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    Hepatitis B
    Disease And Treatment Profile

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    Overview

    Hepatitis B (HBV) is a virus that infects and damages the liver. Because hepatitis B can hide inside the body, many people don't know they have the virus until they get tested. In the United States, more than 2 million people have the hepatitis B virus (HBV) and each year, 50,000 new infections occur. Individuals who were born in or whose parents lived in Southeast Asia, the Pacific Islands, Africa, the Amazon Basin in South America, or the Middle East may be more likely to have hepatitis B infection. This is because people in these areas have not always received the hepatitis B vaccine. Also, mothers with hepatitis B who were not vaccinated against the virus may have an active infection, thereby passing the virus to their child unknowingly during birth.

    The word "hepatitis" indicates the presence of inflammation in the liver. Once this inflammation begins, scar tissue (called fibrosis) may form. In 20-30% of patients who carry the hepatitis B virus, this scar tissue leads to cirrhosis and/ or liver cancer.

    Photomicrograph of the liver with chronic hepatitis B.

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    Transmission

    Hepatitis B is carried in an infected person's blood and other body fluids. The virus is contagious and can be spread through:

    • Mother-to-child infection (from a pregnant woman to her baby)

    • Sexual contact (having either heterosexual or homosexual sex with an infected person)

    • Blood-borne infection

    • Having a tattoo or body piercing done with "dirty" tools that were used on someone else

    • Sharing drug needles

    • Sharing a toothbrush or razor with an infected person

    • Getting pricked with a blood- contaminated needle or sharp object

    • Having a blood transfusion with blood that has not been screened

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    Screening Tests for Hepatitis B

    HBV viral particleTo screen for hepatitis B infection, a blood test is performed that initially tests for the following markers of HBV infection or protection:

    • Surface antigen (HBsAg): A positive test means an individual is infected with the hepatitis B virus and can infect others. Further testing is needed.

    • Surface antibody (HBsAb or anti-HBs): A positive test means a person is immune to the hepatitis B virus and cannot infect others. No further testing is needed.

    • Core antibody (HBcAb or anti-HBc) (Optional Test): A positive test usually means the person has been exposed to the hepatitis B virus. Since it does not indicate active infection or immunity, more testing for HBV may be needed.

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    Vaccination

    A vaccine is available for hepatitis B. All household and sexual contacts of a person infected with the hepatitis B virus should be vaccinated. All homosexual men should be vaccinated, as well as individuals of Asian origin and healthcare workers. The vaccine only protects people not infected with HBV.

    The vaccination process involves three injections - an initial injection, then injections at one and six months. A booster shot is not usually required.

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    Symptoms

    Unless you are acutely infected (that is you only recently got the virus), most infected people have no symptoms until cirrhosis or cancer develop. Others may experience symptoms such as:

    • Feeling tired and fatigued

    • Loss of appetite

    • Upset stomach and vomiting

    • Fever and/or pain (including abdominal pain)

    • Jaundice (yellowish eyes or skin)

    • Dark urine

    • Skin rash
    Hepatitis B often leads to cancer and/or cirrhosis - a scarring process where liver cells are replaced or destroyed, and unable to function. Patients with cirrhosis may experience:
    • Swollen feet and/or abdomen (ascites)

    • Confusion (encephalopathy)

    • Vomiting blood

    • Passing blood, or purple or black bowel movements

    • Yellow eyes and/or skin

    • Muscle loss

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    Types and Phases of Hepatitis B Infection

    Chronic Hepatitis B
    This refers to active infection with elevated liver enzymes and/ or inflammation shown on one's liver biopsy. Individuals with active hepatitis B are at risk for progressive liver damage resulting in cirrhosis and are at highest risk for developing liver cancer.

    Immune Tolerance
    Historically, individuals were identified as "silent carriers" or "healthy carriers" if they had persistently normal liver enzymes and a normal liver biopsy. Currently, the term used is an "immunotolerant patient" or "carrier" if one is asymptomatic, has persistently normal liver and "healthy" enzymes, elevated HBV DNA and a normal liver biopsy.

    Inactive Carrier
    These individuals have undetectable virus by PCR and normal (healthy) liver enzyme levels (an ALT less than 20 for women and less than 30 for men at most testing sites). These patients have a lower risk of liver disease progression.

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    Treatment

    Individuals with chronic hepatitis B should be referred to a specialist trained in managing HBV, such as a hepatologist at a transplant center. Blood tests should be performed regularly. Medications are available for chronic hepatitis B and include:

    Entecavir, Adefovir and/ or Tenofovir: These oral medications can be prescribed to suppress HBV infection; however, they rarely lead to HBsAg seroconversion.

    Lamivudine and Telbivudine: Lamivudine, a medication of historical interest, is now a second-line therapy due to high rates of resistance and its failure to suppress viral infection. Telbivudine is also categorized as a second-line therapy. While it was approved for the treatment of HBV, it has an intermediate level of potency and intermediate rates of resistance.

    PEG Interferon: This drug, which is administered through an injection under the skin for one year (similar to an insulin shot for diabetes), can slow liver disease by reducing the amount of virus in the body. In a few people, PEG Interferon treatment may put the virus in an inactive phase.

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    Surveillance and Referral

    Even if one feels healthy with hepatitis B, he/she should still get regular surveillance exams to monitor liver status (inflammation, function and liver cancer). Suggested tests include:

    1. Every 3 to 6 months: ALT blood test screens for liver damage 2. Every 6 months: AFP blood test screens for your risk of liver cancer 3. Every 3 to 6 months: HBV DNA test screens for your need or response to treatment 4. Every 6 months to a year: Utrasound scan screens for liver cancer

    Note: If you are determined to be at increased risk of liver cancer or if you have cirrhosis or a family history of liver cancer, increase the frequency of your ultrasound exam to every 6 months.

    If the surveillance exams show a high AFP result, cirrhosis or hepatic mass(es), a referral to a transplant center should be made. If there are any signs of liver dysfunction such as low albumin, elevated bilirubin or abnormal coagulation, a transplant and liver specialist referral should be initiated. Additionally, the presence of ascites and/or encephalopathy (mental confusion) should lead to a liver specialist referral.

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    Why Choose Us?

    California Pacific's Liver Disease Management and Transplant Program offers comprehensive specialty care for adult end-stage liver disease. We emphasize on-going communication with refer-ring physicians and incorporate them into the decision process of their patient's medical management. We follow up our care with an organized discharge report to the referring physician.

    For patients requiring hospitalization, we have a dedicated critical care liver unit, hospitalists who specialize in liver disease, physician assistants, on-call anesthesia staff and a specialized O.R. nursing team.

    Our hepatologists and hepatobiliary surgeons are members of Sutter Pacific Medical Foundation, a not-for-profit medical foundation that provides primary and specialty care, combining the latest in medical technology with a compassionate touch. Sutter Pacific doctors deliver health care services in San Francisco, Marin, Sonoma and Lake Counties, with additional outreach locations throughout Northern California. The relationship between Sutter Pacific physicians and local Sutter Health facilities helps link both doctors and patients with hospital services, enabling the highest quality care delivery. For more information visit www.sutterpacific.org.

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    Research & Innovation

    Our Hepatology Research Center has a comprehensive clinical research program, offering concurrent trials for various liver diseases, including hepatitis B. We also have a Liver Immunology Laboratory that serves as a hub for collaborative viral hepatitis research in the Bay Area.

    We are proud to be at the forefront of advances and research affecting our patients. Multiple pharmaceutical studies and clinical research trials using new, ground-breaking medications and procedures in the area of viral hepatitis, liver cancer, gastroenterology and liver transplantation are continually being pursued in our Research Center.

    California Pacific Medical Center is one of 15 sites in the United States selected to participate in the National Institutes of Health's Hepatitis B Research Network. This initiative brings together clinical centers with expertise in caring for patients with chronic hepatitis B virus infection. The goal of the Network is to conduct research on chronic hepatitis B in order to better understand the physiological effects of the disease and develop effective treatment strategies.

    We are seeking patients with hepatitis B to participate in clinical research studies. Working with our hepatologists, the research coordinators meet patients interested in studies and monitor their treatment. If you are interested, please talk to your physician or call us at 415-600-1163. Study locations are available in San Francisco, Oakland and Sacramento. Learn more about our hepatology clinical trials..

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    About California Pacific Medical Center

    California Pacific Medical Center, part of the Sutter HealthOpens new window network, offers specialized care in liver disease and liver transplant. Our program is based in San Francisco and has outreach locations throughout Northern California and Nevada.

    California Pacific Medical Center
    San Francisco Center for Liver Disease
    2340 Clay Street, 4th Floor
    San Francisco, CA 94115
    Tel: 415-600-1020

    For referrals and patient transfer, contact California Pacific's Specialty Referral Program
    Tel: 1-888-637-2762
    Fax: 1-415-600-2955

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