Approach to HBeAg-Negative Patients with Increased Hepatic Aminotransferase Levels

Author: H. Nina Kim, MD, MSc

Last updated: March 1, 2013

A 40-year-old Asian man is referred for evaluation by his primary care physician for further evaluation of chronic hepatitis B infection. The patient has been a known hepatitis B carrier for 3 years. At the time of initial diagnosis, blood tests revealed a positive hepatitis B surface antigen (HBsAg), negative hepatitis B e antigen (HBeAg), and normal hepatic aminotransferase levels. Routine laboratory tests now show his alanine aminotransferase (ALT) is elevated to 100 U/L and aspartate aminotransferase (AST) elevated to 86 U/L. Serum albumin and total bilirubin are normal.

The patient reports that he feels well. As part of his recent health evaluation, he had a normal fasting lipid profile and complete blood count. He runs 15 miles per week, does not smoke, and does not describe any constitutional symptoms. On physical examination, he is 135 lbs, 67 inches tall, with a blood pressure of 110/70 mm Hg. His skin demonstrates no stigmata of chronic liver disease. Abdominal examination revealed mild tenderness in the right upper quadrant but was otherwise unremarkable.

Which of the following best explains this patient’s situation?

A The patient has most likely developed hepatocellular carcinoma and should be scheduled immediately for a triple phase liver computed tomography (CT) scan.
B The patient likely has a precore or core promoter mutant hepatitis B virus, which could be presumptively diagnosed by obtaining a serum hepatitis B viral load.
C The patient is likely infected with a precore mutant hepatitis B virus, which would best be diagnosed by obtaining a hepatitis B genotype.
D The patient's liver enzyme elevation is probably unrelated to his hepatitis B. He may have developed fatty liver disease, and an ultrasound should be ordered to evaluate him for this condition.