Outpatient Clinics

This condition is treated in the Gastroenterology clinic

Pre-referral work-up

History

The Hepatology clinic is staffed by Gastroenterologists/Hepatologists and Hepatology nurses. The Hepatology nurses can provide an advisory service during normal business hours when the guidelines are insufficient.

The clinic prioritises appointments according to clinical need as per the ASHM decision making chart.

HBV antiviral treatment is available to those with chronic hepatitis B. The aim of treatment is to achieve long term suppression of HBV replication and clearance if possible, and to arrest/reverse the progression of liver damage including the prevention of hepatomas. Patients do  not need  to be referred to the Liver clinic: if they have Chronic hep B without cirrhosis or elevated ALT. GP monitoring and care is appropriate for these patients.( see below)

Patients in the immune clearance and immune escape phases (HBe Ag negative) should be considered for antiviral therapy as indicated on the ASHM decision making chart.

Treatment is indicated for those with High HBV DNA, elevated ALT, or evidence of inflammation +/- fibrosis on liver biopsy or >F2 on Fibroscan/elastography. NB Patients with cirrhosis only need a positive HBV DNA to qualify for treatment.

Please review ASHM website for Hepatitis B virus testing and interpreting test results.

Please provide all requested information in your referral. Please refer patients to the clinic in your region.

Note: All referrals should comply with Referral Standards and for all patients the following parameters assist in triage and potential choices of care. Please provide in particular :

History

• An  overview of current health status with regard to manifestation of liver disease and extrahepatic manifestations of chronic HBV ( polyartertis nodosa, colitis, renal issues, neurological or dermatology issues)
• Age and communication issues and if an interpreter is required
• Current medical conditions including co-infections, cardiovascular, GIT, psychiatric  or urological illnesses
• Current medication list , including OTC and drug use
• History of acquisition of Hepatitis B infection  (risk factors include ethnic background, family history of chronic hepatitis B, family history of  hepatocellular carcinoma, blood transfusions, IVDU etc)
• If from endemic country full details are required – must specify country of birth/residence and not just region
• Ongoing risk factors for viral transmission and reinfection
• Social factors which may affect compliance: alcohol and smoking status, social
• Vaccination history

Physical examination

• Features of cirrhosis: hard liver edge, spider naevi, leukonychia
• Features of decompensation or portal hypertension: jaundice, ascites, oedema, bruising, muscle wasting, encephalopathy
• Weight and BMI
• Extrahepatic manifestations of  HBV

Tests

Pathology:

• LFT
• FBC
• U&E
• Alpha fetoprotein (AFP) (only where performed)
• HBV serology
• Hepatitis B Viral Load / HBV DNA PCR
• HCV serology

Imaging:

Upper abdominal USS

Investigations:

Nil

Interim/GP management

To refer a patient with this condition, please see the Gastroenterology clinic page for the full referral process and templates.

The ASHM website includes guidance for primary care clinicians “ All you need to know about Hepatitis B”.

All patients with chronic hepatitis B require regular monitoring for disease progression and liver damage; 6 monthly LFTs, FBE, INR and annual US with fibrosis assessment.

Consider vaccination for Hepatitis A, offer testing and vaccination of household and sexual contacts for Hepatitis B as per Immunisation Handbook.

Counsel the patient to avoid liver toxins (alcohol, some medications) and about compliance which is critical

Those not requiring antiviral treatment require 6 monthly monitoring of LFTS and annual HBV DNA, US with fibrosis assessment.

Offer HBV testing (HBs Ag, anti-HBs, anti-HBc) to:

• At risk ethnic groups : Asian, southern European,  Middle Eastern, African , Central America, ATSI people
• People undergoing immunosuppressive therapy
• Pregnant woman – if +ve referral to Hepatologist will be organised by antenatal service
• Infants and children ( >9months)  of HBV positive woman
• People with liver disease
• People at occupational risk of exposure.
• People undergoing dialysis
• Partners and household contacts of those with HBV
• People at risk through sexual contacts or IVDU
• People who are currently or have been in custodial settings

For more information please see the Tasmanian Health Pathways website.

Red flags are clinical indicators of possible serious underlying conditions requiring further medical intervention. They may or may not indicate an emergency.

• Decision making in HBV table
• ASHM website for Hepatitis B includes guidance for primary care clinicians “ All you need to know about Hepatitis B”.