Viral Hepatitis (B & C)
Chronic hepatitis B and C are important causes of chronic liver disease, cirrhosis, and hepatocellular carcinoma worldwide.
Many patients are asymptomatic and diagnosed incidentally.
This guide focuses on how doctors should recognise, investigate, and manage hepatitis B and C in everyday NHS practice.
What is viral hepatitis B and C?
Both are blood-borne viral infections that cause chronic inflammation of the liver.
If untreated, they may progress to:
- Fibrosis
- Cirrhosis
- Liver failure
- Hepatocellular carcinoma (HCC)
Key difference:
- Hep B → often controlled, sometimes lifelong
- Hep C → now usually curable
How does it present?
Most patients are:
Completely asymptomatic
Common ways you’ll find it:
- Incidental abnormal LFTs
- Antenatal screening
- Immigration screening
- Blood donation screening
- IVDU history
- Known cirrhosis
- HCC diagnosis
Less commonly:
- Fatigue
- Jaundice (rare unless acute or advanced disease)
Never rely on symptoms.
Common risk factors (think practically)
Always ask sensitively.
Hepatitis B:
- Born in high-prevalence countries (Asia, Africa)
- Mother-to-child transmission
- Sexual contact
- Household contact
- Needlestick injury
- Healthcare exposure
Hepatitis C:
- IV drug use (past or present)
- Blood transfusions pre-1991
- Prison history
- Tattoos (unregulated settings)
- Needlestick injuries
If you don’t ask, you won’t find it.
On the ward or clinic, always ask
Is this acute infection, chronic infection, or past exposure?
Because management is completely different.
🟦 Hepatitis B
How to interpret Hep B blood tests (simple approach)
This confuses many juniors — keep it simple:
HBsAg positive
→ Current infection (acute or chronic)
Anti-HBs positive
→ Immune (vaccinated or past infection)
Anti-HBc positive
→ Past exposure
Next steps if HBsAg positive
Do:
- HBV DNA (viral load)
- LFTs
- Fibrosis assessment (FibroScan/FIB-4)
- Ultrasound liver
- Refer to hepatology/infectious diseases
Not everyone needs treatment immediately.
When do Hep B patients need treatment?
Specialist decision, but generally:
- High viral load
- Elevated ALT
- Fibrosis/cirrhosis
- Immunosuppression planned
- Pregnancy (to reduce transmission)
Treatment:
- Long-term antivirals (e.g. tenofovir/entecavir)
Most patients are monitored, not treated straight away.
🟩 Hepatitis C
How to interpret Hep C tests
Step 1 – Antibody:
Anti-HCV positive
→ Past exposure
Step 2 – PCR:
HCV RNA positive
→ Active infection
Antibody alone ≠ active disease
Management of Hep C
Big difference from Hep B:
Hep C is usually curable
Treatment:
- Direct-acting antivirals (8–12 weeks)
- 95% cure rate
All patients with active HCV should be referred for treatment.
Early referral is key.
🟥 First priority = assess liver damage
For both Hep B and C, your main concern is:
How much liver damage already exists?
Do:
- FIB-4
- FibroScan
- Ultrasound
- LFT trend
Because fibrosis stage predicts outcomes, not viral status alone.
Immediate management on the ward (what juniors should actually do)
If you incidentally discover viral hepatitis:
Do:
- Confirm tests properly
- Don’t panic the patient
- Explain calmly
- Arrange appropriate referral
- Avoid hepatotoxic drugs
- Vaccinate for Hep A/B if indicated
- Screen for other blood-borne viruses (HIV, etc.)
You are coordinating care, not starting antivirals yourself.
When to escalate urgently
Urgent/same-day senior review if:
- Acute hepatitis with jaundice
- Coagulopathy
- Suspected acute liver failure
- Decompensated cirrhosis
- GI bleeding
- Encephalopathy
These are liver emergencies, not outpatient issues.
Common mistakes juniors make
- Misinterpreting Hep B serology
- Treating antibody-positive Hep C as active infection
- Forgetting fibrosis assessment
- Not screening for co-infections
- Delaying referral
- Assuming asymptomatic = safe
Take-home concept
Viral hepatitis is often silent but can quietly lead to cirrhosis and cancer.
Your job is early detection, correct interpretation of tests, fibrosis assessment, and timely referral.