Mistakes in chronic hepatitis B management and how to avoid them

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Mistakes in chronic hepatitis B management and how to avoid them

Patrick Kennedy, Upkar S. Gill

Summary

AI Generated

Hepatitis B virus infection is the most common chronic viral infection globally, affecting more than 250 million people and causing over 850,000 deaths annually from cirrhosis and hepatocellular cancer.

HBV infection acquired at birth or in early childhood results in chronicity in greater than 95% of cases, whereas only 5–10% of adult-acquired infections progress to chronic infection.
HBV is transmitted haematogenously and sexually, with the majority of infections transmitted vertically or perinatally in high prevalence regions.
Despite the availability of a preventative vaccine, chronic HBV complications including cirrhosis and hepatocellular cancer account for more than 850,000 deaths per year.
This material provides foundational epidemiological context for clinicians managing or studying hepatitis B virus infection.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Stanaway JD, Flaxman AD, Naghavi M, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013. Lancet 2016; 388: 1081–1088. [Link]

Gill US and Kennedy PTF. The impact of currently licensed therapies on viral and immune responses in chronic hepatitis B: Considerations for future novel therapeutics. J Viral Hepat 2019; 26: 4–15. [Link]

Gill US and Kennedy PT. New insights in the management of chronic hepatitis B. Clin Med (Lond) 2015; 15: 191–196. [Link]

European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017; 67: 370–398. [Link]

Prati D, Taioli E, Zanella A, et al. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med 2002; 137: 1–10. [Link]

Kennedy PT, Sandalova E, Jo J, et al. Preserved T-cell function in children and young adults with immune-tolerant chronic hepatitis B. Gastroenterology 2012; 143: 637–645. [Link]

Mason WS, Gill US, Litwin S, et al. HBV DNA integration and clonal hepatocyte expansion in chronic hepatitis B patients considered immune tolerant. Gastroenterology 2016; 151: 986–998.e4. [Link]

Invernizzi F, Vigano M, Grossi G, et al. The prognosis and management of inactive HBV carriers. Liver Int 2016; 36 (Suppl 1):100–104. [Link]

Yurdaydin C. Recent advances in managing hepatitis D. F1000Res 2017; 6: 1596. [Link]

10.

Townsend SA and Newsome PN. Mistakes in nonalcoholic fatty liver disease and how to avoid them. UEG Education 2017; 17: 39–41. [Link]

11.

Peleg N, Issachar A, Sneh-Arbib O, et al. Liver steatosis is a major predictor of poor outcomes in chronic hepatitis C patients with sustained virologic response. J Viral Hepat ePub ahead of print 27 Jun 2019. DOI: 10.1111/jvh.13167. [Link]

12.

Seto WK. Chronic hepatitis B and metabolic risk factors: A call for rigorous longitudinal studies. World J Gastroenterol 2019; 25: 282–286. [Link]

13.

Gill US, Zissimopoulos A, Al-Shamma S, et al. Assessment of bone mineral density in tenofovir-treated patients with chronic hepatitis B: can the fracture risk assessment tool identify those at greatest risk? J Infect Dis 2015; 211: 374–382. [Link]

14.

Gill US and Bertoletti A. Clinical trial design for immune-based therapy of hepatitis B virus. Semin Liver Dis 2017; 37: 85¬–94. [Link]

15.

Koffas A, Dolman GE and Kennedy PT. Hepatitis B virus reactivation in patients treated with immunosuppressive drugs: a practical guide for clinicians. Clin Med (Lond) 2018; 18: 212–218. [Link]

Abstract

Hepatitis B virus (HBV) infection is the most common chronic viral infection in the world. Despite the availability of a preventative vaccine, more than 250 million people worldwide are chronically infected with HBV. The complications of chronic HBV infection—cirrhosis and hepatocellular cancer (HCC)—account for more than 850,000 deaths per year. HBV is transmitted haematogenously and sexually, with the majority of HBV infections being transmitted vertically (or perinatally) in high prevalence regions. HBV infection acquired at birth or in early childhood results in chronicity in >95% of cases, whereas only 5–10% of those who are infected in adulthood will progress to chronic infection.

Topics

Hepatobiliary

Citation

Gill US and Kennedy PTF. Mistakes in chronic hepatitis B management and how to avoid them. UEG Education 2019; 19: 22–24

Published

2019

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Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Antonio Facciorusso

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Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Antonio Facciorusso

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Guideline

Abstract

This Technical and Technology Review from the European Society of Gastrointestinal Endoscopy (ESGE) represents an update of the previous document on the technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including the available types of needle, technical aspects of tissue sampling, new devices, and specimen handling and processing. Among the most important new recommendations are:

ESGE recommends end-cutting fine-needle biopsy (FNB) needles over reverse-bevel FNB or fine-needle aspiration (FNA) needles for tissue sampling of solid pancreatic lesions; FNA may still have a role when rapid on-site evaluation (ROSE) is available.

ESGE recommends EUS-FNB or mucosal incision-assisted biopsy (MIAB) equally for tissue sampling of subepithelial lesions ≥20 mm in size. MIAB could represent the first choice for smaller lesions (<20 mm) if proper expertise is available.

ESGE does not recommend the use of antibiotic prophylaxis before EUS-guided tissue sampling of solid masses and EUS-FNA of pancreatic cystic lesions.

Publisher

European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

Topics

Endoscopy

Citation

Endoscopy 2025; 57(04): 390-418

Published

2025

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Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Antonio Facciorusso

International Multidisciplinary Consensus Report on Definitions, Diagnostic Criteria, and Management of Fatty Pancreas: A Joint Statement Endorsed by EPC, APA, EASD, EASL, ESGAR, ESGE, ESP, ESPCG, ESPEN, ESPGHAN, IAP, JPS, KPBA, LAPSG, and UEG

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International Multidisciplinary Consensus Report on Definitions, Diagnostic Criteria, and Management of Fatty Pancreas: A Joint Statement Endorsed by EPC, APA, EASD, EASL, ESGAR, ESGE, ESP, ESPCG, ESPEN, ESPGHAN, IAP, JPS, KPBA, LAPSG, and UEG

Miroslav Vujasinovic

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Guideline

ABSTRACT

This international, multidisciplinary consensus report represents the first effort to systematically define and characterize fatty pancreas. A key outcome of this endeavor was the recommendation to adopt “fatty pancreas” as the standardized and inclusive term to describe all forms of fat accumulation in the pancreas. This terminological consensus provides a critical foundation for unified reporting and clinical communication. Another major contribution of the report is the consensus on diagnostic imaging findings, which was based on radiological and endoscopic modalities. The proposed criteria aim to enhance consistency in clinical assessment and support the development of standardized research protocols. In addition to establishing terminology and diagnostic frameworks, the report also synthesizes current knowledge across a wide range of relevant domains. These include the etiology and epidemiology of fatty pancreas, as well as its associations with alcohol consumption, smoking, acute and chronic pancreatitis, pancreatic exocrine insufficiency, type 2 diabetes mellitus, and surgical outcomes. The potential links between fatty pancreas and neoplastic conditions such as intraductal papillary mucinous neoplasms and pancreatic cancer are also addressed, alongside the current understanding of its metabolic implications (beta-cell function and glucose homeostasis) and treatment strategies. Throughout the consensus process, a consistent theme emerged: the limited availability of high-quality, prospective clinical data. Therefore, many of the recommendations in this report are based on expert consensus rather than strong empirical evidence. As such, the statements require rigorous prospective validation before they can be adopted into routine clinical practice. This underscores a critical need for further research, particularly studies aimed at clarifying causal relationships, validating diagnostic tools, and determining the clinical relevance of fatty pancreas across diverse patient populations. This report serves as both a summary of our current understanding and a roadmap for future investigations, aiming to close existing knowledge gaps and guide evidence-based clinical practice in this emerging field.

Publishers

European Society for Paediatric Gastroenterology, Hepatology and Nutrition, The European Society for Clinical Nutrition and Metabolism, European Society for Primary Care Gastroenterology, European Society of Pathology, European Society of Gastrointestinal Endoscopy, European Society of Gastrointestinal and Abdominal Radiology, European Association for the Study of the Liver, European Pancreatic Club

Guideline

Consensus

Topics

Pancreas

Citation

United European Gastroenterology Journal, 2026; 14:e70185

Published

2026

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European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Juan Enrique Dominguez-Munoz

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Guideline

Abstract

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Publishers

European Society for Primary Care Gastroenterology, European Society of Digestive Oncology, European Society for Paediatric Gastroenterology, Hepatology and Nutrition, The European Society for Clinical Nutrition and Metabolism, European Digestive Surgery, European Pancreatic Club

Guideline

Clinical Practice Guideline

Topics

Pancreas

Citation

United European Gastroenterol J. 2024; 1–48. https://doi.org/10.1002/ueg2.12674

Published

2024

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Ian Gralnek on UEG Week 2024

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Abstract

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2025

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Endoscopic ultrasound-guided tissue sampling: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

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American Society for Gastrointestinal Endoscopy–European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

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Guideline

Abstract

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m², or with a BMI of 27.0–29.9 kg/m² with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

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European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

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Endoscopy Stomach & H. Pylori

Citation

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Published

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ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

Javier P. Gisbert

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Guideline

Introduction

Ulcerative colitis [UC] is a chronic inflammatory bowel disease [IBD] characterised by colonic inflammation extending to a variable extent from the rectum. Care of the patient with UC requires appropriate input from across the multiprofessional team. These guidelines summarise the recommended medical treatment for adults with UC.

In 2022, the European Crohn’s and Colitis Organisation [ECCO] published new guidelines on the management of UC in two papers focused on the medical and surgical management of the disease.¹^,² For the 2022 UC guidelines, ECCO adopted the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] approach, a systematic process for developing guidelines that addresses how to frame healthcare questions, summarise the evidence, formulate recommendations, and grade their strength and the quality of associated evidence.³ The present paper represents an update to the 2022 guidelines and focuses specifically on the medical management of UC, while a companion paper developed as part of the same process addresses optimal surgical management [ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment].

For this iteration of the guidelines, we have introduced several new, clinically relevant questions selected by members of the guidelines group, alongside a systematic approach to reviewing and updating previous topics to incorporate new evidence and to reappraise all findings within the context of contemporary practice. We have also introduced several “practice points” to summarise evidence and provide expert recommendations in key areas where the evidence remains limited but clinical decisions are still required. In such instances, where application of the GRADE methodology may be impractical, we adopted an approach based on systematic literature review, expert discussion, and voting to reach consensus recommendations outside the formal GRADE process.

Patients living with UC can have a variable disease course.⁴ In this document, we discuss therapeutic approaches stratified by disease severity [mildly-to-moderately active and moderately-to-severely active disease]. Definitions of disease severity are commonly used to establish clinical trial inclusion criteria and may be based on several distinct assessment frameworks.⁵ It is also important to remember that these definitions capture severity at a given point in time and may not reflect the cumulative long-term burden of disease experienced by a patient.⁶

It is also important to consider disease extent when planning treatment in UC, as this may affect the optimal route of drug administration. This is typically defined according to disease involving the rectum only [proctitis], disease distal to the splenic flexure [left-sided or distal UC], or disease extending proximal to the splenic flexure [extensive UC].⁷ It should be noted that disease distribution can change⁴ and that proximal disease extension can be a negative prognostic marker.⁸

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 20, Issue 7, July 2026

Published

2026

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