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  #1  
Old 05-21-2013
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Liver Gastroenterology Q16

A 38-year-old woman is evaluated for elevated transaminase levels that were identified during routine laboratory testing for life insurance. She is originally from Thailand and immigrated to the United States 10 years pre-viously. She has been married to an American for the past 12 years, having met him while he was living abroad for business. She previously worked in Thailand as a deputy tourism minister for the government, but is not currently employed. She has no significant past medical history.
She had one uncomplicated pregnancy at the age of 22.
When queried about risk factors for liver disease, she denies alcohol intake or drug abuse. She has never had a blood transfusion. She recalls an episode of jaundice that she did not seek evaluation for about 15 years ago. It resolved spontaneously. She currently feels well, and her husband wished to have her added to his life insurance policy. There are no stigmata of chronic liver disease.
Her laboratory studies reveal an AST of 346 U/L, ALT of 412 U/L, alkaline phosphatase of 98 U/L, and total bilirubin of 1.5 mg/dL. Further workup includes the following viral studies: hepatitis A IgG +, hepatitis B surface antigen +, hepatitis B e antigen +, anti-HBV core IgG +, and hepatitis C IgG negative. The HBV DNA level
is 4.8 × 10 4 IU/mL. What treatment do you recommend for this patient?
A. Entecavir.
B. Pegylated interferon.
C. Pegylated interferon plus entecavir.
D. No treatment is necessary.
E. Either A or C.
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Old 05-21-2013
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Treating hepatitis B is not recommended because 90% of cases will resolve spontaneously.. if she continues to be positive after 6 months and starts to have liver changes then treatment is indicated..

You never give dual treatment for Hepatitis B, that is only for hepatitis C.. therefore E and C are out
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Old 05-21-2013
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no treatment...
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Old 05-24-2013
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no treamtment is necessary in acute hepatitis B infection
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Old 05-24-2013
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Default hepatitis b

This is not acute hepatitis B since IgG is positive. Can somebody please explain?I think its interferon only.
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Old 05-25-2013
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The answer is E. Either A or C.

The patient in this scenario has evidence of chronic active hepatitis B virus (HBV) infection. The presence of hepatitis B e–antigen (HBeAg) is indicative of ongoing viral replication, and individuals with HBeAg positivity typically have high levels of HBV DNA on testing. The spectrum of clinical infection in chronic hepatitis B is quite variable, and often individuals are asymptomatic with elevated liver enzymes identified on testing for other reasons. Thus, the decision to treat chronic HBV infection should not be based on clinical features. Most experts recommend treatment of HBeAg-positive chronic HBV infection with HBV DNA levels above 2 × 10 4 IU/mL if the ALT is elevated greater than twice the upper limit of normal. At present, many treatment options are available for the treatment of HBV infection and fall broadly into two cat-egories: nucleoside analogues and interferons. While lamivudine and interferon were the first drugs used for the treatment of chronic HBV infection, these drugs have largely been supplanted by entecavir, tenofovir, and pegylated interferon as first-line therapy. When choosing among these agents, treatment can be tailored to specific patient preferences.

Pegylated interferon achieves more rapid clearance of HBeAg and does not contribute to viral mutations. However, it is associated with systemic side effects that many find intoler-able and requires weekly SC injections. In contrast, the oral agents often require a longer duration of therapy, are very well tolerated, and yield a more profound suppression of HBV DNA. However, mutations can occur with the use of these medications. Combina-tion therapy does not appear to be more effective than single-drug therapy. The patient’s husband should also be screened for hepatitis B given the continued viremia.

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Old 05-25-2013
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Old 05-25-2013
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Last edited by cingulate.gyrus; 05-25-2013 at 10:46 PM.
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Old 05-25-2013
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Quote:
Originally Posted by XpaezX View Post
Treating hepatitis B is not recommended because 90% of cases will resolve spontaneously.. if she continues to be positive after 6 months and starts to have liver changes then treatment is indicated..

You never give dual treatment for Hepatitis B, that is only for hepatitis C.. therefore E and C are out
But I also think this to be the answer as we have to wait for 6 months for seroconversion of HbeAg before treatment....?.....comments...
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Old 05-26-2013
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Quote:
Originally Posted by cingulate.gyrus View Post
But I also think this to be the answer as we have to wait for 6 months for seroconversion of HbeAg before treatment....?.....comments...
Hi man.. i dont agree with this at all.. i do agree you treat hepatitis B when it is chronic and /or there are persistent elevelated liver enzymes etc.. but option E is wrong because you never EVER give dual drugs for hepatitis B.. that is a consensus found in MTB and uworld... that is only for hepatitis C.. in fact that treatment (Option C) is the tratment of choice for hepatitis C NOT B...

I dont know what is the source of this.. but thats basically what I have learned for years.. unless I have been lied lol

All the algorithms you have put either retest for HBV DNA at 6 months or go to liver biopsy.. after that you decide...
I believe this question is wrong
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Gastroenterology-, Infectious-Diseases, Step-3-Questions

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