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Chronic Hepatitis B Decision Tool

posted 2011-09-11, updated 2019-12-22

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Chronic Hepatitis B Decision Tool
Summary: A decision tool for initial management of Chronic Hepatitis B.
See soapnote's Hepatitis B Screening Decision Tool [link url="https://www.soapnote.org/infectious/hepatitis-b-screening" memo="here"] and Hepatitis B Chronic Decision Tool [link url="https://www.soapnote.org/infectious/hepatitis-b-chronic" memo="here"]
Evaluation of Chronic Hepatitis B should include a thorough history and physical examination, with special emphasis on risk factors for coinfection, alcohol use, and family history of HBV infection and liver cancer. Laboratory tests should include ALT, quantified Hepatitis B viral DNA, Hepatitis B e antigen, and tests for coinfection with HCV, HDV, or HIV in those at risk.
[select name="Q1" value="negative=0|positive=100"] <-- HBeAg - Hepatitis B e antigen
[select name="Q2" value="less than Upper Limit of Normal (ULN)=0|1 to 2 times the Upper Limit of Normal (ULN)=10|more than 2 times the Upper Limit of Normal (ULN)=20"] <-- ALT - alanine aminotransferase
[select name="Q3" value="less than 2000=0|2,000 to 20,000=1|more than 20,000=2"] <-- Hepatitis B virus DNA level (units = IU/mL)
Interpretation --> [calc memo="Result" value="score=(Q1)+(Q2)+(Q3);score>121?'Active phase.  Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>120?'Check ALT and HBeAg every 1-3 months.  Treat if HBeAg persists.  Liver biopsy optional.  Treat immediately if jaundice or decompensated.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>119?'Check ALT and HBeAg every 1-3 months.  Treat if HBeAg persists.  Liver biopsy optional.  Treat immediately if jaundice or decompensated.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>111?'Active phase.  Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>110?'Check ALT every 3 months.  Check HBeAg every 6 months.  If HBeAg persists or age greater than 40, consider biopsy.  Treat as indicated.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>109?'Check ALT every 3 months.  Check HBeAg every 6 months.  If HBeAg persists or age greater than 40, consider biopsy.  Treat as indicated.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>101?'Consider liver biopsy examination, particularly if patient is > 35-40 years.  Treat if disease.  If no biopsy, observe for increase in ALT levels.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>100?'No treatment.  Monitor ALT and HBV DNA every 6-12 months.  Consider therapy in patients with known significant histologic disease.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>99?'No treatment.  Monitor ALT and HBV DNA every 6-12 months.  Consider therapy in patients with known significant histologic disease.  ':score>21?'Active phase.  Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>20?'Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>19?'Monitor ALT & HBV DNA.  A liver biopsy may be helpful.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>11?'Active phase.  Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>10?'Should be offered treatment.  Liver biopsy may not be necessary.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>9?'Monitor ALT & HBV DNA every 3 months.  Consider biopsy if persistent.  Treat as indicated.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>1?'Consider liver biopsy.  Treat if disease present.  If no biopsy, observe for rise in ALT.  Check ALT in 3 months or less.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.  ':score>0?'Inactive phase.  Treatment not indicated.  Liver biopsy not indicated.  Monitor ALT every 6-12 months for reactivation.  Screening is often recommended for patients at risk for developing hepatocellular carcinoma.  This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL.  Screening with alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.':'Inactive phase.  Treatment not indicated.  Monitor ALT every 3 months for 3 times.  Then monitor every 6-12 months for reactivation.'"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
references:  
 AFP article on diagnosis and treatment of hepatitis B - Wilkins (2010) Am Fam Phys 81: 965-72 [link url="//www.aafp.org/afp/2010/0415/p965.html" memo="#1"]
American Association for Study of Liver Diseases (AASLD) Hepatitis B Guidelines [link url="//www.aasld.org/practiceguidelines/Pages/default.aspx" memo="#2"]
Article with a slightly different algorithm at Keefe (2008) Clin Gastroenterol Hepatol 12:1315-41 [link url="//www.ncbi.nlm.nih.gov/pubmed/18845489" memo="#3"][/conditional]

Chronic Hepatitis B Decision Tool
Summary: A decision tool for initial management of Chronic Hepatitis B.
See soapnote's Hepatitis B Screening Decision Tool here and Hepatitis B Chronic Decision Tool here
Evaluation of Chronic Hepatitis B should include a thorough history and physical examination, with special emphasis on risk factors for coinfection, alcohol use, and family history of HBV infection and liver cancer. Laboratory tests should include ALT, quantified Hepatitis B viral DNA, Hepatitis B e antigen, and tests for coinfection with HCV, HDV, or HIV in those at risk.
<-- HBeAg - Hepatitis B e antigen
<-- ALT - alanine aminotransferase
<-- Hepatitis B virus DNA level (units = IU/mL)
Interpretation --> Resultscore=(Q1)+(Q2)+(Q3);score>121?'Active phase. Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>120?'Check ALT and HBeAg every 1-3 months. Treat if HBeAg persists. Liver biopsy optional. Treat immediately if jaundice or decompensated. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>119?'Check ALT and HBeAg every 1-3 months. Treat if HBeAg persists. Liver biopsy optional. Treat immediately if jaundice or decompensated. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>111?'Active phase. Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>110?'Check ALT every 3 months. Check HBeAg every 6 months. If HBeAg persists or age greater than 40, consider biopsy. Treat as indicated. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>109?'Check ALT every 3 months. Check HBeAg every 6 months. If HBeAg persists or age greater than 40, consider biopsy. Treat as indicated. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>101?'Consider liver biopsy examination, particularly if patient is > 35-40 years. Treat if disease. If no biopsy, observe for increase in ALT levels. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>100?'No treatment. Monitor ALT and HBV DNA every 6-12 months. Consider therapy in patients with known significant histologic disease. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>99?'No treatment. Monitor ALT and HBV DNA every 6-12 months. Consider therapy in patients with known significant histologic disease. ':score>21?'Active phase. Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>20?'Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>19?'Monitor ALT & HBV DNA. A liver biopsy may be helpful. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>11?'Active phase. Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>10?'Should be offered treatment. Liver biopsy may not be necessary. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>9?'Monitor ALT & HBV DNA every 3 months. Consider biopsy if persistent. Treat as indicated. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>1?'Consider liver biopsy. Treat if disease present. If no biopsy, observe for rise in ALT. Check ALT in 3 months or less. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options. ':score>0?'Inactive phase. Treatment not indicated. Liver biopsy not indicated. Monitor ALT every 6-12 months for reactivation. Screening is often recommended for patients at risk for developing hepatocellular carcinoma. This includes patients over 40 years with ALT elevation and/or HBV DNA level above 2,000 IU/mL. Screening with alpha-fetoprotein (AFP) alone or AFP and ultrasound every 6-12 months are two options.':'Inactive phase. Treatment not indicated. Monitor ALT every 3 months for 3 times. Then monitor every 6-12 months for reactivation.'
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