VIRAL HEPATITIS TRAINING MANUAL

Federal Ministry of Health

National Hepatitis Control Program
2021
 TRAINING MODULE
Staging of Liver disease
Pre-Treatment Assessment

1) Determine whether a patient has cirrhosis or other health conditions

2) Gather information for making treatment decisions about:

• Who to treat
• How and How long to treat
• Readiness for treatment
• What extra support or monitoring is required

3) Determine if there are risks to adherence to manage

Pre-Treatment Assessment

• Hepatitis vs infection

• Different stages of liver injury

• About 1/3 of HBV presented with significant fibrosis

• Liver cirrhosis in 20%

• Decompensated cirrhosis in 20-23%

• HCC:6-15%
 Phases of chronic HBV

HBeAg

Anti-HBe

New HBeAg-positive HBeAg-positive HBeAg-negative HBeAg-negative

nomenclature2 chronic HBV infection chronic hepatitis B chronic HBV infection chronic hepatitis B

*See new nomenclature slide.

EASL CPG HBV. J Hepatol 2017;67:370–98
 Algorithm for the management of CHBV

Suspected chronic HBV infection

HBsAg positive HBsAg negative, anti-HBc positive

Chronic HBV infection* Chronic hepatitis B No specialist follow-up

(no signs of chronic hepatitis) ± cirrhosis* but inform patient and general practitioner
about the potential risk of HBV reactivation
Monitor
(includes HBsAg, HBeAg, HBV DNA, ALT,
fibrosis assessment) Start antiviral treatment

NO
Consider
Risk of HCC, risk of HBV reactivation, In case of immunosuppression, start oral
extrahepatic manifestations, risk of antiviral prophylaxis
YES
HBV transmission or monitor

*See new nomenclature slide.

EASL CPG HBV. J Hepatol 2017;67:370–98
Clinical presentation of HCV
Step 2: Assessing stage and severity
Delivery of blood to liver, Synthesis, Excretion

INR Bilirubin

Platelets Albumin

Symptoms
Imaging, Biopsy

8
Fibrosis (Liver damage)
Stages of Fibrosis

• F0 = No fibrosis
• F1 = Portal fibrosis without septa
• F2 = Portal fibrosis with rare septa
• F3 = Numerous septa, not cirrhosis
• F4 = Cirrhosis
Assessing stages of liver disease
Pre-treatment Assessment:
Assessment of Hepatic Injury / Severity/ Comorbidty
 Mandatory test:
o CBC, Liver enzymes and function test (AST, ALT, ALP/ Bilirubin, ALB and INR)
o RFT (Creatinine, BUN), eGFR
o HIV
o HBeAg, HBV Viral load
o Quantitative HCV RNA (IU/ml)
• Signs of cirrhosis and cxns
o Abdominal Ultrasonography, AFP if hepatic mass is detected
 Assessing the degree of liver fibrosis and cirrhosis
 Invasive
 Non invasive
Pre-treatment Assessment:
Methods for assessing degree of Fibrosis

• Invasive Measures of liver damage

• Liver biopsy

• Non-Invasive Measures of liver damage

• APRI
• FIB-4
• Transient elastography (Fibroscan)
Non Invasive Methods

1. Fibroscan
2. FIB-4 (Normal range =/< 2)
Calculation: Age (yrs) x AST (IU/L) / platelet count (109/L) x ALT (IU/L)1/2
3. Aspartate aminotransferase (AST) to Platelet Ratio (APRI) score (Normal range =/< 2)
Calculation: AST / ULN / platelet count (109/L) x 100

Example of APRI calculation >2 Cirrhosis

AST 82, upper limit of normal for the lab 45 >1.5 Associated with Advanced
Platelet count 70,000/mm 3
Fibrosis, Risk of Cirrhosis
APRI = (82/45) x 100 = 2.6
70
 Referral to specialists is not required with APRI>1 and no signs of decompensation.
However when/where available, screening for advanced liver disease (ascites,
encephalopathy, GI bleeding) should be done
ULN – Upper limit of normal
 APRI
Alternatives to liver biopsy: APRI

Lin ZH Hepatology 2011

Chou R et al Ann Intern Med 2013
Non Invasive Assessment

Low and high cut-off values for the detection of significant cirrhosis and fibrosis; (WHO. Guide lines
for screening, care and treatment of persons with HCV infection, April 2014.P 60.)
Fibroscan

dz

dt

Hepatoma: unusual if FS < 10 kPa

Varices: unusual if FS < 20 kPa
Ascites: cut-off> 30

Laurant
AAU-CHS, Sandrin
GIU March 19, 2021et al. Ultrasound in Med & Biol 2003;29:1705
16
 Pre-Treatment
Staging assessment
Protocol Step #2: Complete Physical Exam
Perform complete Distended abdominal
veins and caput
physical exam, especially: Terry’s nails
medusa
Spider Nevi
• Calculate BMI
• Look for the following
symptoms:

Wasting Gynecomastia Jaundice Palmar erythema

Imaging revealing Shurunken liver with irregular margin, ascites

18
AAU-CHS, GIU March 19, 2021 18
 Stages of cirrhosis
Stage Staging event Annual
MR
1 Compensated Cirrhosis 1%

2 Cirrhosis with Varices 3.4%

3 Cirrhosis with Ascites 20%

DECOMPENSATED
4 Cirrhosis with GI bleeding 57% CIRRHOSIS

5 Cirrhosis with infection and renal 67%

failure
Assessing severity- Child pugh score

AAU-CHS, GIU March 19, 2021 20

Assessing severity: MELD

AAU-CHS, GIU March 19, 2021 21

 Drug Formulations
Conclusion and Routes

• Infection vs hepatitis (HBV)

• Hepatitis with or without significant fibrosis
• VH with Liver cirrhosis
• Compensated
• Decompensated (Stages of cirrhosis)
• With HCC