Examination methods

• What can be detected by physical examination?
• Which diagnostic procedures are available?
• Which results does the laboratory provide?
• How is a liver biopsy performed?
• Do alternatives to liver biopsy exist?

Treatment options / prevention by vaccination

• Which vaccines against which types of viral hepatitis exist and when does a vaccination make sense?
• Which drugs are available?

Physical examination

• palpation and percussion of the abdominal wall
• determination of the size and consistency of the liver

Laboratory analysis

• determination of parameters in the blood to assess liver function
  (PT/INR, cholinesterase, albumin, thrombocytes, bilirubin)
• degree of inflammation (ALT, AST)
• affection of the bile ducts (alkaline phosphatase, GGT, bilirubin)
• detection of viral infection (e.g hepatitis B virus antibodies, hepatitis C virus
  antibodies, hepatitis D virus antibodies, hepatitis A antibodies, hepatitis E antibodies)
• presence and level of replication of a virus (HBV-DNA, HCV-RNA, HDV-RNA)
• identification of the (sub)type of the virus (HBV, HCV)

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Imaging

• ultrasound examination including assessment of the blood flow in the liver and portal vein system (Doppler, coloured flow measurement)
• computed tomography (CT)
• magnetic resonance imaging (MRI)
• Fibroscan
• Assessment of structural liver tissue changes (degree of liver fibrosis) using a no-risk, painfree method
• Placing the diagnostic probe at the right side of the ribcage over the liver
• Measurement of liver stiffness, thereby determining possible structural changes in the tissue

Liver biopsy

Taking a small sample of liver tissue by:

• ultrasound examination to localize the place of biopsy
• local anesthesia
• insertion of a 1.4 mm fine needle between the ribs on the right side
• aspiration of liver tissue
• compression of the biopsy area by a sandbag to prevent secondary hemorrhage and resting for 2-4 hours after biopsy

Treatment of hepatitis C

Treatment of hepatitis C today is interferon free and based on antiviral combination therapies administered as pills. Treatment duration is usually between 8 or 12 weeks total, tolerability is very good and efficacy in most circumstance >95%. The choice of the regimen depends on HCV Genotype, level of HCV RNA, HCV pretreatment and drug drug interactions with co-medications.

Current regimes of choice are:

• Sofosbuvir + Velpatasvir (Epclusa®)
• Grazoprevir + Elbasvir (Zepatier®)
• Glecaprevir + Pibrentasvir (Maviret®)
• Sofosbuvir + Velpatasvir + Voxilaprevir (Vosevi®)

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Treatment of hepatitis B

For the treatment of hepatitis B two drugs are the preferred treatment options:

• entecavir
• tenofovir

Approved are also lamivudine, adefovir and telbivudine, but not considered first choice because of more rapid development of drug resistance. Interferon is an option mainly in HBe-Antigen positive patients with the aim of inducing HBe-Antigen or even HBs-Antigen loss or seroconversion. However interferon is associated with flue like symptoms and other frequent adverse events reducing the quality of life of the patients taking this drug.

Therapy schedule, course & aims

It is always an individual decision which drug is chosen for therapy of hepatitis B.

Variables guiding the treatment decision are the level of HIV-DNA, possible pre-treatments, the level of ALT, HBV-genotype and the degree of liver fibrosis. Regular controls to assess the efficacy of therapy are necessary.

To avoid the development of resistance, full suppression of HBV-DNA should be achieved. The development of resistance eliminates the therapeutic effect of the drug used and may lead to cross-resistance to other medications. Immunological control can be induced by hepatitis B therapy resulting in the induction of HBe- or HBs-antibodies. The development of these antibodies can be assessed by laboratory controls. Several months after the development of such antibodies hepatitis B therapy with polymerase inhibitors can be discontinued.