Chronic hepatitis B: diagnosis

Lab tests

Only the levels of bilirubin, γ-globulins, and AST activity in the serum are moderately increased. The serum albumin content is often normal. At the time of presentation, signs of hepatocellular damage are usually insignificant.

If antibodies to smooth muscles appear, their titer is low. Antimitochondrial antibodies are absent in the serum.

The HBsAg test is positive. In the later stages, HBsAg is difficult to detect in the blood, while anti-HBc IgM is usually still present. HBV DNA, HBeAg and anti-HBe are not consistently detected.

HBV DNA can be detected by PCR in plasma of HBsAg-negative patients.

Liver biopsy in chronic hepatitis B

Histological examination may reveal chronic hepatitis, active cirrhosis, and hepatocellular carcinoma. The constant differential diagnostic criteria for chronic hepatitis B include the presence of HBsAg in the form of opaque vitreous hepatocytes or characteristic orcein staining, as well as detection of HBeAg by immunoperoxidase reaction. Other signs have diagnostic value only in the presence of the above criteria. In chronic hepatitis caused by HBV, cirrhosis is detected less frequently at presentation than in autoimmune hepatitis.

Laboratory data in chronic hepatitis B associated with the replication phase

• Complete blood count: moderate anemia, lymphopenia, increased ESR are possible;
• General urine analysis shows no significant changes, however, with high activity of hepatitis, proteinuria, cylindruria, and microhematuria are possible as a manifestation of glomerulonephritis;
• Blood biochemistry: possible hyperbilirubinemia and increased conjugated bilirubin, hypoprothrombinemia, hypoalbuminemia and increased alpha2- and y-globulin levels, increased aminotransferase levels (most typically increased alanine aminotransferase), alkaline phosphatase, organ-specific liver enzymes (ornithilcarbamoyltransferase, arginase, fructose-1-phosphoaldolase). The severity of hypertransaminotransferase corresponds to the degree of chronic hepatitis activity. With low activity, the alanine aminotransferase content is usually less than three times the norm, with moderate activity - from 3 to 10 times the norm, with high activity - more than 10 times the norm;
• Immunological blood test: possible decrease in the number and function of T-lymphocyte suppressors, high antibody titers and a high degree of sensitization of T-lymphocytes to a specific liver lipoprotein, an increase in the number of immunoglobulins; possible detection of circulating immune complexes;
• Serum markers of hepatitis B virus replication are determined - HBV-DNA, HBeAg, HBsAblgM, DNA polymerase, pre-S antigens. The most reliable criterion for confirming high replicative activity is the detection of high HBV-DNA content in the blood (> 200 ng/l).

Morphological study of the liver in chronic hepatitis B associated with the replicative phase

During morphological examination of the liver (puncture biopsy), “stepwise” necrosis is most often detected, and with high activity of the inflammatory process, “bridge-like” and multilobular necrosis of the liver parenchyma, lymphoid-histiocytic infiltration of the portal tracts and liver lobules.

In the replicative phase, HBV DNA is detected in liver tissue and HBcAg is detected in the nuclei of hepatocytes.

The presence of hepatitis B virus in hepatocytes can be suspected by the presence of frosted glassy hepatocytes when examining preparations stained with hematoxylin and eosin or by the Van Gieson method. These are large hepatocytes with cytoplasm palely stained with eosin. It should be taken into account that frosted glassy hepatocytes are found not only in the presence of HBsAg, but also in drug-induced and alcoholic hepatitis. However, frosted glassy hepatocytes containing HBsAg are specifically stained with orcein and aldehyde fuchsin.

Instrumental data in chronic hepatitis B associated with the replication phase

Radioisotope hepatography reveals a violation of the secretory-excretory function of the liver.

Ultrasound and radioisotope scanning reveal diffuse liver enlargement.

The duration of the replicative phase and the degree of activity of the inflammatory process in the liver determine the course and prognosis of chronic hepatitis B. If virus replication ceases before the development of liver cirrhosis, the prognosis is favorable, since the active phase of chronic hepatitis is transformed into an inactive one. Cessation of virus replication in the case of already formed liver cirrhosis cannot lead to the reverse development of the process, but to a certain extent it allows delaying further progression of the disease.