36
or watch it just when you're done here
0:38
but also there's a chichi down below
0:40
this video that you can print out keep
0:41
at your desk to help you with
0:42
interpretation and some further
0:44
resources if you're interested in
0:45
learning a little bit more if you like I
0:47
said if you there's a lot to say so if
0:49
you want to hear more from me definitely
0:50
have a comment below and I'll talk a
0:51
little bit more about the different
0:53
scenarios of testing and management and
0:55
all that kind of stuff another note
0:57
though is that the lab interpretation
0:58
crash course for new nurse practitioners
1:00
is opening up this month registration
1:02
opens on January 24th so put it on your
1:05
calendar if you want to get on a
1:06
waitlist you can go over to real-world
1:08
NP comm slash labs and I'll send you a
1:10
reminder with the link to sign up and
1:11
all that information if you're on a lab
1:13
interpretation journey definitely I'd
1:15
love for you to join us so definitely go
1:18
over to that link at real-world NP comm
1:19
slash labs but without further ado I'm
1:21
gonna be sharing a case study with you
1:23
and I'm gonna share my screen with you
1:24
alright so jumping into the hepatitis B
Case Study
1:27
case study so this is Misha she's 62
1:30
she's a new patients of the clinic and
1:32
this is not her real name or her photo
1:34
although lovely photo she's moving here
1:37
she moved here from Singapore she's
1:38
establishing care with the new PCP she
1:41
doesn't have any concerns she just needs
1:42
some refills today her past medical
1:44
history includes hypertension anemia and
1:46
hypothyroidism she doesn't smoke use
1:48
alcohol or drugs and she has no current
1:51
sexual partners so past surgical history
1:53
includes up and decadent appendectomies
1:55
and she doesn't know anything about her
1:56
family history
1:57
she's taking em loaded peen 5 milligrams
1:59
daily and levothyroxine 15 micrograms
2:02
daily so her blood pressure is 124 over
2:04
72 which is great well controlled heart
2:07
rate of 68 and oxygen RESP rate in BMI
2:09
are all normal so planned so I'm going
2:11
to be focusing today on hepatitis B we
2:13
zooming in on this particular workup as
2:15
it relates to elevated lfts but I'll
2:18
touch on the other components of a
2:19
holistic care at the end and I one other
2:23
note is that there is quite a lot to say
2:25
about hepatitis B but I'm really gonna
2:27
be focusing on just this one particular
2:29
part so I'm gonna check her labs today
2:32
CBC a CMP to check for signs of anemia
2:36
and her kidney function liver function
2:39
and then her TSH because she has high
2:41
hypothyroidism is taking levothyroxine
2:44
and I put in the parentheses HIV and
2:46
hepatitis B screening because I really
2:48
should have done that at the time and I
2:50
did not and I'm gonna be making a video
2:51
about I'm screaming guidelines and I'll
2:53
talk a little bit more about that but
2:54
she did qualify for both of those things
2:56
and I did not order it at the first past
2:58
visit I'm so a result so here her lab
3:00
results um her CBC was normal awesome so
3:03
she actually didn't have anemia anymore
3:04
basic metabolic panel was normal the TSH
3:07
was normal but here's her her lfts the
3:10
portion of the complete metabolic panel
3:12
so albumin is normal alkaline
3:15
phosphatase bilirubin and total protein
3:17
are also normal but the alt and ast are
3:20
slightly elevated so the normal range is
3:22
about 10 to 40 and hers is for both of
3:25
them and then her alt is 74 and her ast
3:27
is 62 so some really important
3:31
background before we jump in I think
3:33
it's really important to understand
3:34
what's going on so that you can kind of
3:36
just more quickly move through the labs
3:38
because you understand them versus kind
3:40
of that rote memorization that comes
3:41
with all the letters of the alphabet
3:42
soup and the numbers so hepatitis B is a
3:45
virus that affects liver cells about 95
3:48
percent of people exposed to and have
3:50
acute infection will cure it cured on
3:53
their own and usually about by six
3:55
months and about five percent of those
3:57
people transition to a chronic hepatitis
3:59
B so 70 percent of acute hepatitis B is
4:03
actually subclinical so they're not
4:05
symptomatic at all and of the 30 percent
4:08
that are symptomatic and going back to
4:09
the LFT lecture you know you're looking
4:12
for signs of liver dysfunction so pain
4:15
abdominal pain jaundice not a jaw things
4:18
like that so definitely go back and
4:20
watch that video if you haven't watched
4:21
it already but about only 1% of those
4:23
people that are symptomatic lead to
4:24
what's called quote like fulminant acute
4:26
liver failure which is great but it
4:29
still happens so it'd be nice to kind of
4:31
prevent those with a with a vaccine and
4:33
then one other background thing to say
4:35
is that just going back to immunology
4:36
when viruses come into our body they
4:38
have surface proteins that are that are
4:42
called the antigens right and so our
4:45
body forms antibodies in response to
4:46
that and so the hepatitis B virus has
4:48
antigens on its surface and then once it
4:51
gets inside the hepatocytes they liver
4:53
cells itself there's an intracellular
4:54
antigen as well called the core antigen
4:57
and that's important because that's one
4:58
of the tests that we're going to be
4:59
looking at and then antibodies are
5:01
formed in response to both the surface
5:03
antigen and the cir in the core antigen
5:05
and so that's why there's so many
5:06
different tests here because we're
5:07
talking about surface and core when
5:09
we're talking with the blood tests and
5:11
we can't measure core antigen again
5:13
because it's inside the liver cells and
5:15
so the only way we can look and see if
5:16
there's an infected liver cell inside of
5:19
its core is by looking at the antibodies
5:21
that come in response to it which is
5:23
really important so some key labs for
5:25
hepatitis B I mean really the most labs
5:27
that you're going to do I'm gonna
5:28
introduce them on this slide because
5:30
there's it's kind of a lot again it's
5:32
like an alphabet soup for a reason but
5:34
it's just it's kind of a lot so I'll
5:35
introduce it here and then I'll walk you
5:37
through kind of the ways to think about
5:39
it so hepatitis B I'm gonna present it
5:42
in a very specific way because this is
5:43
actually the order that your body will
5:45
it will become positive in your body so
5:47
surface antigen again if you have a
5:49
virus with a protein on its surface
5:51
that's the antigen that's going to be
5:52
detectable first because our body
5:54
doesn't automatically make an antibody
5:56
it takes a little bit of time so the
5:57
surface antigen comes first and that's
5:59
usually abbreviated as het bs AG and
6:02
again unfortunately what comes down to
6:04
is with your lab is that um it's it may
6:07
be a little bit different but if you
6:08
understand what you're looking for you
6:09
can kind of talk with your laboratory
6:10
technician to kind of figure out which
6:13
is the right one to order hepatitis B
6:15
core antibody remember like I said the
6:17
core antigen you can't detect because
6:19
inside of the cells and so the first
6:21
thing you're going to look for is the
6:23
core antibody something that your body
6:25
is making in response to an actual
6:27
infection within your cells and that's
6:29
usually written as an anti HBC's
6:32
anything that's anti - something is an
6:34
antibody so anti-hbc
6:37
there's going to be different endings h
6:39
b c HB
6:40
in hbe which stick with me for a second
6:42
but surface antigen core antibody and
6:45
then the next thing is your surface
6:47
antibody there's some other ones that
6:48
kind of come up this is a little bit out
6:49
of order but the Hep B surface antibody
6:52
is what your body makes in response to
6:54
that surface antigen that's on the virus
6:56
HBV DNA I put this later in the list
6:59
because it's not one of the first tests
7:01
you're going to order but it comes into
7:02
the algorithm that really what that is
7:04
is looking at the actual number of virus
7:06
particles that you have so is it in a
7:08
hundred it's going to be reported as
7:09
like hundreds tens tens hundreds
7:12
thousands millions and that's really
7:13
important for management I'm really
7:15
talking about the evaluation in this
7:16
video I'm not gonna be talking about
7:17
management but if you're interested in
7:18
that I'm happy to make another one
7:19
specifically to kind of talk about that
7:21
most of the management's gonna be in
7:23
with GI but there are some cases where
7:25
you can monitor and kind of keep them
7:27
in-house but there's a little bit more
7:28
involved that I want to make its own
7:30
video about it so I have this in
7:32
parentheses here have B e antigen and E
7:35
antibody
7:36
this I don't want to confuse you just
7:38
know the brief note that I'm gonna make
7:40
before I get into that is that it's a
7:42
test that you would order if somebody
7:44
had Hep B confirmed which again I'll get
7:47
into and that really just points to
7:48
whether or not it's actively replicating
7:50
or not the antigen again similar and
7:52
I'll talk you through the natural course
7:54
of the virus but typically you'll have
7:56
the antigen become positive and then
7:57
your body can cure it on its own with
7:59
that antibody and that will kind of help
8:01
you figure out where we are in the
8:02
illness so just stick with me for a
Natural Course
8:04
second so the natural course I've had B
8:06
and the reason I'm spending so much time
8:07
and this kind of foundational
8:08
information is because once you
8:10
understand this like the labs are going
8:11
to be so much faster so the natural
8:13
course I've had B you're exposed to the
8:15
virus
8:16
so the first available blood test is
8:17
going to change is the detection of the
8:19
antigen on those cells on them on the
8:22
virus rather you'll also have the HPV
8:24
DNA detectable around the same time and
8:27
this happens about for weeks on average
8:29
after exposure and these patients are
8:33
not symptomatic they just are exposed
8:35
and those things are forming and all
8:37
that this is only I'm really only
8:39
focusing on the scenario for this
8:40
particular patient but if you were
8:42
worried about a post exposure that's
8:44
kind of a different scenario but anyway
8:45
fYI it becomes positive about a month
8:48
after on average of getting exposed to
8:50
it so the next stage is that they can
8:52
become symptomatic
8:53
although 70
8:54
or some of them will never become
8:55
symptomatic right so the 30% the thing
8:57
would be symptomatic you would be able
8:59
to see these other labs which is nice
9:00
because if it once they get symptomatic
9:02
you can kind of be sure that the labs
9:03
that you need to order to figure things
9:05
out are going to be there right so the
9:07
next thing that comes positive again
9:09
because the antibodies don't get formed
9:10
right away whereas the antigens are
9:11
immediately detectable is this core
9:14
antibody again because it's inside the
9:16
cells we can't detect that antigen but
9:18
we can get the core antibody and the
9:20
kind of the complicate things a little
9:22
bit further there's total and then
9:23
there's the different kinds right going
9:25
back to immunology again if you have
9:27
your IgM that's the first available so
9:30
you're kind of like where are we in this
9:31
illness you're thinking about an IgM
9:34
versus like the total or the IgG which
9:35
forms a little bit later and so this
9:37
becomes positive around eight to twelve
9:38
weeks approximately don't really
9:40
memorize this and actually in the cheat
9:41
sheet down below this video is going to
9:43
have this particular side you can print
9:45
out and just kind of reference as well
9:46
because I don't know I think visually it
9:48
helps me feel a little bit better about
9:50
it so about two to five months after
9:52
they're exposed they become can become
9:54
symptomatic and then they can also have
9:56
that IgG IgM form and the IgM actually
9:59
goes away after awhile right because
10:00
it's that first pass kind of like acute
10:02
symptoms so if you have an IgM positive
10:05
and it's pretty consistent that it's
10:06
this early on thing right which again
10:08
this is all kind of come back together
10:09
in just a moment so the next phase is
10:12
about six months after exposure or about
10:15
15 weeks after they get their symptoms
10:17
if they do they're gonna clear it on
10:19
their own and what's going to happen is
10:20
that that surface antigen that first lab
10:23
that you're gonna have and HBV DNA are
10:26
gonna go away and what's gonna happen
10:28
instead is that you're going to have the
10:30
Hep B surface antibody not the core
10:32
antibody the surface antibody that's
10:33
gonna take over and the antigen is gonna
10:35
go away and this again typically happens
10:39
about six months after exposure so if
10:41
you persistently have this about after
10:43
six months it's going to be chronic and
10:45
again that's about 5% of people so the
10:49
next stage is if you have chronic Hep B
10:51
so if it hasn't cured itself what's
10:53
going to be left over that you're going
10:55
to still have surface antigen you're
10:57
going to still have core antibody
10:58
because the core antibody never goes
11:00
away that's there for life whether it's
11:02
total on the IgM goes away but the total
11:04
IgG goes stays for life
11:07
but you'll still have either a B surface
11:09
antigen and/or HPV DNA and the caveat I
11:14
have here down the bottom inch which is
11:15
why it's included in the handout if you
11:17
want to print that out is that it's kind
11:19
of a lot of information first of all but
11:21
that the the if you are if you're kind
11:24
of walking into the situation of like I
11:26
don't know where we are in this illness
11:27
if somebody has Hep B if you order the
11:29
IgM typically that will have gone away
11:32
by about six to nine ish months and so
11:34
if you have an IgM there of your core
11:36
IgM then you're gonna be in an acute
11:38
infection so again this is a lot of
11:40
information and it all comes together
11:41
when I walk you through it in just a sec
11:43
so let's go back to Nisha so again her
11:45
CBC BMP TSH were all normal and here are
11:48
her labs her alt and are a STR just
11:50
slightly elevated and so definitely go
11:52
back and watch that slightly elevated
11:53
lfts sure that I posted a couple weeks
11:56
back because that will really kind of
11:58
help clue you into what we're talking
12:00
about here because this is really just
12:01
zooming in on one particular aspect of
12:03
that elevated lfts workup this is not
12:05
comprehensive for LFT evaluation this is
12:07
just talking about does this person have
12:09
happy or not so again your question here
12:13
is is this happy and then we're in the
12:15
illness issue is this acute is this in
12:18
the middle or is this towards the end or
12:20
is it chronic so specifically for this
12:24
scenario of somebody with elevated lfts
12:25
again going back and watch that video if
12:26
you haven't already does do they have a
12:29
happy infection that's your kind of
12:30
question there's a couple different ways
12:31
you can order happy labs whether it's
12:33
for screening or you have some of these
12:35
acutely symptomatic like that's a little
12:36
bit different but in terms of it this
12:38
particular scenario of slightly elevated
12:40
lfts that are generally asymptomatic
12:42
this is the approach you're going to
12:44
take so your number one question again
12:45
do they have a Hep B infection or just
12:47
because of something else so they let
12:49
the three labs you're going to order
12:50
again going back again kind of like
12:52
being repetitive on purpose Hep B
12:54
surface antigen that first one that's
12:56
available in an infection you're gonna
12:58
check that number two you're going to
13:00
check the anti-hbc which is the core
13:02
antibody and you can check either the
13:05
total or the IgM and I don't think that
13:07
there's a great way to do this either
13:10
way like there aren't necessarily
13:11
recommendations that I found you could
13:13
just start with the total again if
13:14
you're worried about somebody with acute
13:16
liver symptoms you probably order the
13:18
IgM however if this is kind of like
13:20
someone who's a symptom
13:22
slightly elevated lfts just order the
13:24
core antibody total right because you
13:26
don't even know if this person was happy
13:27
yet because you're gonna have to order
13:29
more labs than just these three
13:31
so anti-hbs which is the surface
13:34
antibody again that appears once the
13:36
antigen goes away and once they've
13:38
cleared the infection you're gonna want
13:40
to test that too right because we're
13:41
just kind of dropping you into the
13:42
middle of evaluating this patient's
13:44
illness like where are we I'm just
13:46
you're just trying to get your bearings
13:47
right so if they have signs of infection
13:49
which I'm going to talk about and this
13:51
is actually in the handout if you
13:52
haven't you haven't downloaded it
13:54
already what's kind of like the positive
13:56
marks but just stick with me for a
13:57
second HPV this this is the second pass
14:00
of labs if they have signs of an
14:02
infection HPV DNA again you're going to
14:04
measure the quantity that you have which
14:06
is important for management you're gonna
14:08
jump into this if you have this
14:10
available at your lab if you don't then
14:11
you can kind of skip this and send them
14:13
to GI but Hep B II antigen and anti HPE
14:17
which is the antibody to that e antigen
14:20
really speaks to if something is rapidly
14:22
replicating so if you if that is very
14:24
expected if it's an acute infection but
14:27
if it's a chronic infection and you
14:28
still have that rapidly replicating
14:30
antigen in there that's a little bit
14:32
more concerning in those patients again
14:33
that influences who needs treatment
14:34
versus who needs monitoring the other
14:37
thing you want to think about if you
14:38
haven't ordered it already is that
14:40
anti-hbc IgM which is the core antibody
14:44
IgM like the first pass of like an acute
14:47
infection to the core antigen right to
14:49
the core antibody and then if you if you
14:52
you know just this is going a little bit
14:54
more into Hep B management which I'm not
14:55
getting super into this video is about
14:57
how is good ordering a Hep C antibody
14:59
and ordering an HIV antibody because
15:01
those co-infections kind of are really
15:04
influential in the heavy management so
Recap
15:06
kind of going back to this really
15:08
overwhelming slide I just want to
15:11
highlight again just to reinforce what
15:12
we're looking at is number one we're
15:13
looking at the Hep B surface antigen
15:15
happy core antibody and then the Hep B
15:19
surface antibody and then when we're
15:20
getting it to the other things once
15:23
you've kind of determined if they're on
15:24
that path of a chronic infection versus
15:26
not then you can kind of order those
15:28
next fancier tests so again recapping
15:30
one more time so happy surface antigen
15:32
core antibody and
15:34
surface antibody and so if you have
15:37
antigen positive core antibody or core
15:41
antigen positive that's signs of
15:43
infection so you're going to do that
15:44
second pass which I already kind of
15:46
mentioned if for example though if you
15:48
only have a positive surface antibody
15:50
but there's no antigen and there's no
15:52
core antibody then those patients are
15:54
just immune from having a vaccine so you
15:56
don't you can just stop your work up
15:58
there however if you have signs of
16:00
active infection for all intents and
16:02
purposes right now I think with
16:04
depending on where you are in your
16:06
practice I recommend as a new nurse
16:08
practitioner you know you do these
16:09
initial labs and then you have them CGI
16:11
because the management and determining
16:13
who stays in primary care with
16:14
monitoring versus who needs treatment is
16:17
a little bit more nuanced especially for
16:19
the scope of this presentation if you're
16:20
interested in learning more they're
16:22
definitely patients that I feel more
16:23
comfortable with monitoring in-house but
16:25
there's just a couple more elements you
16:26
need to be mindful of if you're
16:28
interested in learning more about that
16:29
definitely I'm happy to make a kind of
16:30
like a longer happy specific management
16:33
type of video if you are interested in
16:35
that definitely let me know leave a
16:36
comment below
16:37
but yeah so just and then just a recap
16:40
if somebody has a positive DNA and the e
16:42
antigen those patients are actively
16:44
replicating whether their acute versus
16:46
chronic and in any of these situations
16:49
before if you're hesitating with
16:51
referring to GI or not you can
16:52
definitely consult with your supervisor
16:53
and they can kind of let you know what
16:55
they recommend for monitoring going
16:57
forward so again I'm actually I'm gonna
Lab Interpretation
17:00
give you the opportunity to pause if
17:02
you'd like if you want to kind of work
17:04
through these labs and I'm gonna go
17:05
through her labs and kind of my
17:07
recommendation so you can hit pause if
17:08
you want but um Hep B so I've got her
17:11
lab results here Hep B surface antigen
17:13
is positive her again the alphabet soup
17:17
I apologize it's anti-hbc which is the
17:19
core antibody so anti meaning antibody
17:22
and then the C meaning the course a core
17:24
antibody total is positive on this first
17:27
pass I ordered the IgM which again plus
17:30
or minus you could do anti hepatitis B
17:34
core IgM which is the first pass of an
17:36
acute infection is negative and then the
17:38
last one is the surface antibody which
17:40
is the anti-hbs or the happy SAV so
17:44
sorry that's so confusing but those are
17:45
the options and again this is all on the
17:46
cheat sheet so you don't have to like
17:48
these right now and that's negative and
17:51
so depending if you've paused or not
17:53
welcome back so again for checking the
17:56
first past lives for this patient again
17:57
we're walking into her labs with an
17:59
elevated lfta like hey is this from
18:00
happy or is it from something else and
18:02
these are the labs that you would do and
18:03
so number two we have the second past
18:05
labs because this is consistent with a
18:07
chronic hepatitis B because of the
18:11
antigen being positive the core being
18:13
positive and the IgM is negative and so
18:15
if the IgM is positive it would be more
18:16
of an acute infection and the fact that
18:18
the surface antibody isn't there any
18:20
more isn't there yet means that it
18:21
hasn't quite reached that point of
18:24
clearing on its own and again if the IgM
18:26
is already gone then it's probably gonna
18:29
be a hanging on persistent infection
18:31
compared to the acute ones that still
18:33
could clear on their own in the next
18:35
like six months so again again that's
18:37
the the HPV DNA HB e antigen and E
18:40
antibody and then Hep C and HIV to make
18:43
sure they don't have a CO infection yeah
Conclusion
18:45
and then kind of wrapping up with Nisha
18:47
so she's 62 so we're concerned here
18:50
about a chronic hepatitis B and so I'm
18:52
gonna refer her to GI because again I'm
18:54
not really talking about the management
18:55
in this video I'm happy to do that if
18:56
you're interested in in talking about a
18:58
little bit more and another thing to
19:00
think about yeah maybe I'll get into
19:04
this more into the management video but
19:06
there are cases where you can kind of
19:08
continue to monitor in-house and recheck
19:10
these at a certain interval but again I
19:12
just I want to keep this short and sweet
19:13
so we'll leave it at that for right now
19:14
hypertension thyroid going back to the
19:17
beginning those are all well controlled
19:18
which is awesome so you're returning to
19:20
clinic I really leave that up to the
19:22
patient do you wanna come back in three
19:23
months you wanna come back in six months
19:24
I feel comfortable with about six months
19:26
I mean depending on the on the happy
19:28
making sure that she's kind of still
19:30
getting connected with GI and hasn't
19:31
been lost to follow-up and then coming
19:33
back for a physical exam because we
19:34
haven't really talked about screening
19:35
tests vaccines are other preventative
19:38
measures because you really have to
19:39
manage your time like in 15 minutes it's
19:41
kind of a hard thing to address all of
19:42
those things so again about its kind of
19:45
depending on your scheduling in the
19:46
clinic and what her comfort level is but
19:48
I definitely want to ever come back here
19:49
full physical when you talk a little bit
19:50
more about stuff did you like this video
19:52
if so hit like and subscribe and share
19:54
with your MP friends so together we can
19:56
reach as many
19:57
you grads as possible don't make their
19:58
transition to practice a little bit
20:00
easier and like I said if you want to
20:02
join us for the lab interpretation crash
20:04
course this month go over to real-world
20:06
NP comm slash labs I'll send you all the
20:08
details as they come about and you'll
20:11
also get in the loop for those fast
20:13
action bonuses that are coming along
20:14
with the early registration and I hope
20:17
to talk to you soon and thank you so
20:19
much again for watching hang in there
20:21
and I'll see you soon

Podcast

Liz Rohr