1. Immunotolerant phase: Patients often had high amount of Hepatitis B virus but despite that, there is little inflammation in the liver and patients' liver panel are normal. It is because patient's immune system does not recognize the virus.

2. Immunoclearance phase: Patients' immune system started to recognize the virus and begin to kill the viruses. As Hepatitis B virus live in the liver, such killing also causes the liver cells to die. Patients often has abnormal liver panel at this stage. If this stage persists for prolonged period, patients progress to complications faster.

3. Inactive carrier stage: At this stage, patients have low amount of Hepatitis B virus and there is little liver damage. Risk of progression decreases but may still occur.

4. Reactivation phase: At this stage, patients' Hepatitis B virus becomes reactivated and increases in amount, with active liver damage.

• Chronic Hepatitis (inflammation of the liver)

• Hepatitis Flare (sudden increase of the ALT , > 5 times upper limit of normal)

• Cirrhosis (hardening of the liver)
  

• Ascites (fluid accumulation in the abdomen)

• Bleeding of the esophageal or gastric varices (Burst of vessels in gullet or stomach)

• Liver cancer

• Liver failure (confusion and coma due to poor liver function)

• Spontaneous Bacterial Peritonitis (SBP) - infection of ascites fluid by bacteria

• Hepatorenal Symdrome (HRS) - Kidney failure secondary to liver failure

Liver Cancer	Ascites
Esophageal Varices Bleeding	Liver cancer in a liver with cirrhosis
[ More Pictures on Complications of Hep B... ]

Rate of progression among patients with chronic Hepatitis B

• Among patients with abnormal liver panel, risk of developing liver cirrhosis occurs at a rate of 2-10% yearly.

• Risk factors for development of liver cirrhosis include older age, male gender, active liver inflammation, high amount of Hepatitis B virus in blood, and alcohol abuse.

• Risk of development of liver cancer is about 0.6% in carriers of Hepatitis B, but increases to about 2% once liver cirrhosis occurs. Once a patient develops liver cancer, even if it is treated, rate of recurrence is high, at about 10% yearly.

• Although patients with flares may develop liver failure and progress to cirrhosis faster, they may not have symptoms in the early stage and the only sign is abnormal liver panel. Once they are jaundiced (yellowing of eyes), it may already be late.

• Liver cirrhosis (or liver hardening) is divided into early and late. Patients with early cirrhosis do not feel any symptoms, but once they progress to late cirrhosis (or what doctors called decompensated cirrhosis), they will have symptoms such as yellowing of eyes, ascites (abdomen filled with fluid), ankle edema, vomiting of blood, reduced energy level, and even confusion and coma. In other words, patients with early cirrhosis cannot tell they have cirrhosis.

• Patients with liver cancer also do not have any symptoms till the late stage. Patients with advanced liver cancer often have jaundice (yellowing of eyes), ascites (accumulation of fluid in the abdomen), and lack of energy and weight loss. By the time patients have these symptoms, it is often too late and is beyond the curative stage.

• Patients with chronic Hepatitis B but without complications such as cirrhosis or cancer can lead a normal life, without any symptoms. Their lifespan is often similar to those without Hepatitis B.

• However, once cirrhosis develops, their lifespan may be affected. Patients with early cirrhosis still have >80% chance of survival 5 years later, but once late complications (such as jaundice, ascites, and confusion) occur, less than 20% are still alive after 5 years.