Deciding on treatment and liver biopsy

Hi Thomas
Could you pls share your thoughts on my results many thanks
I have had been diagnosed Hep B since 2013 had no treatment yet.My Dr said I dont need medical treatment till 2019.
Last year I moved to another country did my regular cheak up in Feb 2021
My results are : ALT, SGPT 14U/L
ULTRASOUND liver is normal
HVB DNA(PCR)Quantitative 5.698 IU/ ml
My Dr suggested to do liver biopsy before to prescribe medication …as my DNA level is high but liver tests are all normal.
I am bit worried about biopsy…and thinking to get Fibroscan first and again get second opinion.
Is anybody else faces same like me.Pls share your experience of doing biopsy
Regards AsKul.

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No indication to anti-HBV therapy but check fibroscan and HBsAg levels and hbeag status. Age and HBV genotype?

I am 38 years old female . I dont know nothing about HBV genotype. How can I learn about that?
I have asked to cheak HBeAg but my Dr said not necessary if he is going to do biopsy.

I got a biopsy of the liver when I found out that I had hepatitis b. Needle in the skin of stomach was weird and didn’t hurt as much as I thought.

I believe fibroscan is to check the hardness or softness of the liver. Other than that, it does not show anything else.

No indication for a liver biopsy before hbeag status and quantification of hbsag levels

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Thank you very much Neptune J .for your replay.Sounds like procedure itself not painful.

Dear @Askul,

Welcome to the community. Thanks for sharing your story and results.

I guess I can describe a bit more about the reasoning here (or at least my educated understanding of it):

When you first have Hep B (e.g. when you are a kid), the liver can produce a lot of virus, but other than that the liver is OK and there is no liver damage.

At some point (usually around 30-40 years old) our immune response starts trying to clear the virus and that’s when a lot of the damage happens. When this happens, we can slow the liver damage down by giving antiviral medication.

Right now, the doctor is trying to find out if the immune system is already trying to attack the liver. While the ultrasound and other panels are normal, you also have a slightly lower HBV DNA level than expected if the immune system was completely silent (people with little immune response can have 1000 times more virus in their blood).

My interpretation is that the doctor is trying to find out if there really is liver damage and that is done by looking directly at your liver cells. This may be why you are being referred to a liver biopsy.

I have observed several liver biopsies being carried out. Though perhaps not a totally comfortable experience, the local anaesthetic means you don’t actually feel that much pain, it is just a weird feeling. People undergoing it are awake the whole time and are generally fine.

As @PLampertico says (thanks for your expertise, Prof!), there are other tests that you could do prior to a liver biopsy to find out if there are indications for treatment. A quick side-note here: @PLampertico was the chair of the panel that wrote the European clinical guidelines for Hep B treatment, so knows what he is talking about.

In terms of fibroscan, it is so-so at detecting early signs of fibrosis. Given your ultrasound was normal, I am going to guess the fibroscan might be close to normal too. If the HBeAg is positive, then you could consider antivirals at your age (under EASL guidelines at least). While it’s true the liver biopsy would definitely get you the answer, it’s probably worth getting a full picture before going in for a biopsy, but indeed it’s your decision.

Hope this explains things a bit


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Dear AsKul, I agree with Dr. Lampertico and Thomas already wrote to you. I just want to add that in the U.S., liver biopsy is NOT the first thing recommended before deciding on whether treatment should be added. It used to be required many years ago, but the current thinking is that tests like fibroscan and blood tests can be just as good. Having had a liver biopsy myself, it is an invasive procedure and carries some risk of excessive bleeding since the liver is highly vascular (has lots and lots of blood vessels in it to detoxify of our blood). If a liver biopsy is done by a highly experienced physician with good follow-up care, then the risks of the procedure or minimized. For me, it required an entire day off since after the biopsy (needle inserted in the belly to reach the liver) I had to lay on my back with compression bandages on my abdomen for 4 hours to make sure clots developed at the insertion site in my liver so I wouldn’t bleed internally. Then I returned home and had to stay in bed the rest of the day. Unlike Neptune, I had severe pain when I was at home and moving around in the bed, so my husband called the specialist to make sure it was normal. Anyhow, this is response is too long. I just meant to say that a liver biopsy is not the first test that should be done for your situation as others have already spoken to. Always, Joan


Hi Askul, I wanted to add that your liver specialist should read the AASLD Hepatitis B Treatment Guidelines from the American Association for the Study of Liver Diseases (AASLD) or the EASL Hepatitis B Management Guidelines from the European Association for the Study of Liver Diseases (EASL). Both sets of guidelines from the U.S. and Europe do NOT recommend liver biopsy before deciding on treatment. If it’s possible to obtain a blood test for your hepatitis B e-antigen (HBeAg) status that would be ideal since treatment guidelines look at whether you are HBeAg negative or positive. Your genotype is a very specialized test that may or may not be available and is not required for deciding on whether to start treatment or not (it can be helpful in determining whether you would be a good candidate for interferon treatment or not, as well as your potential risk of developing liver cancer, etc.). The key parameters for deciding whether treatment should be started or not are your liver enzymes (ALT), viral DNA, HBeAg status blood test results. Hope this helps! Always, Joan

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Thank you very much Prof Dr Pietro Lampertico for your feedback.I really appreciate your advise.I will do blood test for HBsAg and HBeAg .Will ask the Doctors here in Turkey about Hepatitis B genotype how and where i can do the test.Will discuss about biopsy again…maybe in Turkey biopsy is requested for treatment plan.( i did search myself about Fibroscan in Turkey its about 8 pcs for whole country. Around my area is non …most in Istanbul)
Regards Askul

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Hi all,

I am new to this community.

I was born with hep B. I did a HBV DNA test two years ago, my viral load was slightly above 1k IU/mL, but my viral load had elevated to 5.7k IU/mL. My ALT value shows as 29 U/L in my liver function tests.

I am worry about my situation. Kindly advise which stage of CHB I am currently in now, and do i need to initiate an antiviral treatment?


Hi Askul

Your condition is same as I’m trying to get useful information before starting treatment my DNA load is high and little bit fluctuations in LFT, fibro scan is normal ultrasound is normal but undigested food particles in stool regular loosing weight current weight 52 kg height 172 cm

Dr. Suggested liver biopsy before starting treatment.

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Is there any chances that the HBV DNA viral load can be reduced, without the help from anitviral drugs?

Yes off course but with ancient Indian Ayurvedic medicine here in our country a female has experienced now she has zero hbv DNA I’m also thinking to go through with the help of Ayurvedic.

Dear @John, welcome to the community and thanks for your question. You will require more lab tests to really find out what phase of chronic HBV you are in at the moment. I would recommend talking to a liver specialist about this.

Regarding lowering your HBV DNA load, there are no proven other ways to lower your HBV load. However, there are many ways to make your Hep B worse with poor health in other respects (low exercise, eating poorly, stress, etc.).

In any case, the HBV load is not necessarily what you need to worry about: people can have very high levels of virus but have very little damage to their liver. It is a complicated issue, one which I attempt to explain here: EXPLAINER: How Hep B infects the liver (English and Mandarin).

Hope this helps!


Dear @nisarr,

Please do not promote Ayurvedic treatment here.

Firstly, there is no scientific evidence that this sort of treatment works.

More importantly, Ayurvedic treatment has been linked to liver toxicity and damage, with some people dying from it:

From the last paper, many patients that had liver failure from these complementary and alternative medicines (most commonly Ayurveda herbal medicines) died: “Overall, 53% of patients died (median survival 194 days).”

These can be very dangerous substances because they are not regulated (so anything could be in them). Please take care and do not encourage anyone (particularly with Hep B) to take these.


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Dear Thomas

What about bone density if you are going through with entacavir or tenofovir that is why I’m asking to you after my biopsy Dr will start treatment currently viral load 54000 IU/mL detected.

Hi @Nisarr, thanks for raising your concerns which many people share with you about the long-term use of antivirals. These issues have been talked about by the Hep B Foundation here:

In short, bone loss is not associated with Entecavir at all.

With Tenofovir there is a very low risk of bone loss, mostly in people already at risk of lower bone density (female, being older, smoking, and lower body mass or low levels of vitamin D.). Your doctor should be monitoring your bone, vitamin D, and blood calcium levels if there is a risk of bone loss. This also generally occurs fairly slowly, so you have time to act before it is a big problem if you are being monitored. You can also do things to prevent this if you are at risk (e.g. vitamin D and/or calcium tablets).

@Joan_Block has some experience in this and maybe she can share her insights.


Dear @ThomasTu, thank you for all the information that you have shared. It’s help.

And thanks for setting up this forum and community. At least I won’t feel that I am the only person who need to go through this alone, and I find support from this community.

I felt blessed to be part of this community. Thanks again for the invaluable feedback and information.



Hi Nisarr, I agree entirely with Thomas about the difference between entecavir and tenofovir. Entecavir is not known to cause bone loss. Tenofovir is know to cause bone loss, but again as Thomas pointed out already, there are specific risk factors. Not sure what you’re gender is, but men generally have heavier bones than women so aren’t at great risk. As a petite, 62 year old Asian woman, I had to switch from tenofovir to TAF since I was losing too much bone density. Since switching to TAF, my bone loss has actually reversed so I’m pretty happy. But as Thomas already explained, entecavir is not known to affect bone mineral density. Hope this helps. Always, Joan

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