Chronic severe hepatitis B is an end-stage liver disease that evolves from chronic hepatitis and cirrhosis, and is a common critical and difficult clinical condition that is more difficult to treat, takes longer to treat and is more dangerous. The main treatment methods are described in the following options.
Supportive therapy
Once diagnosed with severe hepatitis, patients should be absolutely bedridden, maintain the balance of water, electrolytes and acid-base, and promptly correct hypoproteinemia and coagulation dysfunction.
Nutrition and support are an important part and foundation of the treatment of severe hepatitis and should not be neglected. Due to the extremely poor appetite, poor digestion and absorption, low synthetic capacity of the liver and even complications such as infection and bleeding in patients with severe liver, patients have insufficient caloric intake, low basal metabolism and significant negative nitrogen balance and low blood volume. Also, patients have multiple vitamin and trace element deficiencies. All of these factors cause decreased regenerative repair capacity of liver cells, hypoproteinemia and edema, thrombin coagulation factor deficiency and hemorrhage, decreased immune function, infection, and abnormal amino acid metabolism, leading to clinical complications such as infection, hemorrhage, ascites, and hepatic encephalopathy, as well as induced hepatorenal syndrome. Carbohydrate-based nutritional support therapy should be given to reduce the breakdown of fat and protein and to maintain blood glucose at normal levels to facilitate hepatocyte repair and regeneration and to promote recovery of liver function.
Etiology-specific or mechanism-specific treatment
1. Anti-inflammatory and antioxidant to protect hepatocytes and promote regeneration.
Glycyrrhetinic acid preparation has a clearer anti-inflammatory effect, and is now a routine drug for hepatitis treatment, which can reduce the inflammatory necrosis of liver cells and facilitate the control of the disease after application.
The structure of reduced glutathione contains active sulfhydryl groups, which can combine with toxic substances such as peroxide and superoxide ions to block their damaging effects on hepatocytes, and also has a protective effect on hepatocytes, but the clinical effect needs further verification.
Hepatocyte growth promoter can promote hepatocyte DNA synthesis and hepatocyte proliferation, and inhibit the release of TNF, reduce hepatocyte necrosis, repair liver tissue and anti-liver fibrosis. Clinical observation shows that the early application is more effective and can also reduce the disease and death rate.
2.Anti-viral therapy.
In China, hepatitis B virus (HBV) is an important pathogen of heavy hepatitis, and antiviral therapy will help control the disease. Therefore, for heavy hepatitis with evidence of hepatitis B virus replication . Antiviral therapy should be given immediately. The choice of antiviral drugs for severe hepatitis should be fast and potent nucleoside analogues, such as lamivudine, entecavir or telbivudine, of which entecavir and telbivudine have faster and stronger viral suppressive effects, and adefovir is not suitable for the treatment of severe hepatitis due to its slow onset of action.
3.Immunomodulatory therapy: including immunosuppressants and immune enhancers.
4.Treatment against intestinal-derived toxins: there is intestinal flora dysbiosis in heavy hepatitis, which is the main mechanism of endotoxin production. Therefore, it is very important to apply microecological agents or lactulose to regulate intestinal flora, reduce the absorption of blood ammonia and other toxins and prevent complications such as infections.
Based on the rational application of antibiotics, microecological agents such as Bacillus licheniformis and Bifidobacterium bifidum are applied in time to adjust the dysbiosis of flora, reduce endotoxemia and inhibit blood ammonia production and absorption.
Lactulose is a synthetic disaccharide, which is not decomposed in the small intestine after oral administration, but can be decomposed into lactic acid and acetic acid by bacteria such as Lactobacillus and Enterococcus faecalis after reaching the colon to reduce the pH of the intestine. An acidic intestinal environment reduces the absorption of ammonia and promotes its excretion.
Prevention and treatment of various complications
Severe hepatitis often leads to death due to various complications. The main complications include various infections, hepatic encephalopathy, hepatorenal syndrome and upper gastrointestinal bleeding. Abdominal infections are the most common complicating infections in severe hepatitis. Once spontaneous peritonitis (SBP) is diagnosed, it should be treated with sensitive antibiotics immediately, in addition to actively enhancing comprehensive supportive therapy.
Hepatic encephalopathy is one of the common complications of severe hepatitis. The principles of treatment are to strengthen the basic treatment, reduce blood ammonia and remove toxic substances from the blood; correct the imbalance of amino acid ratio and reduce the formation of pseudo-neurotransmitters; control complications, etc.
In the case of gastrointestinal bleeding, blood accumulation in the gastrointestinal tract should be eliminated immediately to reduce the absorption of toxic substances in the blood.
Once severe hepatitis is complicated by hepatorenal syndrome (HRS), the condition deteriorates and is often irreversible. Therefore, early preventive treatment is especially important.
Artificial liver treatment
Artificial liver is a method to assist in the treatment of liver insufficiency, liver failure or related liver diseases by temporarily and partially replacing liver function with the help of an extracorporeal mechanical, chemical or biological device. Through artificial liver support, time is created for hepatocyte regeneration in the case of heavy hepatitis or early liver failure, so that liver function can be restored in patients with reversible liver injury; by temporarily improving the patient’s physical condition and biochemical coagulation index, the progression of the disease is slowed down and survival time is prolonged, thus creating conditions and time for liver transplantation. Artificial liver is an important transition bridge to liver transplantation for severe hepatitis, and also an alternative measure to the initial non-functional state after liver transplantation.
Clinical applications of artificial liver for the treatment of liver failure in severe hepatitis at home and abroad have shown that the treatment effect is better in the early and middle stages of the disease. It is safe and feasible to be used for the treatment of severe hepatitis, which can reduce the patient’s symptoms, prolong the survival time, improve the survival rate and increase the chance of waiting for liver transplantation. Through artificial liver treatment, patients’ blood bilirubin and blood ammonia levels were significantly reduced, liver function indexes improved, intracranial pressure decreased, cerebral edema was reduced, and impaired consciousness and hepatic encephalopathy were improved
Liver transplantation
Currently, liver transplantation is the only effective treatment that can alter the natural course of severe liver disease. The survival rates after liver transplantation for severe hepatitis have increased to 66%, 60% and 55% at l, 5 and 10 years, respectively. Due to the poor preoperative general condition of patients with severe hepatitis, they often have severe infections, hepatic encephalopathy, hepatorenal syndrome, gastrointestinal bleeding and other organ insufficiencies. Therefore. The perioperative mortality rate of liver transplantation is as high as 14%-25%, which is significantly higher than that of liver transplantation performed for other etiologies. Surgical complications include infection, liver transplant-associated encephalopathy and acute renal failure are the most common. Although liver transplantation is effective in treating severe hepatitis, due to the lack of a donor, many patients become sicker or even die while waiting for a donor, missing the time for surgery. In contrast, artificial liver has a better supporting effect on patients with severe hepatitis, which can prolong their lives and give them more chances to win the waiting time for liver transplantation. Therefore, it should be an important part of the active preoperative preparation.