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Essentials of Diagnosis
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Chronic inflammatory reaction of the liver of more than 3–6 months' duration
Repeated detection of hepatitis B surface antigen (HBsAg) in serum, often with elevated serum aminotransferase levels
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General Considerations
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Early in the course, hepatitis Be antigen (HBeAg) and hepatitis B virus (HBV) DNA are present in serum
Indicative of active viral replication and necroinflammatory activity in the liver
These persons are at risk for progression to cirrhosis and for hepatocellular carcinoma
Low-level IgM anti-HBc is also present in about 70%
Clinical and biochemical improvement may coincide with
If cirrhosis has not yet developed, such persons are at a lower risk for cirrhosis and hepatocellular carcinoma
Chronic hepatitis is characterized on the basis of
The etiology
The grade of portal, periportal, and lobular inflammation (minimal, mild, moderate, or severe)
The stage of fibrosis (none, mild, moderate, severe, cirrhosis)
Five phases of chronic HBV infection are recognized
Immune tolerant phase
Immune active (or immune clearance) phase
Inactive HBsAg carrier state
Reactivated chronic hepatitis B phase
HBsAg-negative phase
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Clinically indistinguishable from chronic hepatitis due to other causes
Immune active phase (HBeAg-positive chronic hepatitis B)
HBeAg and HBV DNA are present in serum, indicative of active viral replication
Serum aminotransferase levels are normal, with little necroinflammation in the liver
This phase is common in infants and young children whose immature immune system fails to mount an immune response to HBV
Inactive HBsAg carrier state (HBeAg-negative chronic HBV infection)
Patients have entered this phase when biochemical improvement follows immune clearance and cirrhosis has not yet developed
Patients in this phase are at a low risk for cirrhosis and hepatocellular carcinoma
Patients with persistently normal serum aminotransferase levels infrequently have histologically significant liver disease
Reactivated chronic hepatitis B phase (HBeAg-negative chronic hepatitis B)
Risk factors for reactivation include
In patients with either HBeAg-positive or HBeAg-negative chronic hepatitis B, the risk of cirrhosis and of hepatocellular carcinoma correlates with the serum HBV DNA level
HIV coinfection is also associated with an increased frequency of cirrhosis when the CD4 count is low
HBsAg-negative phase