Liver Cirrhosis in Chronic Hepatitis B: is it due to Hepatic Vena Cava Syndrome: case report

Abstract

Chronic hepatitis B (CHB) is a common chronic viral infection of man. Hepatitis B Virus is not a cytopathic virus. Extensive intrahepatic viral replication is compatible with normally functioning hepatocytes. Patients with CHB in the West manifest as a ‘healthy carrier’, whereas in Asia and Africa some develop liver cirrhosis and hepatocellular cancer. Liver cirrhosis in CHB is assumed to evolve through chronic hepatitis but its pathogenesis and the geographic difference in the outcome of CHB is not explained adequately. Nepal is a country with low prevalence of CHB, where patients with CHB have hepatic vena cava syndrome (HVCS) as a comorbid condition. HVCS is a bacterial infection induced chronic obstructive disease of inferior vena cava at the site of hepatic vein opening. It is clinically characterized by long asymptomatic courses and occasional episodes of acute exacerbation precipitated by bacterial infection that result in hepatic venous outflow obstruction. Increased frequencies of acute exacerbations led to development of hypersplenism, liver cirrhosis and hepatocellular carcinoma. Long time follow up of patients with CHB in Nepal showed development of cirrhosis in many but it was not related to the severity of viral replication or to the duration of the viral infection. Cirrhosis developed more frequently in patients with hypersplenism and those with severe and recurrent acute exacerbation of HVCS. These observations suggested that the development of cirrhosis in CHB in Afro-Asian countries may be due to the presence of HVCS as a comorbid condition. Reported here are a few cases of CHB that illustrate this point. Pathogenesis of cirrhosis in these patients is discussed.