Department of Gastroenterology, West China Hospital, Sichuan University
Chronic hepatitis B, also known as chronic hepatitis B (CHB), is caused byhepatitis B virus(HBV) and continues to infect for more than 6 months.This disease often causes varying degrees of liver inflammation, necrosis and/or liver fibrosis.The transmission routes of hepatitis B virus are diverse, including mother to child transmission, blood and blood products, damaged skin and mucous membrane, and sexual contact.The infection of hepatitis B virus is strong, and it can tolerate heat, low temperature, dryness, ultraviolet ray and disinfectants of general concentration.There are about 257 million chronic HBV infected people in the world, and about 887000 people die of HBV infection every year.In China, the disease burden of hepatitis B is still significant. It is estimated that there are about 70 million cases of chronic HBV infection in China, including about 20 to 30 million cases of chronic hepatitis B.
The symptoms of hepatitis B virus infection are various, and may present mild symptoms such as fatigue, dizziness, loss of appetite, etc. in the early stage.May occur with the aggravation of the diseaseLiver palms、Spider nevus、HepatosplenomegalyAnd other symptoms.More seriously, patients may have symptoms of serious damage to liver function, such ascirrhosisorHepatocellular carcinoma。
Although there is no cure for hepatitis B at present, drug treatment can help control virus replication, reduce liver inflammation, prevent liver disease progression, improve quality of life, prolong life, and through vaccinationhepatitis B vaccineIt can effectively prevent the incidence of hepatitis B.
TCM disease name
Chronic hepatitis B
Alias
Chronic hepatitis B
Visiting department
Department of Gastroenterology, Department of Hepatology, Department of Infectious Diseases
Multiple population
hepatitis B virusPeople who are persistently infected, whose specific work environment and living habits may increase the risk of HBV infection, those who have a history of injecting drugs, and those who use immunosuppressive drugs, etc
Hepatitis B ishepatitis B virusThe resulting viral hepatitis can be divided into acute and chronic hepatitis B according to the development speed of the disease, but the former is now rare in clinical practice, and the "hepatitis B" commonly said by people usually refers to chronic hepatitis B.
Chronic hepatitis B is caused by infection with hepatitis B virus (HBV), but the onset and progress of the disease are closely related to the virus, infected persons, environment and other factors.
Pathogenesis
Chronic hepatitis B is caused by infection with hepatitis B virus (HBV). HBV has strong resistance and is resistant to heat, low temperature, dryness, ultraviolet rays and disinfectants of general concentration. It can be transmitted through mother and infant, blood and blood products, damaged skin and mucous membrane and sexual contact.Hepatitis B patients and HBV carriers are the main sources of infection.
Some specific working environment and living habits may increase the risk of HBV infection, including unclean sex, sharing syringes and needles, close contact with blood and body fluids of hepatitis B patients, etc.However, it should be noted that HBV is not transmitted through the respiratory tract and digestive tractBloodsucking insectThe possibility of transmission (mosquitoes, bedbugs, etc.) is also very small.
Blood and body fluid transmission
A small amount of blood or body fluid contaminated with HBV can cause HBV infection after entering the human body.In recent years, China has implemented strict screening for blood donors, and the HBV infection caused by blood transfusion has declined significantly, but the transmission through blood and unsafe injection still plays an important role.
Medical operations such as surgery, hemodialysis, organ transplantation, sharing razors or toothbrushes, foot trimming, tattooing, ear ring piercing, etc. may lead to HBV transmission from damaged skin or mucosa.In addition, semen, vaginal secretions and milk all contain HBV, so sexual contact can also transmit HBV.
Mother to child transmission
It includes intrauterine infection, perinatal transmission and post delivery transmission.Intrauterine infection is mainly caused by the placental infection of the baby. Perinatal transmission is mainly caused by the contact of the baby with the mother's blood, amniotic fluid or vaginal secretions due to damaged skin or mucosa. Postpartum transmission is mainly caused by the close contact between mother and baby.
Cesarean section does not reduce the risk of mother to child transmission.
In recent years, the application of hepatitis B vaccine combined with hepatitis B immunoglobulin has significantly reduced the mother to child transmission of hepatitis B, but there are still 5%~10% of newborns delivered by hepatitis B surface antigen (HBsAg) positive pregnant women who have immune failure.
Once infected, more than 90% of newborns will develop into chronic HBV infection.
symptom
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Hepatitis B is a viral hepatitis caused by the hepatitis B virus. It can be divided into acute and chronic hepatitis B according to the speed of disease development, but the former is now rare in clinical practice. People often say that "hepatitis B" usually refers to chronic hepatitis B.
Patients with chronic hepatitis B have mild symptoms in the early stage, and can repeatedly suffer from fatigue, dizziness, loss of appetite and other symptomsLiver palms、Spider nevus、HepatosplenomegalyAnd other symptoms.When the disease is serious to decompensated cirrhosis or hepatocellular carcinoma, the corresponding symptoms of serious damage to liver function will also appear.
Typical symptoms
Chronic hepatitis B is defined as acute hepatitis B with a course of more than half a year, or hepatitis B symptoms, signs and liver function abnormalities occur again after the acute attack of the original hepatitis B.According to the severity of the disease, it can be divided into three degrees: mild, moderate and severe.
Mild hepatitis B
The patient's condition is mild and atypical, and symptoms such as fatigue, dizziness, anorexia, greasy anorexia, yellow urine, discomfort or slight tenderness in the liver area, and poor sleep may occur repeatedly.
Some patients have no obvious symptoms and signs. If liver function test is performed, only one or two indicators are slightly abnormal.
Moderate hepatitis B
Symptoms range in severity from mild to severe.
Severe hepatitis B
There are obvious or persistent hepatitis symptoms, such as fatigue, lack of appetite, abdominal distension, yellow urine, loose stool, etc. The more specific symptoms are as follows:
Liver disease face: dark and lusterless, dark, rough and dry skin, even "bronze";
Liver palm: the palms of the hands are big and small, and the thenar is in sheet congestion, or red spots and patches appear, which turn white when pressed;
Spider nevus: a newly emerging "nevus" with a red dot in the center and capillaries arranged radially around it, which looks like a spider. The nevus disappears after pressing the central point;
Spleen enlargement: The patient may feel left costal distension or no feeling at all, which is generally found by the doctor during examination.
The corresponding laboratory examination can show repeated or continuous increase of transaminase, decrease of albumin, and obvious increase of gamma globulin. See the introduction of "Visit" for details.
Accompanying symptoms
Some patients with chronic hepatitis B may be accompanied by mild fever.
Medical treatment
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Chronic hepatitis B is a chronic disease. If it is not controlled in time in the early stage, the disease will gradually progress, and may progress to cirrhosis or liver cancer. Therefore, it is very necessary to see a doctor in time and check regularly.
Visiting department
The common departments for patients with chronic hepatitis B are Department of Gastroenterology, Department of Hepatology and Department of Infectious Diseases.
Indication for medical treatment
If the course of disease is more than half a year or the date of onset is uncertain, the patient has fatigue, anorexia, greasy, liver discomfort and other symptoms, and has chest telangiectasia, or has spider like red nevus and other signs, they all need medical treatment.
It should be noted that the main reason for the occurrence of liver palm and spider nevus is that the inactivation effect of liver on estrogen (a kind of female hormone) is weakened after the liver is damaged due to disease, and excessive estrogen makes the terminal branches of blood vessels expand, which is manifested as liver palm or spider nevus.However, spider nevus may also be caused by other reasons, which does not necessarily mean the occurrence of liver disease.
With the above manifestations, history of blood transfusion and unclean injection, close contact with chronic hepatitis B virus (HBV) infected persons, family members with HBV infected persons or mothers with positive HBsAg, etc., the possibility of hepatitis B should be considered and early treatment should be given.
Diagnostic process
When patients have symptoms such as fatigue, dizziness, loss of appetite, anorexia, yellow urine, and liver discomfort, they should first consider seeking the help of a physician from the Department of Gastroenterology or the Department of Hepatology.The doctor will inquire about the patient's medical history, make a simple physical examination, and observe whether there are liver palms, spider moles and other conditions.Then the doctor will recommend that the patient receive B ultrasound, liver function test and etiology test to judge the degree of liver function damage and whether there is cirrhosis.
Relevant inspection
Medical history and physical examination
Detailed collection of medical history and physical examination is the clinical basis for diagnosis of hepatitis. Before going to hospital, patients and their families need to be prepared to answer the following questions from doctors.
Basic information: including the patient's age, occupation, whether he has paid blood donation history, whether he has surgery or blood transfusion history, whether he smokes, whether he takes drugs, whether he drinks, whether he has multiple sexual partners, etc.
Time of onset: doctors need to know whether the patient is in the epidemic period of a certain disease at the time of onset to help make a clear diagnosis.
Imaging examination
Abdominal B-ultrasound
This is the most commonly used method for liver examination. It can help to interpret the size and shape of the liver and spleen, the important blood vessels in the liver, and whether there is a space occupying lesion in the liver. It is useful for identifying the causes of liver diseases, such asObstructive jaundice、Fatty liverAnd space occupying lesions in the liver, which has a high diagnostic value for cirrhosis.
CT and MRI
It is more sensitive to differentiate the nature of space occupying lesions.
Instantaneous elastography
Transient elastography (TE) can accurately identify mild liver fibrosis, progressive liver fibrosis or early cirrhosis, which is simple and repeatable.This examination is usually carried out under normal bilirubin, and it needs to be combined with patientsAlanine aminotransferaseThe diagnostic accuracy of liver fibrosis can be improved by using ALT level and other serological indicators.
Etiological examination
HBV surface antigen and antibody (HBsAg and anti HBs)
HBsAg can be positive two weeks after HBV infection, and the positive reaction indicates that there is HBV infection at present;
Anti HBs positive indicates that the body has immunity to HBV, and a small number of patients do not produce anti HBs all the time;
The simultaneous positive of HBsAg and anti HBs can occur in the infection of mutant strains, and anti HBs produced by the original HBV can not eliminate HBsAg of mutant strains.
HBV e antigen and antibody (HBeAg and anti HBe)
The existence of HBeAg indicates that HBV replication is active and has strong infectivity;
The disappearance of HBeAg and the production of anti HBe are called "serological conversion". At this time, HBV is mostly in a low replication state, and the infectivity is reduced.
HBV core antigen and antibody (HBcAg and anti HBc)
Positive HBcAg indicates that HBV is in replication status and infectious;
High levels of anti HBc IgG often coexist with HBsAg, reflecting current infection;
Low levels of anti HBc IgG often coexist with anti HBs, indicating past infection.
HBV DNA
This indicator has different results according to different detection methods in different hospitals. It can be detected as a direct sign of virus replication and infectivity.
laboratory examination
Routine blood test and routine urine test
When liver function is abnormalred blood cell、white blood cell、plateletThe levels of red blood cells, white blood cells and platelets may change. When the disease progresses to cirrhosis with hypersplenism, the "three shortages" phenomenon of red blood cells, white blood cells and platelets may appear;Routine urine examinationIt is helpful for the differential diagnosis of jaundice.
Blood biochemical examination
Liver function test
Alanine aminotransferase(ALT) is released into the blood when hepatocytes are injured, which is the most commonly used indicator to reflect the function of hepatocytes in clinical practice.ALT in chronic hepatitis and cirrhosis is slightly to moderately elevated or repeatedly abnormal.
When chronic hepatitis is moderate or above and cirrhosis occurs, serum albumin decreases, gamma globulin increases, and white/globular (A/G) ratio decreases or even inverts.
Serum bilirubin may also be elevated in the presence of chronic icteric hepatitis or active cirrhosis.
other
When hepatocytes are severely damaged,blood sugar、Blood cholesterol(a kind of blood lipid index) can be significantly reduced.
Alpha fetoprotein (AFP)
AFP is a routine method for screening and early diagnosis of hepatocellular carcinoma.The abnormal increase of AFP indicates suspicious hepatocellular carcinoma, but it will also increase in some cases of benign diseases, such as hepatitis activity, or when liver diseases enter the recovery period and hepatocyte repair, AFP can also increase to varying degrees. Therefore, doctors will arrange several tests to dynamically observe the AFP level.
Histopathological examination of liver
The liver puncture under the guidance of B ultrasound and some tissues were taken for pathological examination. This is a traumatic examination, which is of great value for clear diagnosis, measurement of hepatitis activity, fibrosis and evaluation of curative effect.
differential diagnosis
Hepatitis caused by other pathogens: for example, hepatitis caused by parasitic infection or epidemic hemorrhagic fever, laboratory examination can identify.
Liver injury: He has a history of using drugs for liver injury, and most of the liver functions can return to normal after drug withdrawal, with negative HBV markers.
Alcoholic liver disease: Have a long history of heavy drinking, and HBV markers are negative.
Autoimmune hepatitisIt mainly includes primary biliary cirrhosis and autoimmune liver disease. The diagnosis mainly depends on blood sampling to detect autoantibodies.
Fatty liver or acute fatty liver during pregnancy: Fatty liver mostly occurs in obese people, or secondary to hepatitis, which is easy to be diagnosed by B-ultrasound.Fatty liver during pregnancy usually starts with acute abdominal pain, or may be complicated with pancreatitis, reduced liver volume, and severe hypoglycemia and hypoproteinemia.
Hepatolenticular degeneration(Wilson disease): It is a hereditary disorder of copper metabolism, which can affect the liver. It is characterized by liver cirrhosis and other serious liver damage. Serum copper and ceruloplasmin are reduced. A 1~3mm wide yellow brown pigment ring can be seen at the edge of the patient's cornea.
treatment
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Hepatitis B is a viral hepatitis caused by the hepatitis B virus. It can be divided into acute and chronic hepatitis B according to the speed of disease development, but the former is now rare in clinical practice. People often say that "hepatitis B" usually refers to chronic hepatitis B.
Chronic hepatitis B needs to adopt a comprehensive and individualized treatment plan according to the specific situation of the patient, including adequate rest and reasonable diet and nutrition, regulating the psychological state, avoiding drinking and taking drugs that damage the liver, using appropriate drugs to improve and restore liver function, regulating body immunity, antiviral and anti hepatic fibrosis treatment.
General treatment
Patients with chronic hepatitis B should pay attention to rest, eat reasonably, establish a correct concept of disease, and establish confidence in cure.Those with obvious symptoms or serious illness should stay in bed.
Patients should abstain from alcohol and eat food with high protein, high vitamin and easy digestion, but it is not necessary to overemphasize high nutrition to avoid fatty liver.
Patients with severe hepatitis complicated with hepatic encephalopathy should also be given a low protein diet in strict accordance with the doctor's advice.
medication
Antiviral therapy
According to the serum HBV DNA level, serum alanine aminotransferase (ALT) and the severity of liver disease, combined with the patient's age, family history, accompanying diseases and other factors, the doctor decides whether to give antiviral treatment and what kind of antiviral program to give after comprehensively evaluating the risk of disease progression of the patient.
Nucleoside (acid) analogs (NAs)
These drugs are oral drugs, which play a therapeutic role by inhibiting virus replication. The course of treatment depends on the patient's condition.
HBeAg positive chronic hepatitis B patients continue to use drugs for more than one year after HBeAg serum conversion;
Patients with HBeAg negative chronic hepatitis B should take medicine for at least 2 years;
Patients with cirrhosis need long-term medication.
When applying antiviral therapy with nucleoside (acid) analogues, we should pay close attention to the problem of drug resistance. Once drug resistance occurs, it may cause a sharp rebound of the disease, and a few may appear decompensation of liver function, acute liver failure, or even death. Therefore, we should choose drugs with "high drug resistance barrier", that is, drugs that are not easy to produce drug resistance.Therefore, the level of HBV DNA should be closely monitored during treatment, and once drug resistance is found, relevant detection and rescue treatment should be given as soon as possible.
At present, such drugs approved for marketing in China mainly includeLamivudine、Entecaway、Telbivudine、Adefovir dipivoxil、Tenofovir dipivoxilAnd propofol tenofovir. It is suggested that the newly treated patients should give priority to entecavir, tenofovir dipivoxil or propofol tenofovir to reduce the possibility of drug resistance.
The side effects of nucleoside (acid) analogues are also different. Doctors and patients need to pay attention to the following points:
There are a few cases of entecaviLactic acidosis, nausea, vomiting and other discomfort may occur. In case of discomfort, the possibility of this adverse reaction must be considered according to the medication situation, and relevant blood tests must be arranged;
Long term use of tenofovir dipivoxil and adefovir dipivoxil should be alert to renal insufficiency and low phosphorus osteopathy, and the renal function should be continuously and regularly tested;
There are cases of myositis and rhabdomyolysis in telbivudine, and attention should be paid to the development of severe muscle soreness after medication.
Interferons
It includes ordinary interferon - α (INF - α) and polyethylene glycol interferon - α (Peg IFN - α), which are injection drugs. For patients with antiviral indications, Peg IFN - α can be given priority to relatively young people (including adolescents), those who hope to have children in recent years, those who expect to complete treatment in a short time, and those who receive antiviral treatment for the first time.
Peg IFN - α only needs to be administered once a week, which is a long-term preparation and has better antiviral effect than ordinary INF - α.PegIFN - α commonly used in China mainly includes pegylated interferon α - 2a and pegylated interferon α - 2b, both of which are injected once a week for one year.
Contraindications to interferon therapy are as follows:
Serum bilirubin ≥ 2 times the upper limit of normal value;
Decompensated cirrhosis;
Have autoimmune disease;
There are important organ diseases (serious heart and kidney diseases, diabetes, hyperthyroidism or hypothyroidism, and psychoneurological abnormalities, etc.);
Pregnancy in progress or planned in the short term.
The common adverse reactions of interferon alpha are mainly influenza like syndrome, which are shown as follows:
Most of them have fever, chills, headache, muscle aches and weakness, etc;
A few people may have nausea and vomiting symptoms.
Taking antipyretic and analgesic drugs while injecting interferon, and other adverse reactions, such as bone marrow suppression (decreased blood cell level), neuropsychiatric symptoms, etc.
Anti fibrosis treatment
At present, antiviral drugs are the main drugs with positive anti liver fibrosis effect. Other Chinese patent medicines, such as Anluo Huaxian Pill, Compound Biejia Ruangan Tablet, Huoxue Huayu Capsule, also have certain effects.
surgical treatment
Chronic hepatitis B generally does not require surgical treatment.However, when the disease develops to end-stage cirrhosis, liver transplantation can be considered when liver failure occurs.During liver transplantation, surgeons will remove the damaged liver and replace it with a healthy one.Most of the transplanted livers came from deceased donors, but a few came from living donors who donated part of their livers.
For patients receiving liver transplantation due to HBV infection, lifelong use of antiviral drugs is required to prevent hepatitis B recurrence.
TCM treatment
Chinese herbal medicine plays a certain role in protecting the liver, reducing enzymes, reducing jaundice and combating liver fibrosis, but it is necessary to see a doctor in a regular hospital. You should not listen to folk prescriptions and go to an irregular hospital for TCM treatment.
Other treatments
For chronic hepatitis B patients with multiple complications caused by liver failure, a variety of support treatments and artificial liver support systems need to be given, which is of certain value for advanced severe hepatitis and liver failure, and can buy time to regenerate hepatocytes or prepare for liver transplantation.
Frontier treatment
In recent years, a variety of new drugs have entered the clinical trial stage, mainly including antiviral drugs directly acting on HBV, immunomodulatory drugs such as immune activators, therapeutic vaccines, etc., but they are still in preclinical, clinical trial phase I and phase II.
prognosis
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Hepatitis B is a viral hepatitis caused by the hepatitis B virus. It can be divided into acute and chronic hepatitis B according to the speed of disease development, but the former is now rare in clinical practice. People often say that "hepatitis B" usually refers to chronic hepatitis B.
The prognosis of mild chronic hepatitis is generally good;The prognosis of patients with severe chronic hepatitis is poor. About 80% of patients develop cirrhosis within five years, and some may become hepatocellular carcinoma.
complication
With the prolongation of the course of disease, chronic hepatitis B will lead to intrahepatic complications such as cirrhosis and even liver cancer.The liver function of patients with chronic severe hepatitis is seriously damaged, which may lead to infection, upper gastrointestinal bleeding, hepatic encephalopathy, hepatorenal syndrome and other serious extrahepatic complications.
Intrahepatic complications
Mainly includingFatty liver、cirrhosis、Hepatocellular carcinoma。HBV is closely related to hepatocellular carcinoma. The annual incidence of hepatocellular carcinoma in patients with HBV infection without cirrhosis is 0.5%~1.0%, and that in patients with cirrhosis is as high as 3%~6%.The prevention methods are timely medical treatment, standardized treatment and regular follow-up.
Upper gastrointestinal bleeding is one of the common complications of chronic severe hepatitis and cirrhosis, which can be manifested as hematemesis or hematochezia.The reason is that the liver function is severely damaged, and the coagulation function is impaired. At the same time, cirrhosis of the liver leads to portal hypertension, extensive erosion of the esophageal and gastric mucosa, ulcers or varices.
Patients should avoid eating rough and hard food and taking antipyretic and analgesic drugs on an empty stomach to reduce the chance of damage to gastrointestinal mucosa. Ranitidine, cimetidine, etc. can be used to prevent bleeding, and proton pump inhibitors such as omeprazole can be used for patients with gastrointestinal ulcers;Patients should also pay attention to proper supplementation of vitamin K and C.
Hepatorenal syndrome is a complication of chronic severe hepatitis, which is often the end stage manifestation of severe liver disease, often accompanied by severe infection, bleeding and other incentives.The main manifestations are oliguria or anuria, and electrolyte imbalance.
Patients should try not to take drugs that may lead to serious kidney damage, and avoid various factors that cause blood volume reduction.
Daily health care
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liver function（serumtransaminase）Those who have been working normally for more than 3 months can gradually engage in light work, and then gradually increase the workload until they resume their original work.
chronicHepatitis B patientsThe immune function of the body is low, and it is vulnerable to various viruses, bacteria, etcPathogenic factorInfection, which will make the condition that has been static or tends to be cured reactivate and worsen.The patient is living and drinkingpersonal hygieneWe should be more careful in all aspects, take proper exercise, increase or decrease clothes according to the change of weather and temperature, and preventcoldAnd various infections.
For patients with chronic hepatitis BHigh quality proteinFor high food, pay attention to high fiber, high vitamin food, selenium supplement and low fat, appropriate sugar diet.Avoid alcohol and eat less spicy foodfried food；Avoid sweet food;It is forbidden to supplement blindly to avoid damaging the liver or increasing the burden on the liver.
Develop good personal hygiene habits, and use soap andFlowing waterwash hands;Strictly implement the disinfection system;It is recommended to use disposable injection equipment, and HBsAg test should be carried out for blood products to preventIatrogenic transmission。
Protect vulnerable groups
Hepatitis B vaccination is the most effective way to prevent HBV infection.Susceptible personCan be inoculated,Vaccination targetThey are mainly newborns, and at the same time, they are associated with people infected with HBVClose contacts、medical worker、homosexualityPeople, etcHigh risk groupAnd people engaged in childcare education, food processing, catering services and other professions should be vaccinated with hepatitis B vaccine, and the antibody should be reviewed regularly.
