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What is Hepatitis B?

Hepatitis B is a common virus that affects the liver, especially in places like Singapore. In Singapore, about 6% of people are carriers of hepatitis B. Most of the time, people get infected with hepatitis B when they're born or when they're very young. Often, they don't even know they have it because they don't feel sick. They might only find out when they donate blood, have a health checkup, or get screened before getting vaccinated.

How is hepatitis B transmitted, and who are at a higher risk of acquiring the infection?

Transmitted through body secretions like blood, semen, saliva.

Babies of hepatitis B carrier mothers are infected at the time of birth or soon after birth.

Transmission in childhood can occur through shared utensils like toothbrushes and razors.

Hepatitis B infections can be acquired through blood transfusions if the blood donor is not properly screened for the infection.

HBV infections can also be acquired through acupuncture, tattooing, ear piercing, manicures and dental treatment if non-sterile instruments are used.

Healthcare workers like doctors, dentists and nurses are at risk of finger-prick injuries which also transmit HBV infection.

Unprotected sex promotes HBV transmission. Therefore, individuals who indulge in a promiscuous lifestyle like commerical sex-workers and homosexuals are at a higher risk of HBV infection.

Hepatitis B virus in babies and adults

A baby who acquires the hepatitis B infection manifests a different course of illness from one who is infected in adulthood. Generally, an infection contracted at birth (from mother-to-child), does not manifest in any symptoms. Following such an infection the baby has a 90% chance of becoming a hepatitis B carrier, because they are unable to eliminate the virus from their bodies.

On the other hand, an individual who acquires the infection as an adult displays symptoms of "acute liver inflammation" (acute hepatitis B). Of these patients, 1% develop a very serious clinical course known as fulminant viral hepatitis B. These patients deteriorate very rapidly during the clinical course of the illness and may go into liver failure or even die. However, newer modalities of treatment like liver transplantation exist.

Symptoms

The symptoms of acute hepatitis B include:

Yellowing of skin and the 'whites' of the eyeball (sclera ) known as jaundice

Joint pain

Rash which may be itchy

Fever

Pain over the right upper abdomen

Dark tea-coloured urine

Nausea, loss of appetite and vomiting

Treatment in the acute period of the illness is essentially symptomatic relief of symptoms like itch, nausea and vomiting. It is generally advisable for patients with severe symptoms or deep jaundice to be admitted to hospital for observation because of the potentially severe consequences (fulminant hepatitis ) which may prove to be fatal, albeit rarely. This enables rapid intervention, which may be lifesaving, to be instituted if required. The patient is advised bedrest, and avoidance of alcohol and traditional Chinese remedies which could exacerbate his condition.

Different Phases of Chronic Hepatitis B

A chronic hepatitis B carrier goes through 3 phases, especially if the infection is acquired at birth. This is the usual scenario amongst carriers in Singapore:

High viral replicative ( immune-tolerant ) phase which is usually seen in patients less than 20 year old. There is rapid viral replication but the patient is well and has no symptoms. Blood tests and liver samples indicate minimal liver inflammation.

Low viral replicative (immune-elimination ) phase which occurs in patients between 20 to 40 years old. In this phase, the body's immune system attempts to rid itself of the hepatitis B virus, and this is reflected by abnormal blood tests that indicates active liver inflammation. The carrier may complain of lethargy. Occasionally, if this phase occurs in older patients, especially if more than 60 years, the clinical course is more serious and can cause severe liver dysfunction and death.

Non-replicative ( latent infection ) phase occurs in carriers above the age of 40 years. This phase is characterised by the continuous presence of the hepatitis B virus with a low replicative rate. There may be however, evidence of liver damage which later progresses on to liver cancer. The patient in this last phase may present for the first time with swelling of legs and abdomen, progressive mental deterioration and vomiting or passing out of blood in the stools.

Hepatitis B - How to prevent?

Hepatitis B is best prevented by vaccination. The following groups who are at highest risk for contracting hepatitis B should be vaccinated:

Individuals requiring repeated transfusions of blood and blood products

Patients who have natural or acquired immune deficiency e.g. HIV, or cancer patients.

Patients with kidney failure who require dialysis.

Healthcare workers.

Intravenous drug abusers, homosexuals and commercial sex workers

Individuals living in areas where the prevalence of chronic hepatitis B is high e.g. Southeast Asia.

Offspring of women who are hepatitis B carriers.

Spouses and other sexual contacts of hepatitis B carriers.

Laboratory workers dealing with blood or serum samples.

Side-effects of vaccines are rare and include local soreness at the injection site, mild fever, malaise but extremely infrequently may cause swelling of the lymph nodes (glands in the neck, groin, armpits ), and abnormalities of the nervous system.

The vaccine is administered at time 0,1 and 6 months. However, before one gets vaccinated, one should check oneself for the immune status. Only those who are non-immune to hepatitis B and not carriers should be vaccinated.

Hepatitis B - Treatments

Although we would expect the number of hepatitis B carriers to decrease in time, largely due to widespread screening and immunisation efforts, there still exists a significant proportion of our population who are carriers. The treatment of these carriers include:

Diagnosis and evaluation

Supportive therapy

Surveillance for liver cancer

I) Diagnosis and evaluation

Blood tests, ultrasonography of the liver and liver tissue sampling ( liver biopsy ) are used to assess the severity and stage of the illness. In suitable patients, appropriate treatment e.g. interferon may be instituted.

i) General Advice

A carrier should avoid donating blood, blood products, organs and sperm.

A carrier should inform his doctor, dentist or phlebotomist (health care worker who takes a patient's blood) of his hepatitis B status.

Household contacts / sexual partners should be screened and immunised against hepatitis B if they are not immune.

A carrier should not share his toothbrush / shaving equipment.

A female carrier who delivers should have her child immunised at birth.

Diet: Generally a normal nutritious diet should be recommended to healthy carriers. However, once a patient manifests signs of liver cirrhosis/failure, restriction in water and salt needs to be enforced.

Exercise: A regular exercise programme is beneficial for asymptomatic carriers but patients with severe liver impairment should avoid strenuous jogging and heavy weight lifting.

Drugs and Alcohol: drugs which may potentially damage the liver should be avoided if possible. Hepatitis B carriers should not take alcohol in excessive quantities. Care must be taken when self medicating. If in doubt, consult your doctor.

II) Supportive therapy

The aim of specific therapy is to reduce infectivity, stop the progression of the disease and ultimately prevent complications like cirrhosis ( 'liver failure with hardening' ) and cancer. These are basically 2 groups of drugs that are used by liver specialists, namely:

Those that boost the immune system to eliminate the hepatitis B virus e.g. interferon

Those that suppress viral replication ( anti-viral agents ) like entecavir

III) Monitoring of hepatitis B carriers

Hepatitis B carriers should be followed up regularly at intervals depending on the stage of the disease. Besides monitoring the disease activity or progression, the patient is screened for liver cancer

Taken from https://www.singhealth.com.sg/patient-care/conditions-treatments/hepatitis-b

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Non-Alcoholic Fatty Liver Disease in Children, Adolescents and Young Adults

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Non-Alcoholic Fatty Liver Disease in Children, Adolescents and Young Adults

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NAFLD, or nonalcoholic fatty liver disease, is when too much fat builds up in the liver, but it's not because of drinking too much alcohol. If alcohol is the cause, it's called alcohol-associated liver disease.

There are two types of NAFLD: NAFL and NASH. NAFL means there's extra fat in the liver, but not much inflammation or damage. NASH is more serious—it means there's fat, plus inflammation and damage to the liver. This damage can lead to scarring, which might cause cirrhosis or even liver cancer.

1. NAFLD

NAFLD is the most common liver problem in kids in the U.S. It's more likely to happen in kids who are overweight or have conditions related to being overweight, like diabetes. It's also more common in older kids and boys. Hispanic and Asian American kids tend to get it more than other groups.

Kids with NAFLD have a higher chance of getting liver problems or other health issues.

2. NASH

Most kids with NAFLD have the less serious NAFL type, but some have the more serious NASH type, which can lead to cirrhosis or liver cancer. They're also more at risk for type 2 diabetes and other problems like high blood pressure.

Causes of NAFLD

Experts are still studying the causes of NAFLD. Research suggests that certain health problems, genes, and other factors may make some children more likely to develop NAFLD. Children who are overweight, have diabetes or metabolic syndrome are more likely to develop NAFLD. Certain genes may also increase the child's chances of developing NAFLD.

Diagnosis

It is usually diagnosed using blood tests, imaging and sometimes a liver biopsy.

Treatment

Weight loss is the most effective way of treating NASH. For younger children, we recommend mantaining weight as their height increases.

References

1. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67(1):328–357. doi:10.1002/hep.29367

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How to Treat Fatty Liver Disease in Kids

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Welcome to Paediatric Onset Liver Disease!

We hope that you are here because you are interested to find out more about healthcare transition and how it can work for you!

Patients like yourself, who develop liver disease at an early age are followed up at a children’s hospital. As you mature into young adults, your care will be eventually transferred in a stepwise manner to the healthcare team in an adult hospital. This is what healthcare transition is all about!

Health care transition means the change in how we look after patients like yourself, from the paediatric (child) model you are familiar with to an adult model. In a paediatric model of care, your parents or caregivers make most of the choices regarding your medical needs. In adult model of care where you will transition to soon, you make these important decisions yourself. This change in the focus from your parents or caregivers to yourself requires time and understanding of your healthcare conditions and needs.

We know that this change in environment and healthcare team may be upsetting but we are here to help you during the entire journey. This padlet was started to provide you with more information about how the transition process works. We believe that patients and their families should be empowered, understand their own healthcare goals and take charge of their own health. We believe that it is important for the healthcare team to spend time during each visit to help you set your own healthcare goals and learn how to take charge of your own health.

Your health matters to us.

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This is a useful video that explains the process of healthcare transition. The ages given in the video are a guide and may differ in different places. 

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Health Care Transition Timeline for Youth and Young Adults

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Health Care Transition Timeline for Youth and Young Adults

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The timeline serves as a general guide to give an idea  on how the transition process will happen. Some young adults may feel more ready, whilst others may need more time before they move to the next phase. It is good to look through this timeline such that you know what the process is like.

The team may decide to transition the patient earlier or later depending on both their healthcare needs and readiness.

Age 14-15

Learn about your health condition, medications, and allergies.

Ask your doctor questions about your health.

Ask your doctor if and at what age they no longer care for young adults

Find out what you know about your health, health care, and family medical history.

Both you and your parent/caregiver can  take an assessment on your readiness for transition and discuss this together and with the doctor.

Learn more about your health and what to do in case of an emergency.

Age 16-17

Practice making a doctor’s appointment and ordering top up of medications (either by phone,online, or through an app).

Begin to see the doctor alone for part of the doctor’s visit to help gain independence in managing your health and health care.

Talk with your parent/caregiver about the age you want to transfer to an adult servce.

Age 18-21

You can choose to start making your doctor’s appointments and top up your medications on your own.

You can also choose to see the doctor on your own and ask the doctor any questions you have on your own such that you slowly become more comfortable  and get used to navigating the healthcare system on your own.

Ask the doctor to talk with you about your privacy rights when you turn 21.

Work with your doctor to make a medical summary. Keep a copy for yourself.

Transition to the care of the adult service.

Age 22-25

Continue to get care from your adult doctor, learn to manage your health and health care, and update your medical summary.

Adapted from © Got Transition® Health Care Transition Timeline for Youth and Young Adults

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Health Care Transition Timeline for Parents/Caregivers

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Health Care Transition Timeline for Parents/Caregivers

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Parents and caregivers are an incredible source of support throughout the healthcare transition process. We understand that it can also be nerve wracking, even as adults, to move from a familiar place who has taken care of your child for so many years.  The timeline serves as a general guide to  give an idea of how healthcare transition can occur and how parents and caregivers can support their young adults as they navigate through the transition process.

Age 14-15

Help your teen learn about their own health condition, medications, and allergies.

Encourage your teen to ask their doctor questions about their own health.
• Ask your teen’s doctor if and at what age they no longer care for young adults

Learn what your teen knows about their own health, health care, and family medical history.

Both you and your teen can take a transition assessment questionaire and discuss this together and with the doctor.

Help your teen learn more about their own health and what to do in case of an emergency.

Age 16-17

Help your teen practice making a doctor’s appointment and ordering prescription refills (either by phone, online, or through an app).

Encourage your teen to see the doctor alone for part of the doctor’s visit to help gain independence in managing their own health and health care.

Talk with your teen about the age they want to transfer to an adult service for adult care.

Age 18-21

Encourage your young adult to make doctor’s appointments, see the doctor alone, ask the doctor questions they may have, and refill medications on their own. This is to help them get used to navigating the healthcare system as they mature into becoming an adult.

Ask the doctor to talk with your young adult about their privacy rights when they turn 21.

Encourage your young adult to keep a copy of their medical condition with them.

Transition to the care of the adult doctor.

Age 22-25

Encourage your young adult to get care from their adult doctor, learn to manage their own health and health care, and update their medical summary.

Adapted from © Got Transition® Health Care Transition Timeline for Parents/Caregivers

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Transition to adult health care: overview

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There are many great assessment tools available online which can help you determine if you are ready to transition over to an adult service, and if you are not, it is also useful to identify which areas your healthcare team can work together with you on.

We have linked to both Got Transition Transition Readiness Assessment Questionnaire and the Ready Steady Go Questionnaires. These are two of commonly used tools that are helpful in determining if you are ready to transition over to an adult service.

Got Transition Transition Readiness Assessment Questionnaire

Ready Steady Go

We adapted our questionnaire from both Got Transition and Ready Steady Go. We decided to name it EVOLVE as we believe that the transition process is a form of evolution - with both the patient, caregivers and healthcare team having to develop and grow together.

We divided it into the following key areas of

Expertise

Virtuosity

Opportunity

Life

Values

Emotions

We believe that we need to work on all these areas in order to have a successful, holistic transition to the healthcare service. It is important that all these go hand in hand - as having a successful healthcare transition is more than just management of the underlying condition.

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We created the EVOLVE Questionnaire to find out more about what you understand about your health. Each domain assess a particular aspect of your health and helps us find out which areas you would like to learn more about. After you complete the form, you can share this form with your caregiver and you can compare them. Your answers may be different. You can show this to your healthcare team so they will be able to work together with you and your family to increase yours and your family’s health care skills.

Expertise

I understand how transition occurs.

I know who is in the adult healthcare team and their roles.

I understand the medical terms/words and procedures relevant to my condition.

I understand what each of my medications are for and their side effects.

I know what is likely to happen in the future regarding my condition.

I know about resources that offer support for young people and adults with my condition

Virtuosity

I am knowledgeable about their medical condition and therapy.

I know my allergies to medicine.

I know my family history.

I can explain my health needs to others.

I know how to ask questions when I do not understand what my doctor says.

I talk to the doctor instead of my parents/carers talking for me.

I see the doctor on their own during an appointment.

I know how to contact the medical team.

I know how to make and cancel my appointments.

I know how to get to my doctor’s office.

I know when and how to get emergency care.

I know how to get a summary of their medical information (e.g. HealthHub)

I know how to take my own medications.

I know how to top up their medicines without someone telling me.

I know how to top up my medicine if and when I need to.

I know how to pay my medical bills.

I know where to get help for financial matters e.g. eligibility for benefits and other support

Opportunity (School, Work)

I am managing at school/work e.g. getting around, nature of work, friends

My teachers/employer understand about my condition/treatment/absences

I know what I want to do in the future

I know who to contact for career advice

Life

I can look after myself in terms of dressing, bathing, making meals etc

I am independent away from the home e.g. getting to and around college/work, using public transport, shopping etc

I understand what appropriate eating means for my general health

I exercise regularly/have an active lifestyle. I am aware of any restrictions I may have because of my condition

I understand the effects of smoking, drugs and alcohol on my condition and general health

I understand the implications of my condition and drugs on pregnancy/parenting

I know where and how I can access providers for accurate information about sexual health

Values

I am confident to see the doctor on my own

I understand my rights to information, privacy and confidentiality

I understand my role in shared decision making with the healthcare team

Emotions

I can tell people about my condition e.g. friends, family, employers

I know how to cope with emotions such as anger or anxiety

I know someone I can talk to if we feel sad/fed-up I know how to deal with unwelcome comments

I am comfortable with the way I look to others

I am happy with life

The transfer to adult health services usually takes place between 18 and 22.

How important is it to you to move to a doctor who cares for adults before 22.

0 (not) to 10 (very)

How confident do you feel your ability to move to a doctor who cares for adults before age 22?

0 (not) to 10 (very)

Please list anything else you would like help or advice with:

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We created the EVOLVE Questionnaire to find out more about what you and your child understand about their health. Each domain assesses a particular aspect of your child’s health and assess which areas they want to learn more about. After you complete the form, you can ask your child to share their answers from their completed form and you can compare them. Your answers may be different. You can show this to your healthcare team so they will be able to work together with you and your family to increase yours and your family’s health care skills.

Expertise

I understand how transition occurs.

I know who is in the adult healthcare team and their roles.

I understand the medical terms/words and procedures related to my child’s condition.

I understand what each of my child’s medications are for and their side effects

I know what is likely to happen in the future regarding my child’s condition.

I know about resources that offer support for parents/carers of young people with my child’s condition.

I know how to advise my child about financial matters e.g. eligibility for benefits and other support

Virtuosity

My child is knowledgeable about their medical condition and therapy.

My child knows their allergies to medicine.

My child knows our family history.

My child can explain their health needs to others.

My child knows how to ask questions when they do not understand what their doctor says.

My child talks to the doctor instead of me talking for them.

My child sees the doctor on their own during an appointment.

My child knows how to contact the medical team.

My child knows how to make and cancel their own appointments.

My child knows how to get to their doctor’s office.

My child knows when and how to get emergency care.

My child knows how to get a summary of their medical information (e.g. HealthHub)

My child knows their own medicines.

My child knows how to top up their medicines without someone telling them.

My child knows how to top up their medicine if and when they need to.

My child knows how to pay their medical bills.

My child knows where to get help for financial matters e.g. eligibility for benefits and other support

I feel confident for my child to be seen on their own for part or all of the clinic visit

Opportunity (School, Work)

My child is adequately supported at school/work.

The teachers/employer understand about my child’s condition/treatment/absences

Life

My child is independent at home e.g. dressing, bathing, preparing meals, chores etc

My child is independent away from the home e.g. getting to and around college/work, using public transport, shopping etc

I understand the importance of an appropriate healthy diet for young people

I encourage my child to regularly exercise. I am aware of any restrictions my child may have because of their condition future

I understand the effects of smoking, drugs and alcohol on my child’s condition and general health

I know where to access reliable sexual health information for young people and their parents

Values

I understand my child’s rights to information, privacy and confidentiality

I understand my child’s role in shared decision making with the healthcare team

Emotion

I know how to tell people about my child’s condition e.g. friends, family, employers

I know how to cope with emotions such as anger or anxiety

I know someone we can talk to if we feel sad/fed-up I know how to deal with unwelcome comments

The transfer to adult health services usually takes place between 18 and 22.

Is it important to you for your child to move to a doctor who cares for adults before 22?

0 (not) to 10 (very)

Overall, how confident are you about your child transitioning to the adult services before 22?

0 (not) to 10 (very)

Please list anything else you would like help or advice with:

__________________________________________________________________________________________________________________

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What is Biliary Atresia?

Biliary atresia is a rare liver disease that affects infants, occurring when the bile ducts inside or outside the liver do not develop normally. Bile ducts are responsible for carrying bile (a digestive fluid) from the liver to the small intestine. When these ducts are absent or damaged, bile builds up in the liver, leading to liver damage, scarring, and eventually liver failure if left untreated.

Causes and Risk Factors

The exact cause of biliary atresia is unknown, but it is believed to be a combination of genetic and environmental factors. While there are no known ways to prevent biliary atresia, certain factors may increase the risk, including premature birth and certain infections during pregnancy.

Symptoms

Symptoms of biliary atresia usually appear within the first few weeks to months of life and may include:

Jaundice (yellowing of the skin and eyes)

Dark urine

Pale stools

Enlarged liver or spleen

Poor weight gain and growth

Irritability or fussiness

Diagnosis

Diagnosing biliary atresia typically involves several tests, including blood tests, imaging studies (such as ultrasound and MRI), and a liver biopsy. These tests help doctors assess liver function, bile flow, and the extent of liver damage.

Treatment

The primary treatment for biliary atresia is surgery called the Kasai procedure, usually performed within the first few months of life. During this procedure, the damaged bile ducts are removed, and a section of the small intestine is attached directly to the liver to allow bile drainage. While the Kasai procedure can help restore bile flow and improve symptoms, it may not always be successful, and some infants may require a liver transplant later in life.

Prognosis

The prognosis for biliary atresia varies depending on several factors, including the extent of liver damage at the time of diagnosis, the success of the Kasai procedure, and the overall health of the patient. Without treatment, biliary atresia often leads to liver failure within the first few years of life. However, with early intervention and appropriate medical care, many children with biliary atresia can lead relatively normal lives. Some may require ongoing medical management and, in some cases, a liver transplant.

Living with Biliary Atresia

Living with biliary atresia requires ongoing medical care and monitoring. Following the Kasai procedure or liver transplant, it is essential to attend regular follow-up appointments with healthcare providers. Early intervention and comprehensive care can help manage symptoms, minimize complications, and improve long-term outcomes.

Resources

1. "Biliary Atresia." National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services.

2. Bezerra, J. A. (2015). Biliary Atresia. Seminars in Pediatric Surgery, 24(5), 212–217. doi:10.1053/j.sempedsurg.2015.06.011

3. Superina, R. A., Magee, J. C., Brandt, M. L., Healey, P. J., Tiao, G., Ryckman, F. C., & Kim, H. (2006). The Anatomic Pattern of Biliary Atresia Identified at Time of Kasai Hepatoportoenterostomy and Early Postoperative Clearance of Jaundice Are Significant Predictors of Transplant-Free Survival. Annals of Surgery, 243(4), 604–614. doi:10.1097/01.sla.0000205757.76489.29

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Biliary atresia: Video, Anatomy, Definition & Function | Osmosis

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Biliary atresia Videos, Flashcards, High Yield Notes, & Practice Questions. Learn and reinforce your understanding of Biliary atresia.