Hepatitis B: treatment

Treatment of hepatitis B is the same as for hepatitis A. Nevertheless, in the development of therapeutic tactics, it must be borne in mind that hepatitis B, in contrast to hepatitis A, often occurs in severe and malignant forms, in addition, possibly the chronic course of the disease, even the formation cirrhosis. Therefore, specific recommendations for the treatment of patients with hepatitis B should be more detailed than in the treatment of patients with hepatitis A.

At present, there are no principal objections to the fact that patients with mild and moderate forms of hepatitis B are treated at home. The results of such treatment are not worse, and in some cases even better than in a hospital, but given that it is not easy to organize a qualified examination and monitoring patients in out-patient settings, it can be recommended as a temporary measure the hospitalization of all patients with acute hepatitis B.

Specific recommendations for the motor system, therapeutic nutrition and indications for their expansion are the same as for hepatitis A; it should only be taken into account that the timing of all restrictions for hepatitis B usually slightly increase in full accordance with the duration of the course of the disease.

In general, with a smooth course of the disease, all restrictions in the motor and nutrition regime should be removed after 3-6 months from the onset of the disease, and sports can be resolved after 12 months.

[1], [2], [3], [4], [5], [6], [7], [8], [9],

Treatment of hepatitis B of mild and moderate form

Drug therapy is carried out on the same principles as in hepatitis A, that is, all patients are prescribed phosphoglue: for children up to 3 months for 1/2 capsule, from 3 to 7 years for 1 capsule, from 7 to 10 years for 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 alfa-2a (viferon, roferon-A, intron A, etc.) can be used for 1-3 million units once daily for 10-20 days. If necessary, treatment can be continued for 1-3 million units 3 times a week until recovery. In the acute period of hepatitis B, the administration of inosine (riboxin), choleretic preparations, and in the period of reconvalescence - legalona, karsila, is justified.

With a mild form of hepatitis B, they are limited to the basic treatment of hepatitis B (diet number 5, fractional drink, gentle motor mode). Patients with a moderate form of hepatitis B under certain indications (pronounced intoxication, changes in biochemical parameters, alarming in terms of development of severe course), carry out detoxication therapy: intravenously inject 5% glucose solution, polyionic solutions, up to 500-1000 ml / day.

Treatment of severe hepatitis B

In severe form of hepatitis B, a strict bed rest is prescribed, diet No. 5a. The infusion therapy is carried out using the same solutions as for the medium-heavy form up to 2.0 liters, day. Diuresis is boosted by furosemide (40 mg / day). Complex treatment also includes hyperbaric oxygenation and plasmapheresis. The introduction of cryoplasm to 200-600 ml / day and / or 10-20% albumin solution of 200-400 ml / day was shown.

In case of severe forms of the disease, rheopolyglucin, 10% glucose solution with a total volume of up to 500-800 ml / day, and also appoint glucocorticoids at the rate of 2-3 mg per 1 kg of body weight (according to prednisolone) per day during the first 3-4 days (before clinical improvement) followed by a rapid reduction in the dose (the total course is no more than 7-10 days). In children of the first year of life, the indication for the appointment of glucocorticoids is also the medium-heavy forms of the disease.

In case of an increase in intoxication, the appearance of signs of acute hepatic encephalopathy patients are transferred to the intensive care ward. The volume of intravenous fluid is calculated taking into account diuresis. It is advisable to administer 10% glucose solution. 10% albumin solution, amino acid mixtures. Plasmapheresis is indicated. The threat of the development of liver dystrophy dictates the need for the use of proteolysis inhibitors (aprotinin 50 000 units intravenously drip 2 times a day). In addition, given the possibility of developing progressive coagulopathy, for the prevention of hemorrhagic syndrome, 100 ml of a 5% solution of aminocaproic acid, freshly frozen plasma, intramuscularly administered etamzilate is administered intramuscularly. To prevent the progression of swelling-swelling of the brain, prescribe dexamethasone intravenously at a dose of 0.15-0.25 mg (kg x 10). Intravenous administration of a 10% mannitol solution in a dose of 0.5-1.0 g / kg. Diuresis is boosted by furosemide in a dose of 40-60 mg / day intravenously or intramuscularly. Oxygenotherapy is carried out by intranasal administration of 30-40% oxygen-air mixture and correction of acid-base state by 4% sodium bicarbonate solution. Psychomotor agitation is stopped with a 20% solution of sodium oxybate (0.05-0.1 g / kg slowly intravenously on a 5-40% solution of glucose), diazepam intravenously slowly 10 mg. With a violation of consciousness, difficult to stop excitation, unstable hemodynamics and the presence of severe metabolic acidosis, the patient is transferred to the IVL. To prevent intestinal autointoxication, poorly absorbed antibiotics (kanamycin, 1 g 4 times a day, orally) are administered (through a constant gastric tube), antisecretory drugs (ranitidine 100 mg 2 times a day orally) are used to prevent gastrointestinal bleeding. High cleansing enemas are needed twice a day. Many studies have shown 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 body weight per day), hydrolysis lignin.

Mode for hepatitis B

Return to work, associated with great physical stress or occupational hazards, is permissible not earlier than 3-6 months after discharge. Before this, it is possible to continue working in light conditions.

After discharge from the hospital should beware of hypothermia and avoid overheating in the sun, do not recommend trips to southern resorts during the first 3 months. Also, you should beware of taking medications that have an adverse (toxic) effect on the liver. After normalization of biochemical parameters of blood for 6 months, participation in sports competitions is prohibited. Those who have recovered from acute hepatitis B are exempt from preventive vaccinations for 6 months. Sports activities are limited only to a complex of therapeutic gymnastics.

Diet for hepatitis B

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

Allowed

• Milk and dairy products in all kinds.
• Boiled and stewed meat - beef, veal, chicken, turkey, rabbit.
• Boiled fresh fish - pike, carp, pike perch and sea fish: cod, perch. Ice cold.
• Vegetables, vegetable bluela, fruit, sauerkraut.
• Groats and flour products.
• Vegetable soups, cereals, dairy.

Limited

• Meat broths and soups are low-fat, not more often 1-2 times a week.
• Butter (not 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, only not sharp.
• Beef sausages, sausage doctor's, dietary, dining room.
• Caviar of salmon and sturgeon, herring.
• Tomatoes.

Forbidden

• Alcoholic beverages.
• All kinds of fried, smoked and pickled products.
• Pork, lamb, geese. Ducks.
• Sharp seasonings - horseradish, pepper, mustard, vinegar.
• Confectionery products - cakes, pastries.
• Chocolate, chocolate sweets, cocoa, coffee.
• Tomato juice.

[10], [11], [12], [13],

Outcomes of hepatitis B, prognosis

The prognosis for life as a whole is favorable, the mortality rate is less than 1%. Recovering is the most frequent outcome of the UGA. Comes in time from 1 to 6 months after discharge from the hospital for more than 90% of convalescents. With viral hepatitis B, there may be a prolonged (up to 6 months) course and the formation of a chronic (more than 6 months) course. Signs of chronicity - persisting hyperfermentemia, persistence of HBsAg and HBeAg in the serum of blood more than 6 months.

Reconvalvescents with viral hepatitis B can start their studies, work not earlier than 3-4 weeks after discharge from the hospital, provided that the state of health and activity of liver enzymes are normalized (a value exceeding 2 norms for persons not engaged in manual labor is permissible). For 3-6 months, the convalescents are released from sports and exercise and heavy physical activity. Within six months, routine preventive vaccinations are contra-indicated.

The period of clinical examination of convalescents is 12 months; Withdrawal is made only after stable normalization of the indicators of clinical and biochemical studies and double negative results for the presence of HBsAg. Reconvalescents with persistent HBs-antigenemia represent a risk group for possibly joining a delta-viral infection, and therefore it is recommended that patients avoid parenteral interventions that can be postponed (dental prosthetics, planned operations, etc.) until the disappearance of HBsAg from the blood.

Extract from the hospital and dispensary observation

The discharge of convalescent hepatitis B is carried out for the same clinical indications as for hepatitis A. Usually patients are discharged on the 30-40th day from the onset of the disease; while moderate hepatomegaly, hyperfermentemia, and dysproteinemia are tolerated. When discharging from the hospital, the patient is given a reminder indicating the recommended regimen and diet. If the patient still has HBsAg at the time of discharge, the information on this is entered in the card / outpatient observation and is notified to the Sanitary and Epidemiological Station at the place of residence.

Follow-up monitoring of convalescents is best conducted in a consultative-dispensary room, organized at an infectious hospital. In the absence of such a cabinet, the outpatient supervision of those who underwent hepatitis B should be performed directly by the attending physician. The experience of our clinic showed that it is expedient to organize a separate advisory-dispensary cabinet. 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 doctors of the polyclinic.

The method of examination, timing, periodicity of dispensary follow-up of hepatitis B convalescent in the regulation of the Ministry of Health.

The first dispensary examination is conducted no later than 1 month after discharge from the hospital, the following - after 3, 6, 9 and 12 months. In the absence of subjective complaints and deviation from the norm of biochemical indicators, convalescents are removed from dispensary records, and in the presence of continuing to be examined once a month until complete recovery,

The regulated calendar periods for dispensary follow-up can not be considered absolute. Recent studies have shown that with hepatitis B, complete restoration of 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 assume that with normal clinical and laboratory data and the absence of subjective complaints, hepatitis B convalescence can be withdrawn from dispensary registration after 6 months from the onset of the disease.

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

End of follow-up and removal from the record are carried out in cases where two regular studies fix the normalization of clinical and biochemical data, and HBsAg is not detected in the blood.

Clinical follow-up is necessary for patients who received transfusion of blood products (plasma, fibrinogen, leukocyte mass, erythromass, etc.). Especially it concerns the children of the first year of life. The period of medical examination 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 hospital. In doubtful cases resort to the study of serum on the activity of hepatic cell enzymes.

The system of rehabilitation measures for hepatitis B is the same as for hepatitis A. It provides for the regulation of permissible physical exertion, food restrictions, use of medicines,

With a favorable course of illness, children can be admitted to preschool or to school in 2-4 weeks after discharge from the hospital. Students are exempt from physical education for 6 months, and from participation in competitions - for 1 year. During these terms, physical exercises and other physical doses are permitted.

Postponed hepatitis B is not a contraindication to the conduct of active immunization according to the vaccination calendar. In these cases, the rejection of vaccination in its consequences may cause more harm than possible undesirable effects of the vaccine response on the course of the reparative process in the liver in the convalescent viral hepatitis. The same can be said for operational interventions. It, in the convalescent period of viral hepatitis does not lead to a significant deterioration of the functional state of the liver and does not affect the timing of recovery. In each case, the question of surgical intervention should be addressed individually.

The recommendations regarding food restrictions as a factor contributing to a more smooth flow of the convalescent period need clarification. Diet for hepatitis B should be as full as possible even in the acute period of the disease, especially in the period of convalescence. Restrictions should concern only fatty, excessively sharp, salty dishes, and also smoked products, marinades, sauces, extractive substances. Recommendations regarding the prescribed diet should be indicated in the memo issued to each convalescent when discharging from the hospital.

It is somewhat more difficult to resolve the issue of administering drug therapy in hepatitis B reconvulsants. Obviously, in all cases, the appointment of phosphoglucin is indicated, in a number of cases, especially with prolonged convalescence, it is possible to appoint carpsil, legal, multivitamins; with dyskinesia of the gallbladder - cholagogue (corn stigmas, broth of immortelle, flamin, etc.), spasmolytic (drotaverin (no-sppa)), mineral water (Borjomi, Essentuki, Slavyanovskaya, Smirnovskaya and others .). According to the indications, other medications may be prescribed.

In the system of rehabilitation measures, great importance is given to psychotherapeutic effects. Positive influence is provided by the hospitalization of the dey along with the parents, an early discharge from the hospital, outdoor walks, examination and treatment in conditions as close as possible to outpatient. At the same time, one can not disagree with the recommendation of many of those pathological centers to treat the convalescents of acute hepatitis B in conditions of local sanatoriums and even more so in special rehabilitation departments. The best results can be achieved with treatment at home or early discharge of reconstituted patients from the hospital, that is, with the organization of individual care and treatment, to avoid stratification of other intercurrent infections and superinfection with other hepatotropic viruses. At the same time, individually convalescent congeners who underwent hepatitis B can be sent for treatment to specialized local sanatoriums or to well-known resorts (Zheleznovodsk, Druskininkai, Essentuki, etc.).

[14], [15],

What does the patient need to know?

You have suffered acute viral hepatitis B, and you need to know that the disappearance of jaundice, satisfactory laboratory performance and well-being do not serve as indicators of complete recovery, since a full recovery of liver health occurs within 6 months. In order to prevent the exacerbation of the disease and the transition to chronic forms, it is important to strictly follow the medical recommendations relating to follow-up and examination in a polyclinic, the regime of the day. Diet, as well as working conditions.

Medical supervision and control

Examination of survivors of viral hepatitis B is carried out at 1. 3, 6 months, and then, depending on the conclusion of the dispensary. Withdrawal taking into account with a favorable outcome is not earlier than 12 months after discharge from the hospital.

Remember that only the supervision of an infectious disease doctor and a regular laboratory examination will determine 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 mode of administration of the drug and regularly come to laboratory monitoring of blood counts, as this will minimize the chance of a side effect of the drug and provide control over the infection.

To appear for a laboratory examination is necessary at a doctor's appointed day on an empty stomach.

Your first visit to the polyclinic is prescribed by your doctor.

The established control periods for repeated medical examinations in a polyclinic or a hepatological center are mandatory for all who have transferred viral hepatitis B. If necessary, you can contact the office of follow-up hospital observations, or a hepatology center, or a polyclinic CIC, in addition to these terms.

Be attentive to your health!

Strictly adhere to diet and diet!

Be on regular check-ups!