Hepatitis B infection is the most common liver infection globally, caused by the hepatitis B virus (HBV).
People from endemic areas (Asia, Africa), or injection drug users and those with high-risk sexual behaviours, are at an increased risk for infection.
Most people are asymptomatic, although some will present with complications such as cirrhosis, hepatocellular carcinoma, or liver failure.
Serological markers are essential in making the diagnosis and evaluating disease activity, including differentiating between people with acute and chronic infection and chronic asymptomatic carriers.
Goal of treatment is to improve survival and quality of life by preventing disease progression. Current treatments do not completely eradicate the virus. The mainstay of management is antiviral therapy, although some patients also require referral to a liver transplant centre.
The most common liver infection globally, caused by the hepatitis B virus (HBV). HBV is a DNA virus transmitted by percutaneous and permucosal routes. HBV infection is also a sexually transmitted infection. HBV infection may result in a self-limiting disease requiring no treatment, particularly in adult-acquired infection, but it may also result in a chronically infected state with cirrhosis, hepatocellular carcinoma, or liver failure, particularly if it is acquired perinatally or in early childhood.
BMJ Best Practice podcast: hepatitis B - how to approach diagnosis and management of chronic infection Opens in new window
History and exam
Key diagnostic factors
- presence of risk factors
Other diagnostic factors
- maculopapular or urticarial rash
- right upper quadrant pain
- palmar erythema
- spider angiomata
- perinatal exposure in an infant born to an HBV-infected mother
- high-risk sexual behaviours
- injection drug use
- male sex
- born in highly endemic region
- family history of HBV, hepatocellular carcinoma, and/or chronic liver disease
- infected with HIV
- infected with hepatitis C virus
- blood or blood product transfusion
- healthcare workers
- household contact with HBV infection
- history of incarceration
- solid organ transplantation
1st investigations to order
- liver function tests
- urea and electrolytes
- coagulation profile
- serum hepatitis B surface antigen
- serum antibody to hepatitis B surface antigen
- serum antibody to hepatitis B core antigen
- serum hepatitis B e antigen
- serum antibody to hepatitis B e antigen
- serum HBV DNA
Investigations to consider
- abdominal ultrasound
- liver biopsy
- transient elastography
- serum liver fibrosis biomarkers
- CT/MRI abdomen
- testing for co-infections
- drug resistance testing
- HBV genotype
acute HBV infection
chronic HBV infection: adult non-pregnant without co-infection or cirrhosis
chronic HBV infection: adult non-pregnant with cirrhosis
chronic HBV infection: adult non-pregnant with HIV co-infection
chronic HBV infection: adult non-pregnant with hepatitis C co-infection
chronic HBV infection: adult non-pregnant with hepatitis D co-infection
chronic HBV infection: adult pregnant or breastfeeding
chronic HBV infection: children
Jawad Ahmad, MD, FRCP, FAASLD
Professor of Medicine
Division of Liver Diseases
Mount Sinai Hospital
JA declares that he has no competing interests.
Dr Jawad Ahmad would like to gratefully acknowledge Dr Sateesh R. Prakash, Dr Siddarth Verma, Dr Smruti R. Mohanty, and Dr Jared Hossack, previous contributors to this topic.
SRP, SV, and JH declare that they have no competing interests. SRM serves as a speaker bureau for Bristol-Myers Squibb regarding the use of entecavir for the treatment of chronic hepatitis B.
George Y. Wu, MD, PhD
Department of Medicine
University of Connecticut Health Center
GYW is on the medical advisory boards of Gilead Sciences and Bristol-Myers Squibb.
Lucieni Oliveira Conterno, MD, PhD
Clinical Epidemiology Unit
Marilia Medical School
LOC declares that she has no competing interests.
Mamun-Al-Mahtab, MB BS, MSc, MD
Bangladesh Primary Care Research Network
MAM declares that he has no competing interests.
- Acute hepatitis A virus infection
- Acute hepatitis C virus infection
- Chronic hepatitis C virus infection
- Recommended immunization schedule for adults aged 19 years or older - United States, 2023
- Recommended immunization schedule for children and adolescents aged 18 years or younger - United States, 2023
Hepatitis B: should I have the vaccine?
6-in-1 vaccine (diphtheria, hepatitis B, Haemophilus influenzae type B, polio, tetanus, whooping cough)More Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer