Prepare for the PANCE with this comprehensive topic on pulmonary function testing (PFT) in asthma assessment. Follow the case of a 62-year-old man with psoriasis and a family history of hepatocellular carcinoma presents with positive HBsAg, negative HBsAb, and positive anti-HBc IgG. What’s the best next step in management before starting immunosuppressive therapy? Ace your PANCE exam and excel in clinical practice with this valuable resource.
A 62-year-old man presents to the primary care office to be evaluated before his dermatologist starts him on immunosuppressive medications to treat psoriasis. He has mild fatigue and occasional GI upset but no other concerns. Past medical history is significant for psoriasis and diet-controlled type II diabetes mellitus. His father recently died of hepatocellular carcinoma at age 83. Temperature is 37.0°C (98.6°F), pulse is 60/min, respirations are 12/min, and blood pressure is 120/70 mmHg BMI is 28. The skin has numerous scaly plaques. Abdomen is soft and nontender with no masses. Screening tests are ordered including a colonoscopy and hepatitis B serology. Laboratory results show a positive HBsAg, negative HBsAb, and positive anti-HBc IgG. Additional labs can be seen below. Which of the following is the best next step in management?
| Laboratory value | Result | Reference |
| HBV DNA | 24,000 IU/mL | Not detected |
| HBeAg | + | – |
| ALT | 82 IU/L | 8-40 IU/L |
A. Hepatic elastography and initiation of entecavir
B. MRI of the liver and initiation of tenofovirC. CT scan of the liver and initiation of lamivudine
D. Ultrasound of the liver and referral for liver transplantE. Ultrasound of the liver and serial monitoring of labs
Scroll down to find the answer!
The correct answer to today’s PANCE® Question is…
A. Hepatic elastography and initiation of entecavir
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s PANCE® Question are…
B. MRI of the liver and initiation of tenofovir
Incorrect: Screening for hepatocellular carcinoma in patients with chronic hepatitis B is necessary and is typically done with ultrasound. MRI can be used for further evaluation of concerning findings, or if the ultrasound is inconclusive.
C. CT scan of the liver and initiation of lamivudine
Incorrect: Screening for hepatocellular carcinoma in patients with chronic hepatitis B is necessary and typically done with ultrasound. CT scan can be used for further evaluation of concerning findings,, or if the ultrasound is inconclusive and the patient has a contraindication to having an MRI.
D. Ultrasound of the liver and referral for liver transplant
Incorrect: Ultrasound of the liver is indicated for hepatocellular carcinoma screening in patients with chronic hepatitis B, however, liver transplant is not indicated at this time in this stable patient without signs of fulminant hepatic failure.
E. Ultrasound of the liver and serial monitoring of labs
Incorrect: Ultrasound of the liver is indicated for hepatocellular carcinoma screening in patients with chronic hepatitis B; however this patient also requires initiation of antiviral medication given his family history, age, laboratory findings, and plans for use of immunosuppressive medications.
Main Explanation
This patient’s screening Hepatitis B labs are consistent with chronic hepatitis B infection. He should be treated with antiviral therapy given his age, family history of hepatocellular carcinoma, high viral load with active replication, and plans to start immunosuppressing medication. Patients with chronic hepatitis B should also have a hepatic elastography to assess for fibrosis unless liver biopsy is indicated.
Treatment of hepatitis B infection varies depending on the stage and presenting features of the disease. Treatment may be purely supportive in mild cases, and in more severe cases treatment may include medications or even liver transplantation.
The need for antiviral medication in chronic hepatitis B infection is determined by assessment of viral load using HBV DNA, viral replication, and hepatitis e antigen and antibody status along with consideration of patient-specific risk factors and the condition of the liver. High levels of HBV DNA, active viral replication, elevated ALT, family history of hepatocellular carcinoma, age over 40, pregnancy, acute liver failure, presence of cirrhosis, immunosuppression, and coinfection with hepatitis C or HIV are all indications for treatment with antiviral therapy.
When indicated, first-line treatment is with nucleoside inhibitors such as entecavir or tenofovir. Pegylated interferon alpha may also be considered in the treatment of chronic hepatitis B. Benefits of therapy include viral suppression, reduced risk of recurrent HBV if a liver transplant is needed, reduced risk of hepatocellular carcinoma, and decreased risk of developing cirrhosis. Long-term management of chronic hepatitis B should include regular laboratory monitoring of CBC, CMP, PT/INR, hepatitis B DNA, and e antigen as well as routine surveillance for hepatocellular carcinoma with liver ultrasound and measurement of alpha-fetoprotein. Hepatic elastography should be done in all patients to assess for fibrosis unless a liver biopsy is needed. Counseling on lifestyle modifications should advise against the use of hepatotoxic medications including those sold over the counter, and cessation of smoking. Protective measures may help limit spread of the virus to others such as hepatitis B vaccination for household contacts and safe sexual practices. Hepatitis A vaccination should be administered and screening for other blood-borne infectious diseases should be performed.
Major Takeaway
Treatment of chronic hepatitis B includes antiviral medication when laboratory evaluation or risk factor analysis indicates an increased likelihood of complications from the disease. Long-term care consists of hepatic elastography, ultrasound, and alpha-fetoprotein for surveillance of hepatocellular carcinoma, routine lab monitoring, and lifestyle counseling.
References
Afdhal NH, Bacon BR, Brown RS Jr. Chronic hepatitis B: integrating long-term treatment data and strategies to improve outcomes in clinical practice. Gastroenterol Hepatol (N Y). 2011 Mar;7(3 Suppl 4):1-16. PMID: 22557938; PMCID: PMC3337661.
Wu YL, Shen CL, Chen XY. Antiviral treatment for chronic hepatitis B: Safety, effectiveness, and prognosis. World J Clin Cases. 2019 Jul 26;7(14):1784-1794. doi: 10.12998/wjcc.v7.i14.1784. PMID: 31417924; PMCID: PMC6692272.
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