Hepatitis B: treatment

Treatment of hepatitis B is the same as for hepatitis A. However, when developing therapeutic tactics, it is necessary to take into account that hepatitis B, unlike hepatitis A, often occurs in severe and malignant forms, in addition, chronic course of the disease is possible, even the formation of cirrhosis. Therefore, specific recommendations for the treatment of patients with hepatitis B should be more detailed than for the treatment of patients with hepatitis A.

At present, there are no fundamental objections to patients with mild and moderate forms of hepatitis B being treated at home. The results of such treatment are no worse, and in some respects even better, than in a hospital, but given that it is sometimes difficult to organize qualified examination and observation of patients in outpatient settings, it is possible to recommend hospitalization of all patients with acute hepatitis B as a temporary measure.

Specific recommendations regarding physical activity, therapeutic nutrition, and indications for their expansion are the same as for hepatitis A; it should only be taken into account that the duration of all restrictions for hepatitis B is usually somewhat increased in full accordance with the duration of the disease.

In general, it can be said that if the disease progresses smoothly, all restrictions on physical activity and nutrition should be lifted 3-6 months after the onset of the disease, and sports activities can be allowed after 12 months.

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Treatment of mild to moderate hepatitis B

Drug therapy is carried out according to the same principles as for hepatitis A, that is, all patients are prescribed phosphogliv: children under 3 months - 1/2 capsule, from 3 to 7 years - 1 capsule, from 7 to 10 years - 1.5 capsules, over 10 years and adults - 2 capsules 2-3 times a day for 10-30 days. In addition to this basic therapy for moderate and severe forms of hepatitis B, interferon alpha-2a (Viferon, Roferon-A, Intron A, etc.) can be used at 1-3 million IU once a day for 10-20 days. If necessary, treatment can be continued at 1-3 million IU 3 times a week until recovery. In the acute period of hepatitis B, it is justified to prescribe inosine (riboxin), choleretic drugs, and in the convalescence period - legalon, carsil.

In the case of a mild form of hepatitis B, basic treatment for hepatitis B is limited (diet No. 5, fractional drinking, gentle exercise regimen). Patients with moderate hepatitis B, according to certain indications (severe intoxication, changes in biochemical parameters that are alarming in terms of the development of a severe course), undergo detoxification therapy: 5% glucose solution, polyionic solutions are administered intravenously, up to 500-1000 ml / day.

Treatment of severe hepatitis B

In severe hepatitis B, strict bed rest and diet No. 5a are prescribed. Infusion therapy is performed using the same solutions as in moderate hepatitis up to 2.0 l per day. Diuresis is forced with furosemide (40 mg/day). Complex treatment also includes hyperbaric oxygenation and plasmapheresis. The introduction of cryoplasm up to 200-600 ml/day and/or 10-20% albumin solution 200-400 ml/day is indicated.

In severe forms of the disease, rheopolyglucin and 10% glucose solution in a total volume of up to 500-800 ml/day are administered intravenously by drip for the purpose of detoxification, and glucocorticoids are prescribed at a rate of 2-3 mg per 1 kg of body weight (based on prednisolone) per day during the first 3-4 days (until clinical improvement) with subsequent rapid reduction of the dose (the total course is no more than 7-10 days). In children of the first year of life, moderate forms of the disease are also an indication for the prescription of glucocorticoids.

In case of increasing intoxication, the appearance of signs of acute liver encephalopathy, patients are transferred to the intensive care unit (department). The volume of intravenous fluid is calculated taking into account diuresis. It is advisable to prescribe a 10% glucose solution, 10% albumin solution, amino acid mixtures. Plasmapheresis is indicated. The threat of developing liver dystrophy dictates the need to use proteolysis inhibitors (aprotinin 50,000 IU intravenously by drip 2 times a day). In addition, given the possibility of developing progressive coagulopathy, in order to prevent hemorrhagic syndrome, 100 ml of 5% aminocaproic acid solution, fresh frozen plasma are administered intravenously, etamsylate is used intramuscularly. To prevent progression of cerebral edema-swelling, dexamethasone is prescribed intravenously at a dose of 0.15-0.25 mg (kg x day). Intravenous administration of 10% mannitol solution at a dose of 0.5-1.0 g / kg. Diuresis is forced with furosemide at a dose of 40-60 mg / day intravenously or intramuscularly. Oxygen therapy is carried out by intranasal administration of 30-40% oxygen-air mixture and correction of acid-base balance with 4% sodium bicarbonate solution. Psychomotor agitation is relieved with 20% sodium oxybate solution (0.05-0.1 g / kg slowly intravenously in 5-40% glucose solution), diazepam intravenously slowly 10 mg. In case of impaired consciousness, difficult to control agitation, unstable hemodynamics and severe metabolic acidosis, the patient is transferred to artificial ventilation. To prevent intestinal autointoxication, poorly absorbed antibiotics (kanamycin 1 g 4 times a day orally) are administered (through a permanent gastric tube), and antisecretory drugs (ranitidine 100 mg 2 times a day orally) are used to prevent gastrointestinal bleeding. High cleansing enemas are necessary twice a day. Repeated studies have shown the ineffectiveness of interferon preparations and high doses of glucocorticoids in fulminant viral hepatitis B.

Patients with viral hepatitis B with a pronounced cholestatic component are prescribed ursodeoxycholic acid preparations (ursofalk 8-10 mg/kg of body weight per day), hydrolytic lignin.

Hepatitis B regimen

Return to work activities associated with high physical stress or occupational hazards is permitted no earlier than 3-6 months after discharge. Until then, continuation of work activities under easier conditions is possible.

After discharge from the hospital, you should be careful of hypothermia and avoid overheating in the sun, trips to southern resorts are not recommended for the first 3 months. You should also be careful of taking medications that have a side (toxic) effect on the liver. After normalization of biochemical blood parameters, participation in sports competitions is prohibited for 6 months. Those who have had acute hepatitis B are exempt from preventive vaccinations for 6 months. Sports activities are limited to a set of therapeutic exercises.

Diet for Hepatitis B

For 6 months after discharge, special attention should be paid to nutrition, which should be sufficiently complete, with the complete exclusion of substances harmful to the liver. Alcoholic beverages (including beer) are strictly prohibited. It is necessary to eat regularly during the day every 3-4 hours, avoiding overeating.

Allowed

• Milk and dairy products in all forms.
• Boiled and stewed meat - beef, veal, chicken, turkey, rabbit.
• Boiled fresh fish - pike, carp, pike perch and sea fish: cod, perch. Ice.
• Vegetables, vegetable dishes, fruits, sauerkraut.
• Cereals and flour products.
• Vegetable, cereal and milk soups.

Limited

• Meat broths and soups - low-fat, no more than 1-2 times a week.
• Butter (no more than 50-70 g/day, for children - 30-40 g), cream, sour cream.
• Eggs - no more than 2-3 times a week, protein omelets.
• Cheese in small quantities, but not spicy.
• Beef sausages, doctor's sausage, dietary sausage, table sausage.
• Salmon and sturgeon caviar, herring.
• Tomatoes.

Forbidden

• Alcoholic beverages.
• All types of fried, smoked and pickled products.
• Pork, lamb, geese, ducks.
• Hot spices - horseradish, pepper, mustard, vinegar.
• Confectionery - cakes, pastries.
• Chocolate, chocolate candies, cocoa, coffee.
• Tomato juice.

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Hepatitis B outcomes, prognosis

The prognosis for life is generally favorable, the mortality rate is less than 1%. Recovery is the most common outcome of acute hepatitis B. It occurs within 1 to 6 months after discharge from the hospital in more than 90% of convalescents. In viral hepatitis B, there may be a protracted (up to 6 months) course and the formation of a chronic (more than 6 months) course. Signs of chronicity are persistent hyperfermentemia, persistence of HBsAg and HBeAg in the blood serum for more than 6 months.

Convalescents with viral hepatitis B may return to school and work no earlier than 3-4 weeks after discharge from the hospital, provided that their health and liver enzyme activity have returned to normal (a value exceeding 2 norms is acceptable for individuals not engaged in physical labor). For 3-6 months, convalescents are exempted from sports, physical education, and heavy physical exertion. Scheduled preventive vaccinations are contraindicated for six months.

The period of clinical observation of convalescents is 12 months; deregistration is performed only after stable normalization of clinical and biochemical test results and two negative results for the presence of HBsAg. Convalescents with persistent HBs antigenemia represent a risk group for the possibility of delta virus infection, and in this regard, patients are recommended to avoid parenteral interventions that can be postponed (dental prosthetics, planned operations, etc.) until HBsAg disappears from the blood.

Discharge from hospital and outpatient observation

Discharge of hepatitis B convalescents is carried out according to the same clinical indications as for hepatitis A. Usually, patients are discharged on the 30th-40th day from the onset of the disease; moderate hepatomegaly, hyperfermentemia, and dysproteinemia are allowed. When discharged from the hospital, the patient is given a memo indicating the recommended regimen and diet. If HBsAg is still detected in the patient at the time of discharge, this information is entered into the outpatient observation card and reported to the sanitary and epidemiological station at the place of residence.

Follow-up observation of convalescents is best carried out in a consultative and dispensary office organized at an infectious diseases hospital. In the absence of such an office, dispensary observation of those who have had hepatitis B should be carried out directly by the attending physician. The experience of our clinic has shown that it is advisable to organize a separate consultative and dispensary office. In this case, it is possible not only to ensure continuity of observation and a high level of examination, but also to provide consultative and methodological assistance to the clinic doctors.

The examination methodology, timing, and frequency of dispensary observation of hepatitis B convalescents are regulated by the order of the Ministry of Health.

The first dispensary examination is carried out no later than 1 month after discharge from the hospital, the subsequent ones -• after 3, 6, 9 and 12 months. In the absence of subjective complaints and deviations from the norm of biochemical parameters, convalescents are removed from the dispensary register, and if present, they continue to be examined once a month until complete recovery,

The regulated calendar periods of dispensary observation cannot be considered absolute. Research in recent years has shown that with hepatitis B, complete restoration of the liver structure and function occurs within the first 3-6 months from the onset of the disease and, in addition, typical forms do not lead to the formation of chronic hepatitis. This allows us to consider that with normal clinical and laboratory data and the absence of subjective complaints, hepatitis B convalescents can be removed from the dispensary register as early as 6 months from the onset of the disease.

Patients with significant or increasing clinical and laboratory changes, as well as with exacerbation of the disease or suspected development of chronic hepatitis are re-hospitalized to clarify the diagnosis and continue treatment. Patients who have persistent HBs antigenemia in the absence of signs of chronic hepatitis are also subject to re-hospitalization.

The end of dispensary observation and removal from the register are carried out in cases where normalization of clinical and biochemical data is recorded during two subsequent studies, and HBsAg is not detected in the blood.

Outpatient monitoring is also necessary for patients who have received transfusions of blood products (plasma, fibrinogen, leukocyte mass, erythrocyte mass, etc.). This is especially true for children in their first year of life. The period of outpatient monitoring is 6 months after the last blood transfusion. During this period, the child is examined monthly and, at the first suspicion of hepatitis, is hospitalized in an infectious diseases hospital. In doubtful cases, they resort to testing the serum for the activity of liver-cell enzymes.

The system of rehabilitation measures for hepatitis B is the same as for hepatitis A. It includes regulation of permissible physical activity, dietary restrictions, use of medications, etc.

If the disease progresses favorably, children may be admitted to preschool institutions or to school 2-4 weeks after discharge from the hospital. Schoolchildren are exempt from physical education classes for 6 months and from participation in competitions for 1 year. During these periods, therapeutic physical education classes and other measured physical activities are permitted.

Previous hepatitis B is not a contraindication to active immunization according to the vaccination calendar. In these cases, refusal of vaccination can cause more harm in its consequences than possible undesirable effects of the vaccine reaction on the course of the reparative process in the liver of a convalescent of viral hepatitis. The same can be said about surgical interventions. In the convalescent period of viral hepatitis, it does not lead to a significant deterioration in the functional state of the liver and does not affect the recovery period. In each specific case, the question of surgical intervention should be decided individually.

Recommendations regarding dietary restrictions as a factor contributing to a smoother course of the convalescent period also need to be clarified. The diet for hepatitis B should be as complete as possible even in the acute period of the disease, especially in the convalescent period. Restrictions should only concern fatty, excessively spicy, salty dishes, as well as smoked foods, marinades, sauces, and extractives. Recommendations regarding the prescribed diet should be indicated in the memo given to each convalescent upon discharge from the hospital.

It is somewhat more difficult to decide on the issue of drug therapy for hepatitis B convalescents. Obviously, in all cases, phosphogliv is indicated; in some cases, especially with prolonged convalescence, carsil, legalen, multivitamins can be prescribed; in case of gallbladder dyskinesia - choleretic agents (corn silk, immortelle decoction, flamin, etc.), antispasmodics (drotaverine (no-shpa)), mineral water (Borjomi, Essentuki, Slavyanovskaya, Smirnovskaya, etc.). Other medications can be prescribed as indicated.

In the system of rehabilitation measures, great importance is attached to psychotherapeutic influence. A positive effect is exerted by hospitalization of the patient together with parents, early discharge from the hospital, walks in the fresh air, examination and treatment in conditions as close as possible to outpatient ones. At the same time, one cannot but agree with the recommendation of many pathological centers to conduct follow-up treatment of convalescents from acute hepatitis B in local sanatoriums and especially in special rehabilitation departments. The best results are achieved with home treatment or early discharge of convalescents from the hospital, that is, with the organization of individual care and treatment, allowing to avoid layering of other intercurrent infections and superinfection with other hepatotropic viruses. At the same time, on an individual basis, convalescents who have had hepatitis B can be sent for further treatment to specialized local sanatoriums or well-known resorts (Zheleznovodsk, Druskininkai, Essentuki, etc.).

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What does a patient need to know?

You have had acute viral hepatitis B, and you need to know that the disappearance of jaundice, satisfactory laboratory parameters and good health do not serve as indicators of complete recovery, since complete restoration of liver health occurs within 6 months. In order to prevent exacerbation of the disease and transition to a chronic form, it is important to strictly follow the doctor's recommendations regarding subsequent observation and examination in a clinic, daily routine, diet, as well as working conditions.

Medical supervision and control

Examination of those who have had viral hepatitis B is carried out after 1.3, 6 months, and then depending on the conclusion of the dispensary doctor. Removal from the register in case of a favorable outcome is carried out no earlier than 12 months after discharge from the hospital.

Remember that only observation by an infectious disease specialist and regular laboratory testing will allow you to establish the fact of your recovery or the transition of the disease to a chronic form. If the doctor prescribes antiviral treatment, you must strictly adhere to the regimen for administering the drug and regularly come for laboratory monitoring of blood counts, as this will minimize the likelihood of side effects of the drug and ensure control over the infection.

You must show up for a laboratory examination on the day strictly prescribed by your doctor, on an empty stomach.

Your first visit to the KIZ polyclinic is scheduled by your attending physician.

The established control periods for follow-up medical examinations in a polyclinic or hepatology center are mandatory for all those who have had viral hepatitis B. If necessary, you can contact the hospital follow-up office, or the hepatology center, or the polyclinic’s KIZ also in addition to these periods.

Be attentive to your health!

Strictly follow the regime and diet!

Visit your doctor regularly for check-ups!